Department of Health (WA) Surge Management Plan Prepared by: Disaster Preparedness & Management Unit

Transcription

1 Department of Health (WA) Surge Management Plan 2010 Prepared by: Disaster Preparedness & Management Unit July

2 Table of Contents I. Authority to Plan... 3 II. Endorsement... 3 III. Distribution List... 4 IV. Glossary Introduction Aim History The all hazards comprehensive approach Adoption of prevention, preparedness, response & recovery Health Care Service Delivery in a Major Incident Authority to Activate Plans Use of DoH Resources Use of private health facilities Utilising memoranda of understanding Prevention Prevention of Impact Events Preparedness Responsibilities in state-wide and metropolitan planning Responsibility for local and regional planning Education Exercises and system testing Response Command Communications Plan Activation Procedures Master Action Card 1: Managing Deployment of Hospital Response Teams Master Action Card 2: Managing the Emergency Department Master Action Card 3: Managing Theatre Services Master Action Card 4: Managing Radiology Resources Master Action Card 5: Managing Bed Availability Master Action Card 6: Managing Altered Levels of Patient Care Master Action Card 7: Managing Human Resources Master Action Card 8: Managing Resource Requests Master Action Card 9: Managing Hospital Security Recovery Returning Health Services to Normal functioning Debriefing Management of incurred expenses Review and evolution of plans Appendices...29 Appendix A: Model of State Health emergency chain of command Appendix C: Health communications guidelines Appendix D: Processes to manage deployment of medical teams Appendix E: Process to clear the ED of existing patients Appendix F: Examples of altered service levels matrix Appendix G: Process to identify patients for discharge or transfer Appendix H: Hospital Surge Management Response Checklist Appendix I: Recommended Disaster Hospital Staff Training Matrix Appendix J: Guidelines for Health Service involvement in community planning

3 I. Authority to Plan This plan is prepared by the Disaster Preparedness and Management Unit (DPMU) to fulfil obligations of the Department of Health (WA) to act as a key Support Agency in Western Australia. The development and publication of this plan is authorised by the State Health Coordinator and has the approval of both the Hospital Health Coordinators Group and Health Services Subcommittee. II. Endorsement This plan has been reviewed and endorsed by the Health Services Subcommittee of the State Emergency Management Committee. Dr Andrew Robertson Chair - Health Services Subcommittee Date: 3

4 III. Distribution List Organisation Number of Copies Department of Health Director General 1 Director Disaster Management, Regulation & Planning 1 State Health Emergency Operations Centre 2 Hospitals Emergency Operations Centre 2 Chief Executive Officer - WA Country Health Service 2 Operations Manager PathWest 2 Metropolitan Public Sector Hospitals Armadale Health Service 2 Bentley Health Service 2 Fremantle Hospital & Health Service 2 Fiona Stanley Hospital 2 Graylands Selby-Lemnos Health Services 2 King Edward Memorial Hospital 2 Osborne Park Hospital 2 Peel and Rockingham Kwinana Health Service 2 Perth Dental Hospital 2 Princess Margaret Hospital 2 Royal Perth Hospital 2 Sir Charles Gairdner Hospital 2 Swan-Kalamunda Health Service 2 Metropolitan Private Hospitals Bethesda Hospital 2 Hollywood Private Hospital 2 Joondalup Health Campus 2 Mercy Hospital 2 Mount Hospital 2 Peel Health Campus 2 St John of God Murdoch 2 St John of God Subiaco 2 External Agencies St John Ambulance 2 Advanced Medical Services 1 Royal Flying Doctor Service (WA) 2 Australian Government Department of Health & Ageing 1 Emergency Management Australia 1 Department of Defence HMAS Stirling Naval Base (Senior Health Officer) 1 *** All agencies identified in this list also receive an electronic copy of the plan. 4

