Business Continuity Plan

Mackay Hospital and Health
Service
Business Continuity Plan
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Table of Contents
Introduction................................................................................................................... 3
Purpose ........................................................................................................................ 3
Support / Interface with other plans .............................................................................. 3
Geographical Area........................................................................................................ 3
Types of Hazards ......................................................................................................... 4
Pandemic Influenza ...................................................................................................... 5
Reducing the likelihood of staff becoming exposed to the virus ............................ 5
Management of illness and absenteeism .............................................................. 5
Maintaining service/business delivery with specific reference to the maintenance
of essential services .............................................................................................. 6
Staffing .................................................................................................................. 6
Staff accommodation............................................................................................. 6
General Operations ...................................................................................................... 6
Communications........................................................................................................... 7
Activation and Relocation ............................................................................................. 7
Risk Management......................................................................................................... 8
Business Restoration.................................................................................................. 11
Conclusion.................................................................................................................. 11
Contingency Plans For the Mackay Hospital and Health Service ............................... 12
Occupational Health and Safety Unit ...................................................................... 13
Medical Ward.......................................................................................................... 15
Rehabilitation Unit................................................................................................... 22
Operating Theatre Services .................................................................................... 25
Intensive Care Unit ................................................................................................. 34
Coronary Care Unit ................................................................................................. 37
Womens Health Unit ............................................................................................... 40
Special Care Neonatal Intensive Care Nursery ................................................... 42
Womens Health Unit – Ward & Clinics ................................................................ 45
Birth Centre ......................................................................................................... 50
Child & Adolescent Health Unit............................................................................... 51
Specialist Outpatients ............................................................................................. 60
Renal Dialysis Unit.................................................................................................. 65
Mental Health Unit .................................................................................................. 67
Community Mental Health....................................................................................... 70
Alcohol Tobacco & Other Drugs Service................................................................. 73
Early Discharge Surgery Unit.................................................................................. 75
Mackay Breastscreen ............................................................................................. 84
CSSD...................................................................................................................... 85
Health Information Division ..................................................................................... 87
Corporate Services Travel ...................................................................................... 89
Information Division ................................................................................................ 90
Medical Imaging...................................................................................................... 92
Pathology Services. ................................................................................................ 95
Pharmacy................................................................................................................ 97
Bowen Hospital – General & Clinical Services........................................................ 99
Bowen Hospital – Utilities Services ................................................................... 106
Clermont Hospital - General ................................................................................. 110
Clermont Hospital – Utilities Services................................................................ 117
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Monash Lodge – General .................................................................................. 122
Monash Lodge – Utilities Services .................................................................... 128
Collinsville Hospital - General ............................................................................... 133
Collinsville Hospital – Utilities Services ............................................................. 141
Dysart Hospital – Clinical & General..................................................................... 146
Dysart Hospital – Utilities Services.................................................................... 153
Moranbah Hospital................................................................................................ 157
Proserpine Hospital – Clinical & General .............................................................. 162
Proserpine Hospital – Utilities Services ............................................................. 172
Sarina Hospital – Clinical & General..................................................................... 183
Sarina Hospital – Utilities Services.................................................................... 186
Environmental Services............................................................................................ 190
Catering Services ..................................................................................................... 194
Linen Services .......................................................................................................... 196
Emergency Call Directory ......................................................................................... 198
Contact List – Internal ........................................................................................... 198
Contact List – External.......................................................................................... 198
Operational Checklist ............................................................................................... 199
Glossary ................................................................................................................... 200
Amendment register and version control .................................................................. 200
APPENDIX 1 ............................................................................................................ 201
Terms of Reference - Emergency Preparedness and Continuity Management Sub-
Committee ............................................................................................................ 201
APPENDIX 2 ............................................................................................................ 202
MODEL HEALTH INCIDENT MANAGEMENT CHECKLISTS .............................. 202
State Health Coordinator ................................................................................... 202
Health Incident Controller .................................................................................. 202
Site Medical Commander .................................................................................. 203
Planning Officer................................................................................................. 203
Logistics Officer................................................................................................. 204
Liaison Officer ................................................................................................... 204
Media and Communication Officer .................................................................... 204
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Introduction
The aim of the Mackay Hospital and Health Service (MHHS) Business Continuity Plan (BCP) is to promote
continuity and rapid recovery of critical services or functions required to support the core business of the Health
Service. It is a continuous improvement process of establishing and maintaining Business Continuity Plans and
other measures in order to respond to and recover from disruptions that threaten key resources, locations and
functions. Major disruptions can arise from both dramatic crises and from the escalation of routine management
and business failures within an organisation, and poor decision making.
In this plan, business continuity is an all embracing term which addresses organisational recovery following a
disaster. It assumes that prevention arrangements have failed and that an incident has occurred which has
interrupted normal business to the extent that corrective action is required. It aims to provide the availability of
processes and resources in order to ensure the continued achievement of critical objectives.
Purpose
The plan will outline the arrangement guidelines for Business Continuity within the MHHS in accordance with
Government Agency Preparedness for Government for Queensland Government Departments. It will detail the
key people, the responses and actions needed to enable the MHHS to continue essential functions in the event of
a disaster.
Individual areas within the MHHS will be required to have a Business Continuity Plan that clearly identifies the
following;
 Processes carried out within the section

 Impact of possible events
 Contingency plan
 Tasks and allocated responsibilities
 Approximate time frame they can survive without the service
The Emergency Planning committee (EPC) is responsible for establishing and implementing emergency plans and
procedures that include prevention, preparedness, response and recovery strategies.
The EPC for the MHHS is a sub group of the Safe practice & Environment Committee (SP&E) and is convened as
necessary with members being coopted for an advisory capacity. This committee is responsible for the
identification of internal and external stakeholders obtaining input from local emergency services to ensure a
coordinated response.
Support / Interface with other plans

This plan has been developed in accordance with the Qld Health Disaster Plan 2008 and supports / interfaces with:
 Queensland Health Policy Statement 28028 Emergency Preparedness & Continuity Management,
September 2006
 Occupational Health & Safety Management and Emergency Preparedness and Continuity Management:
Implementation Standard 1-28#21
 MHHS Emergency Manual, NC-WPI161 - V1.0 July 2009
 Standards Australia and New Zealand - HB292:2006 & HB293:2006 Business Continuity Management
 Standards Australia and New Zealand AS/NZS4360:2004 Risk Management
Geographical Area
This plan has been developed to cover the Mackay Hospital and Health Service which encompasses the following
shires Mackay, Whitsunday and Isaac Region with total population 163,060. Health facilities include:
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The Mackay Hospital and Health Service
 Bowen Hospital o 162 beds

o 27 beds  Mackay Community Health Centre
 Clermont Multipurpose Centre  Moranbah Hospital
o 10 beds o 12 beds
o 6 aged care o Population (2012) 12,000
Monash Lodge  Proserpine Hospital & Whitsunday
o 16 Aged Care Community Health Centre
 Collinsville Hospital o 33 beds
o 8 beds o Population (2007) 18,610
o 7 aged care  Sarina Hospital & Primary Health Care
o Population (2007) 13,370 Centre
(Includes Bowen & Collinsville) o 16 beds
 Dysart Hospital o Population (2007) 11,440
o 7 beds
 Mackay Base Hospital
Population data extracted from

http://qheps.health.qld.gov.au/hic/infobank/POPPROJ/proj_lga_medium2006v.xls
Types of Hazards
A disaster, event or hazard will cause stress and extra load for the MHHS health care facilities. Hazards are often
associated with injuries and death. The aftermath of a hazard may lead to an increase or a perception that there
will be an increase in disease, placing stress on the MHHS to maintain continuity in health care provision and
recovery.
Far North Queensland's diverse climate conditions give rise to a number of hazards. During the Wet Season,
flooding can occur over large areas of the MHHS cutting communication, causing landslides and damaging
infrastructure. Cyclonic conditions from November to April further compound this hazard with the risk of storm
surge.
Hazards and associated risks include:
 earthquakes—deaths and injuries, mainly due to building collapse;

 flooding—drowning and injuries;
 storms and cyclones—deaths and injuries due to debris impact or building collapse, drowning;
 fire—deaths and injuries due to burns, smoke-inhalation or respiratory failure in vulnerable people:
explosions—deaths and injuries due to building collapse, burns;
 chemical spills or leaks may cause a range of injuries from burns to respiratory problems;
 the perceived risk of epidemics will place significant extra load on health-care facilities;
 primary health-care services must be maintained while the stress levels associated with an emergency or
disaster may actually increase normal rates of heart attacks, strokes, childbirths (as hyperbaric pressure
decreases during cyclones), psychological effects and availability of medication; eg. Methadone etc.
immediately after the event; and
 lack of power may increase loads on health systems by:
 the general public using naked flames for heating or lighting, with increased fire risk and
respiratory problems;
 use of generators with inadequate ventilation may cause suffocation or respiratory problems.
Handling generator fuel may cause fire risks;
 eating contaminated foods or out-of-date foods may lead to gastric disorders;
 Injuries to persons trying to navigate flooded areas and
 lack of power for in-home care of disabled or ill people may lead to these people seeking in-
hospital care.
As well as increased loading on the MHHS, the hazard itself may impact on Queensland Health’s ability to provide
a health care service. This could be due to the following:
 damage to health infrastructure housing the facilities that may make them unsafe for continuing service;
 water damage (mould), cladding damage or smoke damage that may make the facility unserviceable.
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Equipment may have been damaged, records lost or cleanliness compromised;
 Some facilities within the MHHS; such as Community Health and Victoria Street facilities may not have
emergency power or their premises may be inundated or damaged and may be unable to provide
services.
 Staff shortages may occur following hazards, as casualties elsewhere in the community, damage to
transportation and general community disruption may mean that staff rostered on cannot come to work.
 Some equipment may have been affected by the hazard itself. Mobile or portable equipment is vulnerable
to damage in cyclones & earthquakes. Equipment that makes use of gas or gases (critical services in
particular) may be compromised by leaks in pipes or damage to reticulation system or lack of supply, and
gas storage areas could be compromised.
 Many of the above effects have the added complication that the staff and patients of these facilities may
need to be evacuated, placing extra load on surrounding facilities, and also risking the safety of people
who require continuous care or specialised equipment.
Pandemic Influenza
The MHHS must work with other health related agencies to determine how best to assist in responding to the
health and wellbeing needs of the community during a pandemic, as well as minimising the impact of a pandemic
on the service.
In order to reduce the impact of a pandemic on core business and maintain business continuity, absenteeism
needs to be effectively managed. Items to be considered are:
Reducing the likelihood of staff becoming exposed to the virus

Education can reduce fear through understanding and help protect through knowledge. Basic information that staff
should be made aware of includes:
 What is pandemic influenza and how is it spread?
 What are the signs & symptoms?
 When are people considered infectious?
 What can be done to reduce the risk?
Note: Under the Workplace Health and Safety Act 1995 the obligations that an organisation has under this Act continue to apply in the event of
pandemic influenza. An organisation must continue to manage everyday risks to the workplace health and safety of workers and others, as well as
manage risks unique to pandemic influenza.
Management of illness and absenteeism

Well developed workplace policies are integral to the protection of the workforce and the organisation’s operations
during a pandemic. Policies that can be considered include, but are not limited to the following topics:
 Hygiene and cleaning practices

 Social distancing strategies incorporating - working from home, using company vehicles, restricting
access to the workplace, change to working rosters / hours of operation
 Work related restrictions on travel to affected areas
Maintaining service/business delivery with specific reference to the

maintenance of essential services
A Pandemic may create the need for staff members to remain at home to care for their dependants, and may
reduce the numbers of staff that attend work due to fear of the disease, or as an unwillingness to place themselves
at a risk of infection.
Key tasks to be undertaken are:

 Identify the core people required to keep the essential functions of the business running
 Identify opportunities for cross training/multi skilling of staff where appropriate with the intent of creating a
larger internal resource base from which to draw on
 Identify retired staff that may be employed for knowledge as opposed to physicality
 Identify critical resources and projected quantities (required to maintain functioning of key areas) over the
peak period of the pandemic. This can be used to assess the feasibility of bulk purchases/stockpiling
 Discuss preparedness planning with key suppliers/contractors.
 Identify all suppliers of the required resources beyond current contractual arrangements.
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 Identify temporary alternatives and suppliers
 Identify the Critical Breaking Point.
Staffing
The effects of a pandemic on staffing numbers can only be estimated before the actual occurrence. It is not
unreasonable to assume that at various times during a Pandemic the MHHS will experience significant levels of
absenteeism whether directly related to influenza infection, family care responsibilities or fear and fatigue. This may
be as high as 30 - 40% absenteeism at the height of an outbreak.
It is important to note that an influenza pandemic will not be ‘business as usual’ for health services in Australia.
Staff will be required to work flexibly to meet increased demands; usual clinical and infection control practices may
need to be altered to accommodate the exceptional circumstances.
Depending on the epidemiology and virulence of the virus the MHHS may have to rationalise certain services in
order to maintain the ability to provide services directly related to a Pandemic Influenza outbreak.
Historically Pandemics have come in waves of between 6-12 weeks; changes to service provision will be
necessary but temporary.
Staff should be discouraged from presenting to work with flu like symptoms, especially in the early stages where
prevention of spread will be paramount to the governments’ containment strategies. As the stages of a Pandemic
wave progress the staff who have recovered will have immunity and be able to work in the front line of the
response with little risk of further infection from pandemic influenza.
Staff accommodation
During some stages of a critical incident or pandemic there may be a need for staff accommodation within or close
to the Hospital. The reasons include:
 Reduced staff available, increasing the need for overtime and extra shifts
 Staff wishing to remain at hospital rather than risk transmission to family.
If the Hospital staffing is hit hard then it may be that many staff will be required to work extended hours and extra
shifts, all possible measures should be taken to ensure safe practice and to keep fatigue to a minimum.
For more information see:

 MHHS Pandemic Influenza Plan, C-WPI242 – V2.0 May 2009
General Operations
Strategies that may be required to be utilized
(These will vary depending upon the type and severity of the Incident)
 Temporary Cessation of all elective admissions and procedures at Mackay Base Hospital
 Temporary closure of Medical and Surgical Clinics,
 Deployment of staff to areas of greater need and to cover absenteeism will be common,
 Some staff will be required to perform their roles in new environments
 Multiskilling in areas of the same job stream but different roles
All wards and departments within the MHHS should develop an area specific contingency plan that gives
consideration to how they may function in any given incident that may arise. Work requirements should be
prioritised.
Consideration should be given to:
 Patient Flows patients to and from units

 Succession planning,
 Mulitskilling where appropriate
 Changes to work practices that may occur
 Preparation for “knock-on” effects from other departments that may affect your departments functionality
Some departments within the Mackay Health Service will have to maintain elements of their core business,
possibly at a reduced level because their service may not be able to be completely absorbed by other hospitals in
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the MHHS. These may include Emergency Department, Intensive Care Unit, Coronary Care Unit, Theatres,
Maternity, Renal, & Mental Health.
Communications
Locally, where an incident threatens to disrupt normal operations, immediate decisions are required to minimise the
impact of the incident and to resolve issues where possible.
In the event of a crisis, the delegated Health Incident Controller will initiate the Emergency Operation Centre to
manage immediate response activities—for example, authorising and releasing communications with staff and
stakeholders, authorising the activation of business continuity and information disaster recovery arrangements,
standing down staff, declaring the crisis over.
The Emergency Operation Centre would normally include relevant senior and functional managers, or their
delegates, who can provide leadership and who understand agency operations. Sub-groups can also be identified
to support the crisis management team.
The State Disaster Management Group meet and manage disaster arrangements. Queensland’s Disaster
Management arrangements are managed by the Department of Emergency Services (see
www.disaster.qld.gov.au).
Activation and Relocation

The MHHS will be activated and deployed in an appropriate authorised manner according to procedures set out in
the MHHS Emergency Manual
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Risk Management
Possible Types of Exposure and the Risk Assessment:
(According to the Queensland Health Risk Management Matrix (Integrated Risk Management Implementation
Standard 3)
It is assumed that any major loss of hospital/facility global essential resources (eg. Power, fuel, gases, water,
communications etc) will be addressed and co-ordinated through the MHHS Disaster Coordination Centre.
Risk Description Likelihood Consequence Risk Rating

Earthquake (deaths & injuries due Rare Extreme High 15
to building collapse)
Storms & Cyclones Rare Extreme High 15
Flooding (drowning & injuries) Unlikely Major High 14
Fire (deaths & injuries due to burns, Rare Major Medium 11

smoke inhalation or respiratory failure
in vulnerable people)
Fire Alarm Failure Rare Extreme High 15
Water Failure Rare Extreme High 15
Electricity Failure (public or staff Possible Moderate High 13

may use a naked flame for heating or
lighting with an increased fire &
respiratory problems)
Gas Supply failure Rare Moderate Low 5
Medical Gas Failure Rare Extreme High 15
Damage to Infrastructure Rare Extreme High 15

(following an event – impact upon
ability to provide health service)
Water Damage making the Unlikely Major High 14
facility unserviceable
Capacity of the Hospital is Likely Major Very High 20
exceeded
Industrial Disputes Possible Major Very High 19
Epidemic/Pandemic Possible Major Very High 19
Computer system failure – Possible Moderate High 13

greater than 1 day
Bomb or Explosions (deaths & Rare Extreme High 15
injuries due to building collapse &
burns)
Chemical Spills & Leaks (range Rare Major Medium 11
of injuries from burns to respiratory
problems)
Biological Incident – escape, Rare Major Medium 11

spillage or contamination
Radiological incident Rare Major Medium 11
Adverse Public interest Possible Major Very High 19
 Major engineering failures -burst water mains, electrical sub-station failure, generator failure etc.
 Impact upon buildings - helicopter or aircraft
 Chemical spill in vicinity of hospital - road tanker
 Communication Systems failure
 Medical Gas Reticulated Systems failure - oxygen, suction
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Integrated Risk Management Analysis Matrix
The use of integrated Risk Management Analysis Matrix is mandatory when communicating risks (risk Ratings) to Executive and
Senior Management throughout the Department.
The Integrated Risk Management Analysis Matrix is used to assess Consequence(s) should the risk occur and Likelihood
(Probability) of the Risk occurring. Together, the Likelihood and Consequences(s) determines an overall Risk Rating or Level of risk.
CONSEQUENCE TABLE (Consequence Table for types of consequences and degrees of severity)
Degree of Severity
Type of Consequence NEGLIGIBLE MINOR MODERATE MAJOR EXTREME
Adverse Clinical C No injury or harm Minimal harm Loss of function, Permanent loss of A loss of life
Event caused, minor caused, minor major harm caused function or disability
adjustment to interruption to
operational routine routine
Outrage/Damage to O Minimal adverse Significant adverse Significant adverse Significant and Sustained national
Reputation local publicity local publicity Statewide publicity sustained Statewide adverse publicity,
adverse publicity Queensland Health’s
reputation significantly
damaged
Litigation L Potential exposure to Minor exposure to Exposure will result Claims greater than Claims greater than
Queensland Health Queensland Health in a single claim $500,000 or multiple $1M or multiple claims
claims resulting from resulting from multiple
single exposure similar exposures
Disruption to D No interruption to Some disruption Disruption to a All operational areas of Total system
Established service manageable by number of areas a location or MHHS dysfunction and/or total
Routines/Operation altered operational within a location or compromised, other shutdown of operations
al Delivery routine MHHS, possible flow locations or MHHSs are
on to other locations affected
Staff Morale SM Staff dissatisfaction Alteration to routine Disruption spreads Disruption spreads to Statewide cessation of
(may include within local unit. No practice required in across services or routine practice service or programs
absenteeism, effect on services or local area or MHHS programs Statewide
establishment) programs
Workplace Health & H No injury/illness – no No lost time injury Lost time injury Permanent loss of A loss of life
Safety time lost, minor First aid or medical involving a function or disability
adjustment to treatment required temporary loss of
operational routine function or a
notifiable event
Security S Event noted by local Monitored by local A security event that Major event that Extreme event affecting
(may include staff/management, staff, some effect on may threaten a threatens a program a program / service
fraud/theft. no change to routine routine operations program /service. An /service across the areas ability to continue
Unauthorised access operations event requiring wider organisation. its operation resulting in
and areas of internal investigation Events requiring total shutdown
suspected official referral to Police / CMC
misconduct)
Environmental E No lasting Local detrimental Short term local Long term detrimental Having a long lasting
Impact detrimental effect on effect on the detrimental effect effect contained with effect on the
(may include the environment environment contained with outside assistance environment
discharge of outside assistance (i.e.QFRS, EPA)
hazardous or (i.e.QFRS, EPA)
dangerous
substances, carbon
footprint etc)
Workforce Issues W No effect on services Some effect on Restrictions to Cessation of Statewide cessation of
(may include or programs specific service or service/program service/program of a a program or multiplr
recruitment and program – alterations availability within a location or MHHS, programs
retention, capability to routine practice location or MHHS, which could impact
required with possible flow on other locations or
to other locations MHHSs
Operational OM No impact on local Minor impact on local Moderate to long Major impact on Cessation of some
Management operations operations term impact on wider operations across other operations
operations areas of organisation
Corporate M Local management Local management Senior Management Directorate/MHHS/ Statewide management
Management review review on a broader review or Health Service review or intervention
basis intervention Executive Management by EMT / D-G
review or intervention
Financial F ~ 1% of monthly / ~ 2% of monthly / ~ 5% of monthly / ~ 10% of monthly / cost ~ 15% of monthly / cost
(anything that has a cost centre budget cost centre budget cost centre budget centre budget centre budget
financial impact
Please note that the severity for each consequence type is to be considered separately and not relative to each other
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Likelihood (probability) Table
This table defines the likelihood or probability of the risk occurring, based on the information available at the time of assessment.
Rare May occur in exceptional circumstances only / May occur at least once in a period of 5 years or more
Unlikely Might occur sometime but not expected / Might occur at least once during a period of five years or less
Possible Could occur, capable of happening, foreseeable / Could occur at least once in 12 months
Likely Is expected to occur occasionally / Is expected occur at least once per month
Almost Certain Is expected to occur frequently, in most circumstances / Is expected occur at least once per week
Integrated Risk Management Analysis Matrix

←Consequences →
Likelihood ↓ Negligible Minor Moderate Major Extreme
Rare Low (1) Low (4) Low (5) Medium (11) High (15)
Unlikely Low (2) Medium (8) Medium (10) High (14) Very High (21)
Possible Low (3) Medium (9) High (13) Very High (19) Very High (22)
Likely Medium (6) High (12) Very High (17) Very High (20) Extreme (24)
Almost Certain Medium (7) Very High (16) Very High (18) Extreme (23) Extreme (25)
Legend
Low risk (1-5) Manage by routine procedures, unlikely to need specific application of resources
Medium Risk (6-11) Manage by specific monitoring or response procedures locally
High Risk (12-15) Management attention needed and management responsibility specified to control
the risk
Very high risk (16-22) Detailed research and management planning required at a senior management /
executive level
Extreme risk (23-25) Immediate action and involvement required at a senior management /executive level
to control the risk
Actions required in response to the level of risk:
Risks with a residual risk rating of Very High (16-22) and Extreme (23-25) must be reported.
The management must consider the need for legal advice or guidance. If legal advice or guidance is required it
must be reported to Corporate Counsel (or delegate)
All notifiable events (as per the local policy or procedure) must be reported as directed.
All incidents including near misses must be reported.
The risk assessment process is applicable to all processes and levels within the Department.
Source
Integrated Risk Management Implementation standard 3 – Risk Analysis Matrix:
htpp://qheps.health.qld.gov.au/audit/RM_Stream/RM_Policy/31237_ 08_ 2.0.pdf
(September 08)
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Business Restoration
Following the activation of business recovery arrangements to re-establish all core services, arrangements will be
initiated to restore normal operations to pre-crisis capacity.
The extent and duration of business restoration planning will depend on the impact and nature of the crisis.
Business restoration might require, for example, sourcing new accommodation and equipment, re-establishing non-
core or strategic processes or projects, transitioning temporary service delivery arrangements established under
business recovery to a permanent status or relocating staff and resources to new permanent accommodation.
Pre-planning for business restoration is difficult due to its circumstantial nature and the inherent number of
unknowns.
In the event of a major incident, Queensland’s disaster management arrangements would be activated to
coordinate recovery activities across the affected area and this may impact on the Mackay Health Service business
restoration planning.
Conclusion
Business continuity arrangements are the MHHS’s last line of defence in risk management arrangements. They
address the immediate crisis, re-establishment of the delivery of core services and essential business operations,
and the restoration of the facilities to normal operations following a major interruption.
Business continuity thinking will commence as soon as an abnormal incident occurs even if not considered a major
incident, as this could herald the impending need to activate business continuity arrangements.
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Contingency Plans For the Mackay Hospital and Health Service
1. Contingency Plans for the Mackay Hospital and Health Service  Alcohol & Other Drug Service
 Air Conditioning Failure  Early Discharge Day Surgery Unit
 Boilers
 Building Management System 3. Contingency Plans for Hospital Support Services
 Gas Supply  Breastscreen
 Human Resource management  Catering
 Mains Electrical Power (See Emergency Manual)  Central Sterile Supply Department
 Medical Gases, Air and Suction  Cleaning
 Occupational Health & Safety services  Health Information Records
 Safety and Security  Information Department
 Sewerage  Linen
 Telecommunications (See Emergency Manual)  Medical Imaging
 Vehicles and Transport (including fuel supply)  Mortuary
 Water Supply  Pharmacy
 Pathology
2. Contingency Plans for Hospital Clinical Services  Stores/Supples
 General Surgical Unit/Medical Ward/Rehabilitation Ward
 Emergency Department 4. Contingency Plans for Rural facilities
 Operating Theatre  Bowen Hospital General & Clinical
 Intensive Care Unit  Bowen Utilities
 Coronary Care Unit  Clermont hospital
 Womens Health Unit  Collinsville Hospital General & Clinical
 Special Care/Neonatal Care Nursery  Collinsville Utilities
 Ward & Clinic  Dysart Hospital
 Birth Centre  Moranbah Hospital
 Child & Adolescent Unit  Proserpine Hospital
 Renal Dialysis Unit  Sarina Hospital General & Clinical
 Specialist Outpatients  Sarina Utilities
 Mental Health
 Community Mental Health
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Business Continuity Planning
Occupational Health and Safety Unit
The Unit has ten (10) staff, including AO5 OHS Unit Manager (Hinterland) and is based at 73 Victoria Street, Mackay.
Note: The Action Cards, Pandemic Influenza Plan 2009, for corporate services and all Managers are to be used in conjunction with the specific procedures detailed below.
Key contact: Wendy Macfarlane, MHHS OHS Manager
Delegated as necessary in the following order: Gail Cameron, Susie Maddox, Wayne Vidler
A = Up to 24hrs B = Up to 5 Days
OCCUPATIONAL HEALTH AND SAFETY UNIT C = Indefinitely D = Cannot Operate
How long can you function without this
Problem Impact Contingency Task Responsibility
service?
Unable to provide prompt
or timely response for risk
Undertake Executive Members
Insufficient assessment, advice, Prioritize to address
directions / negotiate MHHS OHS Mgr Indefinitely, but with a limited service
staff records management or highest risk/s first
alternatives
W/Comp case
management
Identify tasks to be postponed
until disaster subsides; cancel
all unnecessary commitments
away from base
Assign tasks to existing staff,
monitor progress / wellbeing
throughout day
Determine staff availability if
shifts needed in addition to
8:00-17:00 Mon-Fri.
Availability may change daily.
Engage admin support An unlikely option - other units will be experiencing insufficient
from MHHS units staffing also
Engage expertise from
Arrange travel to Mackay if
other Health Services
necessary
and/or corporate
Coordinate scheduled daily
briefing time / place
Confirm primary and
secondary contact details
whether in Mackay or other
location
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OCCUPATIONAL HEALTH AND SAFETY UNIT C = Indefinitely D = Cannot Operate
How long can you function without this
service?
Staff working from home if Provide laptops and mobile
practicable phones / chargers
Determine infection control,
task assignment and schedule
am/pm briefing to Mgr
Liaise with agencies for extra
critical care staff
Call staff in when possible
Delay in attending to
issues needing face-to- Use taxi service, if
Pool Vehicles Identify which staff accept to
face away from Victoria St available, or private
unavailable use their private vehicles
campus; delay transporting vehicles
ill staff to their residences
Equip each staff spray
disinfectant and tissues for
vehicle
Ensure mobile phones are
charged and taken on all
transfers; ensure Mackay
street maps for all cars
Page - 14 28/08/2013
Medical & Surgical Wards
The following Standard Operating Procedures have been generated for application across clinical units where common processes exist and are grouped thus to avoid replication of
tasks for contingency planning for individual wards.
A = Up to 24hrs
MEDICAL AND SURGICAL WARDS B = Up to 5 Days
C = Indefinitely
D = Cannot Operate
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOU

FUNCTION WITHOUT
THIS SERVICE
Computer Unable to generate ID Record patient details manually  Ensure supply of HBISCUS downtime Administrative and nursing B
failure Labels forms staff
 Pre print labels on existing patients B
 Hand write on blank labels for new
admissions B
Unable to track patient Revert to the manual process  Update patient location and bed status Administrative and nursing B
location and bed status at regular intervals staff
 Notify after hours manager of all patient B
movements Nursing staff
 Develop a process for disseminating B
patient updates as part of the facility Nursing Staff Team
communication plan Leader
Unable to provide patient Revert to manual process  Update patient diet lists and have NUM and Team Leader
dietary requirements available for collection by catering B
services
Unable to record Revert to manual process  Ensure supply of downtime forms Administrative Staff
information relating to available to record information B
patient nurse
dependency
Unable to access Revert to manual process  Ensure supply of Medical Imaging & Administrative staff B
computerised pathology result forms
pathology/radiology  Develop means for notification of
results Medical Imaging & laboratory test B
Use portable phones if working results NUM, Medical Imaging &
 Manual ordering of tests Laboratory Staff
B
Page - 15 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate

FUNCTION WITHOUT
THIS SERVICE
Enter data when system is fixed  Ensure retrospective data entry when
computer services resume Medical & Nursing Staff B
 Backup any non centralised data or Unit Manager, Medical
ward specific computer programs Imaging & Laboratory staff B
Administrative Staff
Power Failure Mains power not Refer to mains power failure plan  Inform and Educate staff NUM & Nurse Educator Depends upon the
available generator
Lighting Difficulties in patient Utilise the emergency lighting  Identify provision for emergency lighting Engineering staff B
Failure observation & care  Relocate immobile patients to the best
lit areas Nursing Staff B
 Ensure there are NO mobile patients
because of increased risk of injury if Nursing Staff B
they move about in poorly lit areas
 Clean & maintain windows & fittings
 Ensure blinds & curtains are open
Maximise natural lighting  Ensure adequate supply of torches &
Battery operated lights & batteries Cleaning Staff B
 Clear patient areas, work areas &
Utilise alternate lighting corridors of all hazards All staff B
 Inform and Educate staff
NUM B
Maintain WH&S precautions
Increased risk for Refer to facility wide power failure NUM & All staff B
patients and staff plan
Educator B
Air Unable to regulate the Use alternate cooling devices eg  Position fans for maximum benefit Nursing Staff Depends upon the
Conditioning temperature & Electrical or manual fan  Identify patients requiring cooling weather season in
Failure environment  Inform & Educate staff Mackay
Refer to facility wide failure plan Nursing Staff
Educator
Telephone No internal or external Refer to facility wide  Inform & Educate staff NUM
Failure telephone telecommunications failure plan Team Leader A
communications Educator
Wall Oxygen Wall oxygen not Use Oxygen cylinder  Identify anticipated requirements of NUM
supply failure available cylinder oxygen for ward patients A–B
Page - 16 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate

FUNCTION WITHOUT
THIS SERVICE
 Order required cylinders from central
storage area NUM A–B
 Ensure all oxygen cylinders are full
 Ensure a corresponding number of Wards person A–B
oxygen fittings available at ward level
 Consider co-locating high oxygen users Wards person A–B
(run on the same bi-connectors)
 Ensure small oxygen cylinder with twin-
o-vac suction on resuscitation trolley Nursing & Medical staff A–B
 Educate staff on use of alternate
devices
Provide emergency oxygen Nursing Staff A–B
/suction
NUM A–B
Educator
Digital Scales Unable to record weight Use alternative scales  Purchase bathroom scales NUM C
fail  Use weighted scales if available
NUM C
Failure of Potential for inaccuracy  NUM
Tymphanic of temperature readings
Thermometer
Failure of non- Unable to electronically Use manual sphygmomanometer  Ensure adequate number of NUM A
invasive Blood measure blood pressure sphygmomanometers
Pressure readings
monitors
Page - 17 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate

FUNCTION WITHOUT
THIS SERVICE
Failure of Potential for decreased Visual readings  Ensure adequate stock of batteries NUM
glucometer accuracy in blood  Inform & educate staff Nursing staff
glucose readings Utilise from CNS Stock from NUM
Community Health Educator
 Develop policy for formal laboratory test
Formal laboratory blood glucose Medical staff
analysis for abnormal results Nursing staff
Failure of 12 Unable to diagnose life Ensure access to emergency  Identify access to emergency power NUM A
Lead ECG threatening conditions power outlet Engineering staff
machine
Use on battery power  Keep batteries fully charged on NUM A
emergency power Nursing Staff
 Identify location of alternative ECG Nursing staff A

machines
 Inform and educate staff NUM /Educator A
Failure of Unable to determine Increase nursing observation  Ensure staff to act as a runner are NUM B
Pulse oxygen saturation Access other portable units from available Educator
oximeters facility /Health Services if
available
Failure of Unable to provide safe Increased staff vigilance  Schedule regular patient rounds Nursing staff
Emergency and secure environment
Alarms  Direct notification via phone switch or
runner to Communication Centre to All Staff B
contact fire services, security & police
 Inform and Educate Staff
Refer to security plan

