Joint Emergency Response Plan
Issue
No.
Version
2
Document Code:
Page
1
Implementation Date: May 2008
Joint Emergency Response Plan
Service / Department: All
Originator:
Catalyst Healthcare
Revision Date:
Approved for Catalyst Healthcare
(Roehampton) Plc:
Name: ………….………
Title: ……….
Signature: ………
Date: ………
Approved for the Wandsworth PCT Trust
Board:
Name: ………...……..
Title: ..………..……
Signature: ………...….
Date: ………
Aim and Scope of Procedure
The purpose of this plan / procedure is to provide a framework for response to, and management
of, those incidents arising from building or system failures occurring at QMH identified as major
risks to the continuity of service provided by the hospital.
This is not to be confused with or replace the Trust’s Emergency Management Plan for major
incidents which are defined as “Any occurrence which represents a serious threat to the health of
the community, disruption to services, or causes (or is likely to cause) such numbers of types of
casualties as to require special arrangements to be implemented”.
Procedure review due xxx
Key Staff Responsibilities
Post Responsibilities
• Trust On Call Emergency
Manager
to ensure that the actions attributed to the Trust staff are carried
out in the event of an incident.
• On Call Manager (as
defined by Sodexo)
to ensure that the actions attributed to the Site staff are carried
out in the event of an incident.
• Trust Associate Director
for Adult Services
to ensure, with Catalyst, that an approved plan is in place and
maintained
• Catalyst General Manager
(Alan Hargreaves)
to ensure, with the Trust, that an approved plan is in place and
maintained
Queen Mary’s Hospital,
Roehampton
Whole Hospital Procedure
Joint Emergency Response Plan
Issue
No.
Version
2
Document Code:
Page
2
Implementation Date: May 2008
References:
Trust’s Major Incident Plan
Change History
Issue
Date
Version Author
Change
4/10/2005
Draft 1
Catalyst, A W Hargreaves
Initial issue for comment
7/4/2008 Version
2
Catalyst, A W Hargreaves
Update following JERP
review
Joint Emergency Response Plan
Issue
No.
Version
2
Document Code:
Page
3
Implementation Date: May 2008
Contents:
Aim and Scope of Procedure
1
Key Staff Responsibilities
1
References:
2
1. Introduction
4
2.
Scope of Procedure
4
3.
Generic Incident Response
5
4. Incident
Control
Team
7
5. Escalation Process
Error! Bookmark not defined.
6.
Hospital On Call Manager and On Call Manager Roles
12
7. Scenario
Training
14
Queen Mary’s Hospital,
Roehampton
Whole Hospital Procedure
Joint Emergency Response Plan
Issue
No.
Version
2
Document Code:
Page
4
Implementation Date: May 2008
1. Introduction
The Joint Emergency Response Plan (JERP) is a controlled document and the
responsibility for keeping it up-dated and distributed lies with Catalyst and the Trust.
It is not intended that this JERP deals with major events of a clinical nature. Where an
event would escalate to a situation where clinical services would be compromised then the
Trust “Emergency Management Plan” would be implemented. The decision on the
significance of the event would be taken by a Trust On-Call Manager.
This JERP is produced in response to the requirement under the Project Agreement for
issue of a “Disaster Plan” for the hospital to operate from the Hospital Handover Date. The
initial response to each major risk is outlined by a number of flow charts, at Section 8.
Additional flow charts will be produced from time to time in response to the identification of
further risks if identified as requiring similar treatment.
It must be noted that it is not possible to cover all eventualities and it must be recognised
that more than one incident can impact upon the Hospital at any one time. It must also be
appreciated that the individual circumstances of every incident will require a specific
response that may only be identified at the time of the incident. The purpose of this
document is not to provide all of the answers but to steer the appropriate staff in the right
INITIAL direction and empower them to act. Thus, this JERP provides the high level
response.
2. Scope
of
Procedure
The purpose of the JERP is to provide a framework to continually assess and manage the
risks facing the Hospital, and is a tool to enable the most effective return to normal
business in the event of an incident.
It needs to be recognised that the person acting as Incident Manager (Trust or Catalyst
representative) has to have the freedom to take alternative courses of action to that
recommended in this guidance document if he/she believes a return to normal can be
achieved more effectively.
It is important that actions during incidents are recorded via the Trust Accident and Incident
Reporting Form (AIR Form), a copy of which is available on the PCT website. The
Incident Manager should use this to keep a record of events and as a checklist to ensure,
as far as is possible, procedures in the initial crisis phase are followed.
Joint Emergency Response Plan
Issue
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Version
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Document Code:
Page
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Implementation Date: May 2008
3. eneric
Incident
Response
The following flow chart identifies the main steps taken in response to an incident.