5 IV. Glossary AUSMAT-WA WA branch of the Australian Medical Assistance Teams. Also see DMAT. DISASTER - see EMERGENCY DISASTER MEDICAL ASSISTANCE TEAMS (DMAT) A DMAT is a group of medical professionals and paraprofessionals including physicians, nurses, allied health and paramedics, and non-medical members such as logisticians that deploy to the site outside the Perth Metropolitan area to a disaster at short notice. DISASTER PREPAREDNESS AND MANAGEMENT UNIT (DPMU). This is the functional unit within the WA Department of Health that manages the Health involvement in the Prevention, Preparation, Response and Recovery of disasters or major incidents. EMERGENCY - an event, actual or imminent, which endangers or threatens to endanger life, property or the environment, and which is beyond the resources of a single organisation to manage or which requires the coordination of a number of significant emergency management activities. NOTE: The terms "emergency" and "disaster" are used nationally and internationally to describe events which require special arrangements to manage the situation. "Emergencies" or "disasters" are characterised by the need to deal with the hazard and its impact on the community. The term "emergency" is used on the understanding that it also includes any meaning of the word "disaster". EMERGENCY COORDINATION CENTRE - see Hospital Emergency Coordination Centre EMERGENCY MANAGEMENT - is a range of measures to manage risks to communities and the environment. It involves the development and maintenance of arrangements to prevent or mitigate, prepare for, respond to, and recover from. GP SUPERCENTRES these are large-scale GP clinic/primary care centres and often incorporate or are collocated with allied health and essential diagnostic services. These types of centres are commercially available in the metropolitan area now and will be enhanced by the addition of two further centres in Midland and Wanneroo. HAZARD MANAGEMENT AGENCY (HMA) - that organisation which, because of its legislative responsibility or specialised knowledge, expertise and resources is responsible for ensuring that emergency management activities pertaining to the prevention of, preparedness for, response to and recovery from a specific hazard are undertaken. Such organisations are either designated by legislation or detailed in State level emergency management plans. HEALTH COMMANDER the person designated to command hospital response teams at the emergency site. HEALTH SERVICES a generic term used to describe any health service facility including, but not limited to; hospitals, nursing posts, community health centres, public health units, St John Ambulance and Royal Flying Doctor Service. HOSPITAL EMERGENCY CONTACT POINT (HECP) the one emergency contact point (telephone number) identified by each hospital designated to accept emergency notifications from the Hospitals Emergency Operations Centre. HOSPITAL EMERGENCY COORDINATION CENTRE (HECC) This is the area designated within each hospital to house the coordination activities required to manage responses within each individual hospital. 5

6 HOSPITALS EMERGENCY OPERATIONS CENTRE (HEOC) The physical location used to; coordinate communications between the medical teams at an emergency site and the metropolitan hospitals, and manage the allocation and distribution of Human and material resources in an incident or emergency across the metropolitan area. HOSPITALS EMERGENCY OPERATIONS CENTRE COORDINATOR (HEOC Coordinator) The individual tasked with the coordinated operational management of the Metropolitan Business Continuity and Disaster Plan and the DoH Surge Management Plan This person coordinates the Hospital Emergency Operations team to meet the clinical resource requirements of the incident/disaster. HOSPITAL RESPONSE TEAM the team of hospital personnel deployed to an incident site to facilitate casualty emergency medical management prior to transportation. HOSPITAL RESPONSE TEAM LEADER the individual informally allocated the role of Team Leader and responsible for the general welfare of the hospital response team. MAJOR INCIDENT see EMERGENCY MASS CASUALTY INCIDENT (MCI) an emergency or disaster that leads to large numbers of casualties. METROPOLITAN AREA the greater Perth geographic region contained within the area bounded by Peel Health Campus, Armadale-Kelmscott Health Service, Swan-Health Service Joondalup Health Campus and Rottnest Island Nursing Post. METROPOLITAN BUSINESS CONTINUITY & DISASTER PLAN (MBCDP) provides the operational framework, to manage and maintain critical business functions in the event of system failure(s) or a mass influx of patients due to an external incident or disaster. REGIONAL HEALTH DISASTER COORDINATOR (RHDC) The disaster coordinator functioning within WACHS at the Regional level. RISK MANAGEMENT the systematic application of management policies, procedures and practices to the task of identifying, analysing, evaluating, treating and monitoring risk. Refer to AS/NZS Standard 4360:2004 (Risk Management). STATE EMERGENCY MANAGEMENT COMMITTEE (SEMC) The state level emergency management committee responsible for the state-wide prevention of, and preparation for emergencies or disasters. STATE EMERGENCY COORDINATION GROUP - The state level emergency management committee responsible for the state-wide coordination of emergency response to any disaster. This committee is in effect only for the response period of an emergency or disaster. STATE HEALTH COORDINATOR (SHC) - The State Health Coordinator has the authority to command the coordinated use of all health resources within WA, for response to and recovery from, the impacts and effects of a major emergency or disaster situation. STATE HEALTH EMERGENCY OPERATIONS CENTRE (SHEOC). This is the State-level Health operations centre that addresses strategic management of an incident/disaster as well as facilitating management of state-wide events. TRAFFIC MANAGEMENT PLAN This is the plan developed by a hospital and implemented in a disaster to manage local traffic flows to facilitate access to and egress from the hospital for casualties and decanting patient transportation. These plans detail staff requirements, roles, resources, processes and traffic flows to be implemented in a disaster. 6

