New Zealand Ambulance Major Incident
and Emergency Plan (AMPLANZ)
The Overview
May 2011
new ze ala nd ambulance major inci de nt a nd em erg enc y p lan (am pl an z)Acknowledgements
Ambulance New Zealand would like to acknowledge and warmly thank the following organisations for their support and contributions towards the completion of AMPLANZ:
Members of Ambulance New Zealand especially St John, Wellington Free Ambulance, LifeFlight and Wairarapa Ambulance for releasing the members of the AMPLANZ work group:
Peter Cain, Wellington Free Ambulance Tim Chiswell, St John
Sharon Cretney, Wairarapa DHB Jeremy Gooders, St John Alan Goudge, St John David Greenberg, Lifeflight Chris Haines, St John Bruce MacDonald, St John
Andy Parr, Wellington Free Ambulance Doug Third, St John
Stephen Smith, St John
Ambulance National Clinical Leadership Group
Ambulance NZ Standards and Accreditation Committee New Zealand Fire Service, Special Operations
Ambulance Victoria, Specialist Emergency Response Department NZ Ministry of Health, Emergency Management Team
UK Department of Health, Emergency Preparedness Division
Thank you to Shirin Sheida (St John Marketing Services) and Paul O’Connell (St John Learning Media) for the design of this document.
Thank you also to Catherine Preston, David Wethey, Glenn Cockburn, Matt Ohs, Oz Golan, The Lifeflight Trust and Hawke’s Bay Today for the use of their photographs in this document
Foreword
New Zealand has for a number of years had a national ambulance major incident and emergency plan – AMPLANZ. This has ensured that there is a common understanding between ambulance services,
communications centres and our emergency management partners as to how an ambulance will respond in a time of crisis.
Today however this new plan has had to take into account a number of emerging aspects in the emergency management environment. These include, for example: a number of high profile and catastrophic events in the last 5-10 years that has seen a greater focus on emergency management internationally; the redevelopment of the New Zealand Ambulance Standard (NZ8156) and the increased requirement to align with national emergency plans across the sector.
There is a continuing requirement on Ambulance Services to develop their own Major Incident and Emergency Plans based in the detailed operational framework that is AMPLANZ. AMPLANZ now provides clearer guidelines and tools to assist services at the local, service and national levels. AMPLANZ is noted within NZS8156 and therefore an Ambulance Service’s Major Incident and Emergency Plan should be audited regularly.
Finally, given the recent emergencies in New Zealand particularly in Canterbury and on the West Coast, it is now clear that major emergencies do indeed occur in New Zealand. Therefore there is a requirement that AMPLANZ and the Ambulance Service’s own Major Incident and Emergency Plans continue to be ‘living documents’ that remain relevant and practical in order to meet the needs of their community and the service.
David Waters CEO
Content
1.0 Introduction 4
1.1 What is AMPLANZ? 4
1.2 The Aim of AMPLANZ 4
1.3 Mandate of AMPLANZ 4
1.4 Format of AMPLANZ 4
2.0 Frameworks and Concepts of Emergency Management 5 2.1 Legislation and National Emergency Management Plans 5
2.2 The 5 ‘Rs’ 5
2.3 CIMS (New Zealand Coordinated Incident Management System) 5 2.4 Concept of Ambulance Emergency Management 6 2.4.1 The Responsibilities of Ambulance Services in a Major Incident 6 2.4.2 A structured and consistent approach 6
2.4.3 Whole of Organisation and Sector 7
3.0 Readiness and Reduction 7
3.1 Risk Reduction 7
3.2 Readiness 7
3.2.1 Readiness: Planning 7
3.2.2 Readiness: exercising 8
3.2.3 Readiness: training and education 8
3.3 Review and Audit 8
4.0 Response 8
4.1 Activations, Level of Response, and Notifications 8
4.1.1 Escalation 9
4.1.2 Types of Incidents 10
4.1.3 Response Matrix Tool 11
4.1.4 Risk Assessment and Response 11
4.1.5 Major Incident Notifications within Ambulance Services and to
partner agencies 12
4.2 Activation based on National Warnings 12
4.3 National Coordination of Ambulance 12
4.4 Activation based on Regional or Local Warnings 12 4.5 Response Command Structures, Roles and Responsibilities 12
4.5.1 First Ambulance Crew at the Scene 12
4.5.2 Ambulance Command at the Scene 12
4.5.3 Ambulance Service Emergency Response
Management Structures 13
4.5.4 EACC Incident Management Structure 14 4.6 Key Facilities for an Ambulance Response 14
4.6.1 Incident Scene Facilities 14
4.6.2 Ambulance Service Emergency Operations Centre (ASEOC) 14 4.7 Communications and Information Management 15
4.8 Ambulance Resources and Equipment 15
4.9 Ambulance Coordination with Health,
Emergency Services and other Agencies 15
5.0 Recovery 16
Appendix 1: Glossary of Terms and Abbreviations 17
1.0 Introduction
1.1 What is AMPLANZ?
AMPLANZ is a detailed operational framework for the New Zealand ambulance sector to provide clear guidance for all Ambulance Services in all parts of the emergency management cycle. It provides standard terminology, structures, and roles. It also provides tools to assist an Ambulance Service in its readiness and reduction, response and recovery, for example, task cards, planning templates, debriefing templates etc. Specific Ambulance Service Operational and Tactical Plans must be developed by Ambulance Services based on this framework.
AMPLANZ cannot be arbitrarily changed. There is a review process through the Ambulance New Zealand Standards and Accreditation Committee outlined as part of AMPLANZ.
In line with health sector and the emergency management sectors as a whole, there are a large number of specialist terms and abbreviations. To assist the reader, there is a glossary in Appendix 1.
1.2 The Aim of AMPLANZ
The aim of AMPLANZ is to:Ensure the effective and consistent management of major incidents at local, service and national levels for the benefit of patients
Minimise the impact of a major incident or multiple major incidents on normal operations
Adopt and encourage a whole-sector approach to major incident management
Adopt and encourage a whole-of-organisation approach within services to major incident management.
1.3 Mandate of AMPLANZ
AMPLANZ applies to all Ambulance Services1 in New Zealand and it is noted in Section 3.2.7 of the Ambulance Standard (NZS 8156:2008) that an Ambulance Service “shall be aware of, and where appropriate, contribute to, regional and/or national large scale contingency planning and be able to operate in accordance with such plans including…. AMPLANZ”. Ambulance New Zealand has approved policy to clarify: “…the mandate of AMPLANZ and to ensure that Ambulance NZ and Ambulance Services understand their roles and responsibilities with regards to the development, maintenance, and operationalisation of AMPLANZ”.
