Procedural document of: Actions to be taken in the … Failure Contingency...Page 1 of 32 Procedural...
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Procedural document of:
Actions to be taken in the event of electronic & telecommunications
failure at St Helens & Whiston Hospital sites
Version 12 May 2015
DOCUMENT NUMBER
APPROVING COMMITTEE Risk Management Council
DATE APPROVED June 2015
DATE IMPLEMENTED July 2015
NEXT REVIEW DATE 30th May 2018
ACCOUNTABLE DIRECTOR Director of Nursing, Midwifery & Governance
POLICY AUTHOR Head of Emergency Management
TARGET AUDENCE All Trust Staff
KEY WORDS Major Incident, Operational Major Incident Plans
Important Note: The Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as “uncontrolled” and, as such, may not necessarily contain the latest updates and amendments.
Note: This document is designed to be printed back to back
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Contents
Page
Introduction Section 1 5
Aim 5
Potential Impact of Communications Failure 5
Diagram of mitigating contingency measures 6
Contingency communications equipment 7
Action Cards Section 2 9
Medical Emergency Team (MET) 11
Coordinator 13
All Wards/ Depts Managers 15
Contacts Lists Section 3 17
Distribution List For Major Incident Portable Phones/ Radios – Whiston
17
Distribution List For Major Incident Portable Phones/ Radios – St Helens
17
Ward Posters Section 4 19
Pager System Failure 19
Complete Communication Failure (Pagers & Phones) 20
Documentation Section 5 21
Emergency Portable Telephone Register 23
Emergency Incident General Message Form 25
Emergency Incident Log 27
Hospital Floor Plans Section 6 29
Whiston 29
St Helens 31
Major Incident Radio Section 7 33
Interoperability 33
Usage 33
Major Incident Radio Standard Operating Procedure 34
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Introduction Section 1
Aim
This document describes the Trust’s telecommunications contingency arrangements. The Trust has several contingency methods to provide resilient communications to ensure robust business continuity and mitigate the risks posed by a potential telecommunication, pager or complete Cisco system failure. These measures are detailed in this document.
Potential impact of communications failure
Equipment Risk Risk Rating
Pager MET, adult and paediatric cardiac arrest teams delayed in attending medical emergencies
VERY HIGH RISK
Clinical staff not responding quickly to messages or attending where required for normal patient care & treatment.
HIGH RISK
Cisco landlines
Staff unable to dial 2222 or 3333 or 9999 in emergencies. VERY HIGH RISK
Switchboard cannot be reached to issue tannoy messages and tannoy enabled phones may not work.
MEDIUM RISK
Combined with pager failure. VERY HIGH RISK
Normal working practice is compromised and communication with internal and external agencies ceases.
HIGH RISK
Facilities Management helpdesk cannot be contacted for reporting any emergency calls e.g. lift entrapments
MEDIUM RISK
Mobiles/ I phone/ pad/ BYOD
Compromises on call managers and clinical staff response VERY HIGH RISK
Slows normal working and communication MEDIUM RISK
All Cisco telecoms and ICT
Compromises business continuity of entire Trust VERY HIGH RISK
Web based systems
Compromises the normal business continuity of the departments that use these systems and others (including patients) dependant upon those departments
HIGH RISK
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Diagram of mitigating contingency measures
The contingency measures in the table below can be invoked and used either as simple individual fall back measures or as combinations of methods of communications as determined by the nature and scale of the incident and the failure of one or more of each type of communications systems.
Equipment failure
Contingency 1 Contingency 2 Contingency 3 Contingency 4
Pager Tannoy Portable Cisco phones,
Mobiles I phones
MI Radios & Runners
Paper-based systems +
Runners
Cisco landlines (therefore Tannoy and portable phones) and pagers too
Remaining analogue landlines
Mobiles & I phones Runners IT required to
issue global email/ divert of helpdesk phone line to alternative number
MI Radios & Runners
Paper-based systems +
Runners
Vodaphone mobiles & I phones
Pagers Landlines MI Radios& Runners
Paper-based systems +
Runners
All Cisco systems
Paper-based systems +
Any remaining analogue landlines
Paper-based systems +
Mobiles & I phones
Paper-based systems +
MI Radios & Runners
Paper-based systems +
Runners
Web based systems
Paper-based systems +
Paper-based systems +
Landlines + Mobiles
Paper-based systems +
MI Radios & Runners
Paper-based systems +
Runners
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Contingency communications equipment
The following contingency equipment is held in secure (locked) Major Incident Cupboards in the locations stated and are charged for a few hours a day on an automatic timer device to avoid them becoming burned out:
No Device Location Access Key officer
6 x Radios Whiston, Exec PA office, 5th floor
Office Manager’s desk Office Manager
6 x Radios Whiston, ED Major Incident Store (Zone 3), Red Level
Senior Nurse key ring, Matrons office, Office-manager’s desk
Matron Forward Medical Team Senior Nurse
10 x Portable Cisco phones Including GM on call phone
Whiston
Separate cupboard in ED Seminar Room 1 (Tactical Command)
Medical Care Group Offices Level 2
Key on Operational Site Manager’s key ring and MET team manager
Operational Site Managers IT taskforce
10 x Radios St Helens ADO PA office
ADO PA and ADO/ DM’s desks
ADO PA and holiday cover staff
2 x MTPAS registered/ Vodaphone mobiles
Exec Admin office major incident cupboard
Key in office manager’s drawer
Office manager Exec PA Team
All above devices are on charge on a timer to prevent them from burning out.