7 1.0 Introduction 1.1 Aim This Surge Management Plan provides guidelines to coordinate the Health Services Management of a major incident in Western Australia at local, regional and state-wide levels. Surge capacity management relates to the ability of a health service to manage a larger-thannormal number of casualties over a defined period of time. This time period varies according to the type of incident, existing capacity of the health system, location and transportation arrangements in place for the movement of casualties. Time periods for the initial presentation of this surge of patients may be over minutes to hours as in the case of impact events, such as plane crash, train derailment and chemical release. The provision of acute care is determined primarily by the capacity to increase acute care bed provision and the graduated application of triaged resources to support the concept of doing the most for the most. The guidelines published within this Surge Management Plan identify practical measures to achieve surge capacity for 1000 casualties for up to 36 hours. 1.2 History Subsequent to the Madrid bombings in March 2004, the (then) State Health Disaster Management Committee requested a review of the Metropolitan Perth Areawide Business Continuity Plan with the goal of identifying existing surge capacity. From this review, plan development goals were finalised to enable management of casualties, casualties and casualties. These figures are in line with the West Australian (WA) Police planning. The Disaster Preparedness and Management Unit (DPMU) is in the process of implementing the Incident Command System (ICS) within the State Health Emergency Operations Centre (SHEOC) and Hospital Emergency Operations Centre (HEOC). Additionally, DPMU are implementing WebEOC, a web based Crisis Information System that will enable the WA Department of Health (DoH) coordinate all health sites electronically. The implementation of the above will necessitate a review of this Surge Management Plan following a major health exercise scheduled for November The all hazards comprehensive approach Health services throughout WA have adopted the All Hazards approach to planning for disasters. This approach utilises a comprehensive planning process that will enable similar Health responses to be used for all identified and unidentified disasters by providing basic, adaptable frameworks. The strategies and guidelines presented in this plan are generic in nature yet provide adaptable, practical guidance to be used for any major incident with large casualty numbers. 1.4 Adoption of prevention, preparedness, response & recovery Disaster planning and management has benefitted considerably with the adoption of the prevention, preparedness, response and recovery (PPRR) framework. This simple framework provides comprehensive risk management processes required to ensure Health Service readiness, and to identify and mitigate risk whilst providing appropriate levels of response and recovery planning. This Surge Management Plan uses the PPRR framework. 7

8 2.0 Health Care Service Delivery in a Major Incident In a Major Incident leading to significantly increased hospital (and health services) presentations, the distribution of health resources to individual patients is dependent on patient injuries balanced with both the number and experience of the Health care team and availability of physical resources. In large scale incidents or disasters, casualty numbers and acuity will certainly stress and may overwhelm healthcare facilities to the point where decisions will need to be made regarding which patients will have priority to resources and care. In delivering health care to victims of a disaster, any basis for the allocation of both human and physical resources must be appropriate, fair and clinically sound. In addition to this, decisions regarding provision or restriction of care must be transparent and reproducible between staff and different healthcare facilities. The goal of any health and medical response in a mass casualty incident (MCI) is to save as many lives as possible. In these incidents, the re-allocation of WA Health resources from routine, everyday practices to the emergency management of large numbers of high acuity casualties will simultaneously improve service provision to casualties while altering the standard of care provided to those health-users not involved in the incident. Additionally, the involvement of any health service in the management of a major incident with catastrophic casualty numbers will challenge the traditional concepts of where care is delivered and also by whom. In a catastrophic incident, medical care may be delivered outside of the traditional setting in areas such as community halls, hotels and schools. Because of overwhelming casualty numbers or significant loss of health staff, the traditional roles of nursing, medical and allied health staff may be modified. 2.1 Authority to Activate Plans All plans used to facilitate the Health response to any major incident must be authorised for use by the State Health Coordinator. This authorisation will be communicated to hospitals and Health services through the State Health Emergency Operations Centre. The plans that may be used activated include: WESTPLAN - Health Metropolitan Business Continuity & Disaster Plan DoH (WA) Surge Plan (this plan) Hospital Response Team Capability Plan Nursing Resource Plan State Trauma Plan State Burns Plan In addition to the WA plans (above), the SHC can request the activation of national response plans through the appropriate State Emergency Management channels to support the health response in WA. These national plans may include: AUSTRAUMAPLAN, which incorporates AUSBURNPLAN COMDISPLAN OSMASSCASPLAN National Health Emergency Response Arrangements 8

9 2.2 Use of DoH Resources As the delegate of the Director General for Health, the State Health Coordinator may authorise the utilisation and coordination of any public health resources within the state to aid in the health management of a major incident or disaster. In addition to this, memoranda of understanding (MOU) are in effect with both service and product suppliers and private health services within the state and can be activated to provide additional support. Health Services will be advised of these activations via standard communications with the Hospital Emergency Operations Centre (HEOC) or State Health Emergency Operations Centre (SHEOC). These MOU are managed by the DPMU. 2.3 Use of private health facilities The utilisation of private Health facilities must be authorised by the SHC and will occur if the number or acuity of casualties is such that facilities within the public health system are unlikely to cope. Private health facilities may include private hospitals, day surgery clinics, GP clinics and in the future, GP Superclinics. Private health facilities may be used in the following manner: To accept and manage casualties direct from an incident site To accept and manage patients decanted from tertiary or other hospitals o This may include general medical, surgical and critical care / ICU type patients To provide specialist services as required (such as specialist surgery or other theatre sessions) 2.4 Utilising memoranda of understanding The State Health Coordinator must authorise the use of any MOU s with private hospitals and key support/supply contractors. All requests to utilise any MOU must be directed through the SHEOC to the State Health Coordinator. 9

