NHS ENGLAND NORTH MIDLANDS Evacuation and Shelter Framework IF AN INCIDENT DO NOT READ THE WHOLE PLAN PLEASE GO STRAIGHT TO APPENDIX A Version 1.0 November 2017
NHS England North Midlands Evacuation and Shelter Framework Date V1.0 Audience NHS England - North Midlands NHS Providers of funded care - North Midlands West Midlands Ambulance Service East Midlands Ambulance Service Clinical Commissioning Groups - North Midlands Copy to Members of Staffordshire Local Health Resilience Partnership Members of Shropshire Local Health Resilience Partnership Members of Derbyshire Local Health Resilience Partnership Members of Nottinghamshire Local Health Resilience Partnership NHS England - North Midlands Directorate of Commissioning and Operations NHS England Heads of EPRR Midland & East NHS funded providers EPRR Leads West Midlands Ambulance Service EPRR staff East Midlands Ambulance Service EPRR staff Directors of Public Health - North Midlands Description This is an operational response plan. Please read this document in the context of: Incident Response Plan (North Midlands) On Call Pack (North Midlands) Incident Coordination Centre Plan (North Midlands) NHS Providers of funded care Evacuation and Shelter Plans NHS England EPRR Lockdown Guidance for NHS England and the NHS in England Cross reference and links http://www.england.nhs.uk/ourwork/gov/eprr/ Action required Timing Contact details This framework has been developed to assist key participants in carrying out their planning and functions when responding to an evacuation and shelter incident. It is important that all strategic, tactical and operational staff understand this framework and are aware of their specific roles and responsibilities. To be used in the conjunction with NHS England Emergency Preparedness, Resilience and Response (EPRR) Planning for the Shelter and Evacuation of people in healthcare settings EPRR Team, Anglesey House, Rugeley, WS15 1UL england.northmids-eprr@nhs.net Document control Version: Date: Revision: Author: Approved by: 1.0 September 2017 Final Christopher Leach Staffordshire/Derbyshire/Shropshire and Nottinghamshire LHRP Co- Chairs Status: Live Next review date: 11/2018 Page 2
Contents Introduction... 4 Context and Scope... 4 Definitions... 4 Risk Assessment... 5 Planning Assumptions... 6 Roles and Responsibilities... 6 Role and Responsibilities of key partners... 7 Plans and Planning... 8 The Basis for Planning and Responding... 9 Activation Triggers... 9 Incident Levels... 10 Command and Control... 10 Health Economy Tactical Coordination Groups (HETCG)... 11 EPRR Response Structure... 12 Shelter... 12 Evacuation Levels and Phases... 13 Patient Management... 15 Transport... 19 Communications... 20 Equipment to Support the Movement of Patients... 20 Site Management... 21 Recovery and Repatriation... 21 Training and Exercising... 23 Equality and diversity... 23 Appendix A Incident Response Flowchart... 24 Status: Live Next review date: 11/2018 Page 3
Introduction This framework has been designed for NHS England (NHSE) North Midlands areas (Staffordshire, Shropshire, Nottinghamshire and Derbyshire) and supplements the NHSE - Emergency Preparedness, Resilience and Response (EPRR) Planning for the Shelter and Evacuation of People in Healthcare Settings. This framework intends to guide all health and social care providers within the NHSE North Midlands areas in and planning and preparation for and response following an evacuation of patients, staff and others from, or within, health care settings (see Table 2). Context and Scope While this framework concentrates on the evacuation and shelter of hospital sites, the principles are sufficiently flexible enough to be adapted for use in respect of other buildings or facilities on healthcare provider sites or to wider primary, social and community care and independent care sector facilities. Evacuation and shelter planning is part of broader EPRR which should take account of existing: Major incident / incident response plans Fire plans and evacuation procedure Business Continuity Plans Lockdown / controlled access plans Definitions For the purposes of this framework: 1. Evacuation - Removal, from a place of actual or potential danger to a place of relative safety, of people and (where appropriate) other living creatures. 2. Horizontal Evacuation - moving away from the area of danger to a safer place on the same floor as the individual(s) is on. If fire is the cause of evacuation, movement should be to the next fire compartment section on that floor (i.e. through at least one set of fire doors). If necessary those who have evacuated horizontally may need to consider a vertical evacuation. 3. Vertical Evacuation - using a stairwell, or lift (if safe and appropriate (i.e. only a designated fire lift should be used during a fire)) to move to either the floor above or below, as appropriate, to move away from the area of danger to a safer place. 4. Shelter - a place giving temporary protection. It may be necessary to move patients into temporary shelters until such time as they are able to return to the affected healthcare facility, or until they are able to be transported to another healthcare facility. Status: Live Next review date: 11/2018 Page 4
5. Invacuation - in certain situations, the safest place to take refuge or cover is to remain in the current location. This is often referred to shelter-in-situ or invacuation. 