Testing Regime
Contingency equipment will be checked weekly by the key officer (or the person covering the role in their absence) to establish that the lights show green on all radios and phones. If they show red or orange or any are missing or broken the key officer will report this to IT Helpdesk immediately. The IT taskforce will also carry out regular tests as part of their normal inspection timetable every fortnight. Maintenance and Repair
Should equipment be found to be faulty or inoperable the key officer must contact IT Helpdesk as soon as possible to report this. IT staff will then check the equipment and if the problem cannot be fixed immediately, the IT engineer will loan out a spare handset/ battery, etc (which must be signed for) and order a replacement.
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When the replacement is supplied the loaned equipment will be returned to IT department by the key officer and this will be recorded by the IT engineer. Trust mobile (Vodaphone) phones & enabled I phones/ I pads (including those with bring your own device (BYOD) applications)
These mobiles or devices are carried by all on call clinical staff and all managers and will be phased in to replace the Trust Blackberries from September 2013. BYOD simply means "Bring Your Own Device" Health Informatics have now made it possible for you to connect your personal iPhone or iPad to the Wi-Fi Network. As a first step, any Trust employee with an Apple iPhone or iPad who wishes to take advantage of this opportunity can request this service be added to their own personal device. This will allow them to: Securely access email and calendar anywhere. Email access will work over
Wi-Fi and 3G Access to the internet Instant Message to colleagues or groups of colleagues from personal devices. See at a glance who is available to communicate with. Carry just "One" device What devices are supported? Apple iPhone 3GS, 4, 4S and 5, iPad 1, 2, 3, 4 and iPad Mini running IOS software versions 5.0, 5.0.1, 5.1, 5.1.1, 6.0, 6.0.1, 6.1, 6.1.3, 6.1.4 and new IOS updates as they are released. To check your personal device is compatible go to - settings - general - about. The software version is listed under Version. To register a device please go to http://byod.shk.nhs.uk You can register your device immediately. All requests will be processed from Monday 2nd September 2013 Other device makes and models to follow very soon...
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ACTION CARDS Section 2
Medical Emergency Team (MET)/ Adult/Paed Cardiac Arrest teams
Coordinator
All Ward & Department Managers
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ACTION CARD FRONT OF SHEET
MEDICAL EMERGENCY TEAMS (MET) & ADULT/ CHILD CARDIAC ARREST TEAMS
PAGER FAILURE Contingency 1
In the event of a failure of the pager system your pager will alarm as “OUT OF RANGE” when you are within the hospital buildings. Report this urgently to IT Helpdesk on ext 5678.
MANY CALLS TO IT HELPDESK =
PAGER SYSTEM FAILURE =
MET/CARDIAC Teams ALERTED BY TANNOY
PLUS CISCO LANDLINE FAILURE Contingency 2
In the event of a partial or complete failure of the telephone system, staff cannot call the Switchboard on ext 2222 to alert the MET so the tannoy system and the Cisco portable telephones may also be inoperable.
IT HELPDESK DETECT PAGER & LANDLINE FAILURES =
MET/CARDIAC TEAMS & OPS SITE MGR ADVISED TO USE MOBILES, MAJOR INCIDENT RADIOS & RUNNERS
Note: Portable telephones or Major Incident Radios only to be used for medical emergency calls and not general medical enquiries Activation, set up and operations
Action Time
When alerted to a pager and landline failure go to Main Reception Rendevous Point (RVP) immediately.
Sign in on the attendance sheet
Obtain your briefing from the Coordinator (Site Manager/ Cardiac Arrest Team Leader/ MET lead/ GM) taking note of arrangements and his/her mobile/ portable telephone number on your mobile phone contacts.
Receive and sign for your Portable Cisco phone or Major Incident Radio
NB: If radios are issued you will receive instructions from the Coordinator at the time on how to use them.
As instructed by the Coordinator: Return to your area with the portable phone or Major Incident Radio
Calls from the Coordinator’s phone/ radio to be answered immediately
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ACTION CARD BACK OF SHEET
MEDICAL EMERGENCY TEAMS (MET) & ADULT/ CHILD CARDIAC ARREST TEAMS
Stand Down
Action Time
Stand Down will be relayed by tannoy or a call/ text/ page from the Coordinator.