Contact Sodexo Help desk
Contact Sodexo Help desk
Contact Sodexo Help desk
Contact trust Emergency Bleep Holder
Queen Mary’s Hospital,
Roehampton
Whole Hospital Procedure
Joint Emergency Response Plan
Issue
No.
Version
2
Document Code:
Page
6
Implementation Date: May 2008
Upon the discovery of an incident the hospital switchboard will be notified.
NO
YES
2
3
1
Incident
Identified
Take any
necessary
steps to save
lives
Inform
Switchboard
Operator
contact 1,2 & 3
Contact
Emergency
Services
Sodexo switch
Manager
Staff nominated to
meet Emergency
Services
Bleep Holder and
Sodexo staff meet to
assess incident
Agree appropriate
emergency action
plan
Emergency Services
met by Trust staff.
Deploy staff as
agreed
Implement
changes
Trust recovery stage
Staff/patients/visitors
Make Safe. Make Good
Sodexo recovery stage.
Restoration phase. Trust
and Sodexo management
agree plan. Agree
Emergency Stand down
INCIDENT
CLOSED
Lessons
learnt
reports.
Review
Is it
Normal
?
Contact
Sodexo
Help desk
Sodexo
staff
mobilised
Contact Sodexo
manager on call
Contact trust
Emergency
Bleep Holder
Bleep Holder
contacts Trust
Operations
Manager
Produce reports.
Trust, Sodexo
Joint Emergency Response Plan
Issue
No.
Version
2
Document Code:
Page
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Implementation Date: May 2008
The hospital switchboard would first contact the emergency services if required.
After agreement with the Sodexo On Call Manager, the Sodexo On Call Manager or the
switchboard operator would notify the Trust On Call Manager.
The appointment of the Incident Manager will be made by agreement between the Hospital
and Sodexo On Call Managers, and will depend on the specifics of the Incident.
4. Incident
Control
Team
The incident control team will consist of a selection of the following persons at the
discretion of the Incident Manager, and the specific roles will be dependent on the nature of
the incident. The following is provided as guidance:
ROLE
NAME
RESPONSIBILITY
Incident Manager
( Agreed at time depending
on nature of incident)
Trust On Call Manager or Sodexo On Call
Manager
Deputy – Hospital On Call Director or
Sodexo On Call Estates Manager
Dealing specifically with the Incident
Control Team
Trust Representative
Trust on-call manager
Act as the Incident Manager if appropriate
and co-ordinate all Trust activities.
Catalyst Representative
General Manager or GM’s nominee
Act as the Incident Manager if appropriate
and co-ordinate the input from the
Catalyst subcontractors.
Sodexo Representative
On Call Manager - Services
Co-ordinate the input from Sodexo
Trust Public Relations
Representative
Trust Communications Department
Public Relations for the Trust
Lend Lease
Communications
Lend Lease Corporate Communications
Public Relations for Catalyst
Health and Safety
Representatives (Catalyst)
Catalyst Health & Safety Manager
Deputy – Catalyst General Manager
Health & Safety Representation for
Catalyst
Health and Safety
Representatives (Trust)
Trust Health & Safety Manager
Health & Safety Representation for the
Trust
Queen Mary’s Hospital,
Roehampton
Whole Hospital Procedure
Joint Emergency Response Plan
Issue
No.
Version
2
Document Code:
Page
8
Implementation Date: May 2008
The Command and Control structure for dealing with a Major Incident is detailed within the Trust’s
“Emergency Management Plan”
5. Escalation
Process
The following flowchart identifys the main escalation steps
during a JERP incident.
EMERGENCY RESPONSE
24 hours
Emergency occurs
1
Switchboard / direct
Informs Sodexo On Call Manager
Informs Trust On Call Manager. Takes appropriate immediate action
May invoke major incident plan if necessary
Informs Communications office - Trust and Sodexho
Inform Site Executive Director, Trust On Call Director
NB: Trust On Call Operational Manager and Sodexo On Call Manager rotas held at
Switchboard
1
Joint Emergency Response Plan
Issue
No.
Version
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Document Code:
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Implementation Date: May 2008
The following flow charts identify the main escalation
steps taken by Catalyst
during
an incident:
CEO LL Europe Executive Director, Catalyst Lend Lease Director, Catalyst On Call Duty Manager, Catalyst Operations Director, VLL Managing Director VLL Regional Operations Director, Sodexo Operations Director, SodexoCATALYST ESCALATION PROCEDURE
CROSS COMPANY COMMUNICATION
General Manager, Sodexo General Manager, Catalyst On Call Manager, ProjectCo (Catalyst)
CATALYST
SODEXO
Roehampton General Hospital
Whole Hospital Procedure
Joint Emergency Response Plan
Issue
No.