10 3.0 Prevention As a component of the Australian and New Zealand Standard (AS/NZS ISO 31000:2009), individual Area Health Services and the Department of Health (WA Health) are responsible for maintaining a risk management process that addresses existing and potential risks to service provision. The outputs of this process identify potential risks and enable thoughtful consideration of impact to the health Service. From this, mitigation strategies can be implemented to reduce or eliminate risk exposure and it is this process that enables Health Services the opportunity to have input to the prevention of major incidents at a local, regional and state-wide level. 3.1 Prevention of Impact Events Mass Casualty Incidents The prevention of a sudden disaster or major incident is largely beyond the functional capacity of the DoH. However, in the case of community-based cultural events (sporting, festivals, special events etc), there is capacity for elements of Area Health Services and the DoH to be involved in the event development and risk management planning process. The Disaster Preparedness and Management Unit (DPMU) has developed a risk assessment matrix to be used by Health Services, Community Health Officers and Event Organisers to assess an event and provide guidelines for inclusion of Health Services in the planning and development of planned community-based events. These guidelines and are available from the Disaster Preparedness & Management Unit. Guidelines have been developed for use by Metropolitan, Regional and Rural Health Services to promote a positive and active involvement in WA communities via Local Emergency Management Committees (LEMC s). These guidelines highlight the expectation of Health involvement as well as providing support information for Health Service representatives on these committees. Broadly, involvement in these committees provides opportunity for Health Services to prevent unnecessary complications of these events in the areas of public health, first aid and acute care services as well as identifying local emergency response processes to be used in a major incident. All Health services in WA are expected to be actively involved in their local LEMC. These guidelines are presented in Appendix H. 10

11 4.0 Preparedness In line with WESTPLAN-Health, Health services are required to ensure that local plans to manage Health Service responses to external disasters are prepared and maintained. 4.1 Responsibilities in state-wide and metropolitan planning The DPMU within the DoH is tasked with the preparation and development of metropolitan and state-wide surge strategies and plans to facilitate coordinated management of casualties and available health resources in a disaster. At a Commonwealth and national level, Disaster Management, Regulation & Planning Directorate (DMRPD) provides representation for Western Australia in the area of Disaster Preparedness & Management and promotes awareness and integration of state and national plans emergency plans. Local hospitals and health services are responsible for development, maintenance and integration of local disaster response plans. These plans shall adhere to Australian standards in terms of both naming conventions and requirements to meet any appropriate ACHS guidelines. 4.2 Responsibility for local and regional planning Regional Health Service plans shall address and incorporate concepts and strategies presented within this Surge Management Plan and associated appendices into regional disaster management plans. Individual hospitals are responsible for ensuring local plans which incorporate guidelines published in this plan, are in place. 4.3 Education Education of both clinical and administrative support staff is essential in ensuring an appropriate response capability within all Health Services. The DPMU provide an extensive range of courses that provide upskilling opportunities for appropriate staff. Hospitals and regional Health Services shall identify which staff will be required to act in various roles and to ensure that these staff are educated appropriately. A matrix of recommended training for hospital staff is provided in Appendix F. 4.4 Exercises and system testing This plan is developed in partnership with the Area Health Services, including the WA Country Health Service. It is the responsibility of all involved parties to ensure that emergency plans are exercised and tested regularly, and reviewed and updated after exercises and activation. Testing of plans can include discussion exercises, table top exercises, field exercises or use of the Emergotrain Training System. Where possible, exercises should include clinical, administrative and executive staff. 11

12 5.0 Response In a MCI, the number of casualties or presentations may be so great that individual Hospitals and Area Health Services will be overwhelmed and unable to function using standard operating procedures. In these instances, the best patient outcomes will be achieved by implementing a coordinated Health response utilising Surge Management Guidelines, which outline strategies and dictate changes in usual practice. The guidelines presented in the accompanying appendices outline the main processes that may be implemented by individual hospitals, corporate DoH and Area Health Services to facilitate the coordinated management of casualties in a major incident. Health Services are to review these guidelines and develop appropriate internal processes and plans to support the implementation of these concepts. 5.1 Command An established command and communications structure is essential to a successful Health response to a major incident with resulting casualties. Command is the vertical transmission of authority within Health with the State Health Coordinator being ultimately responsible for the efficient management of any Health response to a major incident. To enable this, the SHC is delegated the authority to coordinate any and all Health resources to provide an appropriate response to the disaster. Through the Chain of Command, this authority is passed down through the State Health Emergency Operations Centre and on to Health Services and hospitals. A diagram of this structure is presented in Appendix A. 5.2 Communications The basis for successful management of any system-wide emergency within the Health sector in Western Australia is the effective use of communications technologies. In reviewing reports of exercises and incidents in WA, Australia and internationally, inefficient communication both within and between responding agencies is consistently identified as a major problem that significantly degrades response. With the outcomes of poor communication within the Health sector measured in terms of elevated casualty mortality and morbidity rates, appropriate, concise and time-efficient communication is of utmost importance in managing casualty care. The communication guidelines presented in Appendix C ensure consistency and clarity within the Health emergency sector and apply to all UHF radio, telephone, satellite phones, communications and Crisis Information Management Systems used by Health during the management of any threats to Clinical Business Continuity. Examples of these threats may include any mass casualty incident, emergency evacuation of a Health facility and interruption to supply chains, including loss of energy sources, pharmaceuticals, support services or medical consumables. 12