NUM
Failure of Patients unable to Refer to safety and security plan  Have hand bells available NUM B
Page - 18 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate

FUNCTION WITHOUT
THIS SERVICE
Patient call summon assistance
buttons
Failure of Staff unable to titrate Use battery power if available  Charge on generator power if able All Staff A
infusion medications and fluids  Charge batteries fully Nursing Staff
Pumps/Syringe accurately Use burettes  Ensure adequate stock of burettes A
Drivers  Protocols for alternative administration Nursing Staff B
Consider alternate administration  Manually titrate drip rate if necessary
routes NUM B
Medical staff
Failure of Difficulty in maintaining Use alternate feeding methods  Develop a procedure for bolus/gravity NUM
Enteral feed patient nutrition feeding Educator/Nursing staff
pumps
 Ensure adequate supply of tubes and NUM B
feeds
 Manually titrate drip rate if necessary Educator
 Inform and educate staff
Failure of Potential increased risk Use alternate methods of  Identify at risk patients NUM C
Sequential of DVT/Embolus deterring thromboembolus Medical staff
Compression
Devices  Consider compression stockings/drug NUM/Educator
therapy Medical Staff
 Develop Policy NUM/Educator
 Ensure adequate supplies of stockings Medical Staff
Nursing staff
Refrigeration Drugs and medical Place drugs in refrigerators which  Review emergency power outlets NUM
supplies requiring are connected to emergency  Monitor refrigerator temperature with Engineering Staff A-B
refrigeration may power supply thermometer
become unusable Nursing staff
Use eskies and ice  Consider purchase of eskies and supply Infection Control Staff
of ice
 Inform and Educate Staff NUM/Educator
 Consult with Pharmacy
Failure of Difficulties with lifting Identify alternate lifting devices  Use hydraulic lifting devices if available C
Page - 19 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate

FUNCTION WITHOUT
THIS SERVICE
Lifting Devices heavy patients – manual  Mobile power pack All Staff
handling injuries  Use of ski sheets, bed sheets etc
 Ensure staff trained in manual handling
Pan Room Unable to clean bed  Rinse with ‘grey/waste” water and All Staff B
Hopper pans/urinals correctly disinfect with chemical solution
 Reinforce Infection Control Policy
Infection Control CNC B
Educator
Lift Failure Unable to transport Ensure one lift operates on  Review existing supply of emergency Engineering Staff A
patients to different emergency power power Disaster Committee
levels within the facility
Utilise alternate methods of  Walk patients Wardsperson A
transporting patients Nursing staff
 Consider scoop stretchers, fire MHHS Executive A
blankets, stair walkers, cardboard
Consider utilising ground floor stretchers
facilities  Develop facility plan for locating new MHHS Executive A
admissions
Minimise patient transfers
 Critical transfers only Medical Staff A
 Ensure all staff aware of facility NUM A

Fire/Evacuation plan
Failure of Negative Impact on Verbal education  Develop alternate packages for patients NUM C
Video & TV patient  Prepare mobile library Educator
education/enjoyment Alternative recreational activities  Consider hand held games for children Volunteers
MHHS Executive
NUM
Failure of Fax Unable to receive or Utilise alternate lines of  Send patient information via courier or NUM B
send patient information communication runner
Scan and email  Delay the transfer of information until Medical Staff B
services have resumed Administration staff
Failure of Unable to copy Utilise alternate lines of  Telephone information Nursing staff
copier documents communication Medical staff
 Send the original documents with the
patient and document in the chart
Page - 20 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate

FUNCTION WITHOUT
THIS SERVICE
Delay the transfer of information until
services have resumed
Staffing Increased manual tasks Roster extra staff on duty  Estimate staffing numbers for 24 hour All Managers
may increase the period
workload Place staff on call
 Prepare rosters
 Liaise with agencies for extra staff
 Call in staff if possible
Equipment Unable to guarantee Check all equipment for  Identify all equipment to be checked NUM
Function equipment accuracy functionality as soon as possible All Staff
after disruption of power
 Inform and Educate staff
Educator
Page - 21 28/08/2013
Rehabilitation Unit
The Unit is connected to the emergency generator
A = Up to 24hrs
B = Up to 5 Days
REHABILITATION UNIT
C = Indefinitely
D = Cannot Operate
How long can you
Problem Impact Contingency Task Responsibility function without this
service?
Failure of Unable to adjust height Utilise emergency generator Identify emergency power All Nursing & Unit Operational
inpatient of beds for safe power within 10 seconds of outlets staff D
electric beds exit/entry by patient power failure NUM
mechanics Identify alternative battery Confer with engineering re
power pack to operate bed availability of portable
mechanics battery back-up equipment
Failure of Vital Nursing staff can utilise Utilise emergency generator Identify emergency power All Nursing &
Signs Monitors manual equipment – power within 10 seconds of outlets Unit Operational staff
& pulse minimal impact on power failure Ensure batteries are fully C
oximetry nursing resources/time Utilise battery back up charged *NB- Battery life of
Ensure that nursing and Equipment nurse to ensure Monitor is 30 mins to 2
medical staff have access to that there is a sufficient hours
manual vital signs supply of correct sized
equipment batteries for equipment in
Ensure solid stock of unit storage.
alkaline batteries for
portable pulse oximetry unit
Computer Unable to access patient
System information systems and
Rehab Unit D
documentation if system
fails
Paging System Unable to contact

treating medical officer
Teams if system fails- D
patient care mix at risk
Page - 22 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
REHABILITATION UNIT
C = Indefinitely
D = Cannot Operate
How long can you
service?
Failure of Unable to defibrillate Utilise emergency generator Identify emergency power All Nursing and Medical staff
Defibrillator patients power within 10 seconds of outlets Utilise battery back up
power failure
Utilise battery back up Ensure batteries are fully
charged
Utilise other available Identify location of alternate Utilise other available
Defibrillators devices Defibrillators
Unable to communicate Utilise personal mobile
Internal phone
with others internally and phones or ? available MBH
system
externally mobile phone
Nurse Call Patients unable to buzz Supply of hand bells Equipment nurse to ensure Equipment Nurse & NUM
Alarm System for assistance supply and storage
Unable to raise alarm for Use of phones if main phone Use 222
emergency and life system operational
threatening situations
Staffing Unable to provide safe Use Unit base staffing model Calculate individual patient Indefiantly but with a
Resources level of care in the event where possible. staffing requirements Nurse Unit Manager limited service
of reduced nursing Seek support of the Nurse Manager
resources 24/7 volunteer services to assist Nursing Director
with tasks such as bed-
making
Consider “outlieing” patients
to other departments if not
effected or transfer to other
facilities/hospitals Identify care staff able to be
on call and redeployed in the
facility
Estimate staffing numbers Nurse Unit Manager
required for 24 hour period Nurse Manager
Identify nursing staff able to Nursing Director
be on call and redeployed in
the facility
Estimate staffing numbers
required for 24 hour period
Liaise with other
Page - 23 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
REHABILITATION UNIT
C = Indefinitely
D = Cannot Operate
How long can you
service?
facilities/units for extra care
staff
Liaise with agencies for
extra staff
Call staff in when required
Essential Unable to maintain Ensure adequate supply in Equipment Nurse & NUM A
equipment continuity of care stores
i.e. management Access from other
Hoists departments
Dressings and
store supplies
Unable to maintain
Linen Supplies
adequate linen
management if Laundry
effected - potential B
infection control risk
Food Supplies Unable to maintain

Outsource food supplies and
adequate dietary
catering
requirements of A
Transfer patients to other
individual patients if
wards/units
kitchen area effected
Oxygen Would have to rely on Maintain adequate supply of Confer with engineering re NUM
delivery system cylinder supply cylinder O2 and delivery availability of additional Equipment Nurse
devices supply in emergency event Engineering Rep B
Build up of clinical and

Inadequate
general waste products
Waste
in unit
Collection &
Infection Control Issue
Disposal
Page - 24 28/08/2013
Operating Theatre Services
Continuity Plan based on having Emergency generator power to the unit. If no power at all operating would cease and cases would have to be transferred.
Emergency phone Number if no power 6392
A = Up to 24hrs
OPERATING THEATRE SERVICES B = Up to 5 Days
C = Indefinitely
D = Cannot Operate
How long can you
service?
Failure of Unable to schedule /cancel Revert to manual process Utilise downtime forms Administration staff
computerised patients for surgery C
booking system Consider use of Theatre log
book.
Failure of Loss of power to machine Run on emergency Check access to emergency Nurse Unit Manager
anaesthetic generator power . power outlets. Anaesthetic staff
machines & Run on gases if no power Manually ventilate.
ventilators Oxygen driven) for 90 Manually physically assess
minutes only. Monitor pt
for 40 minutes on battery
from PACU monitors
Inaccurate delivery of Use backup cylinder Ensure supplies of cylinder Unit Manager A
anaesthetic gases supplies of oxygen, nitrous gasses available Wards person
oxide & air
Unable to ventilate patients Hand ventilate Ensure adequate supply of
hand operated ventilation
equipment - Disposable Unit Manager
manual resuscitator Anaesthetic staff
Locate and provide air /
oxygen driven ventilator
(oxylog)
Cancel elective surgery Director of Anaesthetics
Director of Surgery
Nurse Unit Manager
ESC &
DMS/DON/ND/EDMS
Failure of Monitors – Unable to identify arrhythmias / Run on emergency Check access to emergency Unit Manager
cardiac oximetry, oxygen saturation and generator power Battey power outlets Anaesthetic staff A
end tidal CO2 problems with ventilation power 40 minutes- One UPS
will operate for 5 hrs Identify & ensure adequate
medical & nursing staff Director of Anaesthetics
coverage CNC
Page - 25 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
How long can you
service?
Defibrillator does Unable to defibrillate patients Use on emergency Check access to emergency Unit Manager
not function generator power or battery power outlets A
power.
Use battery back up if Have batteries fully charged All staff
available
Failure of Unable to perform Revert to non laparoscopic Notify surgeons, medical, Unit Manager
laparoscopic camera laparoscopic surgery (may be methods nursing and booking office
/ light lead done if generator on
emergency power). Postpone all non urgent Contact non urgent patients Bookings/OR Manager
surgery and inform re need to
reschedule at later date A
ensure list of procedures Unit Manager
unable to be under taken Medical staff
available at theatre front
desk
Failure of diathermy Unable to perform electrical Revert to ties/sutures Ensure adequate supply of Unit Manager A
machine coagulation (may be done if ties and sutures
generator on emergency
power).
Failure of operating Unable to position patient Revert to manual processes Adjust bed to optimal height Nursing staff
table. prior to critical dates
Purchase manual override Nursing staff A
for table. Wards persons
Deleted all electric bed
Failure of Sterilising Unable to sterilise endoscopic Consider open procedures Notify surgeons, medical, Unit Manager
equipment for / laparoscopic and orthoscopic where clinically indicated nursing and booking office Medical staff
scopes (ON equipment Identify suitable patients
EMERGENCY Contact non urgent patients Bookings/OR Manager
POWER). and inform re need to
reschedule at later date
Staff education – availability Unit Manager
of types of cases able to be OR Educator A
done
List of procedures unable to Unit Manager
be under taken available at Medical staff
theatre desk
Page - 26 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
How long can you
service?
Failure of Turbine Unable to use orthopaedic Use Tool air cylinders Ensure three full cylinders Wards person
tool outlets power equipment:, Drills, Saw, Use battery tools. available NUM
Phaco Machine, Tourniquet Ensure CSSD recharge B
batteries. In theatre power
outlets
Failure of patient Unable to maintain patient Revert to manual processes • Ensure supply of space Nursing staff
warming devices thermal regulation blankets, warming B
boots/gloves etc.
Failure of transport Unable to monitor critically ill Aim to have at least one PACU Monitors portable & Biomedical staff
monitors or unstable patients compliant transport monitor have battery power Unit Manager B
Charge batteries Duty staff
Failure of lift Unable to transport patient Ensure one lift operates on Review existing supply of Manager Engineering A
to/from theatre emergency power emergency power
Relocate services Consider relocating one MHHS Executive
theatre on ground floor (eg)
in ED
Consider locating all surgical MHHS Executive A
patients on same level as Director of Surgery
Operating Theatre.
Staffing Unable to provide safe level of Centralise surgical services Develop a staffing plan for Unit Manager Director of A
care in the event of equipment at one site in MHHS over MHHS. Surgery
failure critical periods
Roster additional staff Calculate individual unit
staffing requirements Unit Manager
Identify need to maintain Director of Surgery
staff on site as opposed to
on call.
Identify human resources Unit Manager
able to be on call and Nurse manager
redeployed in the facility
Assess competence of on Unit Manager
call staff
Equipment Function Unable to guarantee Check all equipment for Identify all equipment to Unit Manager A
equipment accuracy functionality as soon as checked All staff
possible after disruption of
power Inform and educate staff
Recovery Monitoring equipment not on Monitors have battery power Nurse Unit Manager A
power.
Page - 27 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
How long can you
service?
Staff unable to No available Staff to perform Disaster Plan has all NUM to ensure Disaster Nurse Unit Manager A
come to work. lists. available phone numbers up Plan is current
to date.
No lights in change Staff are unable to change to Torches are available in the Ensure batteries are in unit. NUM C
rooms scrubs Staff unit. Arrange security inspection.
may not feel safe. Security to inspect all areas
before staff enter.
Computer failure Unable to generate ID labels Ensure supply of HBCIS Administrative and nursing staff
downtime forms
Pre –print labels on existing
patients
Hand write on blank labels
for new admissions
Unable to track patient location Update patient location and
and bed status bed status at regular
intervals
Notify after-hours manager Nursing staff
of all patient movements
Develop a process for
disseminating patient Nursing Staff Team Leader
updates as part of the facility
communication plan
Unable to access Revert to manual process Ensure supply of pathology
computerised result forms
pathology/radiology results Develop means for
notification of lab & test
results
Manual ordering tests Medical & nursing staff
Enter data when system Ensure retrospective data Unit Manager & Lab staff
fixed entry when computer
services resume
Backup any non centralised Administrative staff
data or ward specific
computer programs
Power failure Mains power not available Refer to mains power failure Inform and educate staff Unit Manager /Nurse Educator
plan
Lighting failure Difficulties in patient Utilise emergency lighting . Identify provision for Engineering staff
observation and care. Torches in all anaesthetic emergency lighting Nurse Unit Manager
machines.
Page - 28 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
How long can you
service?
Relocate immobile patients Nursing staff
to best lit areas
Maximise natural lighting Clean and maintain windows Cleaning staff
and fittings
Ensure blinds/curtains open
Utilise alternate lighting Ensure adequate supply Unit Manager
torches / battery operated
lights and batteries
Clear patient areas, work
areas and corridors of all
hazards
Increased risk for patients and Maintain WH&S precautions Educate staff
staff Refer to Facility wide power
failure plan
Air conditioning Unable to regulate Open Windows where Position fans for maximum
failure temperature and environment possible. benefit Nursing staff
Unable to perform surgery due Electrical or manual fan Identify patients requiring
to risk of infection cooling
Possible loss of sterile stock Refer to facility wide plan Inform and educate staff
due to high temps.
Telephone failure No internal / external Refer to facility wide Inform and educate staff Unit Manager
telephone communications. telecommunications plan Shift Team Leader /Educator
Wall oxygen supply Wall oxygen not available Use cylinder oxygen Identify anticipated
failure. requirements of cylinder
oxygen for ward patients Unit Manager
Order required cylinders
from central storage area
Ensure corresponding
number of oxygen fittings Wards person
available at ward level.
Ensure all staff educated in Wards person
cylinder changeover Unit Manager /Educator
Consider co-locating high Nursing staff
oxygen users Medical Staff
Page - 29 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
How long can you
service?
Wall suction failure Wall suction not available Use alternate suction Assess need for and number Unit Manager
devices of portable suction units
required (There is two
portable suction unit in the
theatre).
Consider co-locating suction
dependent patients Nursing staff
Ensure adequate supply
alternate drainage systems
Replace drain suction with
manual vacuum or drainage Nursing staff
bottles
Provide emergency Ensure small oxygen
oxygen/suction cylinder with twin-o-vac
suction on resuscitation
trolley Unit Manager
Educate staff on use of Educator
alternate devices
Use weighted scales if Unit Manager
available
Failure of Tympanic Potential for inaccuracy of Use digital thermometer Ensure stock digital Unit Manager
thermometer temperature readings thermometers
Failure of non- Unable to electronically Use manual Ensure adequate number of Unit Manager
invasive blood measure blood pressure sphygmomanometer manual
pressure (NIBP) recordings sphygmomanometers
monitors
Failure of Potential for decreased Visual readings Ensure adequate stock of Nursing staff
Glucometer accuracy in blood glucose batteries. Unit Manager
readings Inform and educate staff Educator
Formal laboratory blood Develop policy for formal Medical staff
glucose analysis for laboratory test
abnormal results
Failure of 12 lead Unable to diagnose potential Ensure access to Identify access to
ECG machine life-threatening conditions emergency power emergency power outlet Unit Manager
Use on battery power Keep batteries fully charged Engineering staff
on emergency power Nursing Staff
Identify location of Educator
alternative ECG machines
Inform and educate staff
Page - 30 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
How long can you
service?
Failure of Pulse Unable to determine oxygen Increase nursing Educate staff re basic Unit Manager
oximeters saturation observation physical assessment of Educator
patient
Failure of Lamson Unable to transport specimens Revert to manual process Inform and educate staff Unit Manager
System Educator
Failure of Unable to provide safe and Increased staff vigilance Schedule regular patient Nursing staff
Emergency Alarms secure environment rounds
Direct notification via phone
to switch or runner to
Communication Centre to
contact fire services,
security, police
Refer to safety and security Inform and educate Staff Unit Manager
plan.
Failure of Patient Patients unable to summon Refer to safety and security Inform and educate staff Unit Manager
call buttons assistance plan.
Failure of Infusion Staff unable to titrate Use on battery power if Charge on generator power
Pumps/Syringe medications and fluids available if able Charge batteries fully A
Drivers accurately Use burettes Ensure adequate stock All staff Nursing staff
burettes
Consider alternate Protocols for alternative Medical staff
administration routes administration
Failure of Enteral Difficulty in maintaining patient Use alternate enteral Develop procedure for bolus
feed pumps nutrition feeding methods. / gravity feeding Unit Manager
Ensure adequate supply Educator
tubes & bags & feeds Nursing Staff
Failure of Sequential Potential increased risk of DVT Use alternative methods of Identify at risk patients
Compression /Embolus deterring thrombo-embolus Unit Manager
Devices Consider compression Medical staff
stockings/ drug therapy Educator
Develop policy
Ensure adequate supplies of
stockings
Page - 31 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
How long can you
service?
Refrigeration Drugs and medical supplies Place drugs in refrigerators Review emergency power
(Connected to requiring refrigeration may which are connected to outlets Unit Manager
Emergency power). become unusable emergency power supply Monitor refrigerator Engineering staff
Alert staff if no temperature with Nursing staff
emergency power to thermometer Infection Control Staff
make plans for Use Eskies and ice Consider purchase of eskies
refrigerated drugs. and supply of ice
Consider purchase of eskies
and supply of ice
Consult with Pharmacy
Failure of lifting Difficulties with lifting heavy Identify alternate lifting Use hydraulic lifting devices All staff
devices patients – manual handling devices if available
injuries Use of ski sheets, bed
sheets, etc. Unit Manager
Ensure staff trained in Educator
manual handling
Pan room hopper Unable to clean bed pans / Single patient use bedpans/ Purchase sufficient for Unit Manager
urinals adequately urinals immobile patients
Rinse with “grey/waste”
water and disinfect with All staff
chemical solution• Rinse
with “grey/waste” water and
disinfect with chemical
solution
Inform staff of Infection Unit Manager
Control policy Infection Control CNC
Lift failure Unable to transport patients to Ensure one lift operates on Review existing supply of Engineering staff
different levels within facility emergency power emergency power Disaster Committee
Utilise alternate methods of Walk patients Wards person
transporting patients
Consider scoop stretchers,
fire blankets, stair walkers, MHHS Executive
cardboard stretchers
Consider utilising ground Develop facility plan for
floor facilities locating new admissions
Minimise patient transfers Critical transfers only Medical staff
Ensure all staff aware of Unit Manager
facility Fire / Evacuation plan
Page - 32 28/08/2013
A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
How long can you
service?
Failure of Fax Unable to receive or send Utilise alternate lines of Send patient information by Unit Manager
patient information communication runner/courier
Delay transfer of information Medical staff
until services resumed. Admin. staff
Failure of Copier Unable to copy documents Utilise alternate lines of Telephone information
communication Send original documents Nursing staff
with patient and document in Medical staff
chart
Delay transfer of information
until services resumed
Staffing Increased manual tasks may Roster extra staff on duty Estimate staffing numbers
influence workload required for 24 hour period All managers
Place staff "on call" Prepare rosters
extra staff Duty managers
Call in staff
Equipment Function Unable to guarantee Check all equipment for Identify all equipment to be Unit Manager
equipment accuracy functionality as soon as checked All staff
power
Inform and educate staff DMHHS Executive
Unit Manager /Educator
Page - 33 28/08/2013
Intensive Care Unit
Note: The Standard Operating Procedures for the general wards and the MHHS Essential Services are to be used in conjunction with the
specific procedures detailed below.
INTENSIVE CARE UNIT C = Indefinitely D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can you function without this service?
Utilise
Failure of Unable to closely emergency
Identify
Central monitor patients generator power
emergency All Nursing and Medical staff
Monitoring from central within 10
power outlets
System station seconds of
power failure
Ensure alarms
Use bedside functional and
Nursing staff
monitors turned "on" on all
monitors
Initiate close
observation of All Nursing and Medical staff
patients
Unable to Use portable
Assess need for
provide monitoring
ward patients to Director ICU, Medical Consultants and Nurse Unit Mangers
Telemetry to devices on the
be on Telemetry
general wards wards
Transfer at risk
patients to Medical Staff, NUM and team Leader
ICU/CCU
Utilise
Failure of Unable to
emergency
Monitors identify Identify
generator power
including arrhythmia’s / emergency All Nursing and Medical staff
within 10
cardiac & oxygen power outlets
seconds of
oximetry saturation
power failure
Utilise battery Ensure batteries
Nursing staff Battery life of Monitor is 30 mins to 2 hours
back up are fully charged
Locate
functioning Prioritise patients
Director of ICU and ICU Consultants
portable for monitoring
monitors
Page - 34 28/08/2013
Increased
nursing &
Inform staff All Nursing and Medical staff
medical
observation
Increased
rostered staffing NUM Depening on staff availability
numbers
Purchase
Utilise
portable
emergency
emergency
supply of NUM
SpO2 monitors
poratble SpO2
for each
monitors
ICU/CCU bed
Note: Monitors work on emergency power. There are three portable Lifepacks and two transport monitor in the unit if emergency power does not work.
Unable to Ensure
Failure of
monitor critically Utilise battery batteriesare fully
Transport Nursing staff Battery life of Monitor is 30 mins to 2 hours
ill or unstable power charged and
monitors
patients operational
Limit any Liaise with
movement of Medical Officer
these patients to regarding need All Nursing and medical staff
essential tests for patient
only transfer
Utilise
emergency Identify location
supply of of emergency All Nursing and Medical staff
poratble SpO2 supply
monitors
Utilise
emergency
Unable to Identify
Failure of generator power
defibrillate emergency All Nursing and Medical staff
Defibrillator within 10
patients power outlets
seconds of
power failure
All nursing and Medical staff
Utilise other Identify location
available of alternate
Page - 35 28/08/2013
Defibrillators devices
Unable to
Calculate Director of ICU,
provide safe Use Unit base
Insufficient individual patient ICU Consultants,
level of care in staffing model Indefiantly but with a limited service
staff staffing NUM and Team
the event of where possible.
requirements Leader
equipment failure
Identify critical
care staff able to
be on call and NUM and Team Leader
redeployed in the
facility
Estimate staffing
numbers
NUM and Team Leader
required for 24
hour period
Liaise with other
facilities for extra NUM
critical care staff
Liaise with
agencies for
NUM
extra critical care
staff
Call staff in when
NUM, Nurse Manager and Team Leader
required
Transfer patients
NUM and Clinical Director
to other facilities
Page - 36 28/08/2013
Coronary Care Unit
Note: The Standard Operating Procedures for the general wards and the MHHS Essential Services are to be used in conjunction with the
specific procedures detailed below.
CORONARY CARE UNIT C = Indefinitely D = Cannot Operate
Utilise
Failure of Unable to closely emergency
Identify
Central monitor patients generator power
emergency All Nursing and Medical staff
Monitoring from central within 10
power outlets
System station seconds of
power failure
Ensure alarms
Use bedside functional and
Nursing staff
monitors turned "on" on all
monitors
Initiate close
observation of All Nursing and Medical staff
patients
Unable to Use portable
Assess need for
provide monitoring
ward patients to Director ICU, Medical Consultants and Nurse Unit Mangers
Telemetry to devices on the
be on Telemetry
general wards wards
Transfer at risk
patients to Medical Staff, NUM and team Leader
ICU/CCU
Utilise
Failure of Unable to
emergency
Monitors identify Identify
generator power
including arrhythmia’s / emergency All Nursing and Medical staff
within 10
cardiac & oxygen power outlets
seconds of
oximetry saturation
power failure
Nursing staff Battery life of Monitor is 30 mins to 2 hours
Locate
functioning Prioritise patients
Director of ICU and ICU Consultants
portable for monitoring
monitors
Page - 37 28/08/2013
Increased
nursing &
Inform staff All Nursing and Medical staff
medical
observation
Increased
rostered staffing NUM Depening on staff availability
numbers
Purchase
Utilise
portable
emergency
emergency
supply of NUM
SpO2 monitors
poratble SpO2
for each
monitors
ICU/CCU bed
Note: Monitors work on emergency power. There are three portable Lifepacks and two transport monitor in the unit if emergency power does not work.
Unable to
Failure of Ensure batteries
monitor critically Utilise battery
Transport are fully charged Nursing staff Battery life of Monitor is 30 mins to 2 hours
ill or unstable power
monitors and operational
patients
Limit any Liaise with
movement of Medical Officer
these patients to regarding need All Nursing and medical staff
essential tests for patient
only transfer
Utilise
emergency Identify location
supply of of emergency All Nursing and Medical staff
portable SpO2 supply
monitors
Utilise
emergency
Unable to Identify
Failure of generator power
defibrillate emergency All Nursing and Medical staff
Defibrillator within 10
patients power outlets
seconds of
power failure
Utilise other Identify location
available of alternate All nursing and Medical staff
Defibrillators devices
Page - 38 28/08/2013
Unable to
Calculate Director of ICU,
provide safe Use Unit base
Insufficient individual patient ICU Consultants,
level of care in staffing model Indefinite but with a limited service
staff staffing NUM and Team
the event of where possible.
requirements Leader
equipment failure
Identify critical
care staff able to
be on call and NUM and Team Leader
redeployed in the
facility
Estimate staffing
numbers
NUM and Team Leader
required for 24
hour period
Liaise with other
facilities for extra NUM
critical care staff
Liaise with
agencies for
NUM
extra critical care
staff
Call staff in when
NUM, Nurse Manager and Team Leader
required
Page - 39 28/08/2013
Women’s Health
The Birth Suites are connected to the Emergency Generator
A = Up to 24hrs
B = Up to 5 Days
WOMENS HEALTH UNIT C = Indefinitely
D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can you
function without this
service?
Failure of Infant Suction and oxygen not Use portable gases Ensure twin-o-vac available Clinicians
resuscitation trolleys immediately available
Ensure oxygen and ir
cylinders on resus cots are Unit Manager
Use emergency generator full and additional bottles are
power available
Ensure trolleys are plugged Clinicians
Unable to maintain infant Ensure alternate warming into red emergency power
warming devices available points. A
Fill Blanket warmer with Ensure supply of linen,
blankets and linen and blankets and bubble wrap Unit Manager
plugged into generator Wardsperson
Dry babies well. Wrap &
dress warmly Nursing staff
Place baby in bed with
mother Consider bubbie wrap,
space blankets, gladwrap Nursing staff
Failure of electric delivery Positioning for an Use emergency generator Ensure trolleys are plugged Clinicians
beds assisted birth more power into red emergency power
difficult points. C
Revert to manual Adjust bed to optimal height Nursing staff
positioning prior to critical dates Wardspersons
Inform staff & patients
Failure of Unable to perform Use emergency generator Ensure trolleys are plugged Clinicians
Cardiotocograph (CTG) continuous foetal heart power into red emergency power C
/pH scalp monitoring monitoring on high risk points.
women Use battery-powered Identify at risk patients &
ultrasound doppler. instigate intermittent
monitoring Unit Manager
Ensure adequate supply of Medical staff D
battery operated dopplers
and gel.
Use Pinard stethoscope Ensure access to Pinard Unit Manager
Page - 40 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
WOMENS HEALTH UNIT C = Indefinitely
D = Cannot Operate
service?
stethoscope Medical staff
Educate staff in use
Failure of Monitors Unable to identify Utilise emergency Identify emergency power Unit Manager A
including cardiac & arrhythmias / oxygen generator power outlets Engineering staff
oximetry saturation
Utilise battery back up Ensure batteries fully Nursing staff
charged
Locate functioning monitors Prioritise patients for Medical staff
monitoring Nursing staff
Increased nursing & Inform and educate staff
medical observation &patients
Potential for complicated Unable to provide Transfer to other centres Early assessment and Medical staff
delivery appropriate level of care identification of at risk clients D
in the intrapartum period Discuss options with Medical staff
patient. Nursing staff
Transfer patient before
critical period
Staffing Unable to provide safe Utilise staff available within Calculate individual unit Unit Manager D
level of care. the facility staffing requirements Medical Director
Plan staffing availability Identify pool of appropriately
skilled staff to be on call Unit Manager
and/or redeployed in the Medical Director
facility
Lift failure Unable to transport Ensure one lift operates on Review exisitng supply of MHHS Executive
patient to theatre or emergency power emergency power. Engineering staff A
labour ward
Consider alternate area for Designate an area MHHS Executive
Caesarean section Medical staff A
Develop unit policies for Nursing staff
procedure, personnel, and
equipment Unit Manager
Inform and educate staff & Medical Director
patients Educator
Equipment Function Unable to guarantee Check all equipment for Identify all equipment to be Unit Manager A
equipment accuracy functionality as soon as checked DEPENDS ON
possible after disruption of MHHS Executive EQUIPMENT
power Inform and educate staff Medical staff
Nursing staff
Page - 41 28/08/2013
Special Care Neonatal Intensive Care Nursery
Special Care Nursery is connected to Emergency Power
Risk Management regular checks of emergency equipment and processes
A = Up to 24hrs
B = Up to 5 Days
SPECIAL CARE – NEONATAL INTENSIVE CARE NURSERY C = Indefinitely
D = Cannot Operate
service?
Failure of ventilators Deterioration / possible Run ventilators on Check emergency power Unit Manager A
death of critically ill emergency power outlets Engineering staff
ventilated neonates
Run ventilators on battery Ensure batteries are Clinical Staff
back up (limited backup life) charged at all times. Medical Staff
Discuss with paediatrician re
review of critically ill patients
and ventilation options the
Use alternative respiratory need to transfer at risk
support methods eg Bubble babies where possible. Unit Manager
CPAP In-service all staff on Medical Director
operation of respiratory Educator
Hand bagging support
Yearly competency.
Ensure rostered staff are
competent
Failure of Humidicrib Difficulty in regulating Use emergency generator Ensure cribs are plugged All Clinicians A
neonate's environment power into red emergency power
points. A
Review of ambient Adjust bedding and clothing
temperature to meet neonatal needs
Use warm blankets and/or Ensure adequate supply of
jump suits blankets/jump suits
Use bubble wrap Ensure supply of bubble
wrap
Use water bed if Clinician to plan best option
emergency power relative to clinical needs of
baby. Unit Manager
Inform and educate staff Educator
Failure of phototherapy Unable to correct Utilise emergency power Ensure access to Unit Manager A
unit jaundice emergency power Engineering staff as long as contingency
Monitor Bilirubin levels Transfer to another centre if Nursing Staff available
clinical care requires Medical staff
Page - 42 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
intervention
Exchange transfusion Transfer to another centre if Nursing Staff
clinical care requires Medical staff
intervention that cannot be
safely performed in the SCN
at the time.
Failure of Monitors Unable to identify Utilise emergency Identify emergency power Unit Manager A
including cardiac & arrhythmias / oxygen generator power outlets Engineering staff
oximetry saturation Utilise battery back up Ensure batteries fully
charged Nursing staff
Locate functioning monitors Prioritise patients for Medical staff
monitoring
Increased nursing & Inform and educate staff
medical observation
Staffing Unable to provide safe Utilise staff available within Calculate individual unit Unit Manager D
level of care in the event the facility staffing requirements Medical Director
of critical event
Plan staffing availability Identify pool of appropriately
skilled staff to be on call
and/or redeployed in the
facility
Equipment Function Unable to guarantee Check all equipment for Identify all equipment to be Unit Manager A
equipment accuracy functionality as soon as checked
power Inform and educate staff
Failure of Infusion Staff unable to titrate Use emergency generator Ensure pumps are plugged All staff Nursing staff
Pumps/Syringe Drivers medications and fluids power into red emergency power
accurately points. C
Use on battery power if Charge on generator power
available if able Charge batteries fully
Use burettes Ensure adequate stock
burettes
Consider alternate Protocols for alternative Nursing staff Medical staff
administration routes. administration
Failure of Breast Pump Unable to express breast Use emergency generator Ensure pumps are plugged Nursing staff
(Minimal significance) milk power into red emergency power C
Express by hand or manual points.
pumps Adequate supplies of Unit Manager
manual breast pumps
Page - 43 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Inform and educate staff Unit Manager
Inform and educate patients Educator
Refrigeration of formula & EBM & formula may Use emergency generator .Ensure fridge is plugged Nursing staff
expressed breast milk become contaminated power into emergency supply
(EBM) Obtain EBM as close to feed
Use fresh EBM as possible Nursing staff C
Discard any defrosted EBM Mothers
Use frozen EBM after 24hrs.
Discard unused EBM after
Ensure date and time of 24hrs
defrosting is marked on any
EBM Discuss options with mother
Use of formula instead of Ensure adequate stocks of Nursing staff
frozen EBM as a last resort bottled sterile water and Infection Control Staff
only. formula (powder & prepared)
Use pre packed formula Formula made and used as
that does not require required
refrigeration Discard unused formula
Develop unit policy and Unit Manager
educate staff Educator
Page - 44 28/08/2013
Womens Health Unit – Ward & Clinics
A = Up to 24hrs
B = Up to 5 Days
WOMENS HEALTH UNIT - WARD & CLINICS C = Indefinitely
D = Cannot Operate
service?
Computer failure Unable to generate ID Record patient details Ensure supply of HBCIS Administrative Staff
labels manually downtime forms Nursing Staff
patients
Hand write on blank labels A
for new admissions
Unable to track patient Revert to manual process Update patient location and
location and bed status bed status at regular
intervals
Notify after-hours manager Nursing Staff Team Leader
of all patient movements A
disseminating patient
communication plan Unit Manager
Unable to provide patient Revert to manual process Update patient diet lists and
dietary requirements have available for collection
by catering services
Unable to record Revert to manual process Ensure supply of downtime Administrative staff
information relating to forms available to record
patient nurse information
dependency A
Unable to access Revert to manual process Ensure supply of pathology Administrative staff
pathology/radiology
results
Develop means for Unit Manager & Lab staff
results
Manual ordering tests Medical & nursing staff
Enter data when system Ensure retrospective data Unit Manager & Lab staff
fixed entry when computer A
services resume
Backup any non centralised Administrative staff
Page - 45 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
computer programs
Power failure Mains power not Refer to mains power Inform and educate staff Unit Manager /Nurse Educator A
available failure plan
Lighting failure Difficulties in patient Utilise emergency lighting Identify provision for Engineering staff
observation and care emergency lighting
Relocate immobile patients Nursing staff
to best lit areas
Maximise natural lighting Clean and maintain windows Cleaning staff D
and fittings
Ensure blinds/curtains open Ensure adequate supply All staff
Utilise alternate lighting torches / battery operated Unit Manager
Increased risk for Maintain WH&S Clear patient areas, work
patients and staff precautions areas and corridors of all
hazards
Refer to Facility wide power Educate staff
failure plan
Air conditioning failure Unable to regulate Use alternate cooling Position fans for maximum Nursing staff
temperature and devices (eg.) Electrical or benefit
environment manual fan Identify patients requiring A
cooling
Refer to facility wide plan Inform and educate staff
Telephone failure No internal / external Refer to facility wide Inform and educate staff Unit Manager A
telephone telecommunications plan Shift Team Leader
communications Educator
Wall oxygen supply failure Wall oxygen not Use cylinder oxygen Identify anticipated Unit Manager
available requirements of cylinder A
oxygen for ward patients
from central storage area.
Ensure all oxygen cylinders Wardsperson
full
number of oxygen fittings
available at ward level. Wardsperson
Ensure all staff educated in Unit Manager
cylinder changeover. Educator
Page - 46 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Consider co-locating high
oxygen users
Wall suction failure Wall suction not Use alternate suction Assess need for and number
available devices of portable suction units
required Nursing staff A
Consider co-locating suction Medical Staff
dependent patients
Replace drain suction with
manual vacuum or drainage
bottles
Provide emergency Ensure small oxygen
trolley Unit Manager
Educate staff on use of Educator
alternate devices
Use weighted scales if
available
Failure of non-invasive Unable to electronically Run on emergency power Check emergency power Unit Manager
blood pressure (NIBP) measure blood pressure if loads permit. outlets Engineering staff C
monitors recordings Use manual Ensure adequate number of Unit Manager
sphygmomanometer manual
sphygmomanometers
Failure of Pulse oximeters Unable to determine Increase nursing Educate staff re basic Educator
oxygen saturation observation physical assessment of A
patient
Failure of Lamson System Unable to transport Revert to manual process Inform and educate staff Unit Manager C
specimens Educator
Failure of Emergency Unable to provide safe Increased staff vigilance Schedule regular patient Nursing staff
Alarms and secure environment rounds
Direct notification via phone D
Communication Centre to All staff
security, police
Refer to safety and Inform and educate Staff
Page - 47 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
security plan.
Failure of Patient call Patients unable to Refer to safety and security Inform and educate staff Unit Manager A
buttons summon assistance plan
Staff unable to titrate Use on battery power if Charge on generator power All staff Nursing staff
medications and fluids available if able Charge batteries fully
accurately
Use burettes Ensure adequate stock Nursing Staff C
burettes
Consider alternate Protocols for alternative Nursing staff
administration routes administration Medical staff
Refrigeration Drugs and medical Place drugs in refrigerators Review emergency power Unit Manager
supplies requiring which are connected to outlets Engineering staff
refrigeration may emergency power supply
become unusable A
Monitor refrigerator Nursing staff
temperature with Infection Control Consultant
thermometer as per Infection
Control Guidelines.
Use Eskies and ice Consider purchase of eskies Unit Manager
and supply of ice
Consult with Pharmacy Educator
Pan room hopper Unable to clean bed Single patient use bedpans/ Purchase sufficient for Unit Manager
pans / urinals adequately urinals immobile patients C
water and disinfect with
chemical solution
Inform staff of Infection Infection Control CNC
Control policy
Lift failure Unable to transport Ensure one lift operates on Review existing supply of Engineering staff
patients to different emergency power emergency power Disaster Committee
levels within facility
Utilise alternate methods of Walk patients Wardsperson
transporting patients D
Consider scoop stretchers, MHHS Executive
fire blankets, stair walkers,
Page - 48 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Consider utilising ground Develop facility plan for MHHS Executive
Ensure all staff aware of
facility Fire / Evacuation plan Unit Manager
Failure of Fax Unable to receive or Utilise alternate lines of Send patient information by Unit Manager
send patient information communication runner/courier B
until services resumed Administration staff
Failure of Copier Unable to copy Utilise alternate lines of Telephone information Nursing staff
documents communication Medical staff B
Send original documents
with patient and document in
chart
Delay transfer of information Nursing staff B
until services resumed Medical staff
Staffing Increased manual tasks Roster extra staff on duty Estimate staffing numbers All managers
may influence workload required for 24 hour period D
extra staff
Call in staff Duty managers
Equipment Function Unable to guarantee Check all equipment for Identify all equipment to be Unit Manager
equipment accuracy functionality as soon as checked All staff A
possible after disruption of DEPENDS ON
power Inform and educate staff MHHS Executive EQUIPMENT
Unit Manager
Educator
Page - 49 28/08/2013
Birth Centre
The Birth Centre has no emergency power connected.
The lighting is not suitable for operation without power
A = Up to 24hrs
B = Up to 5 Days
BIRTH CENTRE C = Indefinitely
D = Cannot Operate
service?
No emergency power No electrical or Transfer all women to the Arrange transfer of all
emergency equipment Women's health Unit women who require ongoing Unit Manager
will work. care. Birth Centre Midwives
Poor lighting Transfer all women to the Arrange transfer of all D
Women's Health Unit women who require ongoing
care.
Unable to provide infant Transfer all women to the Arrange transfer of all
warming Women's Health Unit women who require ongoing
care.
Isolation and Safety of Unable to maintain Transfer program to WHU Send P/N women home.
building communication or safety Transfer to WHU
of staff B/C Midwives to provide
care for BC women where
possible.
Inform all women that the Unit Manager D
service is being conducted Birth Centre Midwives
from the WHU for the
duration of the disaster.
Inform switch
Inform After Hours
Coordinators
Outside furniture and toys Flying objects Refer to cyclone Ensure all flying objects are Wards persons
preparation policy secure
Page - 50 28/08/2013
Child & Adolescent Health Unit
The following Standard Operating Procedures have been generated for application across clinical units where common processes exist and are
grouped thus to avoid replication of tasks for contingency planning for individual wards.
CHILD & ADOLESCENT HEALTH UNIT
C = Indefinitely D = Cannot Operate
HOW LONG CAN YOU
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY FUNCTION WITHOUT
THIS SERVICE?
Computer Unable to generate ID Record patient details manually  nsure supply of HBCIS downtime forms
E Administrative and nursing C
failure labels staff Can function but very
time consuming
Pre –print labels on existing patients A
 dministrative and nursing C
staff Can function but very
time consuming
Hand write on blank labels for new Administrative and nursing
C
admissions staff
Can function but very
time consuming
Unable to track patient Revert to manual process U
 pdate patient location and bed status at Administrative and nursing
location and bed status regular intervals staff
C
Can function
Notify after-hours manager of all patient Nursing staff
movements
C Can function
Develop a process for disseminating patient Nursing Staff Team