AMPLANZ is mandated to provide:
“….all Ambulance Services with the nationally standardised framework to command, control and co-ordinate ambulance resources locally, regionally and nationally, for the greatest good of the greatest number of casualties during major incidents”.
1.4 Format of AMPLANZ
The format of AMPLANZ includes two documents. These are The Overview and The Plan. The Plan is made up of four parts as noted below.
The Overview: This provides a summary for all Ambulance Services and partner agencies of the concepts and approach of the ambulance sector in the management of major incidents.
Part 1: Introduction to AMPLANZ and Emergency Management for the Ambulance Sector: This part summarises what AMPLANZ is, the sector, and key ambulance and emergency management concepts. Part 2: Consistent Operations at the Scene: This Part focuses on the activities to be undertaken by responding crews, the duty management and those operational officers directly involved at the scene in coordination with other responding agencies.
Part 3: Ambulance Service Approach: This Part focuses on the activities to be undertaken by Ambulance Service Management in all parts of the emergency management cycle. It is designed to guide ambulance managers who are required to support the response at the scene, as well as play a role in preparing for or recovering from a major incident.
Part 4: National Coordination Mechanisms: This Part provides a framework for an Ambulance Service to develop its national coordination mechanism to ensure that the ambulance sector is able to respond to a significant regional or national emergency. A CD with AMPLANZ Parts 1-4 and associated appendices is in the back cover of this Overview.
1An Ambulance Service is defined in NZS8156:2008 Section 1.5 page 12.
amplanz – the overview amplanz – the plan Part 1 Introduction to AMPLANZ and Emergency Management for the Ambulance Sector Part 2 Consistent Operations at the Scene Part 3 Ambulance Service Approach Part 4 National Coordination Mechanisms
2.0 Frameworks and Concepts of
Emergency Management
2.1 Legislation and National Emergency
Management Plans
The ambulance sector in New Zealand, unlike many services internationally, does not have its own legislation that guides and regulates the provision of ambulance services.
That said, Ambulance Services are health sector organisations and therefore have responsibilities within, for example, the Health Act 1956 and New Zealand Public Health and Disability Act 2000.
In the context of emergency management, the ambulance sector must comply with, for example, the Civil Defence Emergency Management Act 2002 and Epidemic Preparedness Act 2006.
Ambulance services shall be aware of their
responsibilities under these legislations as well as other health and workplace legislation.
There are two key national plans that relate to emergency management. These are the:
National Civil Defence Emergency Management Plan 2006
National Health Emergency Plan 2008 (NHEP). AMPLANZ shall be read in conjunction with these key national plans.
Appendix 2 lists the key legislation and plans that guide Ambulance Service emergency planning.
2.2 The 5 ‘Rs’
Emergency Management in New Zealand is underpinned by the 4 ‘Rs’ approach to emergency management2:
Reduction Readiness Response Recovery
For the purposes of AMPLANZ, the ambulance sector has identified the importance of building and maintenance of ‘Relationships’ between Ambulance Service Managers and key personnel in health service providers, traditional emergency services, civil defence and welfare agencies, lifeline organisations and the private sector.
2.3 CIMS (New Zealand Coordinated
Incident Management System
3)
CIMS is New Zealand’s approach to incident management. It provides a framework to manage a range of diverse incidents, from routine to major emergencies.
The major incident management structures outlined in AMPLANZ are based on CIMS.
2Taken from the Guide to the National Civil Defence Emergency Management Plan, June 2009, Section 1 Introduction page 2. 3Taken from the NZ Coordinated Incident Management System (CIMS), Teamwork in Emergency Management 2010 pages 8–14.
(IMT) to ensure a coordinated response to the incident To identify, notify and communicate with appropriate
receiving hospital(s), health facilities and DHBs of the prevailing situation and the categories and estimated times of arrival of casualties
To triage all patients prior to evacuation from the scene
To manage all medical resources deployed to the scene for the treatment and care of casualties To determine the priorities for the evacuation of
casualties, ensuring even and simultaneous dispatch to the receiving hospital(s) and health facilities To organise transportation for casualties to the
receiving hospital(s) and health facilities, and any necessary secondary transfers between hospitals To acquire additional ambulance resources, as
necessary, through the use of the Ambulance Service’s national coordination mechanisms To forward to the receiving hospital(s) and health
facilities, Public Health Units and DHB(s), any information acquired at the scene relating to chemical, biological or radiation (CBR) hazards and possible contamination of casualties or rescuers and advise of the potential for self-presenting patients To assume responsibility for casualty
decontamination, in conjunction with the Fire Service To provide the Fire Service with clinical advice and
assistance to support on-site decontamination To maintain adequate emergency ambulance cover
throughout the Ambulance Service’s Operational area for the duration of the major incident To progressively release activated hospital(s) and
health facilities and ultimately issue a message indicating completion of casualty evacuation.
2.4.2 A structured and consistent approach
AMPLANZ is aligned with CIMS, important New Zealand emergency management concepts and with key national emergency plans.
AMPLANZ also notes that to effectively manage large and complex incidents, the processes and procedures used by ambulance services need to be established and understood within the services and also by partner agencies.
Major incidents, such as mass casualty events, are infrequent occurrences and consequently any procedures required to manage such incidents shall follow the same basic processes as for smaller and less complex incidents. Therefore essential processes, such as assigning initial response roles and responsibilities, incident escalation, notifications, situation reports, triage etc are the same no matter what the size or complexity of the incident.
2.4 Concept of Ambulance Emergency
Management
2.4.1 The Responsibilities of Ambulance Services in a
Major Incident
The role of the ambulance sector in response to a major incident is to deliver and maintain appropriate pre-hospital clinical care. In a mass casualty incident, Ambulance will lead the operational health response to the incident at the scene/s and manage the triage, treatment and transport of patients to appropriate receiving hospitals or health facilities. In all emergencies impacting on the health of the communities, an
Ambulance Service will manage and coordinate its response with the DHBs and other emergency services to manage demands on the healthcare system.
