code red: preparedness and response procedure€¦ · effective: 30 september 2016 wachs kimberley...

Effective: 30 September 2016

WACHS KIMBERLEY Wyndham Hospital

Code Red: Preparedness and Response Procedure

1. Guiding Principles

The Fire Safety guidelines aim to assist staff to prevent the outbreak of fire and to minimise subsequent risk/danger. 1.1 It is the responsibility of all staff to know:

· your procedures · your role · your environment

1.2 It is the responsibility of the organisation to ensure:

· fire safety is managed · buildings are maintained in a fire safe condition · training for high, medium, low risk is provided · fire and emergency equipment is maintained

2. Preparedness

2.1 Training

· See Learning Management System (LMS)

2.2 Orientation to work area

2.3 Internal FIRE-FIGHTING Equipment · Health Services have three types of Fire Fighting Equipment:

- Fire Extinguishers - detailed instructions are written on or above each extinguisher.

- Fire Blankets – for use with fat / stove fires / burning persons. - Fire Hose Reels– for ordinary combustibles.

2.4 Fire Rated Doors

‘Rated fire doors’ in the hospital are held open by electronic magnets, which are connected to the fire detection system. Upon activation of the fire detection system, the retaining magnets are demagnetised allowing the doors to close. This is done to prevent the spread of smoke and fire. Never prop open fire doors.

Date of Last Review: September 2016 of 16 Date Next Review: September 2018

Code Red Preparedness and Response Procedure – Wyndham Hospital

3. Announcing the Code

Ensure announcements are made over the public address system (where available): Attention all staff - Attention all staff. This is an unconfirmed/Confirmed Code Red for [Work Area/Location]. All Area Wardens are to proceed to the Emergency Control Points When the colour code is announced over the public address system staff must begin activation of this procedure. Once confirmed, the same announcement is to be made confirming the Code Red.

False Alarm: If false alarm is confirmed, make Public Address announcement No 2 to All Work Areas (refer to Public Address announcement card in fire control panel cupboard). Attention all staff - Attention all staff. This is an All Clear Code Red announcement.

Repeat announcement. Return to the Fire Indicator Panel to isolate the zone in alarm so that monitoring equipment can resume normal operations.

4. Response

4.1 In the event of a fire, RACE

Remove – (Stage 1 Evacuation) anyone in immediate danger Move patients in order; ambulant, semi-ambulant and then non- ambulant. Alert – raise the alarm (if not already raised)

1. Sound the alarm to summon help and for emergency services to fight the fire.

2. Call 000 to ensure notification of the Fire Brigade (Volunteer Fire and Rescue Service) and provide information on:

- Identify yourself with your full Name. - Location of the fire. - Seriousness of the fire. - Number of people in immediate danger, - Action taken, assistance required and - Effectiveness of any fire containment or extinguishing attempted.

3. Activate Manual ‘Call Point’ (break glass alarm) where fitted if alarm not already raised

4. Notify other persons in the area. 5. Report to your Area Warden for instructions.



Confine – close doors to contain the fire if safe to do so 1. Closing the door/windows. 2. Turn off gas valves and electrical apparatus (including air-conditioners

where applicable) 3. Move flammable items to restrict the access to fuel and slow the

spread of fire 4. Leave lights on to increase safety of fire-fighters. Use firefighting

equipment. Fighting the fire is a secondary consideration and is only to be attempted only if staff member has received fire suppression training and the ability to safely extinguish the fire.

Extinguish / Evacuate – If ever in doubt, retreat from the fire and only attempt if:

· it is safe and you are confident to do so · the correct equipment is available (red cylinder/black band fire

extinguisher may be used on all types of fire), and/or have a clear path to the nearest exit

Commence evacuation at direction of the Area Warden. If there is immediate danger to any persons commence Stage 1 Evacuation as per RACE actions without waiting for direction.