updates as part of the facility communication Leader
plan
C Can function
Unable to provide patient Revert to manual process U
 pdate patient diet lists and have available Unit Manager
dietary requirements for collection by catering services
C
time consuming
Page - 51 28/08/2013
HOW LONG CAN YOU
THIS SERVICE?
Unable to record Revert to manual process E
 nsure supply of downtime forms available Administrative and nursing
information relating to to record information staff
patient nurse dependency Nursing staff to feedback to NUM/Bed C
Manager Can function but very
time consuming
Unable to access Revert to manual process Ensure supply of pathology result forms A
 dministrative staff
computerised
pathology/radiology C
results Can function but very
time consuming
Develop means for notification of lab & test Unit Manager & Lab staff
C
results
time consuming
Manual ordering tests Medical & nursing staff C
MO Currently write out
pathology forms
Enter data when system fixed E
 nsure retrospective data entry when Unit Manager & Lab staff
computer services resume
C Will be very time
consuming
Backup any non centralised data or ward Administrative staff

specific computer programs
C Will be very time
consuming
Power failure Mains power not available Refer to mains power failure plan Inform and educate staff Unit Manager /Nurse B
Educator Can function in most
areas, dependent on
patient acuity
Lighting Difficulties in patient Utilise emergency lighting I dentify provision for emergency lighting Engineering staff B
failure observation and care. Can function in most
areas.
Relocate immobile patients to best lit areas N
 ursing staff B
Can function in most
areas.
Maximise natural lighting C
 lean and maintain windows and fittings C
 leaning staff B
areas.
Ensure blinds/curtains open All staff
B
Page - 52 28/08/2013
HOW LONG CAN YOU
THIS SERVICE?
areas.
Utilise alternate lighting Ensure adequate supply torches / battery Unit Manager
operated lights and batteries
B Can function in most
areas.
Increased risk for patients Maintain WH&S precautions Clear patient areas, work areas and Unit Manager /All staff
B Can function in most
and staff corridors of all hazards
areas.
Refer to Facility wide power Educate staff Educator B Can function in most
failure plan areas.
Air Unable to regulate Use alternate cooling devices Position fans for maximum benefit Nursing staff A Especially in summer
conditioning temperature and (eg.) Limited where no
failure environment window
.
Electrical or manual fan A
Especially in summer
Limited where no
window.
Identify patients requiring cooling Nursing staff A
Limited where no
window.
Refer to facility wide plan I nform and educate staff Unit Manager A
Limited where no
window.
Telephone No internal / external Refer to facility wide Inform and educate staff Unit Manager /Shift Team A
failure telephone telecommunications plan Leader /Educator Only for a limited time.
communications . Major impact on
emergency
communication from/to
CAU in current position
Wall oxygen Wall oxygen not available Use cylinder oxygen Identify anticipated requirements of cylinder Unit Manager
B
supply failure. oxygen for ward patients
Need to increase to four
cylinders
Page - 53 28/08/2013
HOW LONG CAN YOU
THIS SERVICE?
Order required cylinders from central Unit Manager
storage area.
B
Ensure all oxygen cylinders full Wards person
B
Ensure corresponding number of oxygen Wards person B
fittings available at ward level.
Ensure all staff educated in cylinder Wards person/Unit B

changeover. Manager /Educator
Consider co-locating high oxygen users Nursing staff /medical B

Staff Paediatric patients need
to stay where there are
paediatric nurses
Wall suction Wall suction not available Use alternate suction devices Assess need for and number of portable Unit Manager B
failure suction units required Not safe for high risk
patients. Area only has
one manual suction.
Post operative patients
not able to cared for
safely.
Consider co-locating suction dependent Nursing staff B
patients Paediatrict patients
need to stay where
there are paediatric
nurses
Ensure adequate supply alternate drainage Nursing staff B
systems Limited supply in
hospital
Replace drain suction with manual vacuum Nursing staff B
or drainage bottles Medical staff Limited supply in
hospital
Page - 54 28/08/2013
HOW LONG CAN YOU
THIS SERVICE?
Provide emergency Ensure small oxygen cylinder with twin-o- Nursing staff B
oxygen/suction vac suction on resuscitation trolley Limited supply in
hospital Only one in
CAU.
3x twin-o-vacs in CAU
Educate staff on use of alternate devices Unit Manager Educator
Digital scales Unable to record weight Use alternative scales Purchase bathroom scales Unit Manager C
fail
Use weighted scales if available Unit Manager C
Failure of Potential for inaccuracy of Use digital thermometer Ensure stock digital thermometers Unit Manager C
Welsh Allen temperature readings
thermometer
Failure of Unable to electronically Use manual sphygmomanometer Ensure adequate number of manual Unit Manager C
non-invasive measure blood pressure sphygmomanometers
blood recordings
pressure
(NIBP)
monitors
Failure of Potential for decreased Change battery in Glucometer. Ensure adequate supply of batteries and Nursing staff /Unit C
Glucometer accuracy in blood glucose test strips. Manager
readings
Inform and educate staff Unit Manager Educator C
Formal laboratory blood glucose Develop policy for formal laboratory test Medical staff A.
analysis for abnormal results Nursing staff A potential treatment
problem.
Failure of 12 Unable to diagnose Ensure access to emergency Identify access to emergency power outlet Unit Manager A
lead ECG potential life-threatening power Engineering staff No problem if
machine conditions emergency power point
kept for use.
Use on battery power Keep batteries fully charged on emergency Unit Manager /Nursing A
power Staff limited battery life
Page - 55 28/08/2013
HOW LONG CAN YOU
THIS SERVICE?
Identify location of alternative ECG Nursing staff
machines
Inform and educate staff Unit Manager /Educator
Failure of Unable to determine Increase nursing observation Educate staff re basic physical assessment Educator C
Pulse oxygen saturation of patient Staff trained in physical
oximeters assessment
Failure of Unable to transport Revert to manual process Inform and educate staff Unit Manager /Educator C
Lamson specimens Can function but very
System time consuming
Failure of Unable to provide safe Increased staff vigilance Schedule regular patient rounds Nursing staff B
Emergency and secure environment Can function but time
Alarms consuming and can
lead to decreased
patient safety.
Direct notification via phone to switch or All staff B
runner to Communication Centre to contact Can function.
fire services, security, police
Refer to safety and security plan. Inform and educate Staff Unit Manager B
Can function.
Failure of Patients unable to Refer to safety and security plan. Inform and educate staff Unit Manager C
Patient call summon assistance Can function
buttons
Failure of Staff unable to titrate Use on battery power if available Charge on generator power if able Charge All staff Nursing staff A
Infusion medications and fluids . batteries fully Batteries can last up to
Pumps/Syring accurately 12 hours.
e Drivers
Use burettes Ensure adequate stock burettes Nursing Staff A
Extra staff will be
required.
Consider alternate administration Protocols for alternative administration Nursing staff Medical staff
routes.
Failure of Difficulty in maintaining Use alternate enteral feeding Develop procedure for bolus / gravity Unit Manager/Educator C
Enteral feed patient nutrition methods. feeding Nursing Staff Extra staff required.
pumps
Page - 56 28/08/2013
HOW LONG CAN YOU
THIS SERVICE?
Ensure adequate supply tubes & bags & Unit Manager
feeds
Inform and educate staff Educator
Failure of Potential increased risk of Use alternative methods of Identify at risk patients Unit Manager Medical C
Sequential DVT /Embolus deterring thrombo-embolus staff Not common in
Compression paediatrics
Devices
Consider compression stockings/ drug Unit Manager /Educator C
therapy /Medical Staff Not common in
paediatrics
Develop policy Unit Manager /Educator C

/Medical Staff Not common in
paediatrics
Ensure adequate supplies of stockings Nursing staff C

Not common in
paediatrics
Refrigeration Drugs and medical Place drugs in refrigerators Review emergency power outlets Unit Manager A
supplies requiring which are connected to Consult with Pharmacy Engineering staff
refrigeration may become emergency power supply Infection Control staff
unusable
Monitor refrigerator temperature with Nursing staff B
thermometer Areas will need to
purchase monitors.
Use Eskies and ice Consider purchase of eskies and supply of Unit Manager A
ice with eskies.
Inform and educate staff Unit Manager Educator
Failure of Difficulties with lifting Identify alternate lifting devices Use hydraulic lifting devices if available All staff B
lifting devices heavy patients – manual
handling injuries
Use of ski sheets, bed sheets, etc. All staff C
Ensure staff trained in manual handling Unit Manager Educator C
Page - 57 28/08/2013
HOW LONG CAN YOU
THIS SERVICE?
Pan room Unable to clean bed pans Single patient use bedpans/ Purchase sufficient for immobile patients  nit Manager
U B
hopper / urinals adequately urinals
Rinse with “grey/waste” water and disinfect All staff B

with chemical solution
Inform staff of Infection Control policy U nit Manager

Infection Control CNC
Educator
Lift failure Unable to transport Ensure one lift operates on Review existing supply of emergency power E
 ngineering staff Disaster
patients to different levels emergency power Committee
within facility
Consider scoop stretchers, fire blankets, MHHS Executive A

stair walkers, cardboard stretchers Need increased staff.
Consider utilising ground floor Develop facility plan for locating new MHHS Executive A
facilities admissions
Minimise patient transfers Critical transfers only Medical staff A
Ensure all staff aware of facility Fire / Unit Manager A

Evacuation plan
Failure of Negative impact on Verbal education Develop alternate education packages for Unit Manager Educator C
Video/TV patient education patients Can still operate.
enjoyment Medical Staff. C
Can still operate.
Alternative recreational facilities Prepare mobile library Volunteers C
Can still operate.
Page - 58 28/08/2013
HOW LONG CAN YOU
THIS SERVICE?
Consider hand held computer games for MHHS Executive Unit C Can still operate.
children Manager
Failure of Fax Unable to receive or send Utilise alternate lines of Send patient information by runner/courier Unit Manager A
patient information communication Can still operate but
time consuming.
Delay transfer of information until services Medical staff
A
resumed. Admin. staff
Can still operate but
time consuming.
Failure of Unable to copy Utilise alternate lines of Telephone information Nursing staff C
Copier documents communication Medical staff Will be very time
consuming
Send original documents with patient and Nursing staff
C
document in chart Medical staff
Will be very time
consuming
Delay transfer of information until services Medical staff
resumed Admin. staff
B
Staffing Increased manual tasks Roster extra staff on duty Estimate staffing numbers required for 24 All managers
may influence workload hour period
B
Place staff "on call" Prepare rosters All managers
B
Liaise with agencies for extra staff All managers
C
B
Equipment Unable to guarantee Check all equipment for Identify all equipment to be checked Unit Manager All staff
Function equipment accuracy functionality as soon as possible
B
Inform and educate staff MHHS Executive
Unit Manager Educator
Page - 59 28/08/2013
Specialist Outpatients
A = Up to 24hrs
B = Up to 5 Days
SPECIALIST OUTPATIENTS C = Indefinitely
D = Cannot Operate
service?
Computer failure Unable to generate ID Record patient details Ensure supply of HBCIS C
labels manually downtime forms Can function but very time
consuming
Pre –print labels on existing Administrative Staff Information may not be
patients Nursing staff accurate
for new admissions
location and bed status bed status at regular
intervals
Notify after-hours manager C
of all patient movements
communication plan
Unable to access Revert to manual process Ensure supply of pathology Administrative staff B
pathology/radiology Develop means for Unit Manager
results notification of lab & test Laboratory staff
results
Manual ordering tests Medical Staff C
Nursing staff
Enter data when system Ensure retrospective data Unit Manager
fixed entry when computer Laboratory staff
services resume
Backup any non centralised Administrative staff C
computer programs
Power failure Mains power not Refer to mains power Inform and educate staff Unit Manager D
available failure plan Nurse Educator unable to function due to
darkness of area and
Page - 60 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
unavailability of Pathology
results etc.
Lighting failure Difficulties in patient Utilise emergency lighting Identify provision for Engineering staff
observation and care. emergency lighting
Relocate immobile patients Nursing staff D
to best lit areas unable to function due to
Clean and maintain windows Cleaning staff darkness of area and
and fittings unavailability of Pathology
Ensure blinds/curtains open results etc.
Utilise alternate lighting Ensure adequate supply Unit Manager
hazards
Refer to Facility wide power Educate staff
failure plan C
Air conditioning failure Unable to regulate Use alternate cooling Position fans for maximum Nursing staff
temperature and devices (eg.) benefit and open doors and C
environment windows
Electrical or manual fan Identify patients requiring
cooling
Refer to facility wide plan Inform and educate staff Unit Manager
telephone telecommunications plan
communications .
Wall oxygen supply Wall oxygen not Use cylinder oxygen Identify anticipated Unit Manager
failure. available requirements of cylinder C
oxygen for ward patients
from central storage area C
Ensure all oxygen cylinders
full
Ensure corresponding Wards person
available at ward level.
Ensure all staff educated in
cylinder changeover
Page - 61 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
oxygen users
Digital scales fail Unable to record weight Use alternative scales Purchase bathroom scales Unit Manager C
Use weighted scales if
available
Failure of Welsh Allen Potential for inaccuracy Use digital thermometer Ensure stock mercury Unit Manager C
thermometer of temperature readings thermometers
Failure of non-invasive Unable to electronically Use manual Ensure adequate number of Unit Manager C
blood pressure (NIBP) measure blood pressure sphygmomanometer manual
monitors recordings sphygmomanometers
Failure of Glucometer Potential for decreased battery change Ensure adequate stock of Nursing staff C
accuracy in blood blood glucose sticks Unit Manager
glucose readings Inform and educate staff
Formal laboratory blood Develop policy for formal
glucose analysis for laboratory test Medical staff
abnormal results Nursing staff
Failure of 12 lead ECG Unable to diagnose Ensure access to Identify access to Nursing staff B
machine potential life-threatening emergency power emergency power outlet Unit Manager required for medical
conditions clinics
Use on battery power Keep batteries fully charged
on emergency power
Identify location of
Failure of Pulse oximeters Unable to determine Use battery operated Educate staff re basic Educator C
oxygen saturation oximeter. physical assessment of
patient
Alarms and secure environment rounds
Direct notification via phone All staff C
security, police
Refer to safety and security
plan.
Refrigeration Drugs and medical Place drugs in refrigerators Review emergency power Unit Manager A
supplies requiring which are connected to outlets Engineering staff Drugs kept in fridge
refrigeration may emergency power supply Infection Control Staff
Page - 62 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
become unusable Monitor refrigerator
temperature with Nursing staff
thermometer
Use Eskies and ice Consider purchase of eskies
and supply of ice
Failure of lifting devices Difficulties with lifting Identify alternate lifting Use hydraulic lifting devices All staff C
heavy patients – manual devices if available
handling injuries Use of ski sheets, bed
sheets, etc.
Ensure staff trained in Unit Manager
manual handling Educator
Pan room hopper Unable to clean bed Single patient use bedpans/ Purchase sufficient for Unit Manager C
pans / urinals adequately urinals immobile patients
chemical solution
Inform staff of Infection
Control policy
Failure of Video/TV Negative impact on Verbal education Develop alternate education Unit Manager c
patient education / packages for patients Educator
enjoyment
Alternative recreational Prepare mobile library Medical Staff
facilities Consider hand held Volunteers
computer games for children
Failure of Fax Unable to receive or Utilise alternate lines of Send patient information by Unit Manager
send patient information communication runner/courier A
Delay transfer of information Medical staff necessary for core
until services resumed. Administration staff business
Failure of Copier Unable to copy Utilise alternate lines of Telephone information Nursing staff A
documents communication Medical staff necessary for core
Send original documents business
with patient and document in
chart
Delay transfer of information
may influence workload required for 24 hour period B
Place staff "on call" Prepare rosters no extra staff for area.
Page - 63 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
extra staff
Equipment Function Unable to guarantee Check all equipment for Identify all equipment to be Unit Manager B
equipment accuracy functionality as soon as checked All staff necessary for most clinics,
possible after disruption of MHHS Executive eg ECG's
power Inform and educate staff Unit Manager /Educator
Page - 64 28/08/2013
Renal Dialysis Unit
RENAL DIALYSIS UNIT
HOW LONG CAN YOU
THIS SERVICE?
Most Haemodialysis patients can survive 3-4 days before the situation becomes life threatening. However with the volume of people on haemodialysis they all cannot be
dialysed at once and one day without a means to dialyse patients will become critical for the group that has been dialysed 2-3 days prior.
Loss of Water Will result in inability to Delay dialysis until treated water Identify volume of water available & number Unit Manager
dialyse patients. is available of patients able to e treated Medical Director
Severe medical impact on
patients
Unit Manager
Failure of Will result in inability to Delay Dialysis until machine Consider dialysis of all patients before Medical Director
Dialysis dialyse patients. available critical periods.
Machines Severe medical impact on Check Urea & Electrolytes to establish
patients. clinical status
Life threatening. Unit Manager
Medical Director
Failure of Will result in inability to Equipment will not operate Relocate patients to other Dialysis centres
Electrical dialyse patients. without electricity
Power Severe medical impact on
patients. Nursing Staff
Life threatening. MHHS Executive
Discuss options with the patient Unit Manager
Consider dialysis of patients after hours Medical Director
Roster staff to cover out of hours if required
Call in staff
Check machinery function before attaching Nursing Staff
the patient
Educate patient re alternative Provide dietary advice regarding fluid
short term plans restrictions and avoidance of high potassium Nurse Unit Manager
food & beverages
Liaise with Infection Control re potential for Nursing Staff
cross infection
Relocate patients to other Discuss options with patient Nurse Unit Manager
dialysis centres Medical Director
Ensure agreements exist for temporary
Page - 65 28/08/2013
RENAL DIALYSIS UNIT
HOW LONG CAN YOU
THIS SERVICE?
referral of patients to nearest dialysis centre
Equipment Unable to guarantee Check all equipment for Identify all equipment to be checked Nurse Unit Manager
Function equipment accuracy functionality as soon as possible
after disruption of power/failure
of machines
Inform and educate staff Nurse Unit Manager
Inability to Unable to discuss with Have radio contact phone Contact radio stations & utilise the police to Nurse Unit Manager
Contact educate or manage numbers of the Unit, ensure all contact patients if needed Medical Director
Dialysis relocation of patient for patients address and contact
Patients dialysis details are correct
Home Patient Water or Power outage in Delay dialysis for 1-2 days Discuss options with the patient Nurse Unit Manager
Dialysis the community may result dependant on the patient needs
in inability to operate the
machine
Educate the patient re potential Provide dietary advice regarding fluid Nursing Staff
problems restrictions and avoidance of high potassium
and beverages
Hospital Dialysis Identify High risk patients Nursing Staff
Assess amount of battery time available and
advise patients
Develop alternative treatment plans,
including hospitalisation of condition
deteriorates.
Home Power outage in If peritoneal fluid available do Discuss options with the patient Nursing Staff
Peritoneal community may result in manual PD exchanges C
Dialysis ability to operate the Can function but very time consuming
machine
Educate patients re fluid and Provide dietary advice
potassium intake
Hospital dialysis if power Identify high risk patients
available
Develop alternative treatment plans
including hospitalisation if condition
deteriorates
Page - 66 28/08/2013
Mental Health Unit
Note: The Standard Operating Procedures for the general wards and the MHHS Essential Services are to be used in conjunction with the specific procedures detailed below.
A = Up to 24hrs
B = Up to 5 Days
MENTAL HEALTH UNIT
C = Indefinitely
D = Cannot Operate
How long can you function
without this service?
Loss of Power Decrease in service Refer to mains power failure plan Inform and educate staff Team Leader
delivery Access to charts denied.
Base some admin staff at MBH Admin staff to ensure batteries Business Manager and
with laptops and limit usage to of laptop charged during Administration staff D
chart search. Unit uses paper warning phase of disaster.
charts for everyday recording.
Medical record charts can be
accessed manually from medical B
records.
No access to UPS limited hours battery Ensure batteries are charged Business Manager and
computer and investigate possibility of Administration staff
programs/lab results having portable generator to A
for patients run some services.
Keys – access to Have keys available to staff Ensure staff are available to Business Manager D
building – will shut members assist with staff access to work
down security access units
to building
Loss of Staff/patient safety Ensure staff safety on home visits Amend protocol for home visits Team Leader A
Communication Ensure staff safety on ward Develop protocol for ward CNC
Consider staffing increase for Nurse Unit Manager
staff to work in pairs and/ or D
use security services
Rationalise services consider Nurse Unit Manager
diverting all but seriously ill A
patients to community on a
temporary basis. Increase
resources at Community to
deal with Nurse Unit Manager A
Inform patients and health care
providers/community services
Communication with Staff contact list available. Policies Manager to keep staff records
staff post event to reflect staff protocols for returning up to date.
assess availability for to work post event.
Page - 67 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
MENTAL HEALTH UNIT
C = Indefinitely
D = Cannot Operate
work to provide Business Manager B
services or assist
MHHS with recovery A
Staff unable to Ensure staff have mobile phones Rationalise services. Charge
contact the centre or charged and ready for use. mobile phones .Engage
communicate within volunteers or operational staff
the centre as runners.
Patients unable to Use media to communicate current Manager to contact media B
contact or be situation and advice.
contacted
Computer Unable to generate ID Record patient details manually Ensure supply of HBCIS Administrative and nursing A
Failure labels downtime forms staff
Pre-print labels for existing B
patients
Hand write on blank labels for
new admissions
Unable to enter Record information manually – Ensure supply of CIMHA
CIMHA data draft extra admin staff to support downtime forms
Unable to enter Record information manually- draft Ensure supply of PRIME
clinical incidents extra admin staff to support downtime forms
Difficulty in Record information manually- draft Possible extra support for the MHA Delegate A
administration of extra admin staff to support MHA Delegate to ensure all NUM
Mental Health Act consumers are correctly
paperwork/forms categorised and that the legal
duty for paperwork is
maintained.
Unable to track Revert to manual process Update patient location and
patients location and bed status at regular intervals A
bed status
Notify after-hours manager of Administrative and nursing
all patient movements staff
disseminating patient updates
as part of the facility
Inability to access communication plan
electronic records - Access client record UR number Staff education re procedure in
relevant client info from MBH utilising mobile phone event of power
unable to be /communication loss
accessed.
Page - 68 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
MENTAL HEALTH UNIT
C = Indefinitely
D = Cannot Operate
Availability and Inability to service Ensure all vehicles are fuelled up Allocate cars to program areas Business Manager A
readiness of clients in an and garaged safely once warnings once event is over
government emergency are issued
cars
Cars No fuel Decrease in service Ensure that cars where practical All staff made aware of the Business Manager and B
delivery to clients are adequately fuelled during any need to keep cars fuelled at all team Leaders
warning phase. times.
Failure of Increased risk to staff Keep only the most ill/high risk Identify emergency power All Nursing and Medical D
Duress Alarm and other consumers patients and divert the rest to outlets. Contacted the staff CANNOT OPERATE
system home/community. Use extra Maintenance Dept. They are SAFELY
security and put resources to confident the system will
community and or other wards to continue to work.
manage outliers.
Failure of Unable to identify Utilise emergency generator power Identify emergency power All Nursing and Medical
Monitors arrhythmia’s / oxygen within 10 seconds of power failure outlets Have ECG machine staff
A
including saturation. Low risk charged. Use manual
cardiac & in the Mental Health Sphygmomanometers. Pulse
oximetry Unit oximeter available which is
battery powered. Ensure all
are charged and have spare
batteries available All Nursing and Medical
Utilise battery back up Ensure batteries are fully staff
charged
A
Locate functioning portable Prioritise patients for Director of ICU and ICU
Battery life of Monitor is 30
monitors monitoring Consultants
mins to 2 hours
Increased nursing & medical Inform staff All Nursing and Medical
A
observation staff
Insufficient staff Unable to provide Use Unit base staffing model where Calculate individual patient NUM
safe level of care in possible. staffing requirements Team Leader
the event of Identify critical care staff able
equipment failure to be on call and redeployed in
the facility
Estimate staffing numbers Indefinitely but with a limited
required for 24 hour period service
Liaise with other facilities for
extra critical care staff
Liaise with agencies for extra
critical care staff
Page - 69 28/08/2013
Community Mental Health
A = Up to 24hrs
B = Up to 5 Days
COMMUNITY MENTAL HEALTH
C = Indefinitely
D = Cannot Operate
How long can you
service?
Loss of Power Decrease in service Refer to mains power Inform and educate staff Team Leader
delivery failure plan
Access to charts denied. Admin staff to ensure
Base some admin staff at batteries of laptop charged
MBH with laptops and limit during warning phase of Business Manager and Admin staff
usage to chart search. disaster.
No access to UPS limited hours battery Ensure batteries are
computer programs charged and investigate
possibility of having portable
generator to run some
services.
Keys – access to Have keys available to Ensure staff are available to
building – will shut staff members assist with staff access to
down security access work units
to building
Loss of Staff/patient safety Ensure staff safety on Amend protocol for home Team Leader
Communication home visits visits
Consider staffing increase
for staff to work in pairs
Rationalise services Service Integration Coordinator
Inform patients and health
care providers/community
services
Communication with Staff contact list available. Manager to keep staff Business Manager
staff post event to Policies reflect staff records up to date.
assess availability for protocols for returning to
work to provide work post event
services or assist
MHHS with recovery
Staff unable to Ensure staff have mobile Rationalise services. Charge Business Manager
contact the centre or phones charged and mobile phones .Engage
communicate within ready for use. volunteers or operational
Page - 70 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
C = Indefinitely
D = Cannot Operate
How long can you
service?
the centre staff as runners.
Patients unable to Use media to Manager to contact media
contact or be communicate current
contacted situation and advice
Computer Unable to generate ID Record patient details Ensure supply of HBCIS
Failure labels manually downtime forms
Pre-print labels for existing
patients
for new admissions
Unable to enter Record information Ensure supply of CIMHA
CIMHA data manually downtime forms Administrative and nursing staff
Unable to enter Ensure supply of PRIME
clinical incidents downtime forms
Inability to access Access client record UR Staff education re procedure
electronic records - number from MBH utilising in event of power
relevant client info mobile phone. /communication loss
unable to be
accessed.
communication plan
Availability and Inability to service Ensure all vehicles are Allocate cars to program Business Manager
readiness of clients in an fuelled up and garaged areas once event is over
government emergency safely once warnings are
cars issued
Cars No fuel Decrease in service Ensure that cars where All staff made aware of the Business Manager and team Leaders
delivery to clients practical are adequately need to keep cars fuelled at
fuelled during any warning all times.
phase.
Insufficient staff Unable to provide Use Unit base staffing Calculate individual patient NUM and Team Leader Indefinitely but with a
safe level of care in model where possible. staffing requirements limited service
the event of
equipment failure
Identify critical care staff
able to be on call and NUM and Team Leader
Page - 71 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
C = Indefinitely
D = Cannot Operate
How long can you
service?
Liaise with other facilities for
Page - 72 28/08/2013
Alcohol Tobacco & Other Drugs Service
A = Up to 24hrs
B = Up to 5 Days
A.T.O.D.S
C = Indefinitely
D = Cannot Operate
Loss of Power Decrease in service Refer to mains power Inform and educate staff Team Leader
delivery failure plan
Access to charts denied. Admin staff to ensure
Base some admin staff at batteries of laptop charged
MBH with laptops and limit during warning phase of
usage to chart search. disaster. Business Manager and Admin staff
No access to UPS limited hours battery Ensure batteries are
computer programs charged and investigate
possibility of having portable
generator to run some
services.
Keys – access to Have keys available to Ensure staff are available to
building – will shut staff members assist with staff access to
down security access work units
to building
Loss of Staff/patient safety Ensure staff safety on Amend protocol for home Team Leader
Communication home visits visits
Consider staffing increase
for staff to work in pairs Service Integration Coordinator
Rationalise services
Inform patients and health
care providers/community
services
Communication with Staff contact list available. Manager to keep staff Business Manager
staff post event to Policies reflect staff records up to date.
assess availability for protocols for returning to
work to provide work post event.
services or assist
MHHS with recovery
Staff unable to Ensure staff have mobile Rationalise services. Charge Business Manager
contact the centre or phones charged and mobile phones .Engage
communicate within ready for use. volunteers or operational
the centre staff as runners.
Page - 73 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
A.T.O.D.S
C = Indefinitely
D = Cannot Operate
Patients unable to Use media to Manager to contact media
contact or be communicate current
contacted situation and advice
Computer Unable to generate ID Record patient details Ensure supply of HBCIS
Failure labels manually downtime forms
Pre-print labels for existing
patients
for new admissions Administrative and nursing staff
Unable to enter Ensure supply of CIMHA
CIMHA data downtime forms
Unable to enter Record information Ensure supply of PRIME
clinical incidents manually downtime forms
Inability to access Access client record UR Staff education re procedure
electronic records - number from MBH utilising in event of power
relevant client info mobile phone. /communication loss
unable to be Develop a process for
accessed. disseminating patient
communication plan
Availability and Inability to service Ensure all vehicles are Allocate cars to program Business Manager
readiness of clients in an fuelled up and garaged areas once event is over
government emergency safely once warnings are
cars issued
Cars No fuel Decrease in service Ensure that cars where All staff made aware of the Business Manager and team Leaders
delivery to clients practical are adequately need to keep cars fuelled at
fuelled during any warning all times.
phase.
Page - 74 28/08/2013
Early Discharge
General EDSU Contingencies:
This Continuity Plan is based on having Emergency Power to the Unit. If there is no power all procedures would cease and cases would have to be
transferred
EARLY DISCHARGE SURGERY UNIT
FUNCTION WITHOUT
THIS SERVICE?
Failure of Loss of power to machine Run on emergency generator Check access to emergency power Unit Manager
anaesthetic power . Run outlets. Anaesthetic staff
machines & on gases if no power Oxygen Manually ventilate.
ventilators driven) for 90 minutes only. Manually physically assess
Inaccurate delivery of Use backup cylinder supplies of
anaesthetic gases oxygen, nitrous oxide & air Ensure supplies of cylinder gasses Unit Manager
Hand ventilate available Wards person
Unable to ventilate
patients Ensure adequate supply of hand Unit Manager D
operated ventilation equipment - black Anaesthetic staff
bag, bag - valve device
Locate and provide air / oxygen driven Unit Manager