13 5.3 Plan Activation Procedures The WA DoH can be notified of a MCI by various sources. A Model of State Health Emergency Response Activation Processes is outlined in Appendix B. Stages of Activation This Surge Management Plan will normally be activated in stages. In an impact event, these stages may be condensed with stages being activated concurrently. a. Stage 1 Alert: The alert stage is activated when advice of an impending or potential emergency is received or when, following the occurrence of an event, it is unclear as to whether a health emergency management response is needed. During this stage, the situation is monitored to determine the likelihood and nature of the health emergency management response. The following actions are undertaken: On-Call Duty Officer The OCDO will receive notification of an actual or potential incident The OCDO shall notify the SHC of the incident and await further instruction. As required, the OCDO will notify the HEOC Coordinator of any hospital preparation/response actions determined by the SHC. State Health Coordinator The SHC will receive notification of the incident from the OCDO. The SHC will determine the extent of preparation or response required and authorise the OCDO to commence notification of these. As required, the SHC may advise the Director General (Health), Executive Director of Public Health and WACHS, SEMC/SECG, State Health Executive Forum (SHEF) members and the DoH Public Affairs Department. Hospitals Emergency Operations Centre The HEOC will notify hospitals (via the hospital emergency contact points) as well as appropriate support agencies of the activation of the ALERT status, providing a brief overview of the incident/potential incident. The HEOC will notify the Ambulance Distribution Coordinator (ADC) of the ALERT status. The HEOC Coordinator will review staffing and operations centre availability. The HEOC will monitor the incident and the impact on Health operations. Hospitals Upon notification of ALERT status, hospitals will ensure that all appropriate hospital executive and emergency management staff are advised of the potential incident. In addition to the above, hospitals shall activate any appropriate internal processes to match the ALERT status. 13

14 b. Stage 2 Standby: The standby stage is activated when information received is sufficient to warrant preparatory activities in readiness for a response. Depending on the situation, the following actions may be undertaken: On-Call Duty Officer As requested by the SHC, the OCDO will review SHEOC staffing and operations centre availability. As requested by the SHC, the OCDO will activate the SHEOC. State Health Coordinator Upon receipt of further information, the SHC may decide to escalate the Health response to Standby. The SHC will communicate the change in status to the HEOC Coordinator & OCDO. As required, the SHC may update or advise the Director General (Health), Executive Director of Public Health and WACHS, SEMC/SECG, State Health Executive Forum (SHEF) members and the DoH Public Affairs Department. Hospitals Emergency Operations Centre The HEOC will notify hospitals (via the hospital emergency contact points) as well as appropriate support agencies of the activation of the STANDBY status, providing a brief overview of the incident. The HEOC will notify the ADC of the activation of STANDBY status. The HEOC will be prepared for use including checking of equipment and ensuring staff availability. The HEOC will monitor the incident and the impact on Health operations. Situation reports will be distributed from the HEOC as required. As required, liaison staff from St John Ambulance (SJA) and Royal Flying Doctor Service (RFDS) are identified. As required, Metropolitan Business Continuity Plan Expert Advisers are notified of the incident. Hospitals Upon notification of STANDBY status, hospitals will activate internal plans to support preparations for response. This may include: o Checking deployable team membership and equipment o Review of ward patients to identify likely early discharges or transfers if required. o Reviewing theatre lists to determine timeframes that individual theatres will next become available. o All areas to review current and expected staffing levels. o Determine current bed status. o Ensure the hospital operations centre is available and functioning. Ambulance Distribution Coordinator Upon notification of STANDBY status, the ADC will contact the St John Ambulance operations centre to establish communications and review current hospital ED and ambulance load. 14