Below are key responsibilities of Ambulance Services in a major incident,
Responsibilities of an Ambulance Service in all major incidents and emergencies:
To save life in conjunction with other Emergency Services
To notify and liaise with the other Emergency Services
To initiate and maintain an Ambulance Service Command and Control structure lead by an Ambulance Service Controller
To protect the health, safety and welfare of all ambulance staff generally, and all health workers on the scene of a mass casualty incident
To supply sufficient ambulances and staff for the incident
To provide a communications system between ambulance and DHBs (including hospitals) To provide Ambulance Liaison Officer/s to the
partner agencies as appropriate for the incident To reduce to a minimum, the disruption of the normal
work of the Service by implementing Business Continuity Plans, as appropriate, ensuring the restoration of normality at the earliest opportunity. Responsibilities of an Ambulance Service for Mass Casualty Incidents:
To provide a structure to support the triage,
treatment and transport of casualties from the scene by establishing an Ambulance Control Point, Casualty Clearing Point and Ambulance Loading Point
To provide a Senior Ambulance Officer at the scene to act as Ambulance Commander (AC)
2.4.3 Whole of Organisation and Sector
AMPLANZ is designed to ensure that all parts of the ambulance sector and the individual services are involved in the response, recovery and development of readiness of the sector. This will then contribute to the resilience of the health sector.
Within an Ambulance Service there are roles and responsibilities of first-responding crews, for ambulance service management and also for key support staff in non-operational or core support positions.
Across the sector, clear guidance is given to further integrate the individual service’s response and planning at the tactical and operational levels and also nationally in the coordination of all services with national agencies, such as MoH.
3.0 Readiness and Reduction
3.1 Risk Reduction
AMPLANZ does not cover all aspects of risk management and therefore risk reduction in individual Ambulance Services of the sector. The incidents covered by the AMPLANZ are normally considered as having risk of:
low likelihood of occurrence and high impact on normal business.
The focus here is on the requirement to ensure that ‘normal’ services can be maintained and Ambulance Services are able to respond safely and appropriately to known hazards in the community. Specifically, the focus is on business continuity, tactical plans and their prioritisation, and coordination of plans with health sector partners and other emergency service partners. Finally, there is a clear emphasis on the need for ongoing education and training within the services and across the sector.
3.2 Readiness
3.2.1 Readiness: Planning
The majority of operational and tactical response
planning is undertaken by individual Ambulance Services with the EACC, their local emergency management agencies and neighbouring Ambulance Services. The planning shall focus on:
Business Continuity Planning within individual Ambulance Services, including the EACC
Specific Ambulance Tactical Plans to respond to known and priority risks in the community. These are to be coordinated with the traditional emergency services, including health, private sector agencies and Civil Defence and Emergency Management Agencies
Ambulance Service Major Incident and Emergency Plans
Inter-Ambulance Service cooperation to ensure a whole of sector approach is developed to specific known hazards, which will require cross border responses
The development of national coordination
mechanisms by each Ambulance Service to ensure that an Ambulance Service is able to call upon or provide support to or from other Ambulance Services Health Emergency Planning with the focus on the
integration of the operational planning of both Ambulance Services and DHB service providers Alignment of the Ambulance Service plans with
national plans such as the National Transport Plan and the National Mass Casualty Plan.
Training needs analysis is required to further enhance the appropriateness of emergency management training and education within Ambulance Services.
Training and education in emergency management for Ambulance Services shall align appropriately with competency frameworks and guidelines of other
emergency service partners, as well as with Civil Defence and Emergency Management Agencies.
3.3 Review and Audit
The Ambulance Service major incident and emergency plans, and the related operational procedures to ensure the notification, activation and management of a full and coordinated ambulance service response, shall be audited and reviewed as part of the Ambulance Service’s quality management systems.
AMPLANZ will be reviewed annually to take into account local and internationally significant development and lessons identified or learnt. There will be a formal review of AMPLANZ no later than every three years. The Ambulance New Zealand Standards and Accreditation Committee has national responsibility for the review of AMPLANZ on behalf of Ambulance New Zealand trustees.
4.0 Response
4.1 Activations, Level of Response
5, and
Notifications
This section is outlines the Ambulance activation mechanisms and levels of response required for an incident in the community that may require escalation to national level.
The aim is to ensure that every major incident is managed appropriately as early as possible in the response. This will improve patient outcomes and ensure that the responding ambulance officers are supported quickly and effectively.
The classification of the type of incident is essential to ensure that appropriate activations and notifications occur. Once an incident has been classified, it triggers certain actions which must be taken by the affected Ambulance Service and the EACC. This will enable quick decision-making to determine the level of coordination required. The major variables that govern the type of response from an Ambulance Service include:
Time to respond to the incident (travel, triage, treat and transport)
The complexity of the incident The number of patients. Plans shall be appropriately tested in exercises involving
Ambulance Services, DHBs, other emergency service partners and national agencies, such as MoH. The ambulance sector contribution to national health emergency planning can be undertaken in a number of ways. These include:
Meeting the obligations set out in legislation (e.g. CDEM Act) for Ambulance Services, DHB, MoH or other national agency. Individual Ambulance Services may be tasked and funded to coordinate the emergency planning and capability development of the ambulance sector. For example, (chemical, biological and
radiological) CBR capability development
Cooperation between services for specific known pre-planned events or known threat (e.g. International Sports Events, VIP tours / meetings etc)
Using an Ambulance Service’s national coordination mechanism in planning for exercises, pre-planned events or known threats, where it is felt necessary that national coordination will be required.
Individual Ambulance Services contributing to specific issues relating to emergency response planning. For example, revision of the New Zealand Influenza Pandemic Action Plan.
The choice as to which approach is used will depend on the planning issue, priority for individual services, capability in the sector and the resources available to assist the sector.
3.2.2 Readiness: exercising
A complete Ambulance Service Response, including the set up and activation of an Ambulance Service Emergency Operations Centre (ASEOC) and activation of the Ambulance Service’s national coordination mechanism, shall be exercised in at least one major CDEM (Tier 3-44) exercise as well as at least one major emergency services or health exercise each year. Communication and activations systems shall be tested as appropriate for all exercises where there is a likelihood of a significant ambulance and health response.
All exercises shall be evaluated and results reported internally within the Ambulance Service. Lessons will be identified and shared. Processes will be developed to incorporate changes into the appropriate level of planning within the sector. This shall include the annual AMPLANZ review by Ambulance New Zealand.
3.2.3 Readiness: training and education
To enable a complete Ambulance Service emergency response, all potential responders shall be trained appropriately to be able to undertake their roles.