6. Vulnerable - vulnerability can generally be defined as affecting those that are less able to help themselves or who are unable to be self-reliant, however, it is diverse and can also be the result of one or more external factors coming together simultaneously that creates vulnerability in some people who were previously not vulnerable. Other commonly used resilience terms are available in the Cabinet Office s Civil Contingencies Secretariat Lexicon available online. Risk Assessment There are many types of emergency that may affect an organisation and its ability to maintain patient safety. There are various risks that may result in a healthcare facility requiring to shelter its patients and staff in places of greater safety or to activate partial or full site evacuation. These can include but is not limited to: Power or utility failure Explosion or suspect package Flooding Fire Irritant fumes or hazardous materials release Terrorist event The nature and severity of these risks will determine the level of evacuation and support that the organisation requires. The primary purpose of evacuating and sheltering is to ensure the safety and security of patients; this will be at the forefront of every decision. Therefore, the decision to shelter or evacuate must be made based on the overall risk to patients and personnel involved in their care, and other members of the public who may be in the vicinity of the event. As part of planning, it is imperative that a risk assessment underpins this process. Site specific evacuation and shelter plans should be informed by those risks most likely to impact the site and the wider local area using relevant resources, including Community Risk Registers. Within the site, the risk assessment process should include the risks associated with the location(s) of certain types of patients in relation to the ease of evacuation. This risk assessment will not only direct any mitigating measures but also lead the planning regime. Status: Live Next review date: 11/2018 Page 5
Planning Assumptions Health and social care organisations need to develop site specific plans that account for triage and identify possible places of shelter. Plans should identify on-site and offsite shelter and hold patients during the initial stages of an evacuation. Planning should identify how patient care will be delivered in the short, medium and long term, depending on the cause of the evacuation in the first instance. Hospitals and healthcare premises with inpatient areas should consider and plan for a partial and/or complete evacuations, which should include triage and shelter outside the building. Planning should also identify the staff required in these areas in order to ensure continued medical care for sheltered patients. It may also be necessary for supporting organisations, such as CCGs to develop a set of operating principles for this eventuality to appropriately support the evacuated site (see Incident Levels on page 10). Where appropriate patient care and safety together with sufficient staff, medications and other resources can be maintained throughout the incident, it may be preferable for some patients and personnel to remain in-situ rather than to evacuate. It has been acknowledged that, in certain circumstances, restrictions or limitations of normal standards of care will be inevitable. As is the case with healthcare in general, in the event of demand for services exceeding or overwhelming supply, the underlying principle is to achieve best health outcomes for patients, based on the ability to achieve the best health benefits. It should also be noted, that some patients may be at risk of greater harm by being moved and this will require both clinical and managerial decision making. Roles and Responsibilities Responsibilities of healthcare providers are to have procedures for evacuating areas of a facility in the event of major disruptions. These should be aligned with the organisation s incident response plans. The total evacuation of a hospital or mental health facility would, however, be considered only under extreme circumstances. In such circumstances the decision to evacuate would be made locally taking into account: The overall risk to patients Appropriate safe transport and patient tracking mechanisms and; a suitably resourced destination Key elements which will need to be considered by the NHS are: Maintaining primary care services to the population being evacuated, including the health resource to any evacuation or humanitarian aid centres, for example community nurses, GPs, and pharmacies, to offer support during the period of evacuation Close working with social services and voluntary organisations, identifying and supporting those deemed vulnerable by the incident who are being evacuated Status: Live Next review date: 11/2018 Page 6
Hospitals and in-patient care facilities should have plans in place to effect a whole-site evacuation, if required. However, such plans should ensure that any evacuation of a hospital is seen as a last resort. The NHS and NHSE North Midlands must plan for the provision of healthcare services for a significant population influx that may have been evacuated from a wider geographical area. This should include providing healthcare to those made ill, or more seriously so, by the process of evacuation. All NHS Trusts are expected to have business continuity arrangements in place to reduce the risk of evacuation in predictable circumstances. NHS organisations have a duty of care to both their patients and their staff, therefore healthcare providers should be aware and understand that it is not the responsibility of the emergency services to evacuate an NHS facility; the responsibility rests with the organisation whose care the patient(s) are under. NHS organisations have responsibilities under: Health and Safety at Work Act 1974, (section 2(1) and (section 2(2) The Management of Health and Safety at Work Regulations 1999 (regulation 3), (regulation 4 and Schedule 1), (regulation 8(1)), (regulation 8(1)(a) and (b)) and regulation 4(4) Safety Signs and Signals Regulations 1996 Regulatory Reform (Fire Safety) Order 2005 (article 14(1) and (article 14 (2) Department of Health Fire code guidance (HTM 05-01) Regulated Activities Regulations Section 9 sub section (2), Section 7 sub section (1 and 2) and Section 10 sub section (2) Role and Responsibilities of key partners The roles and responsibilities of key resilience partners are set out in documents published by the UK Government and are: HM Government - Emergency Preparedness: https://www.gov.uk/government/publications/emergency-preparedness HM Government - Emergency Response and Recovery https://www.gov.uk/government/publications/emergency-response-and-recovery Cabinet Office - Evacuation and Shelter Guidance https://www.gov.uk/government/publications/evacuation-and-shelter-guidance The roles and responsibilities of the NHS is to provide continued primary care for the evacuated population whilst working with other partners such as Local Authorities, utility companies and the voluntary agencies to identify and support the vulnerable. CCGs and NHSE North Midlands - are set out in the NHSE North Midlands Incident Response Plan which should be followed during this type of incident. NHS Trusts - are responsible for patients evacuated from their facilities, for their continuing care and treatment albeit in other locations, whether those are healthcare Status: Live Next review date: 11/2018 Page 7