15 c. Stage 3 Response: The response stage is activated when a health emergency management response is required and resources are deployed accordingly. Depending on the situation, the following actions may be undertaken: On-Call Duty Officer/SHEOC As requested by the SHC, the OCDO will establish the SHEOC. The SHEOC shall provide liaison staff to the HMA and the State Coordination Centre as required. State Health Coordinator Upon receipt of further information, the SHC may decide to escalate the Health response to Response. The SHC will communicate the change in status to the HEOC Coordinator & OCDO. As required, the SHC may update or advise the Director General (Health), Executive Director of Public Health and WACHS, SEMC/SECG, State Health Executive Forum (SHEF) members and the DoH Public Affairs Department. Hospitals Emergency Operations Centre The HEOC will notify hospitals (via the hospital emergency contact points) as well as appropriate support agencies of the activation of the RESPONSE status, providing a brief overview of the incident. If Hospital Response Teams are required, the HEOC will contact the SJA Operations Centre and request ambulance transport for identified teams. The HEOC will notify the Ambulance Distribution Coordinator of the activation of RESPONSE status. Liaison staff from SJA & RFDS are requested to attend the HEOC. The HEOC will continue to monitor the incident and the impact on Health operations. The HEOC assumes responsible for: o Establishing and managing the central Health communications hub. o Management of Health resources across individual sites. o Determining bed and service availability across Health sites. o Casualty distribution across metropolitan hospitals. o Facilitating any required decanting of in-patients to other hospitals. Hospitals Upon notification of RESPONSE status, hospitals will activate internal (Code Brown) plans to support the response. This may include: o Deployment of Hospital Response Teams as requested by the HEOC. o Notification to appropriate hospital executives, managers and emergency management teams. o Ensure the hospital emergency coordination centre is activated and functioning. o Advise the HEOC that the individual hospital emergency coordination centre has been activated. o Complete radio check as outlined in this plan o Complete the HEOC Hospital Status Form and return vie as requested. o Complete the HEOC Decanting Requirements Form and return via as requested. o Implementation of surge strategies as outlined in this plan. Ambulance Distribution Coordinator Upon notification of RESPONSE status, the ADC will contact the St John Ambulance operations centre to establish communications and confirm the ADC will be responsible for casualty distribution until the HEOC is operational. 15

16 d. Stage 4 Stand Down: The stand down stage may be activated when components of the Health response are no longer required. The decision to stand down components, single or multiple health services from an emergency response shall be made by the State Health Coordinator and may be effected in a graduated manner. As the impact of the incident on Health emergency responses will be varied, it is probable that as some components of emergency response (e.g. deployed hospital response teams) are being wound back, other components of the response (such as ED and in-patient management) are increasing and likely to continue so for an extended period of time. It is with this concept in mind that the following actions are provided. On-Call Duty Officer/SHEOC As requested by the SHC, the OCDO may stand down the SHEOC. The SHEOC shall recall liaison staff from the HMA and the State Coordination Centre. State Health Coordinator Upon receipt of further information, the SHC may decide to return the combined Health emergency response to STAND DOWN. The SHC will review ongoing requirements for casualty care and where appropriate, commenced the stand-down of individual components (such as deployed medical teams), single or multiple hospital sites. The SHC will communicate the change in status to the HEOC Coordinator & OCDO. As required, the SHC may update or advise the Director General (Health), Executive Director of Public Health and WACHS, SEMC/SECG, State Health Executive Forum (SHEF) members and the DoH Public Affairs Department. Hospitals Emergency Operations Centre This may include the following actions: The HEOC will notify specific hospitals (via the hospital operations centres) as well as appropriate support agencies of the activation of the STAND DOWN status. The HEOC will notify the Ambulance Distribution Coordinator of the activation of STAND DOWN status. If Hospital Response Teams were deployed, the HEOC will arrange return transport for deployed teams in consultation with St John Ambulance (SJA). Liaison staff from participating support organisations are released. The HEOC will continue to monitor the incident and the impact on Health operations. Hospitals Upon notification of STAND DOWN status, hospitals may commence activities to support a return to standard service levels. This may include: o Activating components of any hospital plan designed to return the hospital to standard functioning. o Notification to appropriate hospital executives, managers and emergency management teams. o Deactivating the hospital s operations centre. o Advising the HEOC that the hospital operations centre has been stood down. The degree to which any Health service is able to return to normal service levels (including corresponding changes to practice) will be determined locally by hospital executive. Ambulance Distribution Coordinator Upon notification of STAND DOWN status, the ADC will contact the St John Ambulance operations centre to establish communications and confirm the ADC will again be responsible for exceptional casualty distribution. NOTE: The HEOC and/or SHEOC will remain activated and operational whilst any WA hospital or health service remains in active emergency response to the incident. 16

17 5.4. Master Action Card 1: Managing Deployment of Hospital Response Teams Within the WA Health system, the two different types of medical teams that may be deployed to assist in the Health management of a major incident are the Hospital Response Teams (HRT) and the Australian Medical Assistance Teams WA (AUSMAT-WA). Activation and deployment processes of HRT s and AUSMAT WA are detailed in the Hospital Response Team Capability Sub-plan. 17

