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

Comms failure plan v11 July 2014

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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



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


Runners

Vodaphone mobiles & I phones

Pagers Landlines MI Radios& Runners


Runners

All Cisco systems


Any remaining analogue landlines


Mobiles & I phones


MI Radios & Runners


Runners

Web based systems


Email


Landlines + Mobiles


MI Radios & Runners


Runners



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.



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...

http://byod.shk.nhs.uk/



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



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.




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




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.




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)




All Wards/ Depts Managers (Or Most Senior Nurse/ Manager on Duty)

Action Time

MAJOR INCIDENT PORTABLE TELEPHONE & RADIO DISTRIBUTION LIST


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


OSM – CONTROL

2093


OSM – MEDICINE

7592


OSM - SURGERY

7670


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


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


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


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


Documentation Section 5

EMERGENCY INCIDENT GENERAL MESSAGE FORM

EMERGENCY INCIDENT LOG


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EMERGENCY INCIDENT GENERAL MESSAGE FORM


MESSAGE FORM

DATE:

TIME:

FROM:

TO:

SUBJECT:

TEXT:

RECIPIENTS NAME:

PASSED ON TO:


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INCIDENT: SHEET No:

TIME IN/OUT FROM/TO MESSAGE ACTION INITIALS



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Hospital Floor Plans Section 6


St Helens

http://nww.sthk.nhs.uk/pages/AboutUs.aspx?iPageId=3830

Ground Floor First Floor

Lower Ground Floor

http://nww.sthk.nhs.uk/pages/AboutUs.aspx?iPageId=3830

http://nww.sthk.nhs.uk/library/documents/5829612_newgroundfloor.pdf

http://nww.sthk.nhs.uk/library/documents/newfirstfloor.pdf

http://nww.sthk.nhs.uk/library/documents/newlowergroundfloor.pdf


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

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