4.2 Action in the event of EVACUATION

· Do not put lives at risk

· If unable to control fire, everyone must with draw - Smoke is responsible for the majority of fatalities in fires. The air is generally more pure at approximately 30cms above floor level. Cover your mouth with a cloth and breather slowly through your mouth.

· Close doors - A standard hospital door can withstand fire for up to 30 minutes and a ‘rated fire door’ for up to 2 hours. Therefore, in the event of a fire, it is important to close all doors and windows, if possible. This will retard the spread of smoke and fire, minimising the damage to the infrastructure and increasing time for persons to evacuate

· Reassure evacuees that help is at hand - Do not re-enter a fire area to retrieve objects or to look for missing persons. YOUR LIFE IS MORE IMPORTANT THAN ANY OBJECT. The Fire Brigade Officers are trained to conduct rescues and have the appropriate protective equipment

4.2.1 Authority to Evacuate · The authority to order a total evacuation will always remain the

responsibility of the Chief Fire Warden/Chief Warden or most senior person present. Any directions given by the Fire Brigade (FESA) should be carried out.



4.2.2 Stages in Evacuation Stage 1 – 3

Stage 1: ROOM – Remove everyone from the room the fire/hazard is in and close the door.

Stage 2: COMPARTMENT - Smoke compartments only extend into the ceiling space and smoke may build up and spill over into the next smoke compartment. Hence this provides safety for a limited time period depending on the rapidity of the smoke build up. If smoke enters your compartment, you must move to the next compartment immediately. Smoke will kill you long before fire does. Fire compartments extend all the way through the roof space from floor to roof and delay the actual progress of a fire for up to four hours.

Stage 3: BUILDING – Evacuate the whole building to a designated muster

station outside, away from the building 4.2.3 Evacuation order

The evacuation of persons should be carried out in this order: · People nearest the danger · Ambulant patients and visitors · Ambulant patients that require assistance · Bedfast patients · Personnel.

4.2.4 Evacuation procedure stages 2/3 1. The Chief Warden, Deputy Chief Warden and/or Fire Brigade will advise

which exit to take to ensure the safest exit route is taken. 2. Direct ambulant patients and visitors to the assembly point, while assisting

semi and then non-ambulant patients to evacuate the Work Area. 3. One staff member should be designated by the Area Warden to collect

patient/staff lists to enable a roll call to ensure all persons have evacuated the danger area.

4. Where practical work in relay teams, i.e. two staff taking patients to one point of safety, and two more taking them to assembly point.

5. Visitors should not be asked to assist with patients unless the situation demands it is essential for patient safety.

6. The last person to leave the Work Area must let the rollcall staff member know.

7. All staff should remain with the group from the affected Work Area at all times for rollcall purposes or advice Area Warden if needing to leave.

8. No person is permitted to return to an evacuated area (including searched rooms) without the authority of the Chief Warden or Fire Brigade.



4.2.5 Search procedures – Stage 2/Stage3 Evacuation.

1. Always conduct search with two people (usually Area Warden and one staff member) to ensure safety.

2. One person to be stationed at doorway of each room to observe the search operation and fire situation while the other conducts the search.

3. Before opening closed doors, check the door with the back of your hand – if hot, do not open the door – if cool, open door cautiously to decide if it’s safe to fully open and enter.

4. Quickly and methodically search all rooms, toilets, cupboards, public toilets, under desks/beds, etc. – basically any space someone could be located (e.g. where children are present, smaller spaces may have to be searched, etc.).

5. Apply labels to doors as rooms are searched, one different coloured label by each person in the search team (sheets of coloured labels kept in Action Card Holder). This provides a visual statement to Fire Brigade that the room has been searched and there are no occupants in danger.

6. Search team to leave the Work Area together, along with rollcall staff member, and join the assembled staff and patients in the adjoining Emergency Control Point.