18 5.5 Master Action Card 2: Managing the Emergency Department The hospital emergency department will be the first and primary entry point for all presenting victims or casualties from any major incident. Consequently, rapid instigation of appropriate management practices in the ED is of paramount importance in minimising the impact of patient surge. Consider the use of the following list of actions to manage the ED: 1. Clearing the emergency department Consider implementing the Clearing the ED guidelines (see Appendix E) 2. Minimising ambulance waiting times Consider the following: Activating the hospital traffic management plan When the casualty is unloaded, move them onto a hospital trolley quickly Allocate staff to accept casualty handover and to continue casualty monitoring Ensure adequate cleaning equipment (mops, buckets, cleansing agents etc) is located in the ambulance reception area If staffing permits, allocate one or more cleaning staff to assist with ambulance cleaning whilst casualty handover is in process 3. Triaging access to the emergency department Consider the following: Implement your hospital s chosen disaster triage system. These choices include: o Continue to use the existing Australasian Triage Standard (ATS) o Adoption of manual (eg. Down-time) ATS systems o Adoption of the Mass Casualty Triage Standard (Triage Sort) Establish a pre-triage staging area to assess casualties where; o Identified high priority casualties are moved through to ED triage o Delayed priority are moved to a dedicated area or alternatively directed to out-of-hospital centres (such as GP supercentres) for ongoing management o Uninjured are returned to community, with follow up instructions to contact their GP if required. 4. Management of Delayed Priority Casualties Consider the following: Designate an area away from the ED to manage delayed priority casualties. Ensure all walking wounded are directed away from the ambulance reception point to the designated area Allocate appropriate levels of staff to manage any alternative treatment areas. 5. Controlling access to theatres and radiology Consider the following: Implement surgical triage - Where possible a senior surgeon should be allocated this role. It is this person that allocates theatre resources and defines the extent of any surgery. Implement standardised radiology screening - A senior ED doctor or consultant in consultation with the duty radiologist must identify which standard radiology procedures are to be used and which will be restricted. 6. Management of ED Security (refer to Master Action Card 9) Consider the following: Establishing a heightened security presence both within and external to the ED Pre-emptively implement hospital Lockdown procedures to manage casualty and general public access to any ED resources. 7. Management of Family & Friends Consider the following Designate an area away from the ED to manage casualty enquiries Ensure a process is in place to manage physical enquiries Ensure a process is in place to manage telephone enquiries Allocate appropriate levels of staff to manage any family areas. 18

19 5.6 Master Action Card 3: Managing Theatre Services In any major incident involving trauma, it is anticipated that approximately 10-15% of presentations will require surgery and critical care management with another 30-40% of presentations requiring significant health resources possibly including theatre, acute care management and rehabilitation. Consequently, the demand for access to appropriately staffed and resourced operating theatres will be significantly increased. On notification of a MCI, health services are requested to assess their theatre capacity and current emergency and elective commitments and notify HEOC of current and future theatre availability. In order to maximise availability of theatre and surgical resources, consider the adoption of these strategies: 1. Graduated cancellation of elective, non life-threatening surgery Consider the following: Individual hospitals may choose to initially delay then cancel non life-threatening elective surgery to provide requested beds. The widespread cancellation of non life-threatening elective surgery can only be authorised by the State Health Coordinator. The following levels identify how cancellation of non life-threatening elective surgery may be implemented: o Level 1 Reduction All non life-threatening elective surgery ceases in receiving hospitals. o Level 2 Reduction - As confirmation of mass casualty details become available, as required, non life-threatening elective surgery is cancelled in all surge hospitals within the metropolitan area. o Level 3 Reduction Depending on known casualty numbers, acuity, critical care utilisation and expected management capacity of metropolitan health services, a state-wide cessation of non life-threatening surgery is called. 2. Introduction of a surgical triage role Consider the following: Adoption of a surgical triage role. Ideally this role should be filled by a senior general or trauma surgeon. The adoption of the theatre triage role is designed to control access to and extent of any theatre procedures that are undertaken. The process of surgical triage may be completed in ED or in the designated theatre holding area and ensure that those casualties with the best opportunity for survival and recovery can be managed appropriately using limited theatre time. 3. Adoption of Damage Control Surgery to maximise theatre availability Consider the following: Adoption of the principles of damage control surgery. o Stage One: Brief, initial surgery to control haemorrhage, save life & limb and to determine the extent of injury. o Stage Two: Continued resuscitation and stabilisation of the patient in an ICU facility before commencing stage three. o Stage Three: Planned, definitive surgical management. The adoption of the above strategies will lead to shorter initial theatre sessions to support lifesaving procedures as opposed to definitive care. The implementation of these principles of damage control surgery integrates with the intent and processes of the surgical triage role. 19