4Ministry of Civil Defence Emergency Management (MCDEM) Tier 3 exercises test territorial local authority (TLA) and CDEM group (CDEMG) operations. MCDEM Tier 4 exercises test National Crisis Management Centre (NCMC), CDEMG and TLA operations. Both of these will require a service and national response from Ambulance.
There are four levels of response: Normal operations
Level 1: medium impact on normal operations Level 2: high impact on normal operations Level 3: severe impact on normal operations.
To allow the identification of correct response levels, two tools have been developed:
An Escalation Flow Chart that notes the actions of all ambulance parties in the initial escalation
A Response Matrix to be used by the EACC.
4.1.1 Escalation
The Escalation Flow Chart – Figure 1 – provides an overview of the actions by the EACC and the Ambulance Duty Operational Manager6 in the initial stages of a major incident. This outlines when to use the Response Matrix and the initial assessment, as well as clearly defining the actions to be undertaken by the EACC and Duty Operational Manager based on the level of incident.
Figure 1: Escalation Flow Chart EACC receive
“111” call, Inter CAD or direct (e.g. airport alert, ambulance approaching
an incident) notification Issue identified by the calltaker and/or Dispatcher
as possibly outside of Normal Operations Escalate to the Comms Centre
Team Manager Use Response Matrix Dispatch immediate appropriate resources What Level? If Level 1, 2, or 3 Then EACC to: 1. Page “Possible Major
Incident” Level 1 2. Inform Duty Operational Manager
Duty Operational Manager to undertake
initial and ongoing assessment Normal
Operations
Level 2 Escalate to Sevice Duty
Executive
Level 3 Escalate to Sevice Duty
Executive Level 1 Manage Locally by Duty Operational Manager Continual reassessment based on situation reports from the scene Ambulance Manager
responded as Commander Ambulance Service Duty
Executive to Manage Other Services on standby /activated National Coordination Mechanisms on standby /activated Brief Ambulance Management Inform/Brief Health
Partners (EACC page/ teleconference) Ensure Public Information
Manager in place Ambulance Manager
responded as Commander Ambulance Service Duty
Executive to Manage Other Ambulance Services
informed / on standby National
Coordination Mechanisms Informed /on standby Brief Ambulance
Management Inform/Brief Health
Partners (EACC page/ teleconference) Ensure Public Information
Manager in place Ambulance Manager Responded as Commander Ensure Public Information Manager in place Inform/Update Ambulance Service Duty Executive Inform Health Partners
(EACC page)
6Duty Operational Manager is a generic position title that covers a number of positions used across the sector such as Operations Team Manager, Duty Operations Manager, and Duty District Manager etc.
4.1.2 Types of Incidents
A major incident or emergency for ambulance is defined as:
Any occurrence that presents serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by appropriate responding agencies including:
Ambulance Services
District Health Boards (including, for example, hospitals, primary care, and public health) The Ministry of Health.
AMPLANZ has adopted a set of descriptors for types of incidents applicable to all hazards. These incident descriptors relate to the ability to access patients, involvement of a lead agency or a comprehensive CIMS structure and the complexity of the response and its impact on normal services.
Time to respond, triage, treat and transport is another factor that will impact on patient care and normal service delivery. Therefore this will need to be taken into account in the decision-making process.
Figure 2: Types of Incidents
Type of Incident
Description
Complex Incident that is not routine or it is an infrequently used procedure (e.g. CBR, Airport emergency, major Civil Defence Emergency Management (CDEM) event (e.g. tsunami)) Controlled Incident that has a lead agency (e.g. Police, Fire, Health, CDEM etc) or comprehensive CIMS
structure in place or a large number of personnel are deployed
Restricted Where access to patients is difficult owing to hazardous, environmental or security factors
Open Where there are no issues regarding the access to or egress from patients
4.1.3 Response Matrix Tool
The initial assessment of an incident is the responsibility of the EACC Team Manager using the response matrix below in Figure 3.
Figure 3: Response Matrix
>21 Level 2 Level 2 Level 2 Level 3 Level 3
11–20 Level 2 Level 2 Level 2 Level 3 Level 3
6–10 Level 1 Level 1 Level 2 Level 2 Level 2
3–5 OperationsNormal Level 1 Level 1 Level 2 Level 2
0–2 OperationsNormal OperationsNormal Level 1 Level 1 Level 2
Simple/
Open RestrictedSimple/
Simple/ Restricted/ Controlled Complex/ Controlled Time <1hr 1–2hr 2–4hr 4–8hr >8hr
How to use the Response Matrix
1. Estimate the total likely ‘Time’ or duration of the incident for ambulance (travel, triage, treatment and transport) and plot on the Response Matrix
2. Determine the ‘Type of Incident’ from Figure 2 and plot it on the Response Matrix
3. Determine the ‘Severity of the Incident’ by comparing the time estimate to the Type of Incident, and select the greater (i.e. further to the right of the matrix)
4. Determine the likely number of patients and plot against the Severity of the Incident on the Response Matrix 5. An Initial ‘Possible Major Incident’ notification will be sent (Level 1) to inform those who will be directly impacted by
this incident
6. The Duty Operational Manager will be informed and will respond accordingly.
4.1.4 Risk Assessment and Response
Once an incident has been classified using the Response Matrix Tool and determined to be outside of normal business, a local Level 1 ‘Possible Major Incident’ notification will be sent by the EACC and the Ambulance Service Duty Operational Manager will be informed.
Ambulance Service Duty Operational Manager will then be required to confirm that a major incident has occurred and will declare a major incident for ambulance at the appropriate level. This will be done using information from the incident scene, the EACC, partner agencies and other reliable sources. Tools have been provided to Operational Managers to assist with decision-making.
Type of Incident Numbers of Patients
4.1.5 Major Incident Notifications within Ambulance
Services and to partner agencies
Partner agencies will be informed of Major Incidents by Ambulance:
Local DHBs will be informed via a paging / text notifications system as part of the activation of the ambulance response for all Level 1, 2, or 3 incidents The MoH Regional Emergency Management Advisors
will be informed for Level 2 and 3 incidents The MoH will be informed via 0800 GET MOH of
Level 3 incidents
The local Civil Defence and Emergency Management Group (CDEMG) will be informed for Level 3 incidents Police and Fire services are informed routinely via
Inter-CAD communications within the Communication Centres.