7. Ensure nominated staff member conducts/confirms rollcall at the assembly point.

8. Area Warden will contact the Chief Warden to confirm the safe Stage 2 / Stage 3 Evacuation of all occupants and advise if evacuation or search procedures were incomplete and identify missing persons.

5. Prevention and Detection

5.1 Detection: A Code Red will be detected and notified - automatic and manual in two ways:

· Automatic detectors in the ceilings through the buildings are activated by Heat (thermal) and/or smoke. When activated these simultaneously activate alarms at the Fire Indicator Board in the hospital and at the Fire Brigade Operations Room.

· Fire and smoke doors close automatically to isolate the affected area. · An alarm that will sound within the Hospital. · Activate Manual ‘Call Point’ (break glass alarm). This is essential as it sets

off all alarm systems, the fire indicator board and notifies the Fire Brigade. · Implement the RACE procedures. · Notify Clinical Nurse Manager and onsite maintenance in hours · Call Maintenance Manager/on call maintenance after hrs, Director of Nursing

and Operations Manager as per escalation process



5.2 Fire Safety Prevention and Management

· Promotion of good housekeeping · Storage of hazards

5.3 Building Inspection and Maintenance

· Fire Safety assessments (audits) are undertaken by an external consultant every four years

· Annual testing of alarms and equipment.

6. Safety in the event of a Fire

Close Doors and Windows · A standard hospital door can withstand fire for up to 30 minutes and a rated fire

door’ for up to two hours. Therefore, in the event of a fire, it is important to close all doors and windows, if possible. This will retard the spread of smoke and fire, minimising the damage to the infrastructure and increasing time for persons to evacuate.

Keep Low in a Smoke Filled Room or Area

· Smoke is responsible for the majority of fatalities in fires. The air is generally more pure at approximately 30cms above floor level. Cover your mouth with a cloth and breather slowly through your mouth.

Never Go Back Into a Fire

· Do not re-enter a fire area to retrieve objects or to look for missing persons. YOUR LIFE IS MORE IMPORTANT THAN ANY OBJECT. The Fire Brigade Officers are trained to conduct rescues and have the appropriate protective equipment.

7. Action Cards and Emergency Evacuation Plans

Action Cards define specific emergency response functional roles and tasks. Individual staff members can hold more than one action card role depending on the circumstances, the size of the facility and available staff. Individuals can also be reassigned different action cards (or roles) as needed. Tasks on an action card can be amended to fit the situation by adding or deleting tasks.

1. Each department / site is to have an Emergency Evacuation Plan /diagram and Emergency Procedures displayed.

2. Plans are to be supplemented with written ‘action cards’. 3. The role of the Regional Health Disaster Coordinator (Regional Director) or

delegated person (usually the Hospital Emergency Coordinator) is to evaluate the emergency from the information provided, to decide the level of assistance that will be required for key support services and to coordinate effective delivery



8. Roles and Responsibilities

Authority for managing the provision of essential health care services during a fire and smoke rests with the Hospital Emergency Coordinator (Operations Manager or Director/Coordinator of Nursing). However Fire and Smoke safety is all employers and employees responsibility. In each facility, there is a designated Hospital Emergency Response Team

8.1 Hospital Emergency Response Team

Chief Warden · Maintenance · Delegated - Clinical Nurse Manager.

Deputy Chief Warden · Ward Shift Coordinator · Delegated Duty Orderly.

Area Wardens / All Staff · Senior Nurse on Duty. · Community Health Manager. · General Staff (all staff)

9. Post Incident Support

Counselling is available to people adversely affected and may be instigated in several ways: · Staff are to inform their line manager if they seek counselling. · The Hospital Emergency Coordinator and line manager is to consider what

counselling and support may be offered. · Staff also need to have an increased awareness of possible behavioural changes

in people around them who have been involved in an incident and who may be suffering from stress, and discuss any concerns with their line manager.

10. Evaluation and Review

The review of the effectiveness of the Fire Safety management system, including the review of this procedure, is to be overseen by the WACHS Kimberley Emergency Management Committee.