20 5.7 Master Action Card 4: Managing Radiology Resources Efficient management of radiology resources will be critical to managing the surge and subsequent flow of patients. The allocation of resources to patients will be changed to providing the greatest clinical coverage for the least number of radiological views or procedures. In order to maximise availability of radiology resources, consider the adoption of these strategies: 1. Adoption of radiology triage role Consider adoption of the following strategies: Implementation of radiology triage. This may be attained by appointing a dedicated individual such as a radiologist or attaching the responsibility for this role to a senior member of ED medical staff. This role manages triaged access to radiology resources within the hospital and includes both ED and main department facilities. 2. Implementation of standard radiological assessment In any patient surge, access to the standard range of radiological investigations will need to be restricted. The senior doctor within the ED should consider adopting a standard, basic range of radiological examinations per patient which may include: Long bones CXR Pelvis This means that other routine examinations such as spinal assessment and CT scanning (particularly head injury) will be delayed until the patient surge subsides. This also means that completion of standard trauma radiology examinations may not be completed for hours to days after the initial incident and resulting patient surge. 3. Development of standardised levels of radiological assessment Hospital planning processes may include work to develop a local concept of how radiological resources can be most efficiently utilised in a patient surge. Hospitals may wish to consider developing a tiered system of radiological examinations that relates to the degree of patient surge being experienced. As an example, the following table is presented: Tiered levels of reduction Patient Numbers Surge Radiology Exams Include Radiology Exams Exclude (unless triaged / authorised) Level 1 Existing maximum routine departmental capacity Level 2 50% over routine departmental capacity Level 3 100% over routine departmental capacity No change to everyday practice Long bones CXR Pelvis CT FAST Scan Long bones CXR Pelvis CT (Head only) No change to everyday practice Minor views MRI Spinal Clearance Minor views MRI CT - other Spinal clearance FAST Scan At both the commencement of an incident and regularly thereafter, the rostered ED consultant or senior doctor should liaise with the Radiology Consultant to determine at which service level radiology services should operate. 20

21 5.8 Master Action Card 5: Managing Bed Availability Bed management practices both within and between Health Services will be the single most important factor in managing any patient surge. Exercises within WA have identified that significant numbers of ward beds are likely to be made available through early discharge and decanting to secondary & private hospitals while the availability of critical care beds will be scarce. There are a number of important bed management changes that can be implemented in an emergency that would otherwise be unacceptable. In order to maximise bed availability in a patient surge, consider the adoption of these strategies: 1. Cancellation of elective non life-threatening admissions Cancelling elective, non life-threatening theatre sessions and outpatient procedures will increase both bed availability and associated staffing and resource provision. 2. Emergency discharge of appropriate patients Hospitals are to review existing in-patients and determine which patients are suitable for early discharge to the community. Patient assessment criteria and process guidelines are presented in Appendix G. 3. Emergency transfer of appropriate patients to secondary and private hospitals Using the discharge/transfer guidelines provided in Appendix G, those patients deemed suitable for transfer to a secondary hospital should be identified and immediately prepared for transfer. Once authority for transfer has been obtained from the HEOC, these patients should be moved to the designated surge discharge/transfer lounge without delay. 4. Increasing discharge/transfer lounge capacity When hospitals have determined which patients are to be discharged or transferred, these patients should immediately be moved out of the wards and into designated discharge/transfer lounge(s). Hospital must have plans in place to pre-identify possible locations of the discharge/transfer lounge(s) and how to safely manage these patients until they can be discharged or transferred to another hospital. 5. Opening of non-conventional areas to house patients As a result of patient surge, non-traditional areas of the hospital (or even community) may need to be used to treat varying acuity of patients. Hospitals must have plans in place to pre-identify possible locations of these areas and how to best resource these areas to safely manage patients care. The use of any out-of-hospital centres to provide patient care must be authorised by the SHC. 6. Cohorting of disaster patients Consider adoption of the following strategies: Empty one or more patient wards by moving, discharging or transferring existing patients. Hospitals should aim to pre-identify priority wards for emergency decanting and develop internal processes to support this. Aim to admit all non-critical care disaster patients to the emptied wards as this will provide better management of relatives, support services such as radiology, attending medical teams and the media. Similarly, if possible, cohort high acuity patients in one or adjacent critical care unit(s) as appropriate. 7. Facilitating patient transportation Consider adoption of the following strategies: Allocating a fixed number of administrative/non-direct clinical staff such as orderlies to assist in the transportation of decanting patients. Utilise internal hospital transportation resources in a prioritised manner. When these resources are exceeded, the HECC shall liaise with the HEOC for additional resources. 21

22 5.9 Master Action Card 6: Managing Altered Levels of Patient Care In any disaster or major incident with large or overwhelming casualty numbers, the strain of increased patient presentations in the hospital combined with relatively fixed or decreased staff numbers is likely to have a negative effect on patient care. A number of strategies have been outlined in this plan to manage patient surge and have largely focused on changes in the standard management of both human and material resources. When changes in clinical, support service and administrative practice fail to provide adequate resources to provide routine levels of patient care, an alteration in the level of care delivered to patients is required. The application of altered service levels is dynamic and is likely to vary based on time, from service to service and geographically across the state. 1. Local implementation of altered levels of care If an altered level of care has been authorised by the SHC, Health Services can make decisions to amend the level of care delivered to patients as deemed appropriate for the incident and hospital. The authorisation and adoption of altered levels of care is designed to enable care to be delivered to a greater number of casualties or patients to fulfil the motto do the most for the most. In order to implement altered levels of patient care in a consistent and transparent manner, evaluation of the following key points is advocated: Total number of patients Acuity of presenting patients Availability of hospital infrastructure Availability of human resources Development of local guidelines detailing local decision making processes and support for staff To support these processes, hospitals should include this concept in routine emergency planning prior to an incident and have plans in place at the hospital and ward or departmental level to implement as necessary. Examples of how altered levels of care may be implemented locally are included at Appendix F. 22