ventilator (oxylog / birds) Anaesthetic staff
Cancel elective surgery Director of Anaesthetics

Director of Surgery
Nurse Unit Manager
ESC & DMS/DON/ND
Failure of Unable to identify Run on emergency generator Check access to emergency power Unit Manager
Monitors – arrhythmias / oxygen power outlets Anaesthetic Staff D
cardiac oximetry, saturation and problems
end tidal CO2 with ventilation Identify & ensure adequate medical & Director of Anaesthetics
nursing staff coverage CNC
Defibrillator does Unable to defibrillate Use on emergency generator Check access to emergency power Unit Manager
not function patients power or battery power. outlets D
Use battery back up if available
Have batteries fully charged All staff
Page - 75 28/08/2013
FUNCTION WITHOUT
THIS SERVICE?
Failure of Unable to perform Use on emergency generator Notify surgeons, medical, nursing and Unit Manager
Endoscopic endoscopic procedures power or battery power. booking office
Equipment (may be done if D
generator on emergency
power) Postpone all non urgent surgery
Contact non urgent patients and inform Bookings
re need to reschedule at later date Theatre Manager
Ensure list of procedures unable to be Unit Manager

under taken available at theatre front Medical Staff
desk
Failure of Unable to perform Use on emergency generator Notify surgeons, medical, nursing and Unit Manager
diathermy electrical coagulation power or battery power. booking office
machine (may be done if generator
on emergency power).
Failure of Unable to store processed Arrange for use on emergency Notify surgeons, medical, nursing and
Fibredryer scopes power booking office D
(NOT ON
EMERGENCY
POWER).
Failure of Unable to sterilise Arrange for use on emergency Notify surgeons, medical, nursing and
Sterilising endoscopic equipment power booking office
equipment for
scopes (ON Identify suitable patients Medical staff
EMERGENCY
POWER) Contact non urgent patients and inform Unit Manager D
re need to reschedule at later date Engineering staff
Staff education – availability of types of Unit Manager

cases able to be done
List of procedures unable to be under Unit Manager

taken available at theatre desk Medical staff
Page - 76 28/08/2013
FUNCTION WITHOUT
THIS SERVICE?
Contaminated Unable to perform/clean Arrange for supply of sterile Ensure large supply of water available Unit Manager
Water supply or and sterilise procedures water before restarting procedures Medical staff D
damage to water and equipment according
filters to Australian Standards
Rationalise service to emergency Identify and prioritise critical services MHHS Executive
use only Unit Manager
Failure of lift Unable to transport patient Ensure one lift operates on Review existing supply of emergency Manager Engineering C
to/from DPU emergency power power
Consider locating all surgical patients MHHS Executive

on same level as Surgical Services Director of Surgery
Staffing Unable to provide safe Centralise surgical services at Develop a staffing plan for MHHS. Unit Manager
level of care in the event one site in MHHS over critical Director of Surgery C
of equipment failure periods
Roster additional staff Calculate individual unit staffing Unit Manager

requirements Director of Surgery
Identify need to maintain staff on site as Unit Manager

opposed to on call. Director of Surgery
Identify human resources able to be on Unit Manager

call and redeployed in the facility Nurse manager
Assess competence of on call staff Unit Manager
No available Staff to Disaster Plan has all available NUM to ensure Disaster Plan is current NUM
provide care phone numbers up to date.
Roster extra staff on duty
Increased manual tasks Place staff "on call" Estimate staffing numbers required for All Managers
may influence workload 24 hour period
Prepare rosters
Liaise with agencies for extra staff All Managers
Call in staff All Managers
Duty Managers
Page - 77 28/08/2013
FUNCTION WITHOUT
THIS SERVICE?
Equipment Unable to guarantee Check all equipment for Identify all equipment to be checked Unit Manager
Function equipment accuracy functionality as soon as possible All staff A
Inform and educate staff MHHS Executive
Unit Manager
No lights in Staff may not feel safe. Torches are available in the unit. Ensure batteries are in unit. Arrange NUM
change rooms Security to inspect all areas security inspection. A
before staff enter.
Computer failure Unable to generate Record patient details manually Ensure supply of HBCIS downtime Administrative and nursing
maitain data base, print forms staff
patient ID & paperwork
Pre –print labels on existing patients Administrative and nursing C
staff
Hand write on blank labels for new Administrative and nursing
admissions staff
Unable to track patient Revert to manual process
location and bed status Update patient location and bed status Administrative and nursing
at regular intervals staff
Notify after-hours manager of all patient Nursing staff

movements
Develop a process for disseminating Nursing Staff Team

patient updates as part of the facility Leader
Unable to provide patient communication plan
dietary requirements Revert to manual process Unit Manager C
Update patient diet lists and have
Unable to record available for collection by catering
information relating to services
patient nurse dependency Revert to manual process
Ensure supply of downtime forms Administrative staff C
Unable to access available to record information
computerised
pathology/radiology
results Revert to manual process
Ensure supply of pathology result forms Administrative staff C
Unit Manager & Lab staff
Page - 78 28/08/2013
FUNCTION WITHOUT
THIS SERVICE?
Develop means for notification of lab & Medical & nursing staff
test results
Manual ordering tests Unit Manager & Lab staff
Enter data when system fixed Ensure retrospective data entry when Administrative staff C
computer services resume
Backup any non centralised data or

ward specific computer programs
Power failure Mains power not available Refer to mains power failure plan Inform and educate staff Unit Manager /Nurse D
Educator
Lighting failure Difficulties in patient Utilise emergency lighting . Identify provision for emergency lighting Engineering staff
observation and care. Torches in all areas. NUM
Relocate immobile patients to best lit Nursing staff
areas
Maximise natural lighting Clean and maintain windows and Cleaning staff C
fittings
Ensure blinds/curtains open All staff
Utilise alternate lighting Ensure adequate supply torches / Unit Manager

battery operated lights and batteries
C
Increased risk for patients Maintain WH&S precautions Clear patient areas, work areas and Unit Manager /All staff
Refer to Facility wide power Educate staff Educator

failure plan
Air conditioning Unable to regulate Open Windows where possible. Position fans for maximum benefit Nursing staff C
failure temperature and
environment Electrical or manual fan
Unable to perform surgery Identify patients requiring cooling Nursing staff
due to risk of infection Inform and educate staff Unit Manager
Possible loss of sterile Refer to facility wide plan Inform and educate staff Shift Team Leader
Page - 79 28/08/2013
FUNCTION WITHOUT
THIS SERVICE?
stock due to high temps. Educator
telephone telecommunications plan A
communications .
Wall oxygen Wall oxygen not available Use cylinder oxygen Order required cylinders from central Wards person
supply failure. storage area.
Ensure all oxygen cylinders full Wards person
Ensure corresponding number of Wards person C

oxygen fittings available at ward level.
Ensure all staff educated in cylinder Wards person

changeover. Unit Manager
Educator
Consider co-locating high oxygen users Nursing staff
medical Staff
Wall suction Wall suction not available Use alternate suction devices Assess need for and number of portable Unit Manager
failure suction units required as there is not
one within the department.
There is one located in theatres
Consider co-locating suction dependent Nursing staff

patients
Ensure adequate supply alternate Nursing staff D

drainage systems
Replace drain suction with manual Nursing staff

vacuum or drainage bottles Medical staff 
Provide emergency Ensure small oxygen cylinder with twin- Nursing staff
oxygen/suction o-vac suction on resuscitation trolley
Educate staff on use of alternate Unit Manager

devices Educator
Page - 80 28/08/2013
FUNCTION WITHOUT
THIS SERVICE?
Failure of Welch Unable to electronically Use manual sphygmomanometer Ensure adequate number of manual Unit Manager D
Allen monitors measure pt observations sphygmomanometers
Use on emergency generator
power or battery power. Check access to emergency power Unit Manager
outlets
Failure of 12 lead Unable to diagnose Ensure access to emergency Identify access to emergency power Unit Manager
ECG machine potential life-threatening power outlet Engineering staff D
conditions
Use on battery power Keep batteries fully charged on Unit Manager
Identify location of alternative ECG Nursing staff

machines

Educator
Failure of Lamson Unable to transport Revert to manual process Inform and educate staff Unit Manager
System specimens Educator D
Failure of Unable to provide safe Increased staff vigilance Schedule regular patient rounds Nursing staff
Emergency and secure environment
Alarms Direct notification via phone to switch or All staff D
runner to Communication Centre to
contact fire services, security, police
Refer to safety and security plan. Inform and educate Staff Unit Manager
Failure of Patient Patients unable to Refer to safety and security plan. Inform and educate staff Unit Manager
call buttons summon assistance D
Failure of Infusion Staff unable to titrate Use on battery power if available Charge on generator power if able All staff
Pumps/Syringe medications and fluids Charge batteries fully Nursing staff D
Drivers accurately Use burettes
Ensure adequate stock burettes Nursing Staff
Consider alternate administration Nursing staff
routes. Protocols for alternative administration Medical staff
Page - 81 28/08/2013
FUNCTION WITHOUT
THIS SERVICE?
Refrigeration Drugs and medical Place drugs in refrigerators Review emergency power outlets Unit Manager
(Connected to supplies requiring which are connected to Engineering staff
Emergency refrigeration may become emergency power supply
power). Alert staff unusable D
if no emergency
power to make
plans for Monitor refrigerator temperature with Nursing staff
refrigerated thermometer
drugs.
Use Eskies and ice Consider purchase of eskies and supply Unit Manager
of ice Infection Control Staff
Consult with Pharmacy Unit Manager
Educator
Pan room Unable to dispose of bed Single patient use bedpans/ Purchase sufficient for immobile Unit Manager
macerator pans / urinals adequately urinals patients
All staff
Rinse with “grey/waste” water and
disinfect with chemical solution A
Inform staff of Infection Control policy Unit Manager

Infection Control CNC
Educator
Lift failure Unable to transport Ensure one lift operates on Review existing supply of emergency Engineering staff
patients to different levels emergency power power Disaster Committee
within facility
Utilise alternate methods of Walk patients Wards person D
Consider scoop stretchers, fire MHHS Executive
blankets, stair walkers, cardboard
stretchers
Consider utilising ground floor Develop facility plan for locating new MHHS Executive
facilities admissions
Ensure all staff aware of facility Fire / Unit Manager

Evacuation plan
Page - 82 28/08/2013
FUNCTION WITHOUT
THIS SERVICE?
Failure of Fax Unable to receive or send Utilise alternate lines of Send patient information by Unit Manager
patient information communication runner/courier
D
Delay transfer of information until Medical staff
services resumed. Admin. staff
Failure of Copier Unable to copy Utilise alternate lines of Telephone information Nursing staff
documents communication Medical staff D
Send original documents with patient Nursing staff

and document in chart Medical staff
Delay transfer of information until Nursing staff

services resumed Medical staff
Page - 83 28/08/2013
Mackay Breastscreen
A = Up to 24hrs
MACKAY BREASTSCREEN B = Up to 5 Days
C = Indefinitely
D = Cannot Operate

FUNCTION WITHOUT
THIS SERVICE
Loss of Power Complete loss of Advise public of service Inform & Educate staff Manager
service delivery communication problems through D
the media
Loss of Unable to communicate Advise the Public of service Administration staff to make client Manager
Communication with clients to book communication problems through appointments in person D
appointments the Media
Equipment Failure of Service has 2 Mammography If problem occurred at the time of taking a Radiographer
Failure Mammography Machines and can continue to mammogram radiographer is able to Data Manager
Ultrasound machine screen with 1 machine down. If manually release client from compression. Service Manager
would unable service to Ultrasound machine failed clients BETS would be contacted to fix equipment.
perform core business would be booked for next Client requiring ultrasound would be A
of screening and assessment clinic. If data base rebooked when machine operational.
assessment. failed bookings and data entry Client info can be entered into data base at
Failure of IT equipment can be entered at a later time. a later time
would unable service to
use State wide data
base to access client
records
Page - 84 28/08/2013
CSSD
Based on emergency generator functioning. No emergency power to CSSD, lighting only No air-conditioning to CSSD when on generator.
A = Up to 24hrs
CSSD DEPARTMENT B = Up to 5 Days
C = Indefinitely
D = Cannot Operate
Failure of steam Unable to process Use disposable linen for all Equipment nurse to facilitate NUM
steriliser. Use theatre/ward linen bundles. procedures. Transport Sterrad to purchase costings MHHS Executive.
Sterrad steriliser theatre to emergency power implementation of disposable
only. linen.
No Unable to process Manually wash all equipment. Explore the possibility of NUM
washer/disinfector reusable medical connecting of one machine to Engineer
connected to equipment/instruments. emergency power.
emergency power.
No dryers Difficulty drying adequate Manually dry all equipment. Explore the possibility of NUM
connected to quantities of equipment to connecting of one machine to Engineer
emergency power. Sterrad sterilisers. emergency power.
Ward instrument Ward/A&E/ICU/shortage of Purchase pre-prepared instruments Equipment nurse to facilitate Unit Manager
shortage. sterile instruments. purchase
/costings/implementation/of
instrument packs.
No red emergency Unable to use any Take equipment to theatre to use. Explore the possibility of NUM
power points in the equipment connecting emergency power. Engineer
department.
Failure of steriliser Unable to process ward Ensure one steriliser on emergency Identify emergency power supply Unit Manager
and theatre instruments power to sterilisers Engineering staff
Unable to provide dental Alternative sterilisation methods Investigate alternative
services sterilisation methods eg ,
chemical sterilisation Unit Manager
Ensure full stock levels of sterile
equipment available prior to
critical periods
Rationalise service to emergency use Identify and prioritise critical MHHS Executive
only services Unit Manager
Failure of Unable to clean Utilise disposable consumables use Ensure stock at maximum levels Manager
instrument / tube instruments / tubes manual method
washer Revert to manual process Manually wash instruments & Nursing staff
tubes
Page - 85 28/08/2013
A = Up to 24hrs
CSSD DEPARTMENT B = Up to 5 Days
C = Indefinitely
D = Cannot Operate
Unable to disinfect Utilise disposable consumables Ensure stock at maximum levels Unit Manager
anaesthetic ventilation
tubing
Failure of Unable to dry instruments Alternative strategies for drying Manually dry instruments & tubes Nursing staff
instrument / tube and tubing effectively
dryers Sterilise instruments just in time for Air dry Nursing staff
use
Set up trays for immediate use Nursing staff
and ‘flash sterilise’ as required
Ward instrument Shortage of sterile Have all available instruments Purchase any additional
shortage instruments available to prepacked in peel packs equipment if required MHHS Executive
wards Unit Manager
Use disposable instruments and Purchase disposables
packs Identify storage area for extra
packs
Notify wards/units of contingency
Failure of sterilised No Sterile Linen bundles Have maximum stores available Prepacked and ensure maximum
linen service store of sterile linen
Rationalise use of linen Develop a plan for rationing
Alternative supplier Consider alternative supplier Unit Manager
Use disposable linen Order extra supplies of
disposable linen
Equipment function Unable to guarantee Check all equipment for functionality Identify all equipment to be
equipment accuracy as soon as possible after disruption of checked
power/failure of machines Unit Manager
Page - 86 28/08/2013
Health Information Division
A = Up to 24hrs
B = Up to 5 Days
HEALTH INFORMATION UNIT C = Indefinitely
D = Cannot Operate
service?
Failure HBCIS Medical Records Unable to locate & send Ensure all records in file Notify all MO’s/wards/depts Manager / Supervisor Depends on the severity of
& Request Tracking System medical records prior to critical dates - to return outstanding records the disaster
presumes there is advance (Antenatal excluded)
notice
Run location by location for Manager to arrange HBCIS Data Manager
charts not returned - appropriate staff to complete
providing power sufficient to task.
run HBCIS
Revert to manual Notify hospital departments Manager / Supervisor
communication systems for about manual system
requesting medical records �Implement manual system Manager / Supervisor
Use manual tracing system
� (eg) tracer cards
Update system with changes Administrative staff & Ward
& new registrations Clerks
Failure of HBCIS Patient Master Cannot allocate new UR Manual allocation of URN’s Check backup PMI file is up HBCIS Data Manager Depends on the severity of
Index (PMI) Numbers to date - may not be the disaster
sufficient notification to do
this
Cannot search for Administrative staff
existing URN’s Use backup PMI to look up Manually allocate & look up
existing URN’s - may not be URN’s HBCIS Data Manager
sufficient notification to do Update system when system
this back online
Manual process Print hard copy of PMI prior

to critical date - may not be Administrative staff
this
Use the block of unissued Allocate downtime UR
downtime UR numbers numbers
Failure HBCIS Admission, Cannot search ADT to Not critical, wait until Update System Administrative staff & Ward C:
Transfer, Discharge (ADT) track patients system returns Clerks Weeks – Indefinitely
Page - 87 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
HEALTH INFORMATION UNIT C = Indefinitely
D = Cannot Operate
service?
Cannot run enquiry Keep hard copy list in Have register and down time Administrative staff
reports Medical Records forms available. Update
Department - may not be patient list as needed
this
Failure of Coding System Unable to enter codes Copy codes to front sheet Update system when system Clinical Coders C:
and use manual tally sheet back online Weeks – Indefinitely
(label & codes)
Update system when system
Unable to access reports Access when system Clinical Coders
back on line
returns
Equipment function H machine not working Use manual record request Check all equipment for
system functionality as soon as Supervisor/Administrative staff C:
Dumb Waiter not possible after disruption of Weeks – Indefinitely
working Revert to physical chart power/failure of machinery
delivered to Emergency
Department
HBCIS Appointment Scheduling Unable to print reports Print reports one week in Manual list of attendees HBCIS Data Manager
for patients attending advance where possible
clinics (Laptop)
No access to activity data Unable to access reports Access when ssytem Retrospective updating of Decision Support Coordinator C:
returns data Weeks – Indefinitely
Unable to fax discharge Unable to respond to Hand write discharge Post copy handwritten ROI Officer
summaries requests from GP's for summaries. Give patients a discharge summaries to C:
follow up discharge copy on discharge General Practitioners Weeks – Indefinitely
information
Flooding of Medical record Destruction of charts If possible move charts to Arrange for staffing to move Manager C:
Department safe area charts Weeks – Indefinitely
Flooding/destruction of Inactive Destruction of charts If possible move charts to Arrange for staffing to move Manager C:
Records Shed safe area charts Weeks – Indefinitely
Prioritise charts to save
Page - 88 28/08/2013
Corporate Support Services –Travel Office
A = Up to 24hrs
TRAVEL OFFICE B = Up to 5 Days
C = Indefinitely
D = Cannot Operate

FUNCTION WITHOUT
THIS SERVICE
Loss of Power Complete loss of Unable to book travel PSA clients advising of situation Manager
service delivery Contact main referral hospitals to advise D
Loss of Phones Unable to communicate PSA to advise clients to present in Business as usual if clients present Manager
with clients to book person B
travel
Equipment Complete loss of
Failure service delivery
Travel Manager Manual data input with data to be Urgent travel only able to be booked Manager D
MFD Delay to processing put in later
travel B
Use MFD in another Department, Business as usual
need fax re-diverted
Page - 89 28/08/2013
Information Division
A = Up to 24hrs
B = Up to 5 Days
INFORMATION DIVISION
C = Indefinitely
D = Cannot Operate
Problem Impact Contingency Task Responsibility without this service?
Failure of primary No impact to application Automatic switch over to Optus Switch over backup ID Team leader
data access, communications backup link. automatic
communications to automatically switches to
Data Centre backup data communication
service
Failure of all data Loss of corporately hosted Escalate issue with Enterprise Liaise with EOC to ID Team leader
communications to Enterprise Applications: eg Operation Centre determine possible
Data Centre Auslab, EDIS, FAMMIS, alternate connection
internet, iPharmacy, QHEPS. options
Access to Groupwise and
HBCIS unaffected
Failure of Loss of corporately hosted Pathology and Finance systems Determine minimal level MHHS Executive
Enterprise Data Enterprise Applications: eg down – Departments revert to of function ID Team leader
Centre Auslab, EDIS, FAMMIS, manual system no available
internet, iPharmacy, QHEPS. contingency.
Access to Groupwise and
HBCIS unaffected
Failure of No access to HBCIS Revert to HBCIS standby server Switch over to standby ID Team Leader
HBCIS primary server
server Restore normal SIM1/ID Team Leader
operation of HBCIS
Primary server
Failure of No access to HBCIS Medical Records use backup Revert to HBCIS SIM1/ID Team Leader
HBCIS PMI Primary Server
application Medical Records revert
to manual look up
system.
Medical Records revert Health Information Manager
to manual look up
system.
Restore operation of SIM1/ID Team Leader
HBCIS application
Page - 90 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
INFORMATION DIVISION
C = Indefinitely
D = Cannot Operate
Problem Impact Contingency Task Responsibility without this service?
Switch to manual business Inform business units of

processes if required issues and timeframes
Failure of No access to G:/H: drives, Restore server operation If hardware failure
Mackay Base network printing, server based initiate vendor support -
Hospital File local applications eg RIPS Investigate available
Server hardware replacement
options as required
If software failure - Tech
ops Directories/Novell
for assistance ID Team Leader/Business
If required restore data units
from backup
Failure of No access to Groupwise Restore server operation If hardware failure
Mackay Base initiate vendor support -
Hospital Investigate available ID Team Leader
Groupwise hardware replacement Technical Operations
Server options as required Support vendor
If software failure - Tech
ops Directories/Novell
for assistance
If required restore data
from backup
INFORMATION DIVISION – DESKTOP SERVICES

Failure of Local Loss of access to Restore network operation If possible reconfigure ID Team Leader
Area Network Enterpise/Local applications network to re-establish Enterpirse Operation Centre
operation
Switch to manual business Inform business units of ID Team Leader
processes if required issues and timeframes Business units
Page - 91 28/08/2013
Medical Imaging
Some areas within Medical Imaging are connected to the emergency generator
MEDICAL IMAGING C = Indefinitely D = Cannot Operate
CT is on
Use alternate
generator power
investigation if
will function as
Loss of Power No CT Service. possible. Director of Medical Imaging, radiographers and Engineering staff. Up to 24hrs, maybe extended
long as
Outsource to in consultation with local private practices ability to provide alternate service
generator is
local private
operational.
practices.
Key equipment
Test and
on UPS.
No X-Ray maintain UPS. Director of Medical Imaging, radiographers, Engineering staff and BTS staff.
Emergency
Service. Assess Indefinitely with reduced capacity as long as generators are operational.
Power.
Emergency
Mobile x-ray
power for x-ray
units.
Test and
Equipment on
maintain UPS. Director of Medical Imaging, sonographers and Engineering staff.
No Ultrasound emergency
Assess Indefinitely with reduced capacity as long as generators are operational.
Service. power. Use
Emergency
alternate test
Power for
Ultrasound
Key Equipment No CT Service. Use alternate Ensure Director of Medical Imaging, radiographers and servicing agent.
failure. investigation if equipment is Up to 24hrs, maybe extended in consultation with local private practices ability to provide
possible. maintained in alternate service
Outsource to good working
local private order through
practices. regular
scheduled
servicing.
No X-Ray Use alternate Director of Medical Imaging, radiographers and BTS Director.
Service. unit. Ensure Indefinitely with reduced capacity as long as other like equipment remains operational.
Mobile x-ray equipment is
Page - 92 28/08/2013
units. maintained in
good working
order through
regular
scheduled
servicing.
Use alternate Ensure

investigation if equipment is
possible. maintained in Director of Medical Imaging, sonographers and servicing agent.
No Ultrasound
Use alternative good working Indefinitely with reduced capacity as long as other like equipment remains operational.
Service.
U/S unit. order through
Outsource to regular
local private scheduled
practices. servicing.
Alternate site to
be identified.
Mobile shielding
Relocate
installed.
ultrasound units.
Medical Necessary Director of Medical Imaging, Medical Imaging staff, BTS staff, Information Division staff and
Service cannot Relocate mobile
Imaging consumables Engineering staff.
be provided in x-ray units.
environment relocated. Up to 5 days with reduced service reflective of the capacity of alternate site
Medical Imaging. Relocate Core
unsafe Emergency
CR Equipment.
network to be
established. CT
outsourced to
Local Private
Practice.
Use alternate
investigation. Outsource to Director of Medical Imaging and Medical Imaging staff.
Outsource to Local Private Up to 24hrs, maybe extended in consultation with local private practices ability to provide the
No CT Service.
local private Practice. No service
practices. onsite
alternative.
Page - 93 28/08/2013
Unable to Director of
Recall of all Calculate
Insufficient provide sufficient Medical Imaging
available staff as individual staffing Indefinitely but with a limited service.
staff and safe level of or
required. requirements.
service. On call
Radiographer.
Estimate staffing
numbers Director of
Indefinitely but with a limited service.
required for 24 Medical Imaging
hour period.
Liaise with other

Director of
HHSs/CASS for Indefinitely but with a limited service.
Medical Imaging
extra staff.
Liaise with locum

Director of
agencies for Indefinitely but with a limited service.
Medical Imaging
extra staff.
Page - 94 28/08/2013
Pathology Services.
A = Up to 24hrs
PATHOLOGY SERVICES B = Up to 5 Days
C = Indefinitely
D = Cannot Operate
How long can you
service?
Failure of Power Laboratory unable to Ensure access to Confirm availability of emergency Lab. Manager Can function indefinity
Supply function without power emergency power power Engineering staff on emergency power
Ensure all critical equipment
supplied with emergency power
Rationalise all services to Lab. Manager
emergency requests only
Use alternate testing facility Source alternate testing facility
outside organisation outside organisation
For example- Private lab or
Townsville/RBH labs
ensure all UPS are charged and
serviced.
Use of the iSTAT for urgent Ensure all iSTATs are placed on Lab manager Hours
tests battery recharger when not in use. NUM's or person in
Stock spare batteries (6-12 charge of iSTAT on
batteries) the wards
Loss of Water Major impact relating to No alternates to water • Ensure adequate stock available Lab manager Can not operate
supply the Major Chemistry
Analyser
Unable to maintain staff Use alternate solutions Ensure adequate supplies of Hexol
hygiene Ensure adequate supplies bottled Lab. Manager
water Infection Control CNC
Temperature Unable to determine Manual monitoring of fridge Install portable probe . Policy will Lab. Manager weeks
monitoring fails. accurate temperature of temperature using portable direct procedure if time becomes
Blood Stock Fridge and probe. an issue
Reagent Fridge.
Develop policy on frequency of Lab. Manager
temperature checks
Failure of Blood Unable to preserve Transfer blood stores Investigate alternative storage Lab. Manager weeks
Bank Fridge integrity of blood. elsewhere solutions.
Private laboratories and Red Cross
Page - 95 28/08/2013
A = Up to 24hrs
PATHOLOGY SERVICES B = Up to 5 Days
C = Indefinitely
D = Cannot Operate
How long can you
service?
Equipment Failure Unable to process blood Use alternate testing facility Source alternate testing facility Lab. Manager weeks
samples outside organisation outside organisation
Inform medical/nursing staff
Equipment Unable to guarantee Check all equipment for Identify all equipment to be Lab. Manager Can not operate
Function equipment accuracy functionality as soon as checked
power/failure of machines
Inform and educate staff Lab. Manager
Page - 96 28/08/2013
Pharmacy
A = Up to 24hrs
B = Up to 5 Days
PHARMACY C = Indefinitely
D = Cannot Operate
service?
Failure of Refrigerators / Spoilage of Ensure fridges and freezers Check access to emergency Pharmacy Director within 30 minutes
Deep Freeze pharmaceuticals connected to emergency generator power Engineering
requiring refrigeration / power
freezing
Ensure fridges monitored Ensure On call pharmacist Pharmacy Director within 30 minutes
for temperature roster to respond to
fridge/freezer failure alarm
Pharmacy Director
Relocate stock to working Engineer one hour
refrigerators, cold rooms and Infection Control Staff
freezers
Failure of air conditioning Unable to maintain air Ensure air conditioning for Check availability of Pharmacy Director six hours
temperature below 25'C pharmacy connected to emergency generator power Engineering
emergency power Ensure pharmacy is a
priority area when air Pharmacy Director
conditioning load shed Engineering
scheduled
Consider portable air Arrange access to portable Pharmacist
conditioner air conditioner
Highlight potential inventory Contact Central Pharmacy Director of Pharmacy
for destruction if for direction
temperature extreme
Higher load on fridges Monitor fridges Director of Pharmacy
Failure of computer IPharmacy not Use fred5 label for Have label available on local Director of Pharmacy Indefinite, more than
accessible but local dispensing, use hard copy drive three days will need
applications okay recoding for issues if complete stock take
needed when available
network printers not restrict data entry to Have some label printers as Director of Pharmacy
available immediate needs local printers Indefinitely
iPharmacy access not at Director of Pharmacy
workable speed
PDE not available for print manual sheets as pharmacy staff
imprest required or record manual Indefinitely
distributions print manual sheets as
Page - 97 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
PHARMACY C = Indefinitely
D = Cannot Operate
service?
required or document Indefinite, more than
manually three days will need
complete stock take
when available
No lighting Not safe to operate Torch light available for Torches available inside Director of Pharmacy URGENT supply only
URGENT supply only goods delivery door, after
hours room and safe
No drug deliveries from May not have drug Maintain stock levels to Maintain max mins monthly Director of Pharmacy up to five days
Brisbane available when required allow for supply chain
interruption of three days
Obtain stock from Symbion Ensure on line ordering from Director of Pharmacy
Townsville Symbion is available
May need to cancel

chemotherapy
Lack of pharmacist Long delays in supply. Build in capacity into Monitor staffing levels. Director of Pharmacy
staffing Potential for increase in pharmacy staffing. Use Monitor availability of locums
error rate locum pharmacist.
Fatigue risk Monitor working hours and Director of Pharmacy
recall
Lack of pharmacy support Long delays in supply. Build in capacity into Monitor staffing levels Director of Pharmacy
staffing Potential increase in pharmacy staffing. Use Monitor availability of locums
error rate casual staff. Monitor working hours
Fatigue risk
No ability to deliver bulk IV IV fluid may not be Adequate supply in wards Director of Pharmacy IV fluids bulk storage is
fluids to wards available when required now a supply function
Backup forklift operators
No proximity card access No access to pharmacy nil
to pharmacy by prox card
No forklift access to IV fluids Set locations of IV fluids in Set locations of IV fluids in Director of Pharmacy and IV fluids bulk storage is
restricted storage racks storage racks Supply services now a supply function
Page - 98 28/08/2013
.