premises (holding areas) or not, until those patients are formally discharged from their care. Local Resilience Forums (LRF) - have an important role to play by ensuring that members are engaged in relation to the planning for evacuation of healthcare facilities in their respective county. Due to the complex nature of these types of incidents, LRFs are asked to ensure that sites are identified in their areas, appropriately risk assessed and specific plans are in place for high and complex sites. Plans and Planning Health organisations will need to develop plans (site specific) for evacuation and shelter. Plans should incorporate where necessary the principles set out in the Cabinet Office - Evacuation and Shelter Guidance 2014. All health sector organisations will need to take into account the diverse needs of all patients, staff, visitors and contractors when developing these plans. It is suggested NHS organisations should undertake: Assessment and planning in the pre-incident phase including engagement with partner organisations Formulation of organisational plans Discussion and dissemination of plans with partners for approval and/or adoption It is suggested that the planning phase should include: The development of a shelter and evacuation plan (site specific) that is an integral part of the organisation s suite of resilience plans (i.e. business continuity arrangements and/or major incident or incident response plan). It should be available in whatever format suits the organisation and be widely available. Developing plans for how a response will be mounted in a reasonable worst case scenario, taking account of the requirements of different times of the day and days of the week and the different circumstances that may apply, for example, number(s) of staff on duty Engaging with the LRF evacuation lead (usually the Local Authority) and any other organisation named in the plan Training and exercising which should be a formal part of training for the organisation and be part of an overall programme which includes exercises to support the requirements of the site and the likely risks faced Status: Live Next review date: 11/2018 Page 8
The Basis for Planning and Responding The following key points have been identified, that health sector organisations should note: The starting point for planning should be the identification of local risks Planning must be flexible to allow the response to be tailored to the event, with dynamic risk assessment There is a need to be joined up at and make use of existing local planning arrangements, e.g. LRF Resources should be sought from a wide range of agencies and partners - locally, regionally, nationally and internationally, as appropriate for the organisation Plans should include the probable/possible loss on site of any Incident Control Centre (ICC) facilities during the evacuation, and any other points that are relevant for strategic and/or tactical command Call-out contracts should be considered Having an up-to-date staff contact list is critical Identifying vulnerable people (including those with communication needs) Registration of evacuees and consideration of a logistics database being quickly established, when necessary (see NHSE North Midlands - Incident Response Plan) Police may not always be able to secure evacuated premises given the likely demands on their resources It has been acknowledged that it is difficult to fully exercise an evacuation and shelter plan and, therefore need to develop other ways of testing arrangements Plans are needed on arrangements for warning and informing, particularly urgent alerting. Mapping of shelter and evacuation zones should form part of planning Transport arrangements with safe routes should be identified both in to and out of the site Take account of all on-site people, e.g. patients, staff, visitors and contractors Please note: the above will form the assurance process for the NHS against the NHSE Core Standards for EPRR, specifically in the requirement to have a plan for evacuation and shelter in place. Activation Triggers The decision to evacuate may be triggered by an internal emergency, e.g. a fire, or an external emergency, e.g. flooding. Hospital staff may activate immediate shelter or partial evacuation plans to ensure the safety of patients, e.g. in the event of a fire in their locality. The decision to conduct whole site evacuation is the responsibility of the organisation s chief officer or those with delegated authority, e.g. Director on-call. Status: Live Next review date: 11/2018 Page 9
It is the responsibility of the organisation to make arrangements for evacuation (or invacuation) and shelter in a manner appropriate to the organisation. NHS organisations will need to consider factors such as, risks they may be exposed to, the nature and diverse needs of the patients being cared for on the site, the level of staffing available at the time, trigger for evacuation, the time of day evacuation may be required and command and control structure that may be required. Incident Levels During an evacuation incident, the levels (below) should be used by NHS organisations (as per the NHSE EPRR Framework 2015). Incident Level Level 1 Level 2 Level 3 Level 4 An incident that can be responded to and managed by a local health provider organisation within their respective business as usual capabilities and business continuity plans in liaison with local commissioners. An incident that requires the response of a number of health providers within a defined health economy and will require NHS coordination by the local commissioner(s) in liaison with the NHS England local office. An incident that requires the response of a number of health organisations across geographical areas within a