There are EACC and Ambulance Service Procedures in place to hold an initial briefing teleconference with partner agencies and neighbouring Ambulance Services, based on the scale of the incident. This will be facilitated by the EACC and managed by the Ambulance Commander, Ambulance Service Controller or their delegate. Following the initial briefing, further teleconference briefings may be required or communication between the Ambulance Services and DHBs will continue via other channels depending on the incident requirements.
4.2 Activation based on National
Warnings
7MoH and MCDEM will send out National Warning notifications to all emergency management stakeholders in the health sector and the wider CDEM sector.
Ambulance Sector Single Point of Contact (SPOC) for MoH and MCDEM notifications is the EACC. The EACC is responsible for cascading these to the ambulance sector. Note: If there is an ambulance major incident response required, this will be activated and escalated using the process noted in Section 3.1 and usually before MoH or MCDEM alerts have been received.
4.3 National Coordination of Ambulance
Each Ambulance Service shall develop and maintain its own ‘national coordination mechanism’. This is broadly defined as a mechanism that, with supporting procedures, is able to:Receive requests from the responding Service or part Service that has been overwhelmed
Coordinate the provision of requested ambulance resources from other Ambulance Services or nationally
Liaise and coordinate with key National Emergency Management Agencies (MoH and MCDEM for
example) and on behalf of the responding Ambulance Service/s in the response and recovery phases of the emergency
Provide a sustainable support structure, with trained personnel and appropriate infrastructure, to be able to operate 24/7 if required.
Notification and activation procedures for an Ambulance Service’s national coordination mechanism will need to be developed and communicated across the sector and to key partners.
4.4 Activation based on Regional or
Local Warnings
There are also Regional Health, Regional CDEM Group or Local Authority notifications. The mechanisms used at these levels currently vary across New Zealand. The EACC will cascade these notifications appropriately to the local or regional Ambulance Service. Local or regional Ambulance Service Management may also receive notification directly and will ensure that the EACC is informed.
4.5 Response Command Structures,
Roles and Responsibilities
This section summarises the key parts of the management structure, and their roles and responsibilities, as used by Ambulance Services in a major incident.
4.5.1 First Ambulance Crew at the Scene
The actions of the first attending ambulance crew at the scene of a Major Incident are crucial to establishing an effective response. The primary role of the first crew can be summarised as being to ‘assess’ and ‘inform’. The scene is assessed and reported to the EACC in a standard (METHANE8 report) format.
Accurate, high quality information must be given as quickly as possible to enable adequate resources to be sent to the scene.
4.5.2 Ambulance Command at the Scene
The overall aim of ambulance management at the incident scene is to provide the operational and tactical leadership. This will include the set up of appropriate command and communications structures, safety of all health responders and the appropriate triage, treatment and transport of patients from the scene to the appropriate healthcare facilities. This will require coordination and communications with receiving health facilities, DHBs and emergency service partners.7The Guide to the National CDEM Plan 2006, Section 19 and The National Health Emergency Plan 2008, page 16. 8See Appendix 1 for the definition of METHANE.
The scale and complexity of the command structure is dependent of the incident. For example:
A Level 1 incident of short duration and low patient numbers may be managed by an Ambulance Operations Manager (AOM) undertaking the CIMS functions
A long duration controlled and / or complex incidents (Level 2 or 3), or simple / restricted incidents equivalent to Level 1 or 2 (short duration but with large numbers of casualties) will require the Ambulance Commander or Ambulance Operations Manager to decide how the Ambulance and CIMS roles will be implemented and the staffing required. The key roles in an Ambulance Command structure are: Ambulance Commander (AC): The officer responsible for scene management for complex and prolonged incidents. The AC will be part of the Incident
Management Team when an IMT has been established for controlled or complex incidents (Level 2 or 3 Incidents). This is an incident management role and therefore shall not have clinical management responsibilities.
Ambulance Operations Manager (AOM): The officer delegated with the responsibility to manage operational activities of the incident at the point of patient contact, and the site role most commonly established for open simple, restricted or minor controlled incidents (Level 0, 1 or 2 incidents). This is an incident management role and therefore shall not have clinical management responsibilities.
Ambulance Triage Officer/s: Responsible for the triage of all patients in an incident or sector. In command of all Triage Areas and is responsible to the AOM or Sector Officer.
Ambulance Treatment Officer/s: Responsible for coordinating patient treatment, liaising closely with the Transport Officer and the Triage Officer. Delegates tasks to all medical and other personnel at the Casualty Clearing Point. Reports to the AOM / Sector Officer. Ambulance Transport Officer: The officer responsible for all transport, loading and parking management in consultation with the AOM. Responsibilities include: ensuring that suitable access and egress is available into the ambulance loading point at or near the CCP, for the efficient use of vehicles, allocating vehicles for transport while taking into account patient priority, establishing an appropriate ambulance parking area. Reports to the AOM / Sector Officer.
There are other roles such as: Ambulance Sector Officer/s Ambulance Safety Officer
Ambulance Administration Officer
Ambulance Communications Officer – on-site Ambulance Logistics Officer
Aviation Co-ordinator
Ambulance Planning and Intelligence Officer. These will be deployed depending on the duration, scale and complexity of the incident. It may be necessary to combine roles depending on the availability of personnel. Medical, Nursing and allied health professionals may also be deployed or volunteer and will be under the command of the Ambulance Commander.
See AMPLANZ Part 2: Consistent Operations at the Scene – for more details.
4.5.3 Ambulance Service Emergency Response
Management Structures
In a similar way, for simple, open or restricted Level 1 incidents of short duration and relatively small patient numbers, an Ambulance Service may be able to provide strategic direction, support and coordination to the Ambulance Commander or Operations Manager through normal business arrangements and structures. For complex, long duration incidents (Level 2–3), an Ambulance Service Controller (ASC) shall be appointed to lead the overall Ambulance Service response. All key CIMS roles or functions will need to be undertaken but it is recognised that an Ambulance Service may not be able to fill all roles with individual managers. CIMS roles may have to be shared. How this issue is managed within the Ambulance Service is the responsibility of the ASC.
A key role/s will be the Liaison Officer roles to partner agencies. These may include:
Ambulance Liaison to ED
Ambulance Liaison to a Hospital EOC or DHB EOC Ambulance Liaison to Emergency Services EOC,
including Police, Fire or CDEM
Ambulance Liaison to the NHCC or NCMC. The type, duration and scale of incident will dictate where Ambulance Liaison Officers should be placed. When local ambulance resources have been
overwhelmed, it may be necessary to request support from neighbouring Ambulance Services or nationally to ensure the appropriate roles are undertaken effectively for the duration of an incident. This will be done by the Ambulance Service’s national coordination mechanism. The Ambulance Service Emergency Response
Management roles are noted in detail AMPLANZ Part 3: Ambulance Service Approach.