11. References

Kimberley Health Region Emergency Management Policy [January 2013]. Wyndham Hospital Facility Fire Response Plan [April 2015]. WACHS Emergency (Disaster) Management Arrangements Policy AS 4083 – 2010 planning for emergencies – Health Care Facilities


https://healthpoint.hdwa.health.wa.gov.au/policies/_layouts/DocIdRedir.aspx?ID=TS4KSNFPVEZQ-89-1435


ACTIONS CARDS TABLE OF CONTENTS

Hospital Emergency Coordinator (Fire and Smoke) .................................................. Page 9 Chief Warden ........................................................................................................... Page 10 Area Warden / All Staff ........................................................................................... Page 11 Regional Health Disaster Coordinator...................................................................... Page 12 APPENDIX A: Wyndham Hospital Response Team and Contact Numbers .......... Page 13 APPENDIX B: Wyndham Hospital Assembly Points ............................................. Page 14 APPENDIX C: WACHS Kimberley Emergency Incident Report ............................ Page 15

This document can be made available in alternative formats

on request for a person with a disability

Contact: East Kimberley Operations Manager (D.Hindmarsh) Directorate: Operations TRIM Record # ED-CO-13-56952

Version: 2.00 Date Published: 30 September 2016 Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.



ACTION CARD - CODE RED FIRE AND SMOKE PREPAREDNESS

Title HOSPITAL EMERGENCY COORDINATOR Applicable to WYNDHAM HOSPITAL Location FIRE BOARD Position Responsible CLINICAL NURSE MANAGER Successor in Absence CLINICAL NURSE MANAGER/MOST SENIOR NURSE ON DUTY Reports to EK OPS MANAGER / DISTRICT DIRECTOR OF NURSING WHEN FIRE ALARM IS ACTIVATED 1. Proceed to the main fire indicator panel 2. Identify Zone and take instructions from Chief Fire Warden (Maintenance Officer) 3. Investigate the nature of the emergency with area wardens, determining cause of

activation and communicate to Chief Fire Warden 4. Assist Chief Fire Warden with Emergency Procedures 5. Communicate Emergency to the East Kimberley Operations Manager / District Director

of Nursing. 6. In the absence of the Chief Warden delegate duties to trained safety wardens. 7. If safe to do so advise the Area Safety warden in the ‘activated area’ to conduct a

search of their area – two way radio to ascertain the nature of the fire/hazard 8. Announce (via PA) immediately to all areas that a search is being conducted in a

specific area and to stand by for further instructions.

Attention all staff – Attention all staff. This is an unconfirmed Code Red for [Work Area/Location]. All Area Wardens are to proceed to the Emergency Control Points

9. Report the situation to the Fire Brigade on arrival 10. On receipt of information from the activated area, determine what action is to be taken

and advise all areas of such action via the PA system.

· Extinguisher fire (if able or trained) · Evacuate ( ask if assistance is required) · False Alarm · Stand Down

NOTE: On advice of a false alarm, a full search of the area MUST be conducted before

‘stand down’ order is given Visitors: A staff member is to be delegated to man the public entrance doors to keep visitors out.

All media calls are to be referred to the East Kimberley Operations Manager or delegate.




Title CHIEF WARDEN Applicable to WYNDHAM HOSPITAL Location MAIN FIRE INDICATOR PANEL Position Responsible MAINTENTANCE OFFICER Successor in Absence CLINICAL NURSE MANAGER / SENIOR NURSE ON DUTY Reports to HOSPITAL EMERGENCY COORDINATOR Resources OPERATIONAL LOG / WARDEN VEST / TWO WAY RADIO WHEN FIRE ALARM IS ACTIVATED 1. Check the “Fire Control Panel’ situated in the main entrance to determine the location

of the fire 2. Instruct another staff member to take a two way radio (the other remains with the Chief

warden) to conduct a search of the ‘activated area’ 3. Receive report from staff member checking the location of the fire / hazard 4. Determine the action to be taken and advice staff on duty of such action.