Attend RVP (Main Reception) for Hot Debrief
Report any issues to the Coordinator including equipment problems.
RETURN YOUR PORTABLE PHONE OR/ MAJOR INCIDENT RADIO AND SIGN OFF.
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ACTION CARD FRONT OF SHEET
CO-ORDINATOR Normal role: Site Manager/ Cardiac Arrest Team Leader/ MET Lead (Med SHO/F2 or most senior MET nurse), GM/ St Helens ADO/ ADO PA
PAGER FAILURE Contingency 1
In the event of a failure of the pager system pagers will alarm as “OUT OF RANGE” when bleep holders are within the hospital buildings. Report this urgently to IT Helpdesk on ext 5678.
MANY CALLS TO IT HELPDESK =
PAGER SYSTEM FAILURE =
IT ALERT Ops Mgr/ /MET LEAD/ GM/ ADO PA TO ACTIVATE TANNOY ALERT VIA SWITCHBOARD
PLUS CISCO LANDLINE FAILURE Contingency 2
In the event of a partial or complete failure of the telephone system, staff cannot call the Switchboard on ext 2222 to alert the MET so the tannoy system and the Cisco portable telephones may also be inoperable.
IT HELPDESK DETECT PAGER & LANDLINE FAILURES =
MET/ CARDIAC TEAM/ OPS SITE MGR/ GM/ ST HELENS ADO/ ADO PA ADVISED TO USE MOBILES, MAJOR INCIDENT RADIOS & RUNNERS
The following contingency equipment is held in secure (locked) Major Incident Cupboards in the locations stated:
No Device Location Access Key Officer
6 x Radios Whiston, Exec PA office, 5th floor
Office Manager’s desk Office Manager or nominee Exec PA
6 x Radios Whiston, ED Major Incident Store (Zone 3), Red Level
Senior Nurse key ring, Matrons office, Office-manager’s desk
Matron Senior Nurse FMT
10 x Portable Cisco phones
Whiston Separate cupboard in ED Seminar Room 1
Operational Site Manager’s key ring and Cardiac Arrest Manager
Operational Site Managers
10 x Radios St Helens security office
ADO PA and ADO/DM’s desks
ADO PA and holiday cover staff
Activation & set up
Action Time
When alerted to a pager and landline failure coordinate the response
Start your personal log &/or appoint a loggist
Attend ED Seminar Room 1 (Whiston) or Bishops Seminar Room (St Helens) and COLLECT THE PORTABLE PHONES or RADIOS and the paperwork and pens in a pull along trolley and go to Main Reception.
Confirm emergency number (portable ext 2091 or mobile or radio) with Switchboard. Note: Switchboard will contact the emergency phone/ radio if they receive any emergency calls
Alert and discuss the incident and response with GM
Message or text managers informing them of bleep and phone failure include MET Lead & other Ops Managers and ask for assistance
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ACTION CARD BACK OF SHEET
CO-ORDINATOR Activation & set up continued
Action Time
Alert MET team via speaking/ messaging/ mobile/ text/ TANNOY or any other means.
Contact IT to gain a situation report and inform GM
Designate staff member to receive any incoming emergency calls
Attend Main Reception set up as a Rendevous Point (RVP) and hand over to the GM on-call when they arrive.
Operations
Action Time Take a register of attendance
Brief staff on the situation and give them your contact no (portable/ radio/ mobile).
Hand out portable phone/Major Incident Radio/mobile to a rep from each area ensuring that they sign for them and complete the equipment register.
Instruct the teams that they will be alerted to emergency calls from you as the Coordinator via the portable phone/ radio that they have been allocated.
Send the teams back to their areas.
Coordinate the response from Main Reception keeping a log throughout (using the notepad).
Carry out communications checks of the portable phones/ radios every hour.
Stand Down
Action Time IT will relay the Stand Down by email alert when the pager and/ or landlines are in service again.
Conduct a bleep test for all emergency teams and cascade the stand down informing responders that the systems are re-instated
Inform GM on call
Retrieve the phones/radios and ensure they are signed back in the register.
Test and charge equipment and ensure all are secured in Major incident Cupboards as appropriate and liaise with key officer for that equipment.
Sign and date and close the log
Notify IT asap of any issues with contingency equipment
Send a bullet point brief report to the Exec in Charge and Head of Emergency Management asap after the Stand Down.
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ACTION CARD FRONT OF SHEET
All Wards/ Depts Managers (Or Most Senior Nurse/ Manager on Duty)
Action Time
On receiving the communication from the Site Manager that the Pager System is out of service be aware that the Medical Emergency Team (MET) will attend the Rendevous Point (RVP) at Main Reception (Whiston or St Helens) immediately.