Bowen Hospital – General & Clinical Services
NOTE: The Standard Operating Procedures for the general wards and the MHHS Essential Services are to be used in conjunction with the specific procedures detailed below.
A = Up to 24hrs
B = Up to 5 Days
BOWEN HOSPITAL – GENERAL & CLINICAL SERVICES C = Indefinitely
D = Cannot Operate
function without
this service?
HBCIS access failure Unable to register Manual registration Adequate supply downtime forms Admin. staff
patients Data Entry at return of service
Hand write requests
B
No Patient ID Manual process Admin and Clinical
labels Filing at return to service staff
Unable
Unable to access Good history taking
UR numbers and Admin and Clinical
existing medical staff
records
A&E Module failure Unable to utilise Manual recording. Adequate Supply of downtime triage Admin. Staff
TRIAGE, treatment forms. Data Entry at return of service
and C
admission/discharg
e screens
Printing services Failure Unable to record Retrospective data entry Check and update missing data Admin.& Nursing
statistical Staff C
requirements
Computer failure Unable to print Manual recording - lead to adequate staff Ensure adequate staffing to cover Business
results / labels etc. numbers workload Manager/Admin.
Record patient details manually Ensure supply of HBCIS downtime Staff
Unable to generate forms
ID labels Pre –print labels on existing patients
Hand write on Medical record and B
specimens as required
Update patient location and bed Administrative and
status at regular intervals nursing staff
Unable to track
patient location and Revert to manual process
bed status Administrative and B
nursing staff
Page - 99 28/08/2013
A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
function without
this service?
Telephone failure No internal / Access hand held radios from SES. Utilise contact SES DON or Delegate C
external telephone Fire Panel Communication for internal
communications . communication.
Cardex System 5hr battery back-up Use back-up keys for door access. Inform and educate staff Business C
When back-up Manager/DONNurs
power failure e Unit Manager
occurs for extended /Shift Team Leader
period. Access with
Cardex will not be
possible. Security
Video Surveillance
will discontinue.
FAX Failure Unable to receive Utilise alternate lines of communication Send patient information by courier Nurse Unit B
or send patient Delay transfer of information until Manager
information services resumed
Medical Staff
Administration Staff
Photocopier Failure Unable to copy Utilise alternate lines of communication Telephone information B
documents
Send original documents with patient Nursing staff
and document in chart /Medical staff
Delay transfer of information until
services resumed
Oxygen supply Use cylinder oxygen Ensure adequate supplies Operational
disrupted Ensure all staff educated in cylinder Officers
changeover. D
Consider co-locating high oxygen Wards
users person/Nurse Unit
Manager /Educator D
Nursing staff
/medical Staff
Failure of Refrigeration / Food spoilage refer Essential fridges on emergency power Assess availability of emergency
cool rooms to Food Safety Plan Source food off campus perhaps power
Develop plan for preparation and Cook/Business C

transport of food from other Manager
Page - 100 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
function without
this service?
Consider long life shelf products appropriate sources B
Purchase dry / tinned food
Consider purchase of long life milk
Consider purchase of bottled water
for drinking Cook/Business
Manager
Refrigeration - Vaccine Drugs and medical Place drugs in refrigerators which are Review emergency power outlets and Nurse Nurse Unit A -B
supplies requiring connected to emergency power supply manage vaccines as per infection Manager
refrigeration may control/vaccine management /Engineering staff
become unusable guidelines.
Monitor refrigerator temperature with Nursing staff
thermometer
Consider purchase of eskies and Nurse Unit
supply of ice Manager
Nurse Unit
Manager
Failure of Dishwashers Refer to Food Use disposables Adequate supply disposables Cook/Business C
Safety Plan Manager
Loss of communication Unable to Use alternate communication channels Consider use of Mobile Phone if Nursing Staff B
with pre-hospital/ communicate with network is operational, use of 2-way
transfer services and QAS radio from community eg Council
referral centres Develop criteria for referral based on
available services
Develop an alternate referral/discharge
process Develop pro forma for required Nursing Staff
Unable to patient information
communicate with Letter and pro forma sent with patient C
local GP’s for admission
Discharge summary sent with patient
at discharge
Use QAS radio to contact ambulance
communications
Use alternate communication strategy Use mobile phone if network is

operational
Use satellite phone
Use ambulance radio
Page - 101 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
function without
this service?
Unable to Nursing Staff
communicate with Use alternate communication strategy Instigate close observation of at risk
Clinical Coordinator patients C
via AMCOM re
patient advice/
transfer/ retrieval
(RFDS, helicopter)
B
Unable to Nursing Staff
communicate with C
receiving/ referring
hospital
Transport monitors Unable to monitor Aim to have at least one compliant Ensure one compliant transport Nurse Unit
malfunction critically ill or transport monitor or list of compliant monitor available in central location Manager
unstable cardiac machines.
patients in transit Assess patients prior to critical dates.
Schedule tests prior to critical dates Medical staff D
Assess pt need for transport Nursing staff B

Charge batteries
Defibrillator malfunction Unable to Have compliant defibrillator available Identify non compliant equipment Nurse Unit
defibrillate patients Manager
Aim to replace non compliant D
equipment
Identify & re allocate compliant
defibrillator
Inform & Educate staff Nurse Unit
Connect to emergency power Identify existing emergency power Manager
outlets D
Use battery backup Have batteries fully charged
Medical equipment Unable to provide Utilise emergency power Check existing emergency power
failure specialised medical outlets
equipment Manual process Nurse Unit A
Bi-PAP/CPAP Battery back-up if available Fully charge batteries Manager
Ventilators Manual ventilation Ensure adequate staff available for
manual ventilation
Warm water bath
Manual process Perform visual examination
Manual process Treat prophylactically
Page - 102 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
function without
this service?
Blood warmers Manual process Refer to ophthalmologist Nursing staff
Slit lamp Use plaster cutters Medical staff C
Apply a back slab
Plaster saw
Failure of Monitors Unable to identify Use on emergency power Check existing emergency power Nurse Unit D
including cardiac & arrhythmias / outlets Manager
oximetry oxygen saturation Identify non compliant equipment
Aim to replace non compliant
equipment
Identify & position compliant monitors
ensuring access to emergency power
Ensure adequate supply of batteries•
Have batteries fully charged
Use battery backup Identify & ensure adequate medical & D
nursing staff coverage Nurse Unit
Prioritise patients for monitoring Manager
Increased nursing & medical observation Inform and educate staff Nursing staff
Unable to provide Pathology services Identify and rationalise use of available Develop a plan for centralising
transport services not available vehicles vehicles
Business manager C
Discontinue non-essential services Prioritise use
Notify clients of potential for
disruption to normal services
Re–admit at risk patients if necessary
Failure of EFTPOS fuel Arrange credit facility Liaise with local fuel distributor for Business manager C
card service credit facilities for fleet vehicles
Overcrowding of Spread of disease Planned areas for habitation Allocate areas for use by public DON C
hospital campus
Staff dislocated from Distress to staff Plan for accommodation Allocate staff accommodation (work & DON/NUM/BM C
family living for staff)
Disease outbreak Infected persons Vaccines Plan for vaccines, fact sheets DON/MBH/AHS/TP C
HU
Waste Disposal Vector Borne Sprays for insects. Antiseptics Assign contractors for pest control TPHU C
Disease Infections
Lack of Public Suspicion - Stockpile of HP Material Stockpile PH Material BM/NUM/DON/TP C
Knowledge Concerned Public Media person to duties HU
Loss of ability to protect Duress alarms Provide alternative alert system for nurses Purchase hand held audible alarms Nursing staff B
staff and patients Aim to have fire alarms compliant and/or whistles
Page - 103 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
function without
this service?
Provide alternative power source for Check fire alarms BM/FSA
Fire alarms alarms
Ensure all staff have recent fire safety Ensure alarms are connected to
training generator power
Liaise with Fire Department
Insufficient staff Unable to provide Roster additional staff Calculate individual unit staffing
safe level of care in requirements
the event of Director Of Nursing
equipment failure Revert to manual process Identify human resources able to be Nurse Unit B
on call and redeployed in the facility Manager
Assess competence of on call staff Business Manager
Courier to collect results
Develop means for notification of lab

& test results
Enter data when system fixed Manual ordering tests Operational Staff B
Unable to access Ensure retrospective data entry when
computerised computer services resume
pathology/radiology Use alternate cooling devices (eg.) Position fans for maximum benefit Nurse Unit
results Open Windows as a requirement Manager & Lab
staff
Medical & nursing

staff
Unable to regulate
temperature and Nursing staff
environment
Air conditioning failure Electrical or manual fan Identify patients requiring cooling,
Use windows. Notify and inform
patients and staff. All staff B
Wall suction failure Wall suction not Use alternate suction devices Assess need for and number of
available portable suction units required
Consider co-locating suction NUM B
dependent patients
Ensure adequate supply alternate
drainage systems
Replace drain suction with manual Nursing staff
vacuum or drainage bottles
Page - 104 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
function without
this service?
Ensure small oxygen cylinder with
twin-o-vac suction on resuscitation
Provide emergency oxygen/suction trolley
Educate staff on use of alternate
devices
Develop policy for formal laboratory Nursing staff
Bloods to path as transport available test
Unable to use ISTAT Unable to diagnose Ensure access to emergency power Identify access to emergency power Nurse Unit D
potential life- outlet Manager /
threatening Engineering staff
conditions
Failure of 12 lead ECG machine Use on battery power Keep batteries fully charged on Nurse Unit D
emergency power Manager /Nursing
Inform and educate staff Staff
Schedule regular patient rounds
Increased staff vigilance
Unable to provide safe and secure
environment
Failure of Emergency Patients unable to Utilise bells with capable patients Inform and educate Staff and Patients Nurse Unit B
Alarms summon Manager
assistance
Failure of Patient call Patients unable to Refer to safety and security plan. More regular rounds of patients in the Nurse Unit B
buttons summon department. Inform and educate staff Manager
assistance and patients
Failure of Infusion Staff unable to Use on battery power if available. Charge on generator power if able All staff Nursing C
Pumps/Syringe Drivers titrate medications Charge batteries fully staff
and fluids
accurately Use burettes Ensure adequate stock burettes
Protocols for alternative
Difficulties with Consider alternate administration routes. administration
lifting heavy Identify alternate lifting devices Use hydraulic lifting devices if
patients – manual available
handling injuries
Failure of lifting devices Use of slide sheets, pat slide, slida All staff C
person etc.
Macerators Unable to dispose Utilise supply of washable pans and Scrub and/or soak. Encourage use of All clinical staff B
of used pans and urinals. Manual Cleaning toilet as much as possible.
urinals
Page - 105 28/08/2013

Bowen Hospital – Utilities Services
A = Up to 24hrs
B = Up to 5 Days
BOWEN HOSPITAL - UTILITIES SERVICES C = Indefinitely
D = Cannot Operate
function without
this service?
Loss of LPG supply Secure LPG site and implement Engineer to establish security of the
retrieval/disposal of hazardous material site and risk assess immediate
needs. BM/Groundsman A
Arrange urgent supply of portable LPG Identify number of cylinders required
cylinders and allocate as per priority listing.
Unable to provide Use alternate energy source Gas Cook top Arrange for supplier to fill storage
cooking facilities or BBQ tanks if not damaged
Identify alternate energy sources for
cooking
Staff Education Educate staff on contingency plans
Oxygen supply disrupted Use cylinder oxygen Ensure adequate supplies BM/Groundsman A
Inability to supply mains Emergency power generation Identify existing supply of emergency BM/Groundsman
power to facilities power generation
Refer to power points/ outlets with
emergency generation in each area
Confirm essential equipment only Nurse Unit A
connected to generator power outlets Manager
Ensure essential lights and
equipment.
Ensure access to extension leads
Contact Contractor to ensure BM/Groundsman
adequate fuel source for use of
generator
Unable to provide Heat water with alternate energy source Identify alternate energy sources for
hot water Gas Quick heat water heater. water heating
Wash / clean with cold water Identify cleaning processes that can
use cold water or use disposable
ware.
Identify alternate washing regime for
patient hygiene Utilise "Bed Bath"
products
Ensure fuel storage standards are
maintained.
Ration use of emergency power Identify generator load capacity Nurse Unit A
Page - 106 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
function without
this service?
Use alternate power sources Fully charge batteries on all essential Manager
equipment
Supply additional lighting Locate/purchase torches/ lanterns
and batteries
Use natural lighting -open windows
and doors
Discharge/ relocate patients within facility Identify patients for discharge or
relocation
Consider activation of MHHS Disaster Plan Consult current MHHS Disaster Plan MHHS Manager
for process
Inform and educate staff MHHS Manager
Close Facility Liaise with alternative service /Medical
provider for care of patients Superintendent
Transfer patients out & close facility MHHS Manager
only
Staff Education Educate staff on contingency Educate staff on
arrangements contingency
arrangements
Loss of water supply for Liaise with Local Ration water usage Rationalise services and develop plan MHHS Executive
general use, e.g., toilets, Council Authority for water restriction
patient hygiene re supplies of
water. Manager A
Identify alternative water sources Source / cost alternate supplies, e.g. / Engineering
Water tankers / Fire service supply
Initiate use of alternate supply
Identify alternative supplies of drinking Consider purchase of bottled water
water
Loss of Macerator See Worksheet "General" Unable to use. All clinical staff
function
Loss of drinking Discharge/ relocate patients within facility Buy containers for storage of
water drinkable water D
Contingency Consider activation of MHHS Disaster Plan Identify patients for discharge or A
Failure relocation MHHS Manager
Use emergency supply Liaise with local council / utilities re
emergency water supply
Close facility Liaise with alternative service
provider for care of patient
Page - 107 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
function without
this service?
Staff education Transfer patients out and close facility
Educate staff on contingency
Sewerage Unable to dispose Ensure facility wide plan Develop facility plan for waste MHHS Executive D
of waste products disposal
due to water
failure
Ensure Local Council and Utilise “grey/used” water Inform staff to save water after patient Nurse Unit
Public Health Unit hygiene Manager
involvement. Place bucket for used water in each Operational
toilet cubicle for flushing purposes Services
Designate toilets to be used Close off toilets not for use and post NUM D
signs
Alternate toilet facilities Identify alternate toilet devices e.g., Manager
porta loos, and number required Engineering
Source supply / cost of alternate
devices
Rinse with “grey/waste” water and
chemical solution
Inform staff of Infection Control policy Nurse Unit
Manager/ Infection
Control CNC
Discharge/ relocate patients within facility Identify patients for discharge or
relocation
Consider activation of MHHS Disaster Plan Consult current MHHS Disaster Plan
for process
Liaise with local council / utilities re MHHS Manager /
emergency water supply Manager
Arrange for septic tank pumping truck Engineering D
to pump sewerage out of hospital
pipes
Medical
Failure of Close facility Liaise with alternative service Superintendent
contingency provider for care of patient
Transfer patients out, close facility Nurse Unit
Staff education Educate staff on contingency plans Manager /
Managers
Power failure Mains power not Refer to mains power failure plan Inform and educate staff DON/NUM/BM/Eng
available. ineering
Generator B
Page - 108 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
function without
this service?
supplies
emergency power
Lighting failure Difficulties in Utilise emergency lighting Identify provision for emergency Engineering staff
patient lighting
observation and
care. B
Maximise natural lighting Relocate immobile patients to best lit Nursing staff
areas
Clean and maintain windows and
fittings
Utilise alternate lighting Ensure adequate supply torches / Nurse Unit
battery operated lights and batteries Manager
Increased risk for Maintain WH&S precautions
patients and staff Clear patient areas, work areas and Nurse Unit
corridors of all hazards Manager /All staff
No Provide additional portable lighting Identify and source alternative lighting Nurse Unit
safety/evacuation Manager /All staff
lighting available Staff member to place lighting in
strategic areas for safety
Issue clinical staff with torches
Page - 109 28/08/2013

Clermont Hospital - General
A = Up to 24hrs
B = Up to 5 Days
Clermont HOSPITAL - GENERAL C = Indefinitely
D = Cannot Operate
service?
HBCIS access failure Unable to register Manual registration Adequate supply downtime Administration staff B
patients forms
A&E Module failure No patient ID labels Manual process Hand write requests Administration staff B
Ensure blank labels are
available
Unable to utilise Manual recording. No Ensure details are recorded
TRIAGE, treatment and written record of Ur nos in chart C
admission/discharge maintained on site
screens
Unable to record Retrospective data entry Check and update missing Administration Staff
statistical requirements data Nursing Staff
Printing services Failure Unable to print results / Manual recording - lead to Ensure adequate staffing to Business Manager B
labels etc. adequate staff numbers cover workload Administration staff
Computer failure Unable to generate ID Record patient details Ensure supply of HBCIS
labels manually downtime forms
patients Administrative Staff B
Hand write on blank labels Nursing staff
for new admissions
location and bed status bed status at regular C
intervals
Revert to manual process Update patient diet lists and Nursing staff C
have available for collection
Telephone failure No internal / external Refer to facility wide Inform and educate staff Nurse Unit Manger C
telephone telecommunications plan Director of Nursing
communications Nursing staff
FAX Failure Unable to receive or Utilise alternate lines of Send patient information by Nurse Unit Manger B
send patient information communication courier Director of Nursing
Delay transfer of information Administrative Staff
until services resumed. Nursing staff B
Page - 110 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Photocopier Failure Unable to copy Utilise alternate lines of Telephone information Administrative Staff B
documents communication Nursing staff
Send original documents Nursing staff
with patient and document in Medical staff
chart
Oxygen supply disrupted Use cylinder oxygen Ensure adequate supplies Operational Officers
Ensure all staff educated in Nurse Unit Manager
cylinder changeover. Director of Nursing D
oxygen users
Failure of Refrigeration / Food spoilage refer to Essential fridges on Assess availability of
cool rooms Food Safety Plan emergency power emergency power
Source food off campus Develop plan for preparation Cook/Business Manager B
perhaps and transport of food from Facility Manager
other appropriate sources
Consider long life shelf Consider purchase of long
products life milk
Consider purchase of bottled
water for drinking
Refrigeration - Vaccine Drugs and medical Place drugs in refrigerators Review emergency power Nurse Unit Manager A
supplies requiring which are connected to outlets and manage Director of Nursing
refrigeration may emergency power supply vaccines as per infection Engineering staff
become unusable control/vaccine management
guidelines.
Monitor refrigerator
temperature with
thermometer
Use Eskies and ice Utilise SBVP Esky C
Failure of Dishwashers Refer to Food Safety Use disposables Adequate supply Cook/Business Manager C
Plan disposables Director of Nursing
Loss of communication Unable to communicate Use alternate Consider use of Mobile B
with pre-hospital/ transfer with QAS communication channels Phone if network is
services and referral operational, use of 2-way
centres radio from community eg
Council Nursing Staff
Page - 111 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Unable to communicate Develop an alternate Develop criteria for referral C
with local GP’s referral/discharge process based on available services
Develop pro forma for
required patient information
Letter and pro forma sent
with patient for admission
Discharge summary sent Nursing Staff C
with patient at discharge
Unable to communicate Use alternate Use QAS radio to contact
with Clinical Coordinator communication strategy ambulance communications
via AMCOM re patient Use mobile phone if network
advice/ transfer/ retrieval is operational
(RFDS, helicopter) Use satellite phone
Unable to communicate Use alternate Use ambulance radio
with receiving/ referring communication strategy Nursing Staff C
hospital Instigate close observation
of at risk patients
Transport monitors Unable to monitor Aim to have at least one Ensure one compliant Nurse Unit Manager D
malfunction critically ill or unstable compliant transport monitor transport monitor available Director of Nursing Medical
cardiac patients in transit or list of compliant in central location staff
machines.
Assess patients prior to Schedule tests prior to
critical dates. critical dates
Assess pt need for transport
Charge batteries Medical staff
Defibrillator malfunction Unable to defibrillate Have compliant defibrillator Identify non compliant
patients available equipment
Aim to replace non Nurse Unit Manager D
compliant equipment Director of Nursing Medical
Identify & re allocate staff
compliant defibrillator
Inform & Educate staff
Connect to emergency Identify existing emergency
power power outlets
Medical equipment failure Unable to provide Utilise emergency power Check existing emergency Nurse Unit Manager C
specialised medical power outlets Director of Nursing
equipment
Bi-PAP/CPAP Manual process Use black bag closed circuit Nurse Unit Manager
Page - 112 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
with 100% oxygen Director of Nursing C
Ventilators Battery back-up if available Fully charge batteries Medical staff
Use alternate oxygen driven
ventilator
Manual ventilation Ensure adequate staff A

available for manual Nurse Unit Manager
ventilation Director of Nursing A
Use alternate equipment Ensure equipment is Nursing staff
available
Spirometer Use peak flow meters C
Slit lamp Perform visual examination Nursing staff
Treat prophylactically
Refer to ophthalmologist
Plaster saw Use plaster cutters
Apply a back slab
C
Manual process Nursing staff
Failure of Monitors Unable to identify Use on emergency power Check existing emergency Nurse Unit Manager D
including cardiac & arrhythmias / oxygen power outlets Director of Nursing
oximetry saturation
Identify non compliant
equipment
Aim to replace non
compliant equipment
Identify & position compliant Nurse Unit Manager D
monitors ensuring access to Director of Nursing
emergency power
Use battery backup Ensure adequate supply of
batteries• Have batteries Nurse Unit Manager D
fully charged Director of Nursing
Increased nursing & Identify & ensure adequate Nurse Unit Manager Director
medical observation medical & nursing staff of Nursing
coverage
Prioritise patients for
monitoring Nurse Unit Manager D
Inform and educate staff Director of Nursing D
Unable to provide Linen, pathology Identify and rationalise use Develop a plan for Business manager C
transport services services not available of available vehicles centralising vehicles
Page - 113 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Prioritise use
Discontinue non-essential Notify clients of potential for
services disruption to normal services
Re–admit at risk patients if Medical staff C
necessary
Failure of EFTPOS fuel Arrange credit facility Liaise with local fuel Business manager C
card service distributor for credit facilities Director of Nursing
for fleet vehicles
Unable to transport Use alternate methods for Identify and engage external Business manager C
supplies from/to facility transport of supplies contractors Director of Nursing
Overcrowding of hospital Spread of disease Planned areas for Allocate areas for use by Director of Nursing C
campus habitation public
Staff dislocated from Distress to staff Plan for accommodation Allocate staff Director of Nursing
family accommodation (work & Nurse Unit Manager Business C
living for staff) manager
Disease outbreak Infected persons Vaccines Plan for vaccines, fact Public Health Unit C
sheets
Waste Disposal Vector Borne Disease Sprays for insects. Assign contractors for pest Public Health Unit C
Infections Antiseptics control
Lack of Public Knowledge Suspicion - Concerned Stockpile of HP Material Stockpile PH Material Director of Nursing
Public Media person to duties MHHS C
Public Health Unit
Loss of ability to protect Duress alarms Provide alternative alert Purchase hand held audible Nursing staff C
staff and patients system for nurses alarms With appropriate
Consider purchase of Nurse Unit Manager security
whistles Engineering staff
Fire alarms Aim to have fire alarms Check fire alarms Business Manager C
compliant With appropriate
security
Provide alternative power Ensure alarms are Manager Engineering
source for alarms connected to generator C
power Director of Nursing
Ensure all staff have recent Liaise with Fire Department Nurse Unit Manager Business
fire safety training Manager
Insufficient staff Unable to provide safe Roster additional staff Calculate individual unit Director of Nursing
level of care in the event staffing requirements Nurse Unit Manager Business B
Page - 114 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
of equipment failure Manager
Identify human resources
able to be on call and
Assess competence of on
call staff
Unable to access Revert to manual process Courier to collect results Operational Staff B
computerised
pathology/radiology
results Develop means for Nurse Unit Manager & Lab
notification of lab & test staff
results
Manual ordering tests Medical Staff
Nursing staff
Ensure retrospective data Nursing staff B
Enter data when system entry when computer
fixed services resume
Air conditioning failure Unable to regulate Use alternate cooling Position fans for maximum Nursing staff B
environment manual fan
Identify patients requiring Nursing staff
cooling B
Refer to facility wide plan Inform and educate staff Nurse Unit Manager
Wall suction failure Wall suction not Use alternate suction Assess need for and number Nurse Unit Manager
required Nursing staff B
dependent patients
Replace drain suction with B
bottles Nursing staff
Provide emergency Ensure small oxygen D
trolley Nurse Unit Manager
Educate staff on use of Director of Nursing
alternate devices
Page - 115 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Unable to use ISTAT Bloods to path Develop policy for formal Medical staff C
laboratory test
Failure of 12 lead ECG Unable to diagnose Ensure access to Identify access to Nurse Unit Manager
machine potential life-threatening emergency power emergency power outlet Director of Nursing
conditions Engineering staff D
Use on battery power Keep batteries fully charged
on emergency power Nursing staff
Inform and educate staff D
Nurse Unit Manager
Alarms and secure environment rounds C
Refer to safety and security Inform and educate Staff Nurse Unit Manager
plan. Director of Nursing
Failure of Patient call Patients unable to Refer to safety and security More regular rounds of Nurse Unit Manager C
buttons summon assistance plan. patients in the department. Director of Nursing
Failure of Infusion Staff unable to titrate Use on battery power if Charge on generator power All staff C
Pumps/Syringe Drivers medications and fluids available if able Nursing staff
accurately Use burettes Charge batteries fully
Ensure adequate stock C
burettes
administration routes. administration Medical staff C
handling injuries Use of slide sheets, pat All staff
slide, slida person etc.
Ensure staff trained in Nurse Unit Manager Back care
manual handling facilitator/Hinterland Educator
Pan room hopper Unable to clean bed Single patient use bedpans/ Purchase sufficient for Nurse Unit Manager C
pans / urinals adequately urinals immobile patients All staff
water and disinfect with Nurse Unit Manager Director
chemical solution of Nursing
Inform staff of Infection Infection Control CNC for C
Control policy MHHS
Page - 116 28/08/2013

Clermont Hospital – Utilities Services
A = Up to 24hrs
B = Up to 5 Days
CLERMONT HOSPITAL - UTILITIES C = Indefinitely
D = Cannot Operate
service?
Loss of LPG supply Secure LPG site and Engineer to establish Manager Engineering/ A
implement retrieval/disposal security of the site and risk Director of Nursing
of hazardous material assess immediate needs.
Arrange urgent supply of Identify number of cylinders A
portable LPG cylinders required and allocate as per Manager Engineering
priority listing
Arrange for supplier to fill
storage tanks if not
damaged
Unable to provide Use alternate energy Identify alternate energy A
cooking facilities source Gas Cook top or sources for cooking Manager Engineering
BBQ
Unable to provide hot Heat water with alternate Identify alternate energy A
water energy source Gas Quick sources for water heating Business manager/Director of
heat water heater. Nursing
Wash / clean with cold Identify cleaning processes
water that can use cold water or
use disposable ware Manager Engineering
B
Identify alternate washing Manager Engineering

regime for patient hygiene Business Manager
Dishwasher heats own No remedial action required Director of Nursing B
water Business
Staff Education Educate staff on Manager/Cook/Director of
contingency plans Nursing
Oxygen supply disrupted Use cylinder oxygen Ensure adequate supplies Operational Officers/ Business A
Manager
Inability to supply mains Emergency power Identify existing supply of Manager Engineering A
power to facilities generation emergency power
generation
Refer to power points/ Manager Engineering
outlets with emergency Director of Nurse Unit
generation in each area Manager
Page - 117 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Confirm essential equipment A
only connected to generator Manager Engineering
power outlets
Ensure essential lights and Nurse Unit Manager
equipment supplied. Nurse Unit Manager
Consider need to purchase
extension leads
Develop a procedure for use Manager Engineering A
of emergency power in each
area and inform staff
Contact Manager Engineering
Engineering/Contractor to A
ensure adequate fuel source
for use of generator
Ensure fuel storage Nurse Unit Manager A
standards are maintained
Ration use of emergency Identify generator load Nurse Unit Manager
power capacity
Use alternate power Fully charge batteries on all All Managers A
sources essential equipment
Supply additional lighting Locate/purchase torches/
lanterns and batteries A
Discharge/ relocate patients Inform and educate staff
within facility
Consider activation of Consult current MHHS MHHS Manager A
MHHS Disaster Plan Disaster Plan for process
Close Facility Liaise with alternative MHHS Manager
service provider for care of Medical Superintendent A
patients
Transfer patients out & close MHHS Manager only
facility
Staff Education Educate staff on Nurse Unit Manager
contingency arrangements
Loss of water supply for Liaise with Local Ration water usage Rationalise services and
general use, e.g., toilets, Council Authority re develop plan for water MHHS Executive A
patient hygiene supplies of water. restriction Manager Engineering
Identify alternative water Source / cost alternate Director of Nursing
sources supplies, e.g. / Water
tankers / Fire service supply
Page - 118 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Initiate use of alternate
supply
Identify alternative supplies Consider purchase of bottled A
of drinking water water Manager Engineering
Liaise with Renal Dialysis
Unit to save empty dialysate MHHS Executive A
containers for water storage Manager Stores
Loss of drinking water Discharge/ relocate patients Buy containers for storage of
within facility drinkable water Business Manager
Identify patients for
discharge or relocation Medical Superintendent
Contingency Failure Consider activation of Consult current MHHS
MHHS Disaster Plan Disaster Plan for process MHHS Manager
Use emergency supply Liaise with local council / A
utilities re emergency water
supply MHHS Manager
Close facility Liaise with alternative A
service provider for care of MHHS Manager / Medical
patient Superintendent
Transfer patients out and
close facility
Staff education Educate staff on
contingency
Sewerage Unable to dispose of Ensure facility wide plan Develop facility plan for MHHS Executive D
waste products due to waste disposal
water failure
Ensure Local council and Utilise “grey/used” water Inform staff to save water Nurse Unit Manager D
Public Health Unit after patient hygiene Operational Services
involvement. Place bucket for used water D
in each toilet cubicle for
flushing purposes Nurse Unit Manager
Designate toilets to be used Close off toilets not for use Director of Nursing D
and post signs
Alternate toilet facilities Identify alternate toilet Manager Engineering
devices e.g., porta loos, and D
number required Manager Engineering
Source supply / cost of
alternate devices Nurse Unit Manager
Single patient use bedpans/ Purchase sufficient for
Page - 119 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
urinals immobile patients All staff
water and chemical solution Medical Superintendent D
Control policy
Discharge/ relocate patients Identify patients for MHHS Manager
within facility discharge or relocation Manager Engineering
Consider activation of Consult current MHHS
Liaise with local council / Manager Engineering D
supply
Arrange for septic tank
pumping truck to pump Medical Superintendent
sewerage out of hospital
pipes
Failure of contingency Close facility Liaise with alternative D
service provider for care of
patient Nurse Unit Manager/Facility
Transfer patients out, close Manager/ Managers
facility
contingency plans
Power failure Mains power not Refer to mains power Inform and educate staff DON/ NUM/BM/Engineering B
available. Generator failure plan
supplies emergency
power
Lighting failure Difficulties in patient Utilise emergency lighting Identify provision for Engineering staff B
Relocate immobile patients Nursing staff B
to best lit areas
Maximise natural lighting Clean and maintain windows Operational Staff
and fittings
Utilise alternate lighting Ensure adequate supply Nurse Unit Manager/Director
torches / battery operated of Nursing
lights and batteries NUM/ All staff
Page - 120 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
hazards NUM/All staff
No safety/evacuation Provide additional portable Identify and source
lighting available lighting alternative lighting
Staff member to place
lighting in strategic areas for
safety
Issue clinical staff with
torches
Page - 121 28/08/2013