Where a fire is found:

· Instruct other staff members to remove any patients in immediate danger and/or extinguish the fire if safe to do so.

· Contact the Local Emergency Coordinator (CNM or delegate), EK Maintenance Manager (on call after hours) and inform of the situation.

· Liaise with Fire Brigade (FESA) and Local Emergency Coordinator on their arrival. NOTE: If evacuation is necessary a head count must be performed as soon as possible. If a false alarm: A further full search of the area MUST be conducted before ‘stand down’ order is given Contact the Fire Brigade (FESA), Maintenance Manager (on call after hours) and the East Kimberley Emergency Coordinator (OPS Manager/D/DON) to advise of the situation. After hours call the Executive on call - 1800 669 229. Complete the operation log and return to the fire panel.





Title AREA SAFETY WARDEN / ALL STAFF Applicable to WYNDHAM HOSPITAL Location MAIN FIRE INDICATOR PANEL Position Responsible SENIOR NURSE ON DUTY Successor in Absence LEANDING HAND SUPPORT SERVICES / ALL PURPOSE

ORDERLY Reports to CHIEF WARDEN WHEN FIRE ALARM IS ACTIVATED 1. Go to the Fire panel to maintain communication with Chief Fire Warden. 2. In the absence of designated Area safety Warden, the most senior staff member to act

as Area Safety Warden. 3. You are required to assist in a search of the ‘activated area’

The roof space is not to be checked by staff. 4. Assist with evacuation if necessary 5. Collect or instruct collection of patient records, visitors book and any relevant

information not in the Medical Records room (only if safe to do so). IF A FIRE IS DISCOVERED BY YOU

Remove – anyone in immediate danger Alert – raise the alarm Confine – close doors to contain the fire Extinguish/Evacuate – extinguish when safe to do so, evacuate when necessary.

1. Remove persons from immediate danger to a safe area, operate the nearest alarm (if

not already alerted), and notify the manager in charge (Do not shout fire) 2. Extinguish the fire only if you think you can control it, close door to isolate the fire and

IF SAFE TO DO SO, close all the windows. 3. If the fire cannot be controlled, persons in the danger area must be evacuated to the

next fire compartment (behind the fire doors) or the nearest safe area. If safe turn oxygen and electrical appliances off.

4. Advice the chief warden of action taken and await further instructions 5. Don’t panic

a) Look after the patients b) Follow instructions of the senior person c) Save inpatient notes, rosters and any other relevant information if able to do so safely d) Close all doors in your areas and indicate with fluorescent sticker if room is clear

Remember: DO not put your own safety at risk at any time.




ACTION CARD – CODE RED FIRE AND SMOKE PREPAREDNESS

Title REGIONAL HEALTH DISASTER COORDINATOR Applicable to WYNDHAM HOSPITAL Location EMERGENCY OPERATIONS CENTRE Position Responsible EK OPERATIONS MANAGER / REGIONAL DIRECTOR

(as per escalation process) Successor in Absence NOMINATED REGIONAL EXECUTIVE MEMBER Reports to CHIEF OPERATIONS OFFICER 1. Liaise with the Hospital Emergency Coordinator at the hospital to confirm Alert and

receive briefing on severity and nature of the fire. 2. Notify Chief Operating Officer and Regional Executive members of fire and convene

meetings as appropriate. 3. Establish the Emergency Operations Centre and liaise with external organisations if

large scale evacuation possibly required. 4. Send an initial report to the WA Health Department On Call Duty Officer 5. Continue to liaise with the Hospital Emergency Coordinator and receive information

(e.g. progress of fire, evacuation and details of patients who may need relocating). 6. Determine any resource requirements required from State Health sources or

elsewhere based on reports from Hospital Emergency Coordinator. 7. Arrange briefing to external agencies if involvement required delegating to other senior

staff as appropriate e.g. Regional Medical Director through to Royal Flying Doctor Service to coordinate patient evacuations.