4.5.4 EACC Incident Management Structure
The EACC may activate its national incident management team in support of the local communication centre depending on the communications demands of the incident and normal service delivery. Level 1–2 incidents may be managed by the Team Manager with support from the Communications Centre Manager and EACC Duty Executive as required.
For more complex, long duration incidents, a formal incident management structure will be required with incident management responsibilities with an EACC Emergency Response Manager.
This is noted in detail in AMPLANZ Part 3: Ambulance Service Approach.
4.6 Key Facilities for an Ambulance
Response
CIMS requires consistent facilities at the incident at the scene. Ambulance also requires specialist facilities. There are also specialist facilities for the Ambulance Service Emergency Response Management and EACC.
4.6.1 Incident Scene Facilities
Below is a summary of the facilities that may be required at an incident. For full descriptions see AMPLANZ Part 2:
Incident Control Point (ICP) Ambulance Command Point Sectors
Assembly Area/s Staging Area/s
Ambulance Parking Area/s
Safe Forward Point/s (SFP)
Landing Zone/s (LZ) or Helipad/s (HP) Forward Triage
Casualty Clearing Point/s (CCP) including a Triage Area/s and Treatment Area/s
Ambulance Loading Point/s (ALP).
4.6.2 Ambulance Service Emergency Operations
Centre (ASEOC)
An ASEOC is a facility that aims to:
Coordinate the ambulance response to a major incident with the Scene Commander(s) and the EACC Plan for future resource requirements of a major
incident
Manage the impact of the incident/s on normal service delivery
Ensure that all ambulance management and key stakeholders are informed of the current incident situation, plans and resource requirements. For smaller incidents, an ASEOC may be ‘virtual’ with minimum staffing and physical set up, or be able to operate from the EACC MCI Room or from a partner agency EOC. However, an ASEOC will physically be required for complex or long duration incidents (Level 2–3) where there is a significant Ambulance response. The Ambulance Service shall have a space appropriately set up or able to be set up as an ASEOC within 30 minutes of a major incident Level 2 or 3 being declared. The ASEOC setup specification shall enable it to operate securely and independently for the duration of the emergency.
Where a non-dedicated space is identified for use as the ASEOC, management protocols shall be in place to give priority to use of this space as an ASEOC for the duration of the emergency response and recovery phases.
The EACC is required to maintain an ‘MCI Room’ in each Communications Centre to enable the communications management of a complex major incident to be separated from normal service delivery when
appropriate. The EACC MCI Rooms will require similar specifications as the ASEOC.
4.7 Communications and Information
Management
The most significant factor that will contribute to successful command and control of an incident is effectiveness of the communications systems, protocols and tools. These include:
On-scene communications within the Ambulance Service and within the Incident Management Team Communications between the responding crews, the
Ambulance Commander and the EACC
The detail and timeliness of information given to the Incident Controller, to the EACC and to health partners The tools available to the Ambulance Commander,
EACC and Ambulance Service Controller to manage the information, including Sitreps, action planning and Emergency Management Information Services (EMIS). A number of protocols, tools and information
management systems have been developed as part of this plan. See AMPLANZ Parts 2 and 3.
4.8 Ambulance Resources and
Equipment
An Ambulance Service shall ensure that key managers are aware of and trained in the use of specialist resources that may be used in their operational area during a major incident. These may include:
Ambulance major incident cache of medical materials and equipment
Ambulance Specialists Operations Teams and their capability (SERT, Rescue, USAR and CBR etc)
DHB medical materials etc that may be accessible to a pre-hospital response
Specialist materials, equipment, services and personnel from a partner emergency service or support agency that may be required by a pre-hospital response. For example, USAR equipment, CDEM logistics, Red Cross volunteers.
All Ambulance Services are required to maintain major incident equipment and materials, with efficient means of deployment, to ensure a major incident in their service area can be appropriately resourced. These materials
and equipment will be nationally consistent kits or caches to ensure interoperability between Ambulance Services. Ambulance officers shall be regularly trained in the deployment and use of these materials and equipment. These major incident caches or kits may also be used in major public events to improve familiarity with the materials and equipment.
The EACC Computer Aided Dispatch (CAD) system will maintain current information on the majority of ambulance resources available for deployment. The status of ambulance resources shall be in a form that is immediately accessible to the NHCC. For example, this may be via the health EMIS (WebEOC, E.SPONDER or similar). This will include the location and detail of major incident caches in urban centres and rural station kits in strategic rural stations.
The Air Ambulance Services, particularly fixed wing, not normally deployed by the EACC, shall ensure that their status is able to be tracked by the EACC and therefore in a major incident may be able to be coordinated by the EACC as part of a major incident response.
The ambulance or event services, including NZ Defence Force (NZDF) or NZ Red Cross, not normally deployed by the EACC, will maintain their resource status, capacity and capability in a form that is immediately accessible to the EACC and NHCC. For example, this may be via the health EMIS (WebEOC, E.SPONDER or similar).
The national coordination of all land-based, rotor and fixed wing assets in a major incident will be outlined in the MoH National Transport Plan.
4.9 Ambulance Coordination with
Health, Emergency Services and other
Agencies
In a complex mass casualty incident or major
emergency, it is unlikely that any one agency will have the required resources to meet the needs of a response. The CIMS approach provides for coordination across all responding agencies.
The Ambulance Service will ensure that there are timely, accurate and ongoing briefings of health partners. Section 3.2.1 also notes the need for ongoing
development and planning by all health and emergency management agencies.
The coordination of patient transport, according to priority, to the most appropriate health facility is recognised as critical. Ambulance Services are responsible for ensuring that all staff who may fulfil the key roles at the scene or in the ASEOC shall be fully aware of and trained in:
Capacity and capability of the local and regional receiving health facilities
Capacity and capability of the Ambulance Services locally, including air ambulance (rotary and fixed wing) Emergency plans of the local DHBs as they impact on
ambulance
The communication channels with receiving health facilities or DHBs to coordinate patient transport The communication channels with Regional Health
Coordination structures
The role, capacity and capability of the emergency services, NGOs, such as Salvation Army and NZ Red Cross, private sector organisations and Civil Defence Emergency Management Organisations
The communication channels with non-health organisations to be able to access appropriate resources (e.g. CDEM Groups).