Monash Lodge Clermont - General
A = Up to 24hrs
B = Up to 5 Days
Monash Lodge - GENERAL C = Indefinitely
D = Cannot Operate
service?
patients forms
for new admissions
intervals
Revert to manual process Update patient diet lists and Nursing staff C
have available for collection
Telephone failure No internal / external Refer to facility wide Inform and educate staff Clinical Nurse C
telephone telecommunications plan Nurse Unit Manager
communications Director of Nursing
Nursing staff
FAX Failure Unable to receive or Utilise alternate lines of Send patient information by Clinical Nurse B
send patient information communication courier Administrative Staff
Delay transfer of information Nursing staff
until services resumed. B
chart
Ensure all staff educated in Clinical Nurse
Page - 122 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
cylinder changeover. Nurse Unit Manager D
oxygen users
Source food off campus Develop plan for preparation Cook/Business Manager/ B
perhaps and transport of food from Director of Nursing
products life milk
water for drinking
Refrigeration - Drugs and medical Place drugs in refrigerators Review emergency power Clinical Nurse A
supplies requiring which are connected to outlets and manage as per Nurse Unit
refrigeration may emergency power supply infection control/ Manager/Engineering staff
become unusable management guidelines.
temperature with
thermometer
Utilise SBVP Esky
Use Eskies and ice Inform and educate staff C
Clinical Nurse
Plan disposables
Page - 123 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
with receiving/ referring communication strategy ambulance communications
hospital Use mobile phone if network
is operational
Use satellite phone
Use alternate Use ambulance radio
communication strategy Nursing Staff C
Instigate close observation
of at risk patients
Transport monitors Unable to monitor Aim to have at least one Ensure one compliant Clinical Nurse, Nurse Unit D
malfunction critically ill or unstable compliant transport monitor transport monitor available Manager Medical staff
cardiac patients in transit or list of compliant in central location
machines.
critical dates. critical dates
Assess pt need for transport Medical staff
Charge batteries
Medical equipment failure
Failure of Monitors Unable to identify Use on emergency power Check existing emergency Clinical Nurse Consultant D
oximetry arrhythmias / oxygen Use battery backup power outlets
saturation
Increased nursing & equipment
medical observation Aim to replace non
compliant equipment
Identify & position compliant Clinical Nurse Consultant D
monitors ensuring access to
emergency power Clinical Nurse Consultant
Ensure adequate supply of
batteries• Have batteries Clinical Nurse Consultant D
fully charged Director of Nursing
Identify & ensure adequate
medical & nursing staff
coverage Clinical Nurse Consultant
Prioritise patients for Clinical Nurse Consultant
monitoring D
Inform and educate staff D
Page - 124 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
transport services services not available of available vehicles centralising vehicles Director of Nursing
Prioritise use
Re–admit at risk patients if C
necessary Medical staff
card service distributor for credit facilities
for fleet vehicles
supplies from/to facility transport of supplies contractors
Overcrowding of Monash Spread of disease Planned areas for Allocate areas for use by Director of Nursing C
Lodgecampus habitation public
family accommodation (work & Clinical Nurse C
living for staff) Business manager
sheets Director of Nursing
Infections Antiseptics control Director of Nursing
Public Health Unit
Consider purchase of Clinical Nurse security
whistles Nurse Unit Manager
Fire alarms Aim to have fire alarms Check fire alarms Director of Nursing C
compliant With appropriate
Engineering staff security
Provide alternative power Ensure alarms are Business Manager
source for alarms connected to generator C
power Manager Engineering
Ensure all staff have recent Liaise with Fire Department
fire safety training Director of Nursing
Clinical Nurse /Business mgr
Page - 125 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
level of care in the event staffing requirements Clinical Nurse, Nurse Unit B
of equipment failure Manager Business Manager
call staff
computerised
pathology/radiology
results
Develop means for Clinical Nurse & Lab staff
results Medical Staff
Manual ordering tests Nursing staff
Nursing staff B
Enter data when system Ensure retrospective data
services resume
cooling B
Refer to facility wide plan Inform and educate staff Clinical Nurse
Nurse Unit Manager
Educate staff on use of
alternate devices
laboratory test
Refer to safety and security Inform and educate Staff Clinical Nurse
plan.
Failure of Patient call Patients unable to Refer to safety and security More regular rounds of Clinical Nurse C
buttons summon assistance plan. patients in the department.
Page - 126 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
slide,slida person etc.
Ensure staff trained in CN
manual handling Back care facilitator
Hinterland Educator
Pan room hopper Unable to clean bed Single patient use bedpans/ Purchase sufficient for Clinical Nurse C
Rinse with “grey/waste” All staff
chemical solution
Inform staff of Infection CN C
Page - 127 28/08/2013

Monash Lodge Clermont – Utilities Services
A = Up to 24hrs
B = Up to 5 Days
MONASH LODGE - UTILITIES C = Indefinitely
D = Cannot Operate
service?
Loss of LPG supply Secure LPG site and Engineer to establish Manager Engineering A
implement retrieval/disposal security of the site and risk Director of Nursing
Arrange urgent supply of Identify number of cylinders A
portable LPG cylinders required and allocate as per Manager Engineering
priority listing Director of Nursing
damaged
Unable to provide Use alternate energy Identify alternate energy A
cooking facilities source Gas Cook top or sources for cooking
BBQ Manager Engineering
Unable to provide hot Heat water with alternate Identify alternate energy A
water energy source Gas Quick sources for water heating
heat water heater. Business manager
Wash / clean with cold Identify cleaning processes
use disposable ware Manager Engineering
B
Identify alternate washing Manager Engineering

regime for patient hygiene Business Manager
Dishwasher heats own No remedial action required Clinical Nurse B
water Business Manager/Cook
Staff Education Educate staff on
contingency plans
Manager/Director of Nursing
Inability to supply mains Emergency power Identify existing supply of Manager Engineering A
generation
Refer to power points/ Manager Engineering
outlets with emergency Clinical Nurse
generation in each area Clinical Nurse
Page - 128 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
only connected to generator
power outlets Manager Engineering
equipment supplied. Clinical Nurse
Consider need to purchase Clinical Nurse
extension leads
Develop a procedure for use A
area and inform staff Manager Engineering
Contact
ensure adequate fuel source Manager Engineering
for use of generator
Ensure fuel storage A
Ration use of emergency Identify generator load Nurse Unit Manager
power capacity
Use alternate power Fully charge batteries on all Nurse Unit Manager A
sources essential equipment
Supply additional lighting Locate/purchase torches/ All Managers
within facility
patients
facility
Staff Education Educate staff on Clinical Nurse, Nurse Unit
contingency arrangements Manager
patient hygiene supplies of water. restriction Manager Engineering
Identify alternative water Source / cost alternate Director of Nursing
Page - 129 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
supply
Identify alternative supplies Consider purchase of bottled A
of drinking water water Manager Engineering
Liaise with Renal Dialysis
Unit to save empty dialysate MHHS Executive A
containers for water storage Manager Stores
Loss of drinking water Discharge/ relocate patients Buy containers for storage of
within facility drinkable water Business Manager
Identify patients for
discharge or relocation Medical Superintendent
Contingency Failure Consider activation of Consult current MHHS
supply MHHS Manager
Close facility Liaise with alternative A
service provider for care of MHHS Manager / Medical
close facility
contingency
water failure
Ensure Local council and Utilise “grey/used” water Inform staff to save water Clinical Nurse Consultant D
Public Health Unit after patient hygiene
involvement. Place bucket for used water Operational Services D
flushing purposes
Designate toilets to be used Close off toilets not for use Clinical Nurse, Nurse Unit D
and post signs Manager
Alternate toilet facilities Identify alternate toilet Director of Nursing
devices e.g., porta loos, and D
number required Manager Engineering
Source supply / cost of
alternate devices Manager Engineering
Single patient use bedpans/ Purchase sufficient for
Page - 130 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
urinals immobile patients Clinical Nurse, Nurse Unit
Rinse with “grey/waste” Manager
water and chemical solution Director of Nursing D
Control policy
Discharge/ relocate patients Identify patients for All staff
within facility discharge or relocation
Consider activation of Consult current MHHS Medical Superintendent
Liaise with local council / D
utilities re emergency water MHHS Manager
supply Manager Engineering
Arrange for septic tank
pumping truck to pump
sewerage out of hospital Manager Engineering
pipes
Failure of contingency Close facility Liaise with alternative D
patient Medical Superintendent
Transfer patients out, close
facility
contingency plans
Clinical Nurse / Managers
Power failure Mains power not Refer to mains power Inform and educate staff DON/ NUMBM/Engineering B
supplies emergency
power
to best lit areas
and fittings
Utilise alternate lighting Ensure adequate supply Clinical Nurse, Nurse Unit
torches / battery operated Manager
lights and batteries Director of Nursing
Page - 131 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
patients and staff precautions areas and corridors of all CN / NUM/DON All staff
hazards
No safety/evacuation Provide additional portable Identify and source
lighting available lighting alternative lighting CN/NUM/DON/All staff
safety
torches
Page - 132 28/08/2013

Collinsville Hospital - General
A = Up to 24hrs
B = Up to 5 Days
COLLINSVILLE HOSPITAL - GENERAL C = Indefinitely
D = Cannot Operate
service?
patients forms
A&E Module failure No patient ID labels Manual process Hand write requests Administration staff B
Ensure blank labels are
available
Unable to utilise Manual recording. No Ensure details are recorded
TRIAGE, treatment and written record of Ur nos in chart C
admission/discharge maintained on site
screens
Unable to record Retrospective data entry Check and update missing Administration Staff
statistical requirements data Nursing Staff
for new admissions
intervals
Unable to provide patient Revert to manual process Update patient diet lists and Nursing staff C
dietary requirements have available for collection
Telephone failure No internal / external Refer to facility wide Inform and educate staff NUM/DON C
telephone telecommunications plan Nursing staff
communications
Tape recorder failure Unable to pre-record Revert to verbal handover Designate time, venue and NUM/DON C
patient handover procedure for verbal hand-
over
FAX Failure Unable to receive or Utilise alternate lines of Send patient information by Nurse Unit Manager B
send patient information communication courier Administrative Staff
Page - 133 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Delay transfer of information Nursing staff
until services resumed. B
chart
Ensure all staff educated in Clinical Nurse Consultant
cylinder changeover. D
oxygen users
Source food off campus Develop plan for preparation Cook/Business Manager B
perhaps and transport of food from
products life milk
water for drinking
Refrigeration - Vaccine Drugs and medical Place drugs in refrigerators Review emergency power Clinical Nurse A
supplies requiring which are connected to outlets and manage Consultant/Engineering staff
refrigeration may emergency power supply vaccines as per infection
become unusable control/vaccine management
guidelines.
temperature with
thermometer
Use Eskies and ice Utilise SBVP Esky Nurse Unit Manager/DON C
Plan disposables
Page - 134 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
with Clinical Coordinator communication strategy ambulance communications
via AMCOM re patient Use mobile phone if network
advice/ transfer/ retrieval is operational
(RFDS, helicopter) Use satellite phone
Unable to communicate Use alternate Use ambulance radio
with receiving/ referring communication strategy Nursing Staff C
hospital Instigate close observation
of at risk patients
Transport monitors Unable to monitor Aim to have at least one Ensure one compliant NUM/DON Medical staff D
malfunction critically ill or unstable compliant transport monitor transport monitor available
cardiac patients in transit or list of compliant in central location
machines.
critical dates. critical dates Medical staff
Assess pt need for transport
Charge batteries
Defibrillator malfunction Unable to defibrillate Have compliant defibrillator Identify non compliant
patients available equipment
Aim to replace non NUM/DON Medical staff D
compliant equipment
Identify & re allocate
compliant defibrillator
Connect to emergency Identify existing emergency
power power outlets
Page - 135 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Medical equipment failure Unable to provide Utilise emergency power Check existing emergency NUM/DON C
specialised medical power outlets
equipment
Bi-PAP/CPAP Manual process Use black bag closed circuit NUM/DON Medical staff
with 100% oxygen C
Ventilators Battery back-up if available Fully charge batteries
Use alternate oxygen driven
ventilator
NUM/DON
Manual ventilation Ensure adequate staff A
available for manual Nursing staff
ventilation A
Use alternate equipment Ensure equipment is
available Nursing staff
Blood warmers Manual process Warm water bath C
Biers machine Manual process Double cuff tourniquet
Level 1 transfuser Blood pumping set and
pressure bag
Spirometer Use peak flow meters
Slit lamp Perform visual examination Nursing staff
Treat prophylactically C
Plaster saw Manual process Use plaster cutters
Apply a back slab
Failure of Monitors Unable to identify Use on emergency power Check existing emergency DON/NUM D
including cardiac & arrhythmias / oxygen power outlets
oximetry saturation
equipment
Aim to replace non
compliant equipment
Identify & position compliant NUM/DON D
monitors ensuring access to
emergency power
Use battery backup Ensure adequate supply of
batteries• Have batteries NUM D
fully charged
Increased nursing & Identify & ensure adequate
medical observation medical & nursing staff Director of Nursing
Page - 136 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
coverage
Prioritise patients for
monitoring NUM/DON D
Inform and educate staff NUM/DON D
transport services services not available of available vehicles centralising vehicles
Prioritise use
Re–admit at risk patients if Medical staff C
necessary
card service distributor for credit facilities
for fleet vehicles
supplies from/to facility transport of supplies contractors
Overcrowding of hospital Spread of disease Planned areas for Allocate areas for use by Director of Nursing C
campus habitation public
family accommodation (work & NUM C
living for staff) Business manager
sheets
Infections Antiseptics control
Public Health Unit
Consider purchase of NUM security
whistles
Fire alarms Aim to have fire alarms Check fire alarms Engineering staff C
compliant Business Manager With appropriate
security
Provide alternative power Ensure alarms are
source for alarms connected to generator Manager Engineering C
Page - 137 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
power
Ensure all staff have recent Liaise with Fire Department Director of Nursing
fire safety training NUM
Business manager
level of care in the event staffing requirements Nurse Unit Manager B
of equipment failure Business manager
call staff
computerised
pathology/radiology
results
Develop means for Nurse Unit Manager & Lab
notification of lab & test staff
results
Manual ordering tests Medical Staff
Nursing staff B
Enter data when system Ensure retrospective data Nursing staff
services resume
cooling B
Refer to facility wide plan Inform and educate staff NUM/DON
Wall suction failure Wall suction not Use alternate suction Assess need for and number NUM/DON
required B
Consider co-locating suction Nursing staff
dependent patients
Replace drain suction with B
Page - 138 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
bottles
Provide emergency Ensure small oxygen Nursing staff D
trolley
Educate staff on use of Nurse Unit Manager
alternate devices
laboratory test
Failure of 12 lead ECG Unable to diagnose Ensure access to Identify access to Nurse Unit Manager
machine potential life-threatening emergency power emergency power outlet Engineering staff
conditions D
Use on battery power Keep batteries fully charged Nursing staff
on emergency power
Inform and educate staff NUM/DON D
Refer to safety and security Inform and educate Staff NUM/DON
plan.
Failure of Patient call Patients unable to Refer to safety and security More regular rounds of NUM/DON C
buttons summon assistance plan. patients in the department.
Failure of Infusion Staff unable to titrate Use on battery power if Charge on generator power All staff C
Pumps/Syringe Drivers medications and fluids available if able Nursing staff
accurately Use burettes Charge batteries fully
Ensure adequate stock C
burettes
administration routes. administration Medical staff C
slide,slida person etc.
Ensure staff trained in NUM/DON
manual handling Back care facilitator
Page - 139 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Pan room hopper Unable to clean bed Single patient use bedpans/ Purchase sufficient for NUM/DON C
Rinse with “grey/waste” All staff
chemical solution
Inform staff of Infection NUM C
Page - 140 28/08/2013

Collinsville Hospital – Utilities Services
A = Up to 24hrs
B = Up to 5 Days
COLLINSVILLE HOSPITAL - UTILITIES C = Indefinitely
D = Cannot Operate
service?
Loss of LPG supply Secure LPG site and Engineer to establish DON/BM/Engineering A
implement retrieval/disposal security of the site and risk
Arrange urgent supply of Identify number of cylinders DON/BM/Engineering A
portable LPG cylinders required and allocate as per
priority listing
damaged
Unable to provide Use alternate energy Identify alternate energy DON/BM/Engineering A
cooking facilities source Gas Cook top or sources for cooking
BBQ
Unable to provide hot Heat water with alternate Identify alternate energy Business manager A
water energy source Gas Quick sources for water heating
heat water heater.
Wash / clean with cold Identify cleaning processes Manager Engineering
use disposable ware
DON/BM/Engineering B
Business Manager
Identify alternate washing NUM/DON
regime for patient hygiene
Dishwasher heats own No remedial action required Business Manager/Cook B
water
Staff Education Educate staff on
contingency plans
Manager
Inability to supply mains Emergency power Identify existing supply of DON/BM/Engineering A
generation
Refer to power points/ DON/BM/Engineering
outlets with emergency
generation in each area Nurse Unit Manager
Page - 141 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
only connected to generator
power outlets Manager Engineering
equipment supplied. NUM/DON
Consider need to purchase
extension leads NUM/DON
Develop a procedure for use A
area and inform staff
Contact DON/BM/Engineering
ensure adequate fuel source
for use of generator DON/BM/Engineering
Ensure fuel storage A
Ration use of emergency Identify generator load
power capacity Nurse Unit Manager
Use alternate power Fully charge batteries on all A
sources essential equipment Nurse Unit Manager
Supply additional lighting Locate/purchase torches/
lanterns and batteries All Managers A
within facility
patients
facility
Staff Education Educate staff on Nurse Unit Manager
contingency arrangements
patient hygiene supplies of water. restriction DON/BM/Engineering
Identify alternative water Source / cost alternate
Page - 142 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
supply
Identify alternative supplies Consider purchase of bottled DON/BM/Engineering A
of drinking water water
Liaise with Renal Dialysis MHHS Executive
Unit to save empty dialysate Manager Stores A
containers for water storage
Loss of drinking water Discharge/ relocate patients Buy containers for storage of Business Manager
within facility drinkable water
Identify patients for Medical Superintendent
discharge or relocation
Contingency Failure Consider activation of Consult current MHHS MHHS Manager
utilities re emergency water MHHS Manager
supply
Close facility Liaise with alternative MHHS Manager / Medical A
service provider for care of Superintendent
patient
close facility
contingency
water failure
Ensure Local council and Utilise “grey/used” water Inform staff to save water Nurse Unit Manager D
Public Health Unit after patient hygiene
involvement. Place bucket for used water Operational Services D
flushing purposes
Designate toilets to be used Close off toilets not for use Nurse Unit Manager D
and post signs
Alternate toilet facilities Identify alternate toilet
devices e.g., porta loos, and NUM/BM/DON/Engineering D
number required
Source supply / cost of DON/BM/Engineering
alternate devices
Single patient use bedpans/ Purchase sufficient for Nurse Unit Manager
Page - 143 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
urinals immobile patients
water and chemical solution D
Inform staff of Infection All staff
Control policy
Discharge/ relocate patients Identify patients for Medical Superintendent
Consider activation of Consult current MHHS
Liaise with local council / Manager Engineering D
supply
Arrange for septic tank DON/BM/Engineering
pumping truck to pump
pipes
Failure of contingency Close facility Liaise with alternative Medical Superintendent D
patient
Transfer patients out, close
facility
Staff education Educate staff on NUM/DON/Managers
contingency plans
Power failure Mains power not Refer to mains power Inform and educate staff DON/NUMBM/Engineering B
supplies emergency
power
to best lit areas
and fittings
Utilise alternate lighting Ensure adequate supply Nurse Unit Manager
Increased risk for Maintain WH&S Clear patient areas, work NUM/DON/BM/ All staff
Page - 144 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
hazards
No safety/evacuation Provide additional portable Identify and source NUM/DON /All staff
lighting available lighting alternative lighting
safety
torches
Page - 145 28/08/2013

Dysart Hospital – Clinical & General
DYSART HOSPITAL – CLINICAL & GENERAL
HOW LONG CAN
YOU FUNCTION
PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY
WITHOUT THIS
SERVICE?
Unable to register Manual registration Adequate supply downtime forms Administration Staff
patients
HBCIS B
Access Failure No patient ID labels Manual Process Hand write requests Administration Staff
Ensure blank details are recorded in Administration Staff

chart
Unable to utilise Manual recording. Ensure correct details are recorded in Nursing Staff
TRIAGE treatment, the chart
admission and No written record of UR Numbers C
HBCIS discharge maintained on site Check and update missing data Administration Staff
Emergency Department Nursing staff
Module failure Unable to record Retrospective data entry
statistical
requirements
Unable to print Manual recording of labels Ensure adequate staffing to cover Business Manager
results/labels workload Administration Staff B
Printing services Failure Results can be obtained via phone or List of relevant phone numbers e.g. Nursing Staff
internet pathology, x-ray etc.
Unable to generate Record patient details manually Ensure supply of HBCIS downtime
ID labels, track forms
patient location, Pre-print labels on existing patients Administration Staff B
Computer failure bed status, lab Hand write on blank labels for new Nursing staff
results, emails, admissions
online policies and Update patient location and bed
procedures status at regular intervals
Page - 146 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Unable to track Revert to manual process Update patient diet lists and have Nursing Staff C
patient location and available for collection by catering Operational Stream
bed status services
Unable to provide
patient dietary
requirements
No internal or NUM
external Refer to facility wide telecommunications Inform and Educate staff Registered Nurse C
Telephone Failure
communications plan Business Manager
DON
Unable to receive Send patient information by courier,
or send patient Utilise alternate lines of communication registered post or scan and email NUM B
FAX Failure information Administration Staff
Delay transfer of information until DON
services resumed
Unable to copy, Utilise alternate lines of communication Telephone Communication
scan or fax Utilise photocopier at Private Surgery B
documents Send original documents with the All Staff
Photocopy Failure patient in chart

services resumed A
Piped oxygen Use oxygen cylinders Ensure adequate supply of cylinders Operational Stream
failure Administration B
Ensure all staff educated in cylinder Nursing
Oxygen Supply Disrupted
changeover
Consider co-locating high oxygen All Staff
users
Wall suction failure Wall suction not Use alternate suction devices Assess need for and number of
dependent patients
Ensure adequate supply alternate NUM B
drainage systems DON Limited supply in
Provide emergency oxygen/suction Replace drain suction with manual Nursing Staff hospital
Page - 147 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
trolley
Potential for Use digital thermometer Ensure stock digital thermometers NUM
Failure of Welsh Allen inaccuracy of DON C
thermometer temperature Nursing Staff
readings
Unable to Use manual sphygmomanometer Ensure adequate number of manual
Failure of non-invasive electronically sphygmomanometers NUM C
blood pressure (NIBP) measure blood DON
monitors pressure Nursing Staff
recordings
Potential for Change battery in Glucometer Ensure adequate supply of batteries C
decreased and test strips NUM
accuracy in blood Formal laboratory blood glucose analysis DON
Failure of Glucometer
glucose readings for abnormal results Inform and educate staff Nursing Staff
Develop policy for formal laboratory A
test
Failure of 12 lead ECG Unable to diagnose Ensure access to emergency power or Identify access to emergency power
machine potential life- access battery backup outlet
threatening Use on battery power A
conditions NUM
Keep batteries fully charged on DON limited battery life
Identify location of alternative ECG
machines
Failure of Pulse oximeters Unable to Educate staff re basic physical NUM / DON
determine oxygen Increase nursing observation assessment of patient Nursing Staff C
saturation
Defibrillator malfunction Unable to Have compliant defibrillator available Identify non compliant equipment
defibrillate patients Aim to replace non compliant
equipment NUM
Identify & re allocate compliant DON A
defibrillator Nursing Staff
Connect to emergency power QAS on standby
Identify existing emergency power
outlets
Page - 148 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Medical equipment failure Unable to provide Utilise emergency power Check existing emergency power C
specialised medical Manual process outlets
equipment Use black bag closed circuit with
100% oxygen C
Battery back-up if available Fully charge batteries
Ventilators Manual ventilation Use alternate oxygen driven ventilator A

Ensure adequate staff available for
manual ventilation A
Use alternate equipment Ensure equipment is available NUM
DON
Blood warmers Manual process Warm water bath Nursing Staff C
Biers machine Manual process Double cuff tourniquet
Level 1 transfuser Manual process Blood pumping set and pressure bag
Spirometer Use peak flow meters C
Slit lamp Perform visual examination

Plaster saw Use plaster cutters

Apply a back slab
Unable to use ISTAT Bloods to path Develop policy for formal laboratory NUM
test DON C
Nursing Staff
Failure of Emergency Unable to provide Increased staff vigilance Schedule regular patient rounds B
Alarms safe and secure Can function but
environment time consuming and
Refer to safety and security plan Direct notification via phone to switch All staff can lead to
or runner to contact fire services, decreased patient
security, police safety
Inform and educate Staff
B
Failure of Patient call Patients unable to Refer to safety and security plan. Use of hand bells NUM
buttons summon Inform and educate staff DON C
assistance Business Manager
Nursing Staff
Page - 149 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Drugs and medical Place drugs in refrigerators which are Review emergency power outlets and
supplies requiring connected to emergency power supply manage vaccines as per infection DON
refrigeration may control guidelines NUM A
become unstable Nursing Staff
Refrigeration Vaccine
Monitor refrigerator temperature with Child & Community
Use eskies and ice thermometer Health Staff
Utilise SBVP Esky
Failure of Infusion Staff unable to Use on battery power if available . Charge on generator power if able A
Pumps/Syringe Drivers titrate medications Charge batteries fully NUM Batteries can last up
and fluids Use burettes DON to 12 hours.
accurately Consider alternate administration routes Ensure adequate stock burettes Nursing Staff
Protocols for alternative
administration
Failure of Sequential Potential increased Use alternative methods of deterring Identify at risk patients
Compression Devices risk of DVT thrombo-embolus
/Embolus Consider compression stockings/ NUM
drug therapy DON C
Develop policy Nursing Staff
Ensure adequate supplies of
stockings
Failure of lifting devices Difficulties with Access Battery back up of lifting devices Use hydraulic lifting devices if NUM
lifting heavy available DON B
patients – manual Use of ski sheets, bed sheets, hover Nursing Staff
handling injuries mattress etc. Nurse Educator
Ensure staff trained in manual WH&S Officer
handling
Failure of Video/TV Negative impact on Verbal education Develop alternate education NUM
patient education / packages for patients DON C
enjoyment Business Manager
Alternative recreational facilities Prepare mobile library
Staffing Increased manual Roster extra staff on duty Estimate staffing numbers required NUM
tasks may influence Place staff "on call" for 24 hour period DON B
workload Prepare rosters Business Manager
Telehealth Unable to Source alternative conferencing unit Communicate with IT NUM

guarantee liaison Communicate by telephone Ensure availability of telephone, DON C
with Specialist Internet e.g. Skype etc. laptop Business Manager
Mobile video calling Educate staff
Page - 150 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Equipment Function Unable to Check all equipment for functionality as Identify all equipment to be checked NUM
guarantee soon as possible after disruption of power DON C
equipment Business Manager
accuracy Nursing Staff
Refer to Food Use Disposables Ensure adequate supply of Cook
Safety Plan disposables Operational Stream C
Failure of Dishwasher
Business Manager
DON
Unable to Use alternate communication channels Consider the use of Mobile Phone if B
communicate with network is operational NUM
QAS Use 2 way radio DON
Develop criteria for referral based on Nursing Staff
Loss of communication
available services Business Manager
with pre Hospital transfer
services and referral
Unable to Develop an alternate referral discharge Develop pro forma for required C
centres
communicate with process patient information
GP’s
Failure of EFTPOS fuel Unable to obtain Arrange credit facility Liaise with local fuel distributor for DON C
card service fuel credit facilities for fleet vehicles / Business Manager
Generator fuel
Unable to transport Unable to receive Use alternate methods for transport of Identify and engage external NUM C
supplies from/to facility Supplies supplies contractors DON
Business Manager
Overcrowding of hospital Spread of disease Planned areas for habitation Allocate areas for use by public NUM C
campus DON
Nursing Staff
Business Manager
Staff dislocated from Distress to staff Plan for accommodation Allocate staff accommodation (work & NUM
family living for staff) DON C
Nursing Staff
Business Manager
Page - 151 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Disease outbreak Infected persons Vaccines Plan for vaccines, fact sheets Public Health Unit C
Child Health
Nurses
DON
NUM
Business Manager
Waste Disposal Vector Borne Sprays for insects. Assign contractors for pest control Public Health Unit C
Disease Infections Antiseptics Business Manager
DON
Page - 152 28/08/2013

Dysart Hospital – Utilities Services
A = Up to 24hrs
DYSART HOSPITAL - UTILITIES B = Up to 5 Days
C = Indefinitely
D = Cannot Operate
Problem Impact Contingency Task Responsibility How long can
you function
without this
service?
Secure LPG site and implement Engineer to establish security of the site and
Unable to provide cooking retrieval/disposal of hazardous risk assess immediate needs. C
facilities material Arrange for supplier to fill storage tanks if
Arrange urgent supply of not damaged
portable LPG cylinders Identify alternate energy sources for cooking
Manager Engineering
Unable to provide hot Use alternate energy source Identify alternate energy sources for water Business Manager
water e.g. Gas Cook top or BBQ heating DON B
Identify cleaning processes that can use Operational Stream
Wash / clean with cold water cold water or use disposable ware
Identify alternate washing regime for patient
Loss of LPG
hygiene.
supply
Dishwasher heats own water No remedial action required
Unable to utilise drier in Utilise drier in staff quarters Clothes trolley baskets and pegs available
laundry Clothes line adequate to hang Workload Management B
washing
Out source laundry – e.g.
Moranbah Hospital, Private
Laundry
Staff Education Educate staff on contingency plans

Emergency power generation Identify existing supply of emergency power
generation
Inability to
A
supply mains
Refer to power points/ outlets with
power to
facilities
Confirm essential equipment only connected
to generator power outlets
Page - 153 28/08/2013

A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
you function
without this
service?
Ensure essential lights and equipment Manager Engineering
supplied. Director of Rural Services
Consider need to purchase extension leads DON A
Develop a procedure for use of emergency NUM
power in each area and inform staff Business Manager
Ensure adequate fuel for generator use All Staff
maintained
Identify generator load capacity
Ration use of emergency power Fully charge batteries on all essential

Use alternate power sources equipment
Locate/purchase torches/ lanterns and A
batteries
Supply additional lighting Use natural lighting -open windows and
doors
Discharge/ relocate patients Identify patients for discharge or relocation
within facility Consult current MHHS Disaster Plan for
process
Consider activation of MHHS Liaise with alternative service provider for
Disaster Plan care of patients
Close Facility Transfer patients out & close facility

Staff Education Educate staff on contingency arrangements
Ration water usage Rationalise services and develop plan for Manager Engineering
water restriction Director of Rural Services
DON
Identify alternative water sources Source / cost alternate supplies, e.g. / Water NUM
Loss of water tankers / Fire service supply Business Manager
supply for Initiate use of alternate supply All Staff
general use,
e.g., toilets, Loss of drinking water Identify alternative supplies of Consider purchase of bottled water
patient drinking water
hygiene
A
Contingency Failure Discharge/ relocate patients Identify patients for discharge or relocation
within facility
Consider activation of MHHS Consult current MHHS Disaster Plan for
Page - 154 28/08/2013

A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
you function
without this
service?
Disaster Plan process
Local Emergency Water Supply Liaise with local council / utilities re

Liaise with alternative service provider for
care of patient
Close facility Transfer patients out and close facility
Staff education Educate staff on contingency

Unable to dispose of Ensure facility wide plan Develop facility plan for waste disposal Manager Engineering
waste products due to Director of Rural Services D
Sewerage
water failure DON
Business Manager
Place bucket for used water in each toilet
Designate toilets to be used cubicle for flushing purposes
Close off toilets not for use and post signs
Source supply / cost of alternate Identify alternate toilet devices e.g., porta
devices e.g. porta loos loos, and number required
Single patient use bedpans/ Purchase sufficient for immobile patients

urinals Inform staff of Infection Control policy
Ensure Local Identify patients for discharge or relocation Manager Engineering

Council and Discharge/ relocate patients Consult current MHHS Disaster Plan for Director of Rural Services D
Public Health within facility process DON
Unit Liaise with local council / utilities re NUM
involvement. Failure of contingency emergency water supply Business Manager
All Staff
Arrange for septic tank pumping truck to
pump sewerage out of hospital pipes
Consider activation of MHHS Liaise with alternative service provider for

Disaster Plan care of patient
facility Transfer patients out
Close facility
Staff education Educate staff on contingency plans
Page - 155 28/08/2013

A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
you function
without this
service?
Mains power not Refer to mains power failure plan Inform and educate staff Manager Engineering
available. Generator Director of Rural Services A
supplies emergency DON
Power failure
power NUM
Business Manager
All Staff
Difficulties in patient Utilise emergency lighting Identify provision for emergency lighting
observation and care Relocate immobile patients to best lit areas
Maximise natural lighting Clean and maintain windows and fittings

DON
Utilise alternate lighting Ensure adequate supply torches / battery NUM B
Lighting operated lights and batteries Business Manager
failure All Staff
Increased risk for patients Maintain WH&S precautions Clear patient areas, work areas and
No safety/evacuation Provide additional portable Identify and source alternative lighting

lighting available lighting Staff member to place lighting in strategic
areas for safety
Issue clinical staff with torches
Page - 156 28/08/2013