Version
2
Document Code:
Page
12
Implementation Date: May 2008
6.
WPCT On Call Manager Roles
2
WPCT operates an On Call Manager rota alongside a Director on call rota. All QMH
emergency or business continuity issues should be reported in the first instance to the
Trust On Call Manager.
The Trust On-Call Manager can be contacted 24 hours a day via the
Wandsworth
Borough Council Emergency Centre (WEC)
on:
1
st
0208 870 2032 direct line
2
nd
0208 874 3200 direct line
Alternatively the Trust On-Call Manager can be contacted by pager
Tel: 08700 555 500 quote code: WAND1
Mobile: 07796 330 440
At any time the Trust On Call Manager can escalate the situation to the Trust On Call
Director then up to Chief Executive.
The Trust On Call Manager will liaise with the Sodexo, On Call Site Manager and
decide on the appropriate actions.
Details of specific responsibilities and actions are outlined in the individual response
flow charts, but principal roles and responsibilities in any emergency incident are to:-
•
Respond to the incident when notified by the Facilities Help Desk, switchboard or
other member of staff;
•
Liaise with Trust staff, senior management and communications staff, keeping all
parties up to date;
•
Liaise with On Call Director;
•
Act as the Incident Manager and instigate an emergency response team if
necessary, depending upon the presence of more senior managers / directors.
•
Assess impact of the emergency situation;
2
Joint Emergency Response Plan
Issue
No.
Version
2
Document Code:
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Implementation Date: May 2008
•
Support
Trust
staff;
•
Complete the SUI or AIR form, where acting as the Incident Manager.
Non emergency incidents
should be dealt with by the Associate Director Adult
Services or Service Head. These staff can also be contacted for assistance during an
emergency situation.
Contact Details:
Name Title Contact
Stuart Reeves
AD Adult Services
QMH X 6804
Allison Brooks
Head of Outpatients
QMH X 6901
[email protected]
Jane Attrill
Head of Rehab
QMH X 6571
Sue Danks
Head of Adult Therapy
QMH X 6900
Sally Hale
Head of Older People
Service
QMH X 6157
Adrian Davey
Head of mental Health
QMH X 6816
Roehampton General Hospital
Whole Hospital Procedure
Joint Emergency Response Plan
Issue No. Version 2
Document Code:
Page
14
Implementation Date: May 2008
The Sodexo On Call Manager
A Sodexo On-call Manager is available at all times. The Sodexo On-call
Manager will provide a single point of contact representing Catalyst in case of
emergency and taking responsibility until it is agreed that another manager
takes control. The escalation procedure will be implemented as necessary.
The Sodexo On-call Manager takes responsibility for the non-clinical aspects
of the response, with the co-operation of the Hospital On Call Manager.
Details of specific responsibilities and actions are outlined in the individual
response flow charts, but principal roles and responsibilities in any emergency
incident are to:
•
Respond to the incident when notified by the Switchboard Operator;
•
Liaise with the Hospital On Call Manager;
•
Act as the Incident Manager depending upon the nature of the incident
and agreement with the Hospital On Call Manager;
•
Visit ward / department to establish impact of emergency situation;
•
Co-ordinate the input from Catalyst, LLFM and Sodexo;
•
Escalate as appropriate;
•
Support ward and department Trust Managers;
•
Inform and update all necessary Catalyst VLL and Sodexo On Call
Managers and on-call staff; and
•
Complete the Trust Accident and Incident Report Form (AIR form), where
acting as the Incident Manager.
7. Scenario
Training
People need to be prepared to respond in an appropriate and controlled
manner in the event of an incident. On occasions where no incidents occur
over a period of at least 1 year, Catalyst should arrange awareness sessions
to include desk to reviews of the Plans. The feedback from these sessions
will be used to revise the Plans and to develop the detailed responses.
8.
Incident Response Flow Charts
Joint Emergency Response Plan
Issue No. Version 2
Document Code:
Page
15
Implementation Date: May 2008
•
Chemical spillage within the hospital
•
External Drainage (see flooding internal for internal drainage procedure)
•
Extreme
weather
•
Fire alarms fail
•
Fire
procedure
•
Flooding,
internal
•
Gas failure (see also Heating loss)
•
Heating loss (see also Gas failure)
•
Hot water supply fails
•
IT
System
Failure
•
Lift
Entrapment
•
Lighting
failure
•
Mains electricity loss
•
Medical gas supply loss
•
Nurse call system failure
•
Operating Theatre UPS failure
•
Security , Intruder
•
Security systems failure (BMS failure?)