Each Ambulance Service is responsible for ensuring that their ASEOC has access to appropriate operational ‘points of contact’ for the local and regional health services and non health agencies.
Each Ambulance Service shall put in place a Liaison Manager who will have the responsibility for maintaining the relationship with coordination mechanisms within partner agencies during a response. This will include: sharing information, requesting resources if required and inputting into a multi-agency action plan.
At a national level, the Ambulance Service’s national coordination mechanism shall specify how liaison with key national agencies and groups will occur. These agencies include but are not limited to:
National Health Coordination Centre (MoH) National Crisis Management Centre (MCDEM) National Welfare Coordination Group
National Fire Service Headquarters National Police Headquarters.
It will be necessary to prioritise the placement
ambulance liaison at the national level according to the incident’s complexity, duration and impact on ambulance operations, health services and the wider community. The NHCC will be given priority.
5.0 Recovery
The process of recovery for an Ambulance Service is defined as the re-establishment of normal service delivery after a major incident. This process should start as soon as possible in the response phase and be aligned with Ambulance Service business continuity plans. Ambulance Services will be required to contribute to the overall recovery of the health services and community. It may also be the case that, dependent on the incident, there may be a new ‘normality’ for the community. Ambulance Services may have to realign themselves appropriately as part of the recovery process.
It is envisaged that even in a moderately sized major incident there will be an effect on staff, supplies, equipment, finance and vehicles. Areas requiring consideration for recovery will include, but should not be limited to:
Staff welfare/debriefs Rosters
Leave
Operational review and learning Consumables (medical/fuel) Equipment
Vehicles (servicing repairs etc) Finance and cost recovery.
Recovery roles have been built into the role descriptions for response managers at the service level as well as key non-operational staff.
For complex incidents that have impacted significantly on the ongoing functioning of the Ambulance Service, a Recovery Manager may be required to concentrate on the rebuilding or modification of the service.
The Ambulance Commander and Ambulance Service Controller are required to undertake a number of actions as part of the recovery process. These are:
Hot Debrief with responding crews and appropriate EACC staff held as soon as possible
Complete an Ambulance Commander’s After Action Report within one month of the incident
Hold an Ambulance Service formal debrief for a significant incident within two months
Complete an Ambulance Service Major Incident Report for significant events within six months Attend and share experience / learning in an
Interagency Debrief and reporting process when and if required.
At the national level, ambulance recovery coordination following a complex and nationally significant emergency shall be based on the requirements of the local
Ambulance Services and / or the needs of the health sector locally and nationally. Therefore an Ambulance Service shall consider recovery functions as part of its national coordination mechanism.
An Ambulance Service’s national coordination mechanism shall have debriefing and reporting
processes in place to capture lessons identified and for action planning and service improvement.
All logs and notes made during an incident at the scene, Ambulance Service and national levels will need to be correlated and stored in case of possible inquiries into an incident management.
Appendix 1
Glossary of Terms and Abbreviations
AA Assembly Area
AAP Agency Action Plan
AC Ambulance Commander
AIO Ambulance Incident Officer (now called Ambulance Operations Manager or AOM)
ALP Ambulance Loading Point
ALS Advanced Life Support
AMPLANZ New Zealand Ambulance Major Incident and Emergency Plan
AOM Ambulance Operations Manager
AOS Armed Offenders Squad (Police)
AS/NZS Australian Standards / New Zealand Standards
ASC Ambulance Service Controller
ASEOC Ambulance Service Emergency Operations Centres
BCP Business Continuity Plan
BLS Basic Life Support
CAD Computer Aided Dispatch (system)
CBR Chemical Biological Radiological
CCP Casualty Clearing Point
CDEM Civil Defence Emergency Management
CDEMG Civil Defence Emergency Management Group (Regional Council)
CEO Chief Executive Officer
CIMS New Zealand Coordinated Incident Management System
CIMS 2 CIMS introductory training
CIMS 4 2-3 day training for Emergency Management personnel at the Scene
Clan Lab Short for ‘clandestine lab’: generally used in any location / facility involving the production of illicit compounds.
Cordon Physical demarcation of the border between zones. e.g.
Inner cordon separates hot and warm zones
Outer cordon separates cold zone for the public areas or traffic exclusion zone (that may still be patrolled by security or police)
DES The Cabinet Committee for Domestic and External Security Coordination. The committee is
chaired by the Prime Minister and includes those ministers responsible for departments that may play essential roles in emergency situations.
DHB District Health Board
Glossary of Terms and Abbreviations continued...
Duty Executive Senior Ambulance Manager with strategic management of an Ambulance service. May also be known as Regional Operational Executive, Ambulance Operational Executive.
Duty Manager Ambulance Officer responsible for the operational management and running of an Ambulance Service for a shift. May also be known as District Duty Manager, Duty Operations Manager.
E.Sponder Emergency Management Information System used by MCDEM (see below)
EACC Emergency Ambulance Communications Centre (St John Communications Ltd and Central
Emergency Communications Ltd)
Emergency Defined in Section 4 of the CDEM Act 2002
EMIS Emergency Management Information System. A system to assist with the recording, flow and timely transfer of information between Emergency Management agencies during an emergency.
EOC Emergency Operations Centre
Executive
Management Team The wider management team (including Human Resources, training, finance and administration, other business arms) of an Ambulance Service headed by a CEO or General Manager. Will provide strategic guidance and oversight to the management of an incident.
HazMat Hazardous Material/s
HEP Health Emergency Plan (of a DHB or health service)
Hot zone The immediate area surrounding the site of a hazardous materials incident and where the hazard level is high. The boundary of this zone should be clearly marked with ‘hot zone’ tape to indicate the high risk to responders and the need for specific protective clothing. Hot zone marking should extend far enough to prevent adverse effects from the release of the hazardous material to any persons outside the hot zone. A hot zone will be defined by Fire or Police.
HP Heli Pad
HR Human Resources
ICP Incident Control Point
ICT or IT Information Communication Technology
ILS Intermediate Life Support
LZ Landing Zone
Major Incident For the ambulance sector this is defined as:
Any occurrence that presents serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by appropriate responding agencies including:
Ambulance Services
District Health Boards (including, for example, hospitals, primary care, and public health) The Ministry of Health.