Designate an individual to patrol your area every 15 minutes systematically until the Stand Down is declared by tannoy or message from the Operational Site Manager or GM.
Stand Down
Action Time
Ensure that all Major Incident portable phones, mobiles and radios deployed to your ward or area are returned and recorded in the booking in/out register as soon as possible to: Whiston: to ED Seminar Room 1 and report any issues (like flat batteries, etc) St Helens: St Helens ADO or ADO’s PA and report any issues (like flat batteries, etc)
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ACTION CARD BACK OF SHEET
All Wards/ Depts Managers (Or Most Senior Nurse/ Manager on Duty)
Action Time
MAJOR INCIDENT PORTABLE TELEPHONE & RADIO DISTRIBUTION LIST
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MAJOR INCIDENT USE ONLY unless agreed with DM for Ops or the Head of Emergency Preparedness/ Management
Whiston
TITLE PHONE NAME SIGNATURE BLEEP DATE
GM
2057
Remains with Op Services
GM
2057
Remains with Op Services
OSM – CONTROL
2093
Remains with Op Services
OSM – MEDICINE
7592
Remains with Op Services
OSM - SURGERY
7670
Remains with Op Services
MEDICAL SPR
MEDICAL SHO
1st ANAESTHETIST
2nd ANAESTHETIST
OBS & GYNAE SPR
PAEDIATRIC SPR
PAEDIATRIC SHO
SURGICAL SHO
ORTHO SHO
ECG
SECURITY
MET TEAM (Internal incident only)
GM 2057 Remains with Op Services
1383 1715 1768 2014 2015 2058 2073 2075 2076 2077
2092 2095 5781
AVAILABLE PHONE EXT’S - PLEASE RECORD WHICH IS ALLOCATED TO
EACH ROLE AND ENSURE IT IS SIGNED FOR BY PERSON TAKING PHONE
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St Helens
MAJOR INCIDENT USE ONLY unless agreed with DM for Ops or the Head of Emergency Preparedness/ Management
PERSONNEL BLEEP PHONE
Medical RMO 7170 6822
Security 7322 5221
Sanderson Suite 6084
Duffy Suite 6428
Seddon Suite 6117/6118
Main Reception 6461
Matron (Surgery) SW 7172 6106
Matron (OPD) CP 7219 6618
Site Bleep Holder 7179
Directorate Manager 6675
PA if needed 7418 6618
Nurse Clinician Whoever is on duty
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Ward Posters Section 4
IN THE EVENT OF A PAGER SYSTEM FAILURE
CALL MEDICAL EMERGENCY TEAM/
ADULT/ CHILD CARDIAC ARREST TEAM
TEL: 2222 OR FIRE TEL: 3333
AS PER NORMAL PRACTICE
THANK YOU
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IN THE EVENT OF A COMPLETE COMMUNICATION
FAILURE (PAGERS & TELEPHONES)
WARD/ AREA MANAGERS
MUST Send a runner to Main
Reception (Atrium) to report immediately to the
OPERATIONAL SITE MGR (clearly identified) for an
emergency briefing and further instruction
THANK YOU
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Documentation Section 5
EMERGENCY INCIDENT GENERAL MESSAGE FORM
EMERGENCY INCIDENT LOG
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EMERGENCY INCIDENT GENERAL MESSAGE FORM
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MESSAGE FORM
DATE:
TIME:
FROM:
TO:
SUBJECT:
TEXT:
RECIPIENTS NAME:
PASSED ON TO:
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EMERGENCY INCIDENT LOG
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INCIDENT: SHEET No:
TIME IN/OUT FROM/TO MESSAGE ACTION INITIALS
EMERGENCY INCIDENT LOG
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Hospital Floor Plans Section 6
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St Helens
http://nww.sthk.nhs.uk/pages/AboutUs.aspx?iPageId=3830
Ground Floor First Floor
Lower Ground Floor
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Major Incident Radio Use
Interoperability
The Major Incident radios held in Whiston Execs are NOT interoperable with either those in Emergency Department or St Helens or Medirest radios. Emergency Department radios are interoperable with Medirest radios as they are a similar model.
Usage
Location Mass Casualty Incident issued to
Pager/ phones failure issued to
Channel
Execs Offices NHS Bronze Command & Control Centre
1. Operational Site Manager 2. Medical Care Group Tactical
Coordinator 3. Surgical Care Group
Tactical Coordinator 4. Clinical Support Care Group
Tactical Coordinator 5. Medirest Tactical
Coordinator 6. Vinci Tactical Coordinator
MET & Cardiac Teams
Emergency Department
Key ED staff and porters MET & Cardiac Teams
St Helens Care Group Command & Control Room (Bishops Seminar Room)
St Helens Tactical Coordinators for different specialisms.
MET & Cardiac Teams
Medirest radios
Security
Porters
Catering
Domestics
Vinci radios