•
Telephone
System
Failure
•
Terrorism
•
Ventilation
contamination
•
Water
Contamination
•
Water,
supply
loss
•
Hostage situation (not included, see Major Emergency Plan)
•
Fuel strike/shortage (not included, see Major Emergency Plan)
•
Loss of paging system (See telephone system failure)
IMPORTANT NOTE
It is not intended that this JERP deals with major events which would have a significant effect
on the provision of clinical services. Where an event would escalate to a situation where
clinical services would be compromised then the Trust “Emergency Management Plan”
would be implemented. The decision on the significance of the event would be taken by a
Hospital On Call Manager or if appropriate by the Emergency Services.
CHEMICAL SPILLAGE
WITHIN THE HOSPITAL
TRUST EMERGENCY BLEEP MES SODEXHO
HOLDER ( Agree Incident Manager)
* Contact on call engineer * Contact on call engineer * Assess whether incident affects medical equipment * Assess actions required and report * Mobilise additional staff to support If so: * Mobilise additional staff as required
* Mobilise additional staff as required * Isolate ventilation system if appropriate * Call equipment maintenance manager * Assist in clean up operation
* Assist in clean-up operation * Return system to operational condition * Close out incident and complete report * Close out incident and complete report
* Deploy containment if safe * Inform adjacent departments * Inform Fire Service if necessary
* Inform departments of leaks or vapour escapes * Impliment clean up operation
* Clear away contaminated material and dispose * Close out incident and complete report INCIDENT REPORTED SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER
Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES yes no If critical If critical * Assess type of spillage
* Consult COSHH risk assessment * Follow spillage procedure if applicable
* If unknown or dangerous, call fire brigade, cordon off area, evacuate.
TRUST EMERGENCY BLEEP MES SODEXHO HOLDER
( Agree Incident Manager)
* Contact on call engineer * Contact on call engineer * Determine if patient move is necessary * Assess whether incident affects medical equipment * Initial assessment of incident
* Inform Infection Control Nurse If so: * Inform Hospital Bleep Holder of likely repair time * Arrange clean up team * Mobilise additional staff as required
* Commence and complete clean up * Call equipment maintenance manager Off-site main sewer * Assist in clean-up operation * Contact local authority. * Close out incident and complete report * Arrange repair
* Inform Hospital Bleep Holder * Monitor progress
* Close out incident and complete report
On site
* Contact specialist contractor
* Prepare risk assessment and method statement * Inform Hospital Bleep Holder
* Arrange pumping around blockage if necessary * Impliment repair plan
* Complete repair and clean up * Close out incident and complete report SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER
Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES no If critical If critical yes
EXTREME WEATHER
TRUST EMERGENCY BLEEP
HOLDER SODEXO
( Agree Incident Manager)
* Ensure Ambulance Service aware During normal working hours Sodexho staff monitor
* Ensure staff aware extreme weather conditions and take action
* Staff may need to be sent home accordingly
early OR provision for staff to stay on duty
* Advise Trust On-call Manager
if necessary Sodexo Estates Manager mobilises appropriate
team to deal with the possible impact on the hospital of the extreme weather conditions EXTREME WEATHER REPORT ISSUED SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES yes no If critical If critical IF OUT OF HOURS
OUT OF HOURS SECURITY STAFF AND TRUST EMERGENCY BLEEP
HOLDER MONITOR CONDITIONS
Trust Emergency Bleep Holder contacts On Call
SODEXO DISCOVER
EQUIPMENT FAILURE
TRUST EMERGENCY
SODEXO REPAIR & TEST
BLEEP HOLDER
WORK COMPLETE
SYSTEM BACK TO NORMAL
IF SODEXO UNABLE TO
RECTIFY IMMEDIATELY
CONTACT SPECIALIST CONTRACTOR
INFORM
ON CALL ESTATES MANAGER
* Inform all departments
ESTATES MANAGER
* Inform all staff to exercise extra
KEEPS
vigilance
TRUST MANAGER
* Develop, agree and impliment repair
* Inform Fire Coordinators
AND BLEEP HOLDER
plan with Specialist
* Inform all departments upon
INFORMED OF
* Call in additional resources if required
repairs being completed
SITUATION
* Issue mobile phones to
wards / departments if required
AGREE WITH
* Complete repair and test
TRUST BEST COURSE