MCDEM Ministry of Civil Defence Emergency Management
METHANE A METHANE report is the internationally recognised tool for incident management and is utilised in this plan. It covers the following:
Major Incident Status Exact location of incident Type of incident
Hazards identified Access to the scene Number of casualties
Emergency services available and Extra resources required
MoH Ministry of Health
Glossary of Terms and Abbreviations continued...
NHCC National Health Coordination Centre (run by MoH)
NGO Non Government Organisation
NZFS NZ Fire Service
ODESC Committee of Officials for Domestic and External Security Coordination. A committee of government chief executives charged with providing strategic policy advice to ministers. It provides support to DES and oversees emergency readiness, intelligence and security, terrorism and maritime security. Activation of ODESC is at ministerial request; for example, where a growing risk of a particular threat has been identified.
OIC Officer in Charge (Fire)
OPF Operational Policy Framework. One of a group of documents collectively known as the ‘Policy Component of the District Health Board Planning Package’ that sets out the operational level accountabilities for DHBs for each fiscal year. The OPF is executed through Crown funding agreements between the Minister of Health and each DHB. The OPF covers emergency obligations based on the four ‘Rs’.
PIM Public Information Management
Recovery The coordinated efforts and processes used to bring about the immediate, medium-term and long-term holistic regeneration of an organisation and community following an emergency. Readiness The process of developing operational systems and capabilities before an emergency occurs. Reduction The process of identifying and analysing long-term risks to human life and property from
natural or non-natural hazards; taking steps to eliminate these risks, if practicable and, if not, reducing the magnitude of the impact and likelihood of them occurring.
Response The actions taken immediately before, during or directly after an incident or emergency to save lives and property, and to help communities recover.
SAR Search And Rescue
Sector For complex and large scale incidents it may be required to divide a scene into sectors. Sectors may be defined by the Incident Controller for overall use or by individual agency commanders for their agency’s needs.
SERT Special Emergency Response Teams
SFP Safe Forward Point
Sitrep/s Situation Report/s
STG (Police) Special Tactics Group
TBC To Be Confirmed
TLA Territorial Local Authority
UHF Ultra High Frequency (radios)
USAR Urban Search And Rescue
VHF Very High Frequency (radios)
VIP Very Important Person/s
Warm zone Zone surrounding the hot zone. An area that presents minimal hazard to personnel. The zone where decontamination takes place. Will be defined by Fire.
WebEOC Emergency Management Information System used by the Health Sector (under review).
Appendix 2
References
LegislationPrimary acts and associated regulations outlining legislative responsibilities for health sector organisations and therefore Ambulance Services are the:
Civil Defence Emergency Management Act 2002 Epidemic Preparedness Act 2006
Health Act 1956
National Civil Defence Emergency Management Plan Order 2005
New Zealand Public Health and Disability Act 2000. Other important acts and regulations covering emergency management include, but are not restricted to, the:
Civil Defence Emergency Management Regulations 2003 Fire Service Act 1955 (section 330)
Forest and Rural Fires Act 1977
Health and Disability Commissioner (Code of Health and Disability Services Consumers’ Rights) Regulations 1996 Health and Safety in Employment Act 1992
Health (Infectious and Notifiable Diseases) Regulations 1966
Health Information Privacy Code 1994 Human Rights Regulations 1993
Injury Prevention, Rehabilitation and Compensation (Ancillary Services) Regulations 2002
Local Government Act 2002
Health Practitioners Competence Assurance Act 2003 (WHO) International Health Regulations 2005. Other References
Ambulance Victoria Emergency Response Plan 2009
Ambulance NSW State Major Incident / Disaster Plan Feb 2006 Ambulances to Nowhere: America’s Critical Shortfall in: Medical Preparedness for Catastrophic Terrorism. Joseph A. Barbera, MD, Anthony G. Macintyre, MD, Craig A. DeAtley, PA-C October 2001. http://www.gwu.edu/~icdrm/publications/ Ambulances_to_Nowhere.pdf
Australian Triage Cards: Toward A National Agreement. Norton and Field 2009
British Columbia Ambulance Service – Mass Casualty Incident Emergency Management Plan Jul 2008
Civil Defence Emergency Management Competency Framework Technical Standard for the CDEM Sector [TS 02/09] June 2009 Comparative Analysis of Multiple Casualty Incident Triage Algorithms: Garner, Lee, Harrison, Schultz. Annals of Emergency Medicine Nov 2001.
Coordinated Incident Management System (CIMS)1998 (Blue Book)
Emergency Medical Services: At the Crossroads 2007. Chapter. 6
http://books.nap.edu/openbook.php?record_ id=11629&page=175
Emergency Medical Services: The Forgotten First Responder—A Report on the Critical Gaps in Organization and Deficits in Resources for America’s Medical First Responders. New York, NY: Center for Catastrophe Preparedness and Response, New York University. Mar 2005 http://www.nyu.edu/ccpr/ NYUEMSreport.pdf
Focus on Recovery: A Holistic Framework for Recovery in New Zealand
Information for the CDEM Sector [IS5/05] Feb 2005
KAMEDO Report 90: Terrorist Attacks in Madrid, Spain, 2004. Roger Bolling; Ylva Ehrlin; Rebecca Forsberg; Anders Rüter; Vivian Soest;Tore Vikström;
Per Örtenwall; Helge Brändström (ed)
Pre-hospital and Disaster Medicine http://pdm.medicine.wisc. edu Vol.22, No. 1
London Assembly: Report of the 7 July Committee June 2006. (London Bombings)
National Health Emergency Plan, NZ MoH, Dec 2008
New Zealand Influenza Pandemic Plan: A framework for action. April 2010.
NSW Heathplan May 2008
NZFS Incident Management – Command and Control Technical Manual Nov 2007
NZS8156:2009 Ambulance Service Sector Standard
NZS 31000:2009 Risk Management – Principles and guidelines Report On Tilt Train Derailment At Rosedale (Berajondo). Dept. of Emergency Services, Queensland Government, Jan 2005 State Major Incident and Disaster Plan (Queensland) July 2004 The Guide to the National Civil Defence Emergency
Management Plan 2006
The New Zealand Ambulance Service Strategy: The first line of mobile emergency intervention in the continuum of health care http://www.naso.govt.nz/wp-content/uploads/2009/10/final-ambulance-strategy.pdf
Tier 1 Emergency Departments Service Specification DHBNZ / MoH Dec 2002
Triage: a position statement. T Hodgetts. May 2001 for the European Union Core Group of Disaster Medicine