Moranbah Hospital
A = Up to 24hrs
B = Up to 5 Days
MORANBAH HOSPITAL C = Indefinitely
D = Cannot Operate
service?
Computer failure Unable to generate ID Record patient details Ensure supply of HBCIS downtime Administrative and nursing C
labels manually forms staff Can function but very
Pre –print labels on existing patients time consuming
Hand write on blank labels for new
admissions
Unable to track patient Revert to manual Update patient location and bed
progress notes location process status at regular intervals C
Notify after-hours On-Call of all
patient movements
Develop a process for disseminating Nursing Staff Team Leader
patient updates as part of the facility
communication plan
Unable to access Revert to manual Ensure supply of pathology result Administrative and Nursing C
computerised process forms staff
pathology/radiology
results Develop means for notification of lab Nurse Unit Manager C
& test results
Manual ordering tests
Enter data when system Ensure retrospective data entry when Nurse Unit Manager / CN C
fixed computer services resume
Backup any non centralised data or Administrative staff
ward specific computer programs
Power failure Mains power not available Generator power Inform and educate staff Nurse Unit Manager /DON B
available Can function in most
areas.
Lighting failure Difficulties in patient Utilise emergency Identify provision for emergency Identify provision for
observation and care generator lighting lighting emergency lighting
Relocate immobile patients to best lit Engineering staff
areas Nursing staff B
Maximise natural Clean and maintain windows and Cleaning staff Can function in most
lighting fittings areas.
Utilise alternate lighting Ensure adequate supply torches / Nurse Unit Manager / DON
battery operated lights and batteries
Page - 157 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Increased risk for patients Maintain WH&S Clear patient areas, work areas and Nurse Unit Manager /All staff
and staff precautions corridors of all hazards
Generator power Educate staff
available
Air conditioning failure Regulate temperature and Use alternate cooling Position fans for maximum benefit Nursing staff A
environment with devices and turn off Especially in summer
Generator power unnecessary air-cons Limited where no
Electrical or manual fan Identify patients requiring cooling window.
Telephone failure No internal / external Refer to facility wide Inform and educate staff Nurse Unit Manager /Shift A
telephone telecommunications Team Leader /DON Only for a limited time.
communications . plan
Wall oxygen supply Wall oxygen not available Use cylinder oxygen Identify anticipated requirements of Nurse Unit Manager / CN
failure cylinder oxygen for ward patients
Order extra required cylinders B
Ensure all oxygen cylinders full
Ensure corresponding number of
oxygen fittings available at ward
level.
Ensure all staff educated in cylinder
changeover.
Wall suction Wall suction not Use alternate suction Assess need for and number of Nurse Unit Manager B
failure available devices portable suction units required
dependent patients
Ensure adequate supply alternate B
drainage systems Limited supply in
Replace drain suction with manual Nursing staff hospital
vacuum or drainage bottles Medical staff
Provide emergency
oxygen/suction Ensure small oxygen cylinder with
trolley
Digital scales fail Unable to record weight Use alternative scales Use bathroom scales Nurse Unit Manager
Use weighted scales if available C
Failure of Welsh Potential for inaccuracy Use digital Ensure stock digital Nurse Unit Manager
Allen of temperature readings thermometer thermometers C
thermometer
Page - 158 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Failure of non- Unable to electronically Use manual Ensure adequate number of Nurse Unit Manager
invasive blood measure blood sphygmomanometer manual sphygmomanometers C
pressure (NIBP) pressure recordings
monitors
Failure of Potential for decreased Change battery in Ensure adequate supply of Nursing staff /Unit Manager
Glucometer accuracy in blood Glucometer batteries and test strips C
glucose readings
Inform and educate staff Nursing staff
Formal laboratory Develop policy for formal
A.
blood glucose laboratory test
A potential treatment
analysis for abnormal
problem
results
Failure of 12 lead Unable to diagnose Ensure access to Identify access to emergency Nurse Unit Manager / DON A
ECG machine potential life- emergency power or power outlet No problem if
threatening conditions access battery emergency power
backup point kept for use.
Use on battery power Keep batteries fully charged on A
Nurse Unit Manager /Nursing
emergency power Staff limited battery life
Identify location of alternative
ECG machines
Failure of Pulse Unable to determine Increase nursing Educate staff re basic physical Nurse Unit Manager C
oximeters oxygen saturation observation assessment of patient Staff trained in physical
assessment
Failure of Unable to provide safe Increased staff Schedule regular patient rounds Nursing staff B
Emergency and secure vigilance Can function but time
Alarms environment consuming and can lead
to decreased patient
safety
Direct notification via phone to All staff
switch or runner to contact fire B
services, security, police
Refer to safety and Inform and educate Staff
security plan
Failure of Patient Patients unable to Refer to safety and Inform and educate staff Nurse Unit Manager
call buttons summon assistance security plan. C
Page - 159 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Failure of Infusion Staff unable to titrate Use on battery power Charge on generator power if A
Pumps/Syringe medications and fluids if available. able Charge batteries fully Batteries can last up
Drivers accurately to 12 hours.
Use burettes Ensure adequate stock burettes Nursing Staff
Consider alternate Protocols for alternative
administration routes administration
Failure of Potential increased risk Use alternative Identify at risk patients Unit Manager Medical staff
Sequential of DVT /Embolus methods of deterring C
Compression thrombo-embolus
Devices Consider compression stockings/ Unit Manager /Medical Staff
drug therapy
Develop policy
Ensure adequate supplies of Nursing staff
stockings
Refrigeration Drugs and medical Place drugs in Review emergency power outlets Unit Manager / DON
supplies requiring refrigerators which A
refrigeration may are connected to
become unusable emergency power
supply - as per Cold
Chain Protocol Nursing staff
Monitor refrigerator temperature with
thermometer
Use Eskies with Consider purchase of eskies and A
portable thermometers Nurse Unit Manager / CN
supply of ice with eskies
and ice as per Cold
Chain Protocol
Failure of lifting devices Difficulties with lifting Access Battery back up Use hydraulic lifting devices if All staff
heavy patients – manual of lifting devices available B
handling injuries Use of ski sheets, bed sheets, etc.
Ensure staff trained in manual Unit Manager
handling WH&S Officer
Pan room hopper Unable to clean bed pans Single patient use Purchase sufficient for immobile Unit Manager / DON
/ urinals adequately bedpans/ urinals patients NB “Hopper” has been
Rinse with “grey/waste” water and Nurse Unit Manager replaced with
disinfect with chemical solution “Macerator” and
Inform staff of Infection Control policy disposable urinals &
bed pans
Page - 160 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Failure of Video/TV Negative impact on Verbal education Develop alternate education Nurse Unit Manager C
patient education / packages for patients Can still operate
enjoyment
Alternative recreational Prepare mobile library Volunteers
facilities
Failure of Fax Unable to receive or send Utilise alternate lines of Send patient information by Unit Manager /Business A
patient information communication runner/courier Manager Can still operate but
Delay transfer of information until Medical staff time consuming
services resumed. Admin. staff
Failure of Copier Unable to copy Utilise alternate lines of Telephone information Nursing staff C
documents communication Medical staff
Send original documents with patient
and document in chart B
services resumed
Staffing Increased manual tasks Roster extra staff on Estimate staffing numbers required Nurse Unit Manager / DON
may influence workload duty for 24 hour period B
Equipment Function Unable to guarantee Check all equipment for Identify all equipment to be checked Nurse Unit Manager/ DON
equipment accuracy functionality as soon as
possible after disruption
of power
Page - 161 28/08/2013

Proserpine Hospital – General & Clinical Services
PROSERPINE HOSPITAL – CLINICAL & GENERAL
HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Failure HBCIS Medical Unable to locate & Ensure all records in file • Notify all MO’s/ward/depts to return Manager of
Records & Tracking send medical outstanding records Support Services B
System records
Run location by location for charts not Manager to arrange approp staff to Manager of
returned. complete task. Support Services
Use manual tracing system Implement manual system (eg) Manager of
tracer cards Support Services
Update system with changes & new
registrations Admin staff
Failure of HBCIS Patient Cannot allocate Manual allocation of URN’s Check backup PMI file is up to date. Manager of
Master Index (PMI new UR Numbers Support Services
B
Cannot search for Use backup PMI to look up existing • Manually allocate & look up URN’s Administrative staff
existing URN’s URN’s
Update system
Manual process • Print hard copy of PMI prior to Manager of
critical date Support Services
Prepare a block of unissued downtime UR • Allocate downtime UR numbers Manager of

numbers Support Services
Failure HBCIS Admission, Cannot search ADT Not critical, wait until system returns • Update System Manager of
Transfer, Discharge (ADT) to track patients Support Services
B
Cannot run enquiry Keep hard copy list in Medical Records • Have register and down forms Admin Staff
reports Department. available. Update patient list as
needed.
HBCIS Appointment Unable to print Print reports one week in advance where Manual list of attendees. Business Manager
Scheduling reports for patients possible.
to attend clinics A
No access to activity data Unable to access Access when system returns Retrospective updating of data. Business Manager C
reports.
Page - 162 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
No access to pathology / Unable to access Revert to manual process Ensure retrospective data entry when DON & FM / B
radiology results computerised computer services resume Business Managers
pathology/radiology
results
Unable to fax discharge Increased requests Post copy handwritten discharge Administrative staff C
summaries. from GP for follow Hand write discharge summaries. Give summaries to General Practitioners.
up discharge patients a copy on discharge.
information.
Flooding of Medical record Destruction of Move charts if possible to safe area. Rolls Arrange for staffing to move charts. Manager of C
Department. charts of black plastic and tape to secure. Or Cover filings bays with plastic and Support Services
secure.
EDIS failure Inability to record manual recording adequate supply of downtime forms NUM, admin staff C
emergency and triage forms
presentations
Computer failure unable to print manual recording of patient details and ensure supply of downtime forms and admin, nursing and C
results / labels etc results. manually record information. medical staff
FAX Failure unable to send or utilise alternate communication lines or Inform and educate staff. Delay NUM / BM B
receive patient delay transfer of information transfer of information or alternate
information means of communications
MDF Failure unable to copy or utilise alternate communication lines or Telephone information. Send original Nursing / medical B
scan documents delay transfer of information documents with patient and and admin staff
document in chart. Delay of
information until restored
Oxygen Supply Disrupted oxygen not use cylinder oxygen Ensure adequate supplies. Ensure NUM, nursing staff, B
available staff education on use. Consider co- operational staff
locating high oxygen users.
Failure of food spoilage refer Essential fridges on emergency power. Access Emergency power. Develop operational B
Refrigeration/Cool Rooms to food safety plan Source food offsite if needed. Consider plan for preparation and transport of services manager
long life options food from other sources. Purchase and BM
dry / tinned food. Consider long life
milk and bottled water if needed
Failure of Dishwasher refer to food safety use disposables adequate supplies needed operational C
plan services manager
and BM
Page - 163 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Unable to monitor Aim to have at least one compliant Ensure one compliant transport Nurse Unit D
Transport monitors critically ill or transport monitor or list of compliant monitor available in central location Manager
malfunction unstable cardiac machines.
patients in transit Assess patients prior to critical dates. Schedule tests prior to critical dates
Assess pt need for transport Medical staff C
Charge batteries Nursing staff
Defibrillator malfunction Unable to Have compliant defibrillator available Identify non compliant equipment Nurse Unit D
defibrillate patients Aim to replace non compliant Manager
equipment
Identify & re-allocate compliant
defibrillator
Inform & educate staff
Identify existing emergency power
outlets
Have batteries fully charged
Connect to emergency power
Use battery backup

Medical equipment failure Unable to provide Utilise emergency power Check existing emergency power
specialised medical outlets
equipment
Bi-PAP/CPAP
Ventilators Manual process Fully charge batteries Nurse Unit

Battery back-up if available Ensure adequate staff available for Manager A
Manual ventilation manual ventilation
Blood warmers Manual process Warm water bath
Slit lamp Manual process Perform visual examination Nursing staff

C
Plaster saw Manual process Apply a back slab / plastic cutters Medical staff C
Page - 164 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Failure of Monitors Unable to identify Use of emergency power Check existing emergency power Nurse Unit D
including cardiac & arrhythmias / outlets Manager
oximetry oxygen saturation Identify non compliant equipment
Aim to replace non complaint
equipment
Identify & position compliant monitors
ensuring access to emergency power
Ensure adequate supply of batteries.
Have batteries fully charged.
Identify & ensure adequate medical &
nursing staff coverage
Prioritise patients for monitoring
Inform and educate staff’
Use battery backup Nurse Unit D

Manager
Increased nursing & medical observation
Nursing staff C
Unable to provide Pathology services Identify and rationalise use of available Develop a plan for centralising DON & FM / C
transport services not available vehicles vehicles Medical Staff
Discontinue non-essential services Prioritise use Business manager C
Notify clients of potential for
disruption to normal services
Re-admit at risk patients if necessary
Overcrowding of hospital Spread of disease Planned areas for habitation Allocate areas for use by public DON & FM C
campus
Staff dislocated from Distress to staff Plan for accommodation Allocate staff accommodation (work & DON/NUM/BM C
family living for staff)
Disease outbreak Infected persons Vaccines Plan for vaccines, fact sheets DON/MBH/AHS/TP C
HU
Lack of Public Knowledge Suspicion - Stockpile of HP Material Stockpile PH Material BM/NUM/DON/TP C
Concerned Public Media person to duties HU
Insufficient staff Unable to provide Roster additional staff Calculate individual unit staffing All Line Managers B
safe level of care in requirements
the event of
equipment failure
Identify human resources able to be Director Of Nursing B
on call and redeployed in the facility
Page - 165 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Assess competence of on call staff Nurse Unit B
Manager
Wall suction failure Wall suction not Use alternate suction devices Assess need for and number of NUM B
Provide emergency oxygen/suction Consider co-locating suction Nursing staff
dependent patients
Ensure adequate supply alternate
drainage systems
Replace drain suction with manual
trolley
Educate staff on use of alternate
devices
Unable to use ISTAT Unable to diagnose Ensure access to emergency power Identify access to emergency power Nurse Unit D
potential life- outlet Manager /
threatening Engineering staff
conditions
Failure of 12 lead ECG Unable to provide Use on battery power Keep batteries fully charged on Nurse Unit D
Machine safe and secure emergency power Manager/ Nursing
environment staff
Increased staff vigilance Inform and educate staff
Schedule regular patient rounds
Failure of Emergency Patients unable to Utilise bells with capable patients Inform and educate Staff and Patients Nurse Unit B
Alarms summon Manager
assistance
Failure of Patient call Patients unable to Refer to safety and security plan. More regular rounds of patients in the Nurse Unit B
buttons summon department. Inform and educate staff Manager
assistance and patients
Failure of Infusion Staff unable to Use on battery power if available . Charge on generator power if able All staff Nursing C
Pumps/Syringe Drivers titrate medications Charge batteries fully staff
and fluids Ensure adequate stock burettes
accurately Use burettes Protocols for alternative
administration
Use hydraulic lifting devices if
available
Consider alternate administration routes.
Page - 166 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Failure of lifting devices Difficulties with Identify alternate lifting devices Use of slide sheets, pat slide,slida All staff C
lifting heavy person etc.
patients – manual
handling injuries
Macerators Unable to dispose Utilise supply of washable pans and Scrub and/or soak. Encourage use of All clinical staff B
of used pans and urinals. Manual Cleaning toilet as much as possible.
urinals
Failure of Blood / Unable to preserve Transfer blood and immunisations stores Investigate alternative storage NUM B
immunisation Fridges integrity of blood. elsewhere solutions.
Failure of Refrigerators / Spoilage of Ensure fridges and freezers connected to Check access to emergency Pharmacist within 30 minutes
Deep Freeze pharmaceuticals emergency power generator power
requiring
refrigeration /
freezing
Ensure fridges monitored for temperature Ensure On call pharmacist roster to Pharmacist / A
respond to fridge/freezer failure alarm nursing staff
If generator not managing load
arrange for portable eskies and or
portable generators to maintain
fridges and freezers
Failure of air conditioning Unable to maintain Ensure air conditioning for pharmacy Check availability of emergency Pharmacy Director A
- pharmacy air temperature connected to emergency power generator power Engineering
below 25'C Ensure pharmacy is a priority area
when air conditioning load shed
scheduled
Arrange access to portable air Pharmacy Director
conditioner Engineering
Contact Central Pharmacy for
direction
Consider portable air conditioner Pharmacist
Highlight potential inventory for Monitor fridges
destruction if temperature extreme
Higher load on fridges Director of
Pharmacy
No drug deliveries from May not have drug Maintain stock levels to allow for supply Maintain max mins monthly Director of B
Brisbane available when chain interruption of three days Pharmacy
required Obtain stock from Symbion Townsville Ensure on line ordering from Symbion Director of
is available Pharmacy
Page - 167 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Loss of Power / equipment Medical Imaging
failure Use alternate investigation if possible. Put CT Gantry onto emergency Staff and DON &
No CT Service. Outsource to local private practices. power. FM / Medical staff B
Key equipment on UPS. Test and maintain UPS. Assess Medical Imaging
Emergency power Emergency power for x-ray Staff and DON &
No Xray service Mobile x-ray units generator. FM / Medical staff B
Medical Imaging
No Ultrasound Equipment on emergency power. Use Test and maintain UPS. Assess Staff and DON &
Service. alternate test Emergency Power. FM / Medical staff B
Failure of steriliser Unable to process Ensure one steriliser on emergency power Identify emergency power supply to NUM
ward and theatre sterilisers B
instruments Alternative sterilisation methods Investigate alternative sterilisation NUM and Nursing
methods eg , chemical sterilisation staff
Ensure full stock levels of sterile
equipment available prior to critical
periods
Identify and prioritise critical services B
Rationalise service to emergency use only NUM/DON&FM
No washer/disinfector Unable to process Manually wash all equipment. Explore the possibility of connecting NUM and Nursing
connected to emergency reusable medical of one machine to emergency power. staff
power. equipment/instrume
nts. B
Failure of sterilised linen No Sterile Linen Have maximum stores available Prepacked and ensure maximum
service bundles store of sterile linen
Rationalise use of linen Consider alternative supplier
Alternative supplier Order extra supplies of disposable
linen
Use disposable linen B
Failure of Infant Suction and oxygen Use emergency generator power Ensure trolleys are plugged into red Midwives A
resuscitation trolleys not immediately emergency power points.
available
Ensure twin-o-vac available
Ensure alternate supply eg portable Ensure oxygen cylinders available CMC
generator and full
Unable to maintain Ensure alternate warming devices Consider bubble wrap, gladwrap Midwives / CMC
infant warming available
Fill Blanket warmer with blankets and
linen
Page - 168 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Dry babies well. Wrap & dress warmly
Place baby in bed with mother
Failure of electric delivery Positioning for birth Use emergency generator power Ensure trolleys are plugged into red Midwives
beds more difficult emergency power points. B
Revert to manual positioning Adjust bed to optimal height prior to Midwives / CMC
critical dates
Inform staff & patients CMC
Failure of Unable to perform Use emergency generator power Ensure trolleys are plugged into red Midwives B
Cardiotocograph (CTG) continuous foetal emergency power points.
/pH scalp monitoring heart monitoring Identify at risk patients & instigate
intermittent monitoring
Ensure adequate supply of battery
operated Doppler’s and gel.
Use battery-powered ultrasound Doppler. Ensure access to Pinard stethoscope CMC
Educate staff in use
Failure of anaesthetic Loss of power to Run on emergency generator power . Check access to emergency power Nurse Unit A
machines & ventilators machine Run on gases if no power Oxygen outlets. Manually Manager
driven) for 90 minutes only. Monitor pt ventilate. Manually physically Anaesthetic staff
for 40 minutes on battery from PACU assess
monitors
Use backup cylinder supplies of oxygen, Ensure supplies of cylinder gasses
nitrous oxide & air available
Hand ventilate Ensure adequate supply of hand
operated ventilation equipment -
Disposable manual resuscitator
Inaccurate delivery Locate and provide air / oxygen NUM A
of anaesthetic driven ventilator (oxylog)
gases
Unable to ventilate Cancel elective surgery DON & FM / NUM B
patients
Failure of laparoscopic Unable to perform Revert to non laparoscopic methods Notify surgeons, medical, nursing and NUM and clinical A
camera / light lead laparoscopic booking office staff
surgery (may be
Page - 169 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
done if generator Postpone all non urgent surgery Contact non urgent patients and NUM / A
on emergency inform re need to reschedule at later Administrations
power). date officer bookings.
ensure list of procedures unable to be Bookings/OR

under taken available at theatre front Manager
desk
Failure of diathermy Unable to perform Revert to ties/sutures Ensure adequate supply of ties and NUM and A
machine electrical sutures Operating theatre
coagulation (may CN
be done if
generator on
emergency power).
Failure of operating table. Unable to position Revert to manual processes Adjust bed to optimal height prior to Nursing staff
patient critical dates Purchase
manual override for table.
Failure of Sterilising Unable to sterilise Consider open procedures where clinically Notify surgeons, medical, nursing and NUM & DON / FM A
equipment for scopes (ON endoscopic / indicated booking office
EMERGENCY POWER). laparoscopic and Identify suitable patients
orthoscopic Contact non urgent patients and bookings officers
equipment inform re need to reschedule at later
date
Staff education – availability of types NUM
of cases able to be done
List of procedures unable to be under
taken available at theatre desk
Failure of glucometer Potential for Visual readings · Ensure adequate stock of Nursing Staff
decreased batteries
accuracy in blood · Inform & educate staff CNC
glucose readings Formal laboratory blood glucose analysis · Develop policy for formal Medical Staff A
for abnormal results laboratory test
Failure of 12 Lead ECG Unable to diagnose Ensure access to emergency power · Identify access to emergency NUM A
machine life threatening power outlet
conditions Use on battery power · Keep batteries fully charged on NUM
emergency power
· Identify location of alternative Nursing Staff
ECG machines
Page - 170 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
· Inform and educate staff CNC
Failure of Pulse oximeters Unable to Increase nursing observation · Ensure staff to act as a runner NUM B
determine oxygen Access other portable units from facility are available
saturation /Health Services if available
Failure of Enteral feed Difficulty in Use alternate feeding methods · Develop a procedure for CNC / nursing Staff
pumps maintaining patient bolus/gravity feeding
nutrition · Ensure adequate supply of NUM
tubes and feeds
· Manually titrate drip rate if nursing staff B
necessary
· Inform and educate staff Educator
Failure of non-invasive Unable to Use manual sphygmomanometer · Ensure adequate number of NUM A
Blood Pressure monitors electronically sphygmomanometers
measure blood
pressure readings
Page - 171 28/08/2013

Proserpine Hospital – Utilities Services
A = Up to 24hrs
B = Up to 5 Days
PROSERPINE HOSPITAL - UTILITIES C = Indefinitely
D = Cannot Operate
service?
Loss of mains power to Inability to supply mains Emergency power Ensure emergency Business Manager,
hospital. power to facilities generation generator is supplying. Operational Services
Supervisor. A
Confirm essential equipment Staff each area.
connected to generator
power outlets A
Ensure essential lights and Business Manager,
equipment supplied with Operational Services
uninterrupted power (UPS) Supervisor.
battery (e.g.) theatre lights A
Consider need to purchase Business Manager,
extension leads Operational Services
Supervisor. A
Continue testing and Business Manager,
maintenance schedule for Operational Services
generators AS/NZS 3009- Supervisor.
1998 A
Ascertain L/per hour fuel use Business Manager,
of generator Operational Services
Supervisor. A
Ensure fuel reserves Business Manager,
available for generator for Operational Services
long term use. Supervisor. A
Ensure manual fuel pumping Business Manager,
capability Operational Services
Supervisor. A
Investigate legal/safe levels Business Manager,
of fuel storage on premises Operational Services
Supervisor. A
Ration use of emergency Identify generator load Hospital Executive
power capacity A
Identify potential for load- Business Manager,
shedding and develop Operational Services
procedures Supervisor. A
Page - 172 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Use alternate power Fully charge batteries on all NUM
sources essential equipment A
Supply additional lighting Locate/purchase torches/ NUM
Use natural lighting -open All staff
windows and doors A
Use alternate emergency Identify alternate suppliers Hospital Executive
generator eg SES, Local industries,
mines/mills, Army, Hire
company A
Discharge/ relocate patients Identify patients for Medical Superintendent
within facility discharge or relocation A
Inform and educate staff Hospital Executive
A
Consider activation of Consult current District District CEO, DON/Facility
District Disaster Plan Disaster Plan for process Manager A
Close Facility Liaise with alternative District CEO, DON/Facility
service provider for care of Manager, Medical
patients Superintendent A
Transfer patients out & close Hospital Executive
facility A
Staff Education Educate staff on Hospital Executive
contingency arrangements A
Loss of water supply for Diminished ability to Ration water usage Rationalise services and DON/Facility Manager A
general use, e.g., toilets, continue clinical services develop plan for water
laundry, boilers, patient restriction
hygiene.
Identify alternative water Source / cost alternate DON/Facility Manager A
sources supplies, e.g. On-site tank
storage, Bore water, Water
tankers, Fire service supply
Initiate use of alternate DON/Facility Manager A
supply
Use emergency supply Liaise with local council / District CEO, DON/Facility A
utilities re emergency water Manager
supply
Page - 173 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Loss of drinking water Identify alternative supplies • Buy containers for storage DON/Facility Manager, A
of drinking water of drinkable water Business Manager
Source/cost supply of Supervisor Operational A
bottled water Services
Discharge/ relocate patients Identify patients for Medical Superintendent, A
within facility discharge or relocation DON/Facility Manager
Contingency Failure Consider activation of Consult current District District CEO, DON/Facility A
District Disaster Plan Disaster Plan for process Manager
Close facility Liaise with alternative District CEO, DON/Facility A
service provider for care of Manager, Medical
Transfer patients out and District CEO, DON/Facility A
close facility Manager, Medical
Superintendent
Staff education Educate staff on DON/Facility Manager, A
contingency Medical Superintendent
Failure of sewerage Unable to dispose of Ensure facility wide plan Develop facility plan for Hospital Executive D
system waste products due to waste disposal
water failure
Utilise “grey/used” water Inform staff to save water DON/Facility Manager D
after patient hygiene
Place bucket for used water Cleaning Services D
flushing purposes
Designate toilets to be used Close off toilets not for use Business Manager, Supervisor D
and post signs Operational Services
Alternate toilet facilities Identify alternate toilet Business Manager, Supervisor D
devices e.g., porta loos, and Operational Services
number required and cost of
these alternatives
Single patient use bedpans/ Purchase sufficient for Business Manager, Supervisor D
urinals immobile patients Operational Services
Rinse with “grey/waste” Nursing staff D
water and chemical solution
Page - 174 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Inform staff of Infection NUM, Infection Control CNC D
Control policy
Discharge/ relocate patients Identify patients for Medical Superintendent D
Consider activation of Consult current District District CEO, DON/Facility D
District Disaster Plan Disaster Plan for process Manager
Liaise with local council / DON/Facility Manager D
supply
Back up of effluent due Isolate hospital drainage Liaise with council to close DON/Facility Manager , D
to council pump failure system from main system valves Business Manager
Arrange for septic tank DON/Facility Manager , D
pumping truck to pump Business Manager
pipes
Failure of contingency Close facility Liaise with alternative Medical Superintendent D
patient
Transfer patients out, close District CEO, DON/Facility D
facility Manager
Staff education Educate staff on Hospital Executive D
contingency plans
Loss of LPG supply Unable to supply to Establish security of the site Secure LPG site and Business Manager, B
relevant areas. and risk assess immediate implement retrieval/disposal Operational Services
needs. of hazardous material Supervisor.
Arrange urgent supply of Identify number of cylinders Operational Services B
portable LPG cylinders required and allocate as per Supervisor.
priority listing.
Arrange for supplier to fill Operational Services B
storage tanks Supervisor.
Reduce use of LPG to Identify priority areas for gas Operational Services B
priority areas rationing Supervisor.
Unable to provide Use alternate energy Identify alternate energy Operational Services B
cooking facilities source or BBQ sources for cooking. Supervisor.
Page - 175 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Identify alternate facility to Operational Services B
prepare patients meals. eg Supervisor.
MOW Proserpine/Proserpine
Nursing Home
Unable to provide hot Heat water with alternate Identify alternate energy Operational Services B
water energy source eg Gas sources for water heating Supervisor.
Quick heat water heater.
Wash / clean with cold Identify cleaning processes Operational Services B
water that can use cold water or Supervisor.
use disposable ware.
Develop procedure for Operational Services B
laundry processes Supervisor.
Develop procedure for ward Operational Services B
cleaning supervisor, Infection Control
CNC
Staff Education Educate staff on CNC B
contingency plans
Internal Telephone failure Establish extend of problem Urgently contact Business Manager, Supervisor A/B
Unable to communicate and likely time for re- IT/communications Dept Operational Services
internally. establishment of MBH.
communication.
Utilise 2 way Radio Locate and centralise Business Manager, Supervisor
existing 2 way radios to Operational Services
communication centre A/B
Identify critical personnel DON/Facility Manager
and reallocate 2 way radios
(eg) Facility Manager, NUM,
ED A/B
Utilise mobile phones Locate and distribute mobile DON/Facility Manager
phones to key personnel. A/B
Maintain and distribute Business Manager
directory of re-allocated
phone unit numbers A/B
Develop procedure for DON/Facility Manager
emergency phone use and
educate staff A/B
Page - 176 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Runners Provide staffing and develop DON/Facility Manager,
a planned circuit Business Manager A/B
Utilise alternate existing Consider use of intercoms, DON/Facility Manager
communication devices nurse call system, WIP
phones, PA system, E mail,
message board A/B
Inform and educate staff DON/Facility Manager
A/B
External telephone failure Unable to communicate Identify alternate means of Liaise with CEO & Media DON/Facility Manager
(dial in ) externally. communication Relations Officer re local
media to inform community A/B
External telephone failure Unable to receive Utilise mobile phones Distribute mobile phones to DON/Facility Manager,
(dial out) communication from key personnel Business Manager
externally. A/B
Limit outgoing calls DON/Facility Manager,
Business Manager A/B
Inform and educate staff DON/Facility Manager,
Utilise existing radio Consider use of existing Hospital Executive, QAS
networks QAS radio phones A/B
Consider access to DON/Facility Manager,
emergency services radios Business Manager
and negotiate for frequency. A/B
Identify alternate SES, Fire Services, Police, DON/Facility Manager,
emergency communication Shire Council vehicles Business Manager
networks A/B
Equipment function That ongoing issues Check all equipment for Identify all equipment to be DON/Facility Manager,
following restoration of functionality as soon as checked in liaison with Business Manager
service. possible after disruption of IT/communications Dept
power MBH. A/B
Inform and educate staff DON/Facility Manager,
Loss of ability to secure Hospital business Provide onsite security Engage services of security DON/Facility Manager, C
site disruption. Risks related firm as necessary over 24 Business Manager.
to lack of security. hour period.
Page - 177 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Identify priority areas for Hospital Executive C
security
Provide security presence Hospital Executive C
in critical areas
Closed circuit TV Manual operation of site Increase indoor and outdoor NUM, Business Manager C
security security rounds
Assess ability to operate NUM, Business Manager C
system manually
Self-opening doors front Manual override of self- Ensure that doors kept in DON/Facility Manager, C
entrance. Security locks opening front entrance door open position. Business Manager.
all entrances. and unlock all other
entrance doors.
Keypad locks / swipe Manual override of keypad Use other means of DON/Facility Manager, C
card access locks securing area, e.g., personal Business Manager.
alarms for isolated staff
members, lockable
cupboards for medications/
expensive equipment
Exterior lights Provide alternative exterior Purchase battery-operated Supervisor Operational C
lighting lights and extra batteries Services
Parking Manual control of parking if Place "No Parking" signs in Supervisor Operational C
any of the car parks are the appropriate areas. Services
flooded.
Helicopter landing site Provide alternative lighting Purchase battery-operated Supervisor Operational
for helicopter landing site lights for landing site Services D
Staff education Educate staff on DON/Facility Manager,
contingency plan Business Manager. D
Loss of ability to protect Increased risk to staff Roster extra staff for Ensure availability of extra NUM & Hospital Executive
staff and patients escorts staff C
Review emergency call in NUM & Hospital Executive
roster C
Loss of ability to protect Duress alarms Provide alternative alert Purchase hand held audible DON/Facility Manager,
staff and patients system for nurses alarms Business Manager. C
Consider purchase of DON/Facility Manager,
whistles Business Manager. C
Page - 178 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Fire alarms Aim to have fire alarms Check fire alarms DON/Facility Manager,
compliant. Business Manager. C
Provide alternative power Ensure alarms are DON/Facility Manager,
source for alarms connected to generator Business Manager.
power C
Messenger sent to all units Appoint messenger DON/Facility Manager,
in event of fire. Business Manager. C
Ensure fire evacuation Review fire procedures and DON/Facility Manager,
procedures in facility policy Business Manager.
disaster manual. C
Sensor alarms for Revert to manual process Visual check of gauges Operational Wards persons
medical gases C
Equipment function Check all equipment for Identify all equipment to be Hospital Executive, All staff
functionality as soon as checked
power C
Inform and educate staff Hospital Executive
C
No safety/evacuation Provide additional portable Identify and source Supervisor Operational
lighting available lighting alternative lighting Services C
Staff member to place Supervisor Operational
lighting in strategic areas for Services
safety C
Issue clinical staff with Supervisor Operational
torches Services C
Failure of hot water Loss of steam for Arrange for laundry Access available services DON/Facility Manager, B
systems sterilisation, laundry, and sterilisation and provision of Supervisor Operational
hot water hot water from external Services
sources.
Equipment Function Check all equipment for Identify all equipment to be Supervisor Operational B
functionality as soon as checked Services
power
Inform and educate staff Supervisor Operational
Services
Page - 179 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Loss of vehicles or fuel Unable to provide Identify and rationalise use Develop a plan for Business Managers C
supply. transport services of available vehicles centralising vehicles with Proserpine Hosp and WCHC
Whitsunday Community
Health
Prioritise use Hospital Executive C
Discontinue non-essential Notify clients of potential for Department staff C