* Stand down staff
OF ACTION
* Close out incident and complete
report form
FIRE PROCEDURE
* Operate nearest fire alarm call point
INCIDENT
* Inform ward / department manager
REPORTED
* Tackle fire if safe to do so
* Close all doors and windows
TRUST EMERGENCY
SWITCHBOARD
BLEEP HOLDER
CALL FIRE BRIGADE
FACILITIES HELP
DESK
* Takes charge of Incident
* Liaise with Fire Brigade
* Issue Tabards
ON CALL ESTATES MANAGER
Fire Alarm signal - continuous tone
Assess situation and involve parties
Fire in patient area
as appropriate
SODEXO
* Continuous tone indicates fire in zone
* Follow Trust Fire procedures
* Be prepared to evacuate if need arises
* Assist Fire Brigade as required
* Reset fire alarms on approval of Senior
Fire in non-patient area
MES
Fire Brigade officer attending site
* Continuous tone indicates fire in zone
* Arrange for any work to be carried out to
* Follow Trust Fire procedures
reinstate systems and generally make safe
* Check all persons are accounted for
* Contact on call engineer
Fire Alarm Signal - Intermittent tone
* Assess whether incident affects medical equipment
Remain alert to change
If so:
* Isolate equipment if required
* Call equipment maintenance manager
* Follow Trust fire procedures
TRUST EMERGENCY SODEXHO BLEEP HOLDER
( Agree Incident Manager)
* Contact on call engineer * Determine if patient move is * Determine extent of incident required
* Porters assist in patient move if IF required * Contact on-call plumber
* Contact domestic for clear up * Ascertain cause and likely time for repair * Porters assist in restricting access * Set up emergency response team to affected areas * Assess impact on hospital
* Move equipment as necessary * Prepare , agree and impliment repair plan * Infection Control Nurse contacted * Impliment containment measures as soon as possible * Contact infection control if contaminated
* Repair complete
* Step down emergency response team * Close out incident and complete report form
IF LOCALISED:-* Contact on-call plumber
* Ascertain cause and likely time for repair * Assess impact on hospital
* Prepare , agree and impliment repair plan * Impliment containment measures * Call in additional resources as required * Contact infection control if contaminated * Repair complete
* Close out incident and complete report form SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER
Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES yes no If critical If critical MES
Review location and equipment at risk Take appropriate action
GAS FAILURE
( See Heating loss)TRUST EMERGENCY BLEEP HOLDER ( Agree Incident Manager)
* Establish Emergency Response Team IF required
* Invoke MIP if required
SODEXHO
* Contact on call engineer * Determine extent of incident
* Establish contact with Hospital Bleep Holder * Switch boilers and steam generator to oil fire * Ensure that pumps running and oil is reaching day tank
* If gas leak isolate incoming main * Evacuate affected area and arrange natural ventilation
* Formulate, agree and impliment repair * Prepare , agree and impliment repair plan Off site failure
* Contact Transco
* Monitor progress and report completion * Recommission system
* Change from oil to gas fire * Close out incident and complete report On site failure
* Risk assessment, method statement and permits
* Isolate and purge system * Undertake and complete repair * Recommission system * Change from oil to gas fire * Close out incident and complete report
INCIDENT REPORTED SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES yes no If critical If critical
TRUST EMERGENCY BLEEP HOLDER ( Agree Incident Manager)
* Establish Emergency Response team * Close all doors and windows * Determine priorities
* Invoke MIP if necessary SODEXO
*Issue blankets if necessary * Find alternative sources of heating * Specifically inform maternity, theatres, wards,
CCU, ECC. * Contact on call engineer * Determine extent of incident Total failure - (see also Gas failure) * Call out staff/contractors as necessary * Inform Hospital Bleep Holder of likely repair time
* Determine agree and impliment repair plan * Carry out repair
* Close out incident and complete report Local zone failure
* Interogate BMS to identify cause * Inform Hospital Bleep Holder of likely repair time
* Determine agree and impliment repair plan * Carry out repair
* Close out incident and complete report SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES yes no If critical If critical
HOT WATER SUPPLY FAILS