8. Update WA Health Department On Call Duty Officer and Chief Operating Officer as appropriate regarding any damage or assistance required. Receive reports on condition of buildings and/or service interruptions from Hospital Emergency Coordinator and inspect site(s) as appropriate.

9. Notify WA Health Department On-Call Duty Officer and Chief Operating Officer of damage status.

10. Coordinate a debrief and Code Red plan review meeting as necessary with Hospital Emergency Coordinator, Chief Warden, Deputy Chief Warden, Regional Executive members and any other staff as appropriate.

11. Arrange additional counselling and support services if required for staff affected by emergency as requested by Hospital Emergency Coordinator.



Appendix A - Wyndham Hospital Emergency Response Team and Contact Numbers

Emergency Control Team and Contact Numbers Regional Health Disaster Coordinator (Regional Director)

9194 1615 0419 862 664

Emergency Control Team: Type Title Contact (Ext) Hospital Emergency Coordinator Reports to: Regional Director Position: Emergency Coordination

Centre (Administration area or as nominated)

Incumbent all hours

Operations Manager District Director of Nursing

9166 4242 9166 4241 0400 626 971

Delegate Clinical Nurse Manager 0428 160 338

Chief Warden (yellow vest) Reports to: Hospital Emergency

Coordinator Position: Point of Alarm

Incumbent Maintenance Manager 9166 4398 0419 912 317

Delegate In hours – Maintenance Officer After Hours – Clinical Nurse / most senior nurse on duty to cover

0467 733 137

Deputy Chief Warden (yellow vest) Reports to: Chief Warden Position: Point of Alarm

Incumbent Duty Orderly Delegate Nursing Staff

Area Wardens (yellow vest) Reports to: Chief Warden Position: Emergency Control Point (ECP)

Delegate Identified staff in each area

General Ward Emergency Control Point Position: WIP exterior to Room 19 Incumbent

Allocated each shift. After Hours – Shift Coordinator assumes the role of Chief Warden

Accident and Emergency Emergency Control Point Position: WIP Emergency Department

Incumbent Nurse Emergency Department

Administration Emergency Control Point Position: Administration Main Office

Incumbent Administration Officer



Appendix B: Wyndham Hospital Evacuation Assembly Points ASSEMBLY POINT LOCATIONS The evacuation area is the marked Muster Point at the car park / grassed areas adjacent to the occupied area.



Appendix C WACHS KIMBERLEY EMERGENCY INCIDENT REPORT

To be completed in an emergency situation by the Hospital Emergency Coordinator. Please complete both sides.

Broome Derby Fitzroy Crossing Halls Creek Kununurra Wyndham

Date: Time alarm raised: Location of emergency: Time code called: þ Colour Code Called RED* BLUE

(complete MRK179)

PURPLE* BLACK* (complete Safety Risk Report form from for armed or unarmed incidents)

ORANGE* YELLOW* BROWN* CBRN* (Chemical, Biological, Radiological, Nuclear)

*specify type of emergency:_____________________________________________________

Hospital Emergency Coordinator Time Notified Time of arrival on site Hospital Emergency Coordinator

Notified

Emergency Services Department of Fire & Emergency

Services

Police Ambulance Other Services (please specify)

Date / Time Record of Events

and Actions Taken

By Whom?

TIME CODE STOOD DOWN @____________HRS



DEBRIEF / COMMENTS / EVALUATION:

RECOMMENDATIONS:

OUTCOMES:

PRINT NAME

Signature of person completing report: Date:

FORWARD COMPLETED REPORT TO OPERATIONS MANAGER (Executive Sponsor Emergency and Disaster Management)


code red: preparedness and response procedure€¦ · effective: 30 september 2016 wachs kimberley...

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