Re–admit at risk patients if Medical staff Community C
necessary health staff
Failure of EFTPOS fuel Arrange credit facility Liaise with local fuel Business Managers C
card service distributor for credit facilities Proserpine Hosp and WCHC
for fleet vehicles
Unable to transport Use alternate methods for Identify and engage Business Managers C
supplies from/to facility transport of supplies external contractors Proserpine Hosp and WCHC
Failure of File Server Loss of access to Inform IT and take direction Urgently contact IT Dept DON/Facility Manager, D
desktop applications from IT Dept, MBH. MBH. Business Manager
Switch to backup file • Flag PC to substitute as • Information Services D
server. replacement file server Manager
Worst case – switch to • Conduct full backup of file • Information Services D
manual system. server Manager
• Reconfigure new file server • Information Services staff D
• Load backup data • Information Services staff D
• Revert back to original • Information Services staff D

server
• Copy amended data • Information Services staff D
Failure of Local Area Loss of access to Inform IT and take direction Urgently contact IT Dept DON/Facility Manager, D
Network desktop applications from IT Dept, MBH. MBH. Business Manager
Switch to condensed Local Flag PC to substitute as • Information Services D
Area Network system. replacement Manager
Page - 180 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Switch to stand alone • Conduct full backup if file • Information Services D
processing server Manager
• Switch to manual • Reconfigure new file server • Information Services staff D
Processing.
• Load backup data • Information Services staff D
• Revert back to original • Information Services staff D

server
• Copy amended data • Information Services staff D
Air conditioning failure Electrical or manual fan Identify patients requiring

cooling, Use windows. Notify
and inform patients and
staff.
Lighting failure Difficulties in patient Utilise emergency lighting Identify provision for business manager / B
observation and care. emergency lighting Operational Services Manager
Relocate immobile patients B
to best lit areas
Maximise natural lighting Clean and maintain windows Nursing staff C
and fittings
Ensure blinds/curtains open C
Ensure adequate supply C

Increased risk for patients Clear patient areas, work C
and staff areas and corridors of all
hazards
Utilise alternate lighting Identify and source Nurse Unit Manager C
alternative lighting
No safety/evacuation
lighting available
Maintain WH&S Staff member to place Nurse Unit Manager /All staff B
precautions lighting in strategic areas for
safety
Page - 181 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Issue clinical staff with Nurse Unit Manager /All staff B
torches
Provide additional portable C
lighting
Page - 182 28/08/2013

Sarina Hospital – Clinical & General
SARINA HOSPITAL – CLINICAL & GENERAL
HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
HBCIS Access Unable to register Manual registration Adequate supply downtime forms Administration Staff
Failure patients
B
Manual Process Hand write requests Administration Staff
No patient ID labels Ensure blank details are recorded in Administration Staff
chart
Emergency Department Unable to utilise Manual recording. Ensure details are recorded in the Administration Staff
Module failure TRIAGE treatment No written record of UR Numbers chart
and maintained on site C
admission/discharg Retrospective data entry Administration Staff
e Check and update missing data Nursing staff
Unable to record
statistical
requirements
Printing services Failure Unable to print Manual recording – lead to adequate staff Ensure adequate staffing to cover Business Manager
results/labels numbers workload Administration Staff B
Computer failure Unable to generate Record patient details manually Ensure supply of HBCIS downtime
ID labels forms B
Pre-print labels on existing patients Administration Staff
Hand write on blank labels for new Nursing staff
Unable to track Revert to manual process admissions
patient location and Update patient location and bed C
bed status Revert to manual process status at regular intervals
Unable to provide Update patient diet lists and have
patient dietary available for collection by catering
requirements services
Page - 183 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Telephone Failure No internal or Refer to facility wide telecommunications Inform and Educate staff Nurse Unit
external plan Manager C
communications Shift Team Leader
FAX Failure Unable to receive Utilise alternate lines of communication Send patient information by courier Nurse Unit
oe send patient Manager B
information Delay transfer of information until
services resumed Medical &
Administration
Staff
Photocopy Failure Unable to copy Utilise alternate lines of communication Telephone Communication
documents B
Send original documents with the All Staff
patient in chart
Delay transfer of information until A
services resumed
Oxygen Supply Disrupted Use oxygen cylinders Ensure adequate supply of cylinders Operational
Officers D
Ensure all staff educated in cylinder
changeover All Staff
Consider co-locating high oxygen
users
Failure of Food spoilage refer Essential Fridges on emergency power Assess availability of emergency
Refrigeration/Cool Rooms to Food Safety Plan Source Food off campus power
Cook B
Consider long shelf life food products Develop a plan for preparation & Business Manager
transport of food from other
appropriate sources
Purchase dry/tinned food
Consider purchase of long life milk
Consider purchase of bottled water
for drinking
Refrigeration Vaccine Drugs and medical Place drugs in refrigerators which are Review emergency power outlets and
supplies requiring connected to emergency power supply manage vaccines as per infection Nurse Unit
refrigeration may control guidelines Manager A
become unstable Engineering Staff
Monitor refrigerator temperature with
Use eskies and ice thermometer
Utilise SBVP Esky
Page - 184 28/08/2013

HOW LONG CAN
YOU FUNCTION
WITHOUT THIS
SERVICE?
Failure of Dishwasher Refer to Food Use Disposables Ensure adequate supply of Cook
Safety Plan disposables Business Manager C
Loss of communication Unable to Use alternate communication channels Consider the use of Mobile Phone if B
with pre Hospital transfer communicate with network is operational Nursing staff
services and referral QAS Use 2 way radio from Community e.g.
centres Develop an alternate referral discharge Council
process Develop criteria for referral based on C
Unable to available services
communicate with Develop pro forma for required
GP’s patient information
Page - 185 28/08/2013

Sarina Hospital – Utilities Services
A = Up to 24hrs
SARINA HOSPITAL - UTILITIES B = Up to 5 Days
C = Indefinitely
D = Cannot Operate
function without
this service?
Loss of LPG Secure LPG site and implement Engineer to establish security of the site and Manager Engineering
supply retrieval/disposal of hazardous risk assess immediate needs.
material Identify number of cylinders required and
Arrange urgent supply of allocate as per priority listing.
portable LPG cylinders Arrange for supplier to fill storage tanks if A
not damaged
Identify alternate energy sources for cooking
Identify alternate energy sources for water
Unable to provide cooking Use alternate energy source heating Business manager
facilities Gas Cook top or BBQ Identify cleaning processes that can use
Unable to provide hot Heat water with alternate energy cold water or use disposable ware
wate source Gas Quick heat water Identify alternate washing regime for patient
heater. hygiene.
Wash / clean with cold water No remedial action required
Educate staff on contingency plans
Dishwasher heats own water CNC/Managers B

Staff Education
Oxygen Use cylinder oxygen Ensure adequate supplies Operational Officers/
supply Business Manager A
disrupted
Inability to Emergency power generation Identify existing supply of emergency power Manager Engineering
supply mains generation Nurse Unit Manager
power to A
facilities Refer to power points/ outlets with
Confirm essential equipment only connected
to generator power outlets
Ensure essential lights and equipment
supplied.
Consider need to purchase extension leads Nurse Unit Manager A
Develop a procedure for use of emergency
power in each area and inform staff
Page - 186 28/08/2013

A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
function without
this service?
Contact Engineering/Contractor to ensure
adequate fuel source for use of generator
maintained
Identify generator load capacity
Fully charge batteries on all essential

equipment Manager Engineering A
Ration use of emergency power Locate/purchase torches/ lanterns and
Use alternate power sources batteries
Use natural lighting -open windows and
Supply additional lighting doors
Identify patients for discharge or relocation
Consult current MHHS Disaster Plan for
Discharge/ relocate patients process
within facility Liaise with alternative service provider for
care of patients Nursing staff
Consider activation of MHHS
Disaster Plan Transfer patients out & close facility All Managers
Close Facility Educate staff on contingency arrangements MHHS Manager A
MHHS Manager /Medical

Superintendent only
Staff Education Nurse Unit Manager

A
Loss of water Ration water usage Rationalise services and develop plan for MMHS Executive •
supply for water restriction Manager Engineering
general use,
e.g., toilets, Identify alternative water sources Source / cost alternate supplies, e.g. / Water Manager Engineering
patient tankers / Fire service supply
hygiene Initiate use of alternate supply
MHHS Executive /
Identify alternative supplies of Consider purchase of bottled water Manager Engineering
drinking water Liaise with Renal Dialysis Unit to save
empty dialysate containers for water storage
Buy containers for storage of drinkable MHHS Executive A
water
Page - 187 28/08/2013

A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
function without
this service?
Identify patients for discharge or relocation
Loss of drinking wate Consult current MHHS Disaster Plan for
Discharge/ relocate patients process
within facility Liaise with local council / utilities re
Consider activation of MHHS emergency water supply
Contingency Failure Disaster Plan Liaise with alternative service provider for MHHS Manager
Use emergency supply care of patient
Transfer patients out and close facility
Close facility Educate staff on contingency
Staff education Nurse Unit Managers

Sewerage Unable to dispose of Ensure facility wide plan Develop facility plan for waste disposal MHHS Executive
waste products due to D
water failure
Ensure Local Utilise “grey/used” water Inform staff to save water after patient Nurse Unit Manager
council and hygiene
Public Health Designate toilets to be used Place bucket for used water in each toilet Operational Services
Unit cubicle for flushing purposes
involvement. Close off toilets not for use and post signs
Identify alternate toilet devices e.g., porta
loos, and number required
Alternate toilet facilities Source supply / cost of alternate devices
Purchase sufficient for immobile patients
Rinse with “grey/waste” water and chemical
solution
Inform staff of Infection Control policy D
Single patient use bedpans/ Identify patients for discharge or relocation Nurse Unit Manager
urinals Consult current MHHS Disaster Plan for
process
Liaise with local council / utilities re
Arrange for septic tank pumping truck to
Discharge/ relocate patients pump sewerage out of hospital pipes All staff
within facility Liaise with alternative service provider for
Consider activation of MHHS care of patient MHHS Manager
Disaster Plan Transfer patients out, close facility
Educate staff on contingency plans Manager Engineering
Page - 188 28/08/2013

A = Up to 24hrs
C = Indefinitely
D = Cannot Operate
function without
this service?
Failure of contingency Close facility Medical Superintendent

Nurse Unit Manager
Managers
Staff education D
Power failure Mains power not Refer to mains power failure plan Inform and educate staff DON/NUM/BM/
available. Generator Engineering B
supplies emergency
power
Lighting Difficulties in patient Utilise emergency lighting Identify provision for emergency lighting Engineering staff
failure observation and care Relocate immobile patients to best lit areas
Clean and maintain windows and fittings Nursing staff
Maximise natural lighting Ensure adequate supply torches / battery Operational Staff
operated lights and batteries
Clear patient areas, work areas and All staff B
Utilise alternate lighting corridors of all hazards
Identify and source alternative lighting
Staff member to place lighting in strategic
Increased risk for patients Maintain WH&S precautions areas for safety Nurse Unit Manager All
and staff Issue clinical staff with torches staff
No safety/evacuation Provide additional portable
lighting available lighting
Page - 189 28/08/2013

Environmental Services
A = Up to 24hrs
B = Up to 5 Days
Environmental Services C = Indefinitely
D = Cannot Operate
service?
Lift Failure Unable to transport Ensure one lift operates on Review existing supply of Engineering staff D
patients to different emergency power emergency power Disaster Committee
levels within facility
Consider scoop stretchers, MHHS Executive
fire blankets, stair walkers,
Consider utilising ground Develop facility plan for MHHS Executive
Ensure all staff aware of Unit Manager

facility Fire / Evacuation plan
Wall oxygen supply Wall oxygen not Use cylinder oxygen Order required cylinders Wards person
failure. available from central storage area.
Ensure all oxygen cylinders Wards person

full
Wards person C
available at ward level. Wards person
Unit Manager
Ensure all staff educated in Educator
cylinder changeover. Nursing staff
medical Staff
oxygen users
Page - 190 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
telephone telecommunications plan
communications .
Power failure Mains power not Refer to mains power Inform and educate staff Unit Manager /Nurse Educator D
available failure plan
Lighting failure Difficulties in patient Utilise emergency lighting . Identify provision for Engineering staff
observation and care. Torches in all areas. emergency lighting NUM
Nursing staff
Relocate immobile patients Security
to best lit areas
Maximise natural lighting Cleaning staff C
Clean and maintain windows Wards person
and fittings
All staff
Utilise alternate lighting Unit Manager
lights and batteries C
Increased risk for Maintain WH&S Unit Manager /All staff
patients and staff precautions
Clear patient areas, work
areas and corridors of all Educator
Refer to Facility wide power hazards
failure plan
Educate staff
Outside furniture/objects Flying objects Refer to cyclone Ensure all flying objects are Wards persons
preparation policy secure
Linen Supplies Unable to maintain Beds only to be changed on Ensure spare linen prepared Disaster Committee A
adequate linen discharge and infectious Corporate Services
management if Laundry patients
effected - potential
infection control risk
Page - 191 28/08/2013

A = Up to 24hrs
B = Up to 5 Days
D = Cannot Operate
service?
Build up of clinical and Use additional disposal Ensure where possible JJ Disaster Committee C
general waste products methods Richards has emptied Corporate Services
Inadequate Waste
in unit compactus. Supply
Collection & Disposal
Infection Control Issue additional bins
may influence workload required for 24 hour period D
extra staff
Failure of Emergency Unable to provide safe Increased staff vigilance  Schedule regular patient Disaster Committee
Alarms and secure environment rounds Corporate Services
Security
 Direct notification via B
phone switch or runner to All staff
security & police
Refer to security plan
 Inform and Educate Staff
Failure of Lamson System Unable to transport Revert to manual process Inform and educate staff Unit Manager
specimens Educator D
Engineering staff
Disaster Committee
Wards person
In addition:
 Environmental Services Manager/Supervisors and Team Leaders to have contact details of all staff
 All management team to the hospital if safe to travel
 Environmental Services Manager attendance to Emergency Disaster Committee Meetings
 Create a ‘Disaster team’ within Environmental Services (or Corporate Services)
 If we have notice of the disaster:
o Ensure adequate supplies of chemicals for at least a week
Page - 192 28/08/2013
o Attendance at emergency meetings
o Liaise with JJ Richards in regards to waste – empty compactus, additional large bins, additional pick up of sharps and clinical
waste
o Staff meetings – rostering, ensure contact details are correct, draft in from other areas ie gardeners
o Wet weather protection – heli-pad, Kids/WHU/Labour ward
o Enough torches/batteries
o Continually update staff
o All outdoor furnishings/objects removed/tied down/locked securely
o Liaise with NUMs/Bed Managers for early discharges – impact on wardies/cleaners
o Enough buckets/bins for water
Page - 193 28/08/2013

BUSINESS CONTINUITY PLAN
Catering Services
Limited connections to the generator during power failure.
Failure of Unable to access Revert to manual • Ensure adequate • Catering Manager
computerised systems electronic forms and systems supply of forms. Catering Supervisor
rosters
B
Failure of Unable to access Revert to manual • Allocate staff to • Catering Manager
computerised systems inpatient status and systems manually collect Catering Supervisor
dietary requirements stats/menus from wards
A
Failure of energy No hot/cooked food Use the 1 oven with •Assess and ensure • Catering Manager
supply to ovens emergency capability emergency power is Catering Supervisor
working.
A
Failure of energy No hot/cooked food Cold menu • Ensure adequate • Catering Manager
supply to cooking supplies of cold food Catering Supervisor
equipment A
Failure of Food spoilage Essential fridges on • Coolrooms are • Catering Manager
Refrigeration / cool emergency power connected to • Engineering staff
rooms emergency power Catering Supervisor
C
Failure of Food spoilage Restrict menu • Utilise cyclone menu • Catering Manager
Refrigeration / cool Catering Supervisor
rooms B
Failure of Food spoilage Restrict menu • Purchase dry / tinned • Catering Manager
Refrigeration / cool food Catering Supervisor
rooms B
Failure of Food spoilage Modify choices • Consider purchase of • Catering Manager
Refrigeration / cool long life milk Catering Supervisor
rooms B
Water quality Patient & staff health Bottled water • Consider purchase of • Catering Manager •
bottled water for Catering Supervisor
drinking C
Failure of Unable to ware wash Use disposables • Adequate supply • Catering Manager
Dishwashers disposables Catering Supervisor B
Inability to transport Unable to deliver patient Utilise emergency • Ensure at least one lift • Engineering staff A
meals meals to floors above power operational on
kitchen area emergency power
Page - 194 28/08/2013

Inability to transport Unable to deliver patient Airline lunches • Develop simple menu • Catering Manager
meals meals to floors above (prepacked lunches) for easy transport Catering Supervisor
kitchen area
A
Inability to transport Unable to deliver patient • Consider use of Coordinate volunteers • Catering Manager
meals meals to floors above volunteers to transport Catering Supervisor
kitchen area meals
A
Inability to cater for No catered functions Resume catering when • Inform staff • Catering Manager
functions held service is available Catering Supervisor C
Inability to maintain Risk of food borne • Refer to facility Wide • Inform and educate • Catering Manager
staff hygiene disease Infection Control Plan staff Catering Supervisor
B
Potential for food Potential for disease • Monitor refrigeration • Increased staff • Catering Manager
spoilage outbreak and temperature vigilance Catering Supervisor C
Potential for food Potential for disease • Monitor refrigeration • Ensure supply of audit • Catering Manager
spoilage outbreak and temperature forms/ thermometers Catering Supervisor B
Equipment Function Unable to guarantee Check all equipment for Identify all equipment • Catering Manager
equipment accuracy functionality as soon as to be checked 
possible after disruption
of power/failure of
machines
A
• Inform and educate • Catering Manager
staff C
Mode of Operation A: Hours up to 24hrs
B: Days up to 5
C: Weeks –
Indefinitely
D: Cannot Operate
Page - 195 28/08/2013

BUSINESS CONTINUITY PLAN
Linen Services
Laundry cannot function if there is no electricity as the generator is not connected.
Boiler function is critical to the laundry. If boiler not operating:- No laundry Service.
service?
Emergency Power Reduced production Utilise emergency power Identify access to Manager Linen Services C
emergency power Supervisor Linen
Services
Emergency Power Reduced production Utilise available existing Identify minimum usage Manager Linen Services B
linen required Supervisor Linen
Services
Emergency Power Reduced production Evaluate linen resources Rationalise the use of Manager Linen Services B
linen Supervisor Linen
Services
Emergency Power Reduced production Evaluate linen resources Develop procedures to Manager Linen Services B
minimise patient use CNC Infection Control
including ‘top & tail’, NUM
change only when
soiled, patients to supply
own linen where able
Equipment breakdown / No production Utilise alternative linen Review existing •Manager Linen Services D
emergency power problem service. arrangements with Supervisor Linen
external provider and Services
negotiate for
supply/removal linen
Page - 196 28/08/2013

Lifts out of service Develop plan for • Manager Linen A
transport of soiled and Services
clean linen and Supervisor Linen
relocation of staff Services
Boiler not working Unable to process any Outsource all linen to Arrange for linen • Manager Linen D
linen at all. private provider. transport to private Services
service. Supervisor Linen
Services
No water Unable to process any Outsource all linen to Arrange for linen • Manager Linen D
linen at all. private provider. transport to private Services
service. Supervisor Linen
Services
Supplies of chemicals Reduced production Ensure chemical stocks Order extra supplies in • Manager Linen C
are adequate cyclone season Services
Supervisor Linen
Services
Mode of Operation A: Hours up to 24hrs

B: Days up to 5
C: Weeks –
Indefinitely
D: Cannot Operate
Page - 197 28/08/2013

Emergency Call Directory
Contact List – Internal
Person Responsibilities Contact Number Email

QH & Board Liaison 4885 6752 Kerry.mcgovern@health.qld.gov.au
Kerry McGovern
(MHHS Chief
Executive Officer)
48856755 David.farlow@health.qld.gov.au
David Farlow Health Incident
(Emergency Controller
Director of Medical
Services)
48856763 Julie.rampton@health.qld.gov.au
Julie Rampton Operations Officer
(District Director
of Nursing)
48856753 Rhonda.morton@health.qld.gov.au
Rhonda Morton Logistics Officer
(Chief Operations
Officer)
48855640 Vicki.barrow@health.qld.gov.au
Vicki Barrow Planning Officer
(Pandemic Project
Officer)
48855984 Danielle.jesser@health.qld.gov.au
Danielle Jesser Media and
(Public Affairs Communications
Manager) Officer
Contact List – External
Key contacts Name Contact number/s
Police 000
Emergency Services 000
Ambulance 000
Medical
Security
Insurance company
Suppliers
Water and Sewerage
Gas
Electricity
Telephone
Page - 198 28/08/2013

Operational Checklist
Immediate Response Checklist
INCIDENT RESPONSE  ACTIONS TAKEN
Have you:

 assessed the severity of the incident?
 evacuated the site if necessary? 
 accounted for everyone? 
 identified any injuries to persons? 
 contacted Emergency Services? 
 implemented your Incident Response Plan? 
 started an Event Log? 
 activated staff members and resources? 
 appointed a spokesperson? 
 gained more information as a priority? 
 briefed team members on incident? 
 allocated specific roles and responsibilities? 
 identified any damage? 
 identified critical business activities that have 

been disrupted?
 kept staff informed? 
 contacted key stakeholders? 
 understood and complied with any 

regulatory/compliance requirements?
 initiated media/public relations response? 
Page - 199 28/08/2013

Glossary
Business Continuity The framework of controls implemented and steps undertaken by
Management an organisation to manage its business continuity risks. The
primary objective of these controls is to ensure the uninterrupted
availability of its key business resources that support key (or
critical) business processes.
Business Continuity A process that helps develop a plan document to manage the risks
Planning to the Mackay Hospital and Health Service, ensuring that it can
operate to the extent required in the event of a crisis/disaster.
Business Continuity A document containing all of the information required to ensure
Plan that the Mackay Hospital and Health Service is able to resume
critical activities should a crisis/disaster occur.
Critical Infrastructure A service, facility or a group of services or facilities, the loss of
which will have severe effects on the physical, social, economic or
environmental wellbeing or safety of the community
Essential Service An indispensable supply or activity
Emergency Control A structured organisation that will initiate an appropriate response
Organisation to emergency situations. During emergencies instructions given by
the EOC personnel shall overrule the normal management
structure.
Incident Business interruption, adverse event, disaster – a series of events
beyond the capacity and resources of a unit or facility to manage
eg fire, flood, loss
Key activities Those activities essential to deliver outputs and achievement of
overall facility objectives.
Recovery Time the time from which you declare a crisis/disaster to the time that
Objective (RTO) the critical facility functions must be fully operational in order to
avoid serious financial loss.
Resources the means that support delivery of an identifiable output and/or
result. Resources may be money, physical assets, or most
importantly, people.
Risk Management is the process of defining and analysing risks, and then deciding on
the appropriate course of action in order to minimise these risks,
whilst still achieving facility goals.
Amendment register and version control

Version Date Prepared by Comments
1 26/8/13 Raelene Burke Updated from 2009 version
2
3
Page - 200 28/08/2013

APPENDIX 1
Terms of Reference - Emergency Preparedness and
Continuity Management Sub-Committee
The Mackay Hospital and Health Service Emergency Preparedness and Continuity Management Sub-
Committee will ensure the Mackay Hospital and Health Service is able to respond effectively to external
and internal potential and actual emergencies and disasters.
Aim:
The Committee will oversee the implementation of systems, policies and procedures that identify and
manage potential emergency situations that may arise, either internally or externally in terms of
consequence, exposure, probability and preventative actions.
The Committee will assess staff preparedness to deal with emergency situations and, where necessary,
develop strategies to improve the preparedness.
Objectives:
The MHHS Emergency Preparedness & Continuity Management Sub-Committee will:
 E
 nsure compliance with relevant standards and legislation.
 Standards Australia – AS 4083-1997: Planning for Emergencies – Health Care Facilities
 Standards Australia – HB221:2004 Business Continuity Management
 Develop and implement appropriate emergency response systems in consultation with relevant
external emergency response organisations.
 Develop strategies, plans, manuals, processes and procedures to manage internal and
external emergencies.
 Ensure appropriate training of staff in cooperation with the
 Liaise with external agencies to ensure responses to both external and internal emergencies
are optimised.
 Report any risks assessed as Very High or Extreme to the MHHS Executive
 Identify key internal and external stakeholders and develop strategies for ongoing
communication with these stakeholders.
Membership:
Chief Operations Officer

District Director of Nursing (or delegate)
Executive Director Emergency Medicine
Environmental Services
Health Information Services
Manager Building Engineering and Maintenance Services
Occupational Health & Safety Officer
Bed Manager
Fire Safety Officer
Information Division
Clinician
Page - 201 28/08/2013

APPENDIX 2
MODEL HEALTH INCIDENT MANAGEMENT CHECKLISTS
(Adapted from the Australian Inter-service Incident Management System)
State Health Coordinator

The State Health Coordinator’s role is to provide the leadership and support for an overall coordinated
health response to the health event and the liaison with other agencies to ensure a planned, effective
and integrated health service response and recovery.
Responsibilities include:
 Obtain (or provide) briefing from/to the Health Incident Controller;
 Provide the high level support required by the Health Incident Controller in meeting the
objectives of the health event management plan;
 Set up the Health Event Management Team and where appropriate with the other agencies
involved in the health response;
 Activate the Health Emergency Coordination Centre - dependent on the nature of the health
event, this may be in conjunction with another agency(s);
 Establish a support management structure that is appropriate to the size, nature and
complexity of the health event;
 Brief and liaise with the SCC or SDCC through the QH Director General or Chief Health Officer;
 Access external resources and agencies to ensure that the human, physical, fiscal and
communication resources are identified and made available to the Health Event Management
Team; and
 Maintain a log of all activities.
Health Incident Controller

The Health Incident Controller is responsible for incident management activities including the
development and implementation of strategic decisions and approving the ordering and
releasing of resources.
 Assume control and obtain incident briefing;
 Assess incident information;
 Conduct initial briefing;
 If required or appropriate activate the Incident Management Team;
 Ensure planning meetings are conducted;
 Brief and allocate operational personnel including the Site Medical Commander
(when not already determined) in accordance with the health event management
plan;
 Approve and authorise implementation of the management plan
 Supervise the health response and operations within the health event
 Coordinate staff activities;
 Assemble and disassemble response teams and task forces assigned
 Approve requests for additional resources and requests for release of resources;
 In consultation with the Media Officer, approve release of information to the news
media;
 Regularly report to the ‘lead’ agency and upwards;
 Approve plan for stand-down activities;
 Ensure safety and welfare of all health personnel; and
 Maintain a log of activities.
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Site Medical Commander
The Site Medical Commander is responsible for the management and coordination of all public health or
medical resources at the scene of the health event. The Site Medical Commander coordinates the
organisational elements providing medical or public health care at the scene in accordance with the site
management plan and directs its execution. The Site Medical Commander coordinates his/her activities
with the Site Commanders from Ambulance, Police and Fire services. The relationship between the Site
Medical and Ambulance Commanders is particularly close.
The Site Medical Commander also liaises frequently with the Health Incident Controller (in a large
incident once the EOC has been established) or individual hospital emergency departments (in a small
incident where the EOC support is in effect provided by the facilitating hospital). This communication will
ensure an accurate flow of information from the scene and appropriate destinations for the patients
leaving the scene. Requests for the provision of additional medical or public health resources to the
scene are also the responsibility of the Site Medical Commander.
 Obtain briefing from the Health Incident Controller;
 Develop the medical and or public health operational objectives of the site management plan in
conjunction with the Health Incident Controller;
 Oversee the implementation of the site management plan;
 Coordinate with the site commanders from all other agencies especially ambulance;
 Provide overall control and coordination of the primary triage area(s) with particular respect to
triage, transport and dispersal ; Coordinate with other site commanders where necessary to
vary the SOP’s to ensure optimum safety for both patients and emergency personnel;
 Brief and allocate (according to the site management objectives) arriving medical or public
health personnel within the triage, treatment and dispersal framework;
 Determine needs and request additional medical or public health resources;
 Report information about special activities events and occurrences to the Health Incident
Controller;
 Liaise with the ambulance transport officer to ensure appropriate provision of transport
services;
 Determine the level of escort required for patients en route to hospital
 Liaise with the Health Incident Controller to ensure appropriate destinations are found for all
patients;
 Maintain frequent communications with hospitals either directly or via the Health Incident
Controller to ensure hospitals have accurate information with which to plan; and
 Maintain a log of all activities.
Planning Officer
The Planning Officer is responsible for the collection, evaluation, dissemination and use of
information about the incident and status of resources.
 Obtain briefing from Health Incident Controller;
 Negotiate with Health Commander the allocation and deployment of initial response
personnel as appropriate;
 Establish information requirements and reporting schedules for all involved in the
management of the incident;
 Establish as required information gathering and planning elements – for example:
 Weather collection system;
 Organise specialist advice; and
 HR requirements to maintain continued services or response;
 Supervise/prepare incident management plan;
 Assemble information on alternate strategies;
 Identify use of specialised resource/s;
 Provide periodic predictions on incident potential;
 Provide management support to the Health Incident Controller;
 Consider safety and welfare implications for all personnel during and
 Maintain log of all activities
Page - 203 28/08/2013

Logistics Officer
The Logistics Officer is responsible for providing facilities, services and material in support of the
incident management. The Logistics Officer participates in the development and implementation of the
management plan and manages the functions within the logistics section.
 Obtain briefing from Health Incident Controller
 Plan organisation of the logistics section;
 Allocate logistics work tasks;
 Participate in preparation of management plan
 Identify medical and support requirements for planned and expected operations; Coordinate
and process requests for resources;
 Estimate logistic needs for continuing operational response;
 Provide advice to IMT on current capabilities; and
 Maintain log of all activities with a particular emphasis on any logistic requirements that may
have financial/funding implications.
Liaison Officer
The Liaison Officer reports to the Health Incident Controller and is the point of contact for assisting and
liaising with other agency representatives.
 Obtain briefing from Health Incident Controller
 Provide a point of contact for assisting agency representatives
 Identify other agency liaison officers including their contact / communication link and location;
 Respond to requests from health incident personnel for inter-organisational support; Monitor
incident response and operations for potential inter-organisational
 problems; and
 Maintain log of activities.
Media and Communication Officer

The Media and Communication Officer is responsible for providing and coordinating media response,
internal and external communication requirements, and stakeholder relations in support of the incident
management. The Media and Communication Officer participates in development and implementation of
the management plan.
 Media and communication response strategy in partnership with the incident management team,
MHHSs, units and senior executives;
 Develop the overall media and communication response category in partnership with the incident
management team, MHHSs, units and executives;
 Manage and coordinate all internal and external communication, media in
 and stakeholder relations outputs.
 Provide strategic internal and external communication and stakeholder relations advice to the
Director-General, senior executives and Incident Controller; Provide direction to media and
communication support staff.
 Act as media and communication liaison key conduit with the Ministers office.
Page - 204 28/08/2013

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Mackay Hospital and Health

Business Continuity Plan

 Processes carried out within the section

Support / Interface with other plans

 Bowen Hospital o 162 beds

Population data extracted from

Hazards and associated risks include:

 earthquakes—deaths and injuries, mainly due to building collapse;

Reducing the likelihood of staff becoming exposed to the virus

Management of illness and absenteeism

 Hygiene and cleaning practices

Maintaining service/business delivery with specific reference to the

Key tasks to be undertaken are:

For more information see:

 Patient Flows patients to and from units

Activation and Relocation

Risk Description Likelihood Consequence Risk Rating

Flooding (drowning & injuries) Unlikely Major High 14

Fire (deaths & injuries due to burns, Rare Major Medium 11

Water Failure Rare Extreme High 15

Electricity Failure (public or staff Possible Moderate High 13

Medical Gas Failure Rare Extreme High 15

Damage to Infrastructure Rare Extreme High 15

Industrial Disputes Possible Major Very High 19

Epidemic/Pandemic Possible Major Very High 19

Computer system failure – Possible Moderate High 13

Biological Incident – escape, Rare Major Medium 11

Adverse Public interest Possible Major Very High 19

Integrated Risk Management Analysis Matrix

Actions required in response to the level of risk:

PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOU

PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOU

PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOU

PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOU

 Identify location of alternative ECG Nursing staff A

 Inform and educate staff NUM /Educator A

 Inform and Educate Staff

Refer to security plan

PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOU

 Manually titrate drip rate if necessary Educator

 Inform and educate staff

PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOU

 Ensure all staff aware of facility NUM A

PROBLEM IMPACT CONTINGENCY TASK RESPONSIBILITY HOW LONG CAN YOU

Paging System Unable to contact

Food Supplies Unable to maintain

Build up of clinical and

Develop a process for disseminating patient Nursing Staff Team

Backup any non centralised data or ward Administrative staff

Ensure all staff educated in cylinder Wards person/Unit B

Consider co-locating high oxygen users Nursing staff /medical B

Inform and educate staff Unit Manager Educator C

Inform and educate staff Unit Manager /Educator

Inform and educate staff Educator

Develop policy Unit Manager /Educator C

Ensure adequate supplies of stockings Nursing staff C

Ensure staff trained in manual handling Unit Manager Educator C

Rinse with “grey/waste” water and disinfect All staff B

Inform staff of Infection Control policy U nit Manager