TRUST EMERGENCY BLEEP HOLDER ( Agree Incident Manager)
Assess situation with Sodexo and take appropriate action
* Infection Control Nurse contacted SODEXO * Restrict use of water
*Alternative hand wash and hand cream/alcogel
* Consider implications for menus * Contact on call engineer and develop and agree action plan * Contact Head porter to arrange * Arrange distribution of water for support if required flushing * Determine extent of incident
* establish contact with Trust Emergency Bleep Holder and give initial briefing * Ascertain cause and likely time for repair * Set up emergency response team * Accelerate as appropriate * Local pipework
* Refer to mains layout and valves as appropriate
* Pumps
* Repair pumps ( pumps duplicate) * Calorifier
* check auto valves and manually adjust if appropriate
* Undertake required repairs * Ensure that system is operational across hospital
* Stand down emergency response team * Engineer to remain on site until satisfied repair is effective * Close out incident and complete report form INCIDENT REPORTED SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES yes no If critical If critical
TRUST EMERGENCY BLEEP HOLDER ( Agree Incident Manager)
* Identify who is in lift * Contact Head porter to arrange
support as required SODEXO
* Clinical team on standby if required * If both lift cores out of action provide care for emergency admissions
* Assist with passenger removals * Contact on call engineer * Determine extent of incident * Contact Otis call centre for Engineer update
* Establish contact with Trust Emergency Bleep Holder and give initial briefing * Ascertain cause and likely time for repair * Isolate power as necessary
* Arrange hand winding of lift to release passengers
* Arrange transfer of food to wards by alternate lifts or stairs * Use external route for porter transfers from LG to G * Liaise with Fire Brigade
* Develop, agree and impliment repair plan
* Complete repair and test * Notify all areas of completion and stand down
* Close out incident and complete report form INCIDENT REPORTED SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER
Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES yes no If critical If critical
LIGHTING FAILURE
TRUST EMERGENCY
BLEEP HOLDER
( Agree Incident Manager)
* Establish Emergency Response team
if necessary
* Relocate patients as appropriate
SODEXO
* Issue torches as appropriate
* Contact on call engineer
* Call out electrician
* Initial fault find and estimate repair time
* Inform Hospital Bleep Holder of likely
repair time
* Determine agree and impliment repair plan
* Carry out repair
* Close out incident and complete report
INCIDENT REPORTED
SWITCHBOARD
FACILITIES HELP
DESK
ASSESS
IF
CRITICAL
ON CALL MANAGER
Assess situation and involve
parties as appropriate (Agree
Incident Manager)
CONTINUE NORMAL
PROCEDURES
yes
no
If critical
If critical
TRUST EMERGENCY BLEEP HOLDER ( Agree Incident Manager)
* Contact critical care areas and divert
staff as appropriate SODEXO * Visit critical care areas
* Arrange Medical Emergency Team to be centrally based
* Issue mobile phones to critical areas * Contact on call engineer
and to wards to raise cardiac calls * On call Engineer contacts on call electrician * Ensure all unnecessary equipment is A.P. Electrical and EDF to
switched off and essential equipment attend site
is plugged into maintained supply * A.P establishes and maintains contact with * Distribute torches as necessary electrician and EDF and Trust Emergency * Increase security in vulnerable and Bleep Holder
controlled entrances * Undertake initial fault find * A.P takes control of incident * Ascertain cause and likely time for repair * Call in additional staff as required * Set up Emergency Response Team * Discuss action plan with Trust Emergency Bleep Holder
* Develop, agree and impliment repair plan
* Continually update Emergency Response Team
* Complete repair and energise circuits * Inform Emergency Response Team of completion
* Stand down ERT and sign off permits * Ensure all systems are operational across hospital
* A.P. to remain on site until satisfied that repair is effective
* Close out incident and complete report form
* Notify all areas of completion and stand down SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES yes no If critical If critical areas will warm up.
If generators cut in as planned, diesel will last for 5 days - top up. Chillers will shut down.
This procedure applies if all mains and generators fail.
MEDICAL GAS SUPPLY LOSS
TRUST EMERGENCY BLEEP HOLDER ( Agree Incident Manager)
* Contact wards / departments to assess priority of use
* relocate patients appropriate to clinical SODEXO needs
* Contact on-call pharmacist * On call pharmacist to order additional
oxygen, entonox, and medical air * Contact on call engineer cylinders as required * Contact A.P. medical gasses * Mobilise porters to distribute bottled
supplies * Oxygen
* Conduct initial fault find and report to Hospital Bleep Holder
* Ensure that porters are despatched with cylinders * Agree and impliment repair plan
* Medical air
* Conduct initial fault find and report to Hospital Bleep Holder
* Ensure that porters are despatched with cylinders * Agree and impliment repair plan
* Vacuum
* Conduct initial fault find and report to Hospital Bleep Holder
* Check operation of duty / standby compressor and switch appropriately
* Agree and impliment repair plan
* Call in specialist contractor as required
* Complete repair and report to Trust Emergency Bleep Holder
* Complete incident report and close out incident INCIDENT REPORTED SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES yes no If critical If critical
TRUST EMERGENCY
BLEEP HOLDER
* LiaIse with affected area to assess risk
* Arrange for potential spare staff to be
SODEXO
deployed to support ward teams
* Call out or On call electrician to
attend
*Initial fault find and estimate repair time
and report to Trust Emergency Bleep Holder
* Develop, agree and impliment repair
plan
* Report progress and completion
* Close out incident and complete
report form
INCIDENT REPORTED
SWITCHBOARD
FACILITIES HELP
DESK
ASSESS
IF
CRITICAL
ON CALL MANAGER
Assess situation and involve
parties as appropriate (Agree
Incident Manager)
CONTINUE NORMAL
PROCEDURES
yes
no
If critical
If critical
OPERATING THEATRE UPS FAILS
TRUST EMERGENCY
BLEEP HOLDER
* Determine effect on other systems
* Assess if patient move is required
SODEXO
* Identify if other systems are available
for transfer
* Call out or On call electrician to
attend
*Initial fault find and estimate repair time
and report to Trust
Emergency Bleep Holder
* Determine with Trust Emergency
Bleep Holder if alternative systems
can be swopped
* Develop, agree and impliment repair
plan
* Report progress and completion
* Close out incident and complete
report form
INCIDENT REPORTED
SWITCHBOARD
FACILITIES HELP
DESK
ASSESS
IF
CRITICAL
ON CALL MANAGER
Assess situation and involve
parties as appropriate (Agree
Incident Manager)
CONTINUE NORMAL
PROCEDURES
yes
no
If critical
If critical
CALL FROM STAFF
SWITCHBOARD
Alert Bleep Holder
Contact Police if necessary
(attack on property or person)
SODEXO SECURITY
Alert On Call Estates Manager
TRUST EMERGENCY
and Trust Duty Manager
BLEEP HOLDER
( Agree Incident Manager)
FACILITIES HELP
DESK
* Bleep Holder and Porter investigate
incident internally and take appropriate
SODEXO
action
* Notify Police if necessary
ON CALL ESTATES MANAGER
Assess situation and involve parties
as appropriate ( Agree Incident Manager)
No specific actions. Follow the directions of
the Police
SECURITY SYSTEMS
FAILURE
TRUST EMERGENCY
BLEEP HOLDER
( Agree Incident Manager)
* Inform all departments
* Determine departments at-risk
SODEXO
* Provide additional staff to at-risk departments
* Contact on call engineer
* Call out electrician
* Conduct initial fault find and report to
Trust Emergency Bleep Holder
* Develop and impliment repair plan
* Call in mobile phones for at-risk staff
* Complete repair and test system
* Close out incident and complete report form
INCIDENT REPORTED
SWITCHBOARD
FACILITIES HELP
DESK
ASSESS
IF
CRITICAL
ON CALL MANAGER
Assess situation and involve
parties as appropriate (Agree
Incident Manager)
CONTINUE NORMAL
PROCEDURES
yes
no
If critical
If critical
FACILITIES HELP
DESK
SODEXO
ON CALL ESTATES MANAGER
Assess situation and involve parties
as appropriate ( Agree Incident Manager)
* Try alternative phones
TRUST EMERGENCY
* Use hospital emergecy mobile number
BLEEP HOLDER
07523 116 909
( Agree Incident Manager)
* Use radios
* Try alternative phones
* Use hospital emergecy mobile number
07523 116 909
* Use stand alone emergency phones
* Issue e-mail alert or send round courier
* Use mobile phones
* Use two way radios for Emergency
Response Team and porters
TERRORISM
EXTERNAL INCIDENT
THREAT
INCIDENT
SWITCHBOARD
TRUST MAJOR
Communications Procedure
INCIDENT PLAN
CALL EMERGENCY
SERVICES
ON CALL ESTATES MANAGER
Assess situation and involve parties
as appropriate ( Agree Incident Manager)
TRUST EMERGENCY
BLEEP HOLDER
( Agree Incident Manager)
* Join with Sodexho to form emergency team
SODEXO
* Invoke bomb / suspect package
procedure if appropriate
* Isolate area if known/possible
* Evacuate if advised by Police
* Implement necessary measures
* Restrict access to hospital as appropriate
* Isolate non critical systems as appropriate
* Meet and assist emergency services
* Isolate any medical equipment as
appropriate
*Cordon off area
* Evacuate non essential staff and patients
CONTACT
to a safe place
CATALYST
TRUST EMERGENCY
BLEEP HOLDER
( Agree Incident Manager)
* Assess impact on hospital
* Arrange alternative locations for affected
SODEXO
patients
* Inform Infection Control Nurse
* Establish Emergency Response Team
* Infection Control Nurse to identify cause of
* Turn off ventilation
contamination
* Contact on call engineer
* Infection Control Nurse to report to
* Assess spread of contamination
Emergency Response Team
* Agree areas to be isolated
* Infection Control Nurse to arrange
* Isolate infected areas and systems
health checks if required
* Risk assessment and method statement
* Formulate action plan, agree and impliment
* Continually monitor air quality
* Keep Infection Control Nurse informed
* Check effectiveness of adopted measures
* Issue cleanliness certificates
* Re-commission system
* Complete incident report and close out incident
INCIDENT REPORTED
SWITCHBOARD
FACILITIES HELP
DESK
ASSESS
IF
CRITICAL
ON CALL MANAGER
Assess situation and involve
parties as appropriate (Agree
Incident Manager)
CONTINUE NORMAL
PROCEDURES
yes
no
If critical
If critical
WATER, CONTAMINATION
TRUST EMERGENCY BLEEP HOLDER ( Agree Incident Manager)
* Assess impact on hospital SODEXO * Inform Infection Control
* Issue alternative handwash and hand gel * Arrange with NHS supplies for bottled water
* Mobilise porters to distribute bottled * Contact on call engineer
supplies * Engineer contacts on-call mechanic to * Relocate patients if appropriate attend site
* Infectioncontrol to arrange samples and * Contact Trust Emergency Bleep Holder and give analysis initial briefing
* Advise Staff/Patients not to use bath or * Conduct initial fault find and report to Trust Emergency showers Bleep Holder
* Establish cause of fault ( escalate if appropriate) * Set up Emergency Response Team * Close off incoming supplies if appropriate * See offsite mains layout
* Contact fire service to arrange pumping from alternative source
* Arrange alternative pumping if long term including duplicates
* Contact Water Authority
* Arrange potable water supply from Water Authority local retail outlets
* Arrange bowsers if required * Escalate if appropriate
* Drain and chlorinate tanks, mains and local pipework
* Recommission system and check purity * Ensure system operational across hospital * Stand down Emergency Response Team * Engineer to remain on site until satisfied that repair is effective
* Complete incident report and close out incident INCIDENT REPORTED SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES yes no If critical If critical
TRUST EMERGENCY BLEEP HOLDER ( Agree Incident Manager) * Restrict use of water as much as possible
* Inform Infection Control SODEXO * Assess impact on hospital use
* Issue alternative handwash and hand gel * Arrange with NHS supplies for bottled water
* Mobilise porters to distribute bottled * Contact on call engineer supplies * Engineer contacts on-call mechanic to
attend site
* Contact Trust Emergency Bleep Holder and give initial briefing
* Conduct initial fault find and report to Trust Emergency Bleep Holder
* Establish cause of fault ( escalate if appropriate) * Set up Emergency Response Team On-site failure
* Ring main - refer to mains layout and valve as appropriate
* Pumps - repair pumps ( pumps duplicate) * Tanks ruptured - as off site failure NB Tanks duplicated. Arrange alternative potable break tank and pumping
* Repair tanks and chlorinate * Ensure system operational across hospital * Stand down Emergency Response Team * Complete incident report and close out incident Off site failure
* Contact Water Authority and switch appropriately * Undertake repair * Arrange bowsers if required * Monitor repair process
* Contact fire service to arrange pumping from alternative source
* See offsite mains layout
* Arrange potable water supply from local water authority local retail outlets
* Ensure system operational across hospital * Stand down Emergency Response Team * Engineer to remain on site until satisfied that repair is effective
* Complete incident report and close out incident SWITCHBOARD FACILITIES HELP DESK ASSESS IF CRITICAL ON CALL MANAGER
Assess situation and involve parties as appropriate (Agree
Incident Manager) CONTINUE NORMAL PROCEDURES yes no If critical If critical
MAIN ROAD ACCESS BLOCKED
INFORM POLICE AND FIRE BRIGADE
TRUST EMERGENCY BLEEP
HOLDER
( Agree Incident Manager)
* Use pedestrian access to the
Minor injuries unit, if available
SODEXO
* Re-route ambulances t service entrance
* Advise appropriate clinical staff
* Implement temporary traffic control
* Assess cause of blockage
* Arrange for use of service access
* Implement alternative traffic route
* Impliment adverse weather procedure
* Remove blockage and report progress
as appropriate
* Complete Incident Form
* If fuel spillage maintain fire extinguishers
at incident
* Impliment arrangements to clear blockage
INCIDENT REPORTED
SWITCHBOARD
FACILITIES HELP
DESK
ASSESS
IF
CRITICAL
ON CALL MANAGER
Assess situation and involve
parties as appropriate (Agree
Incident Manager)
CONTINUE NORMAL
PROCEDURES
yes
no
If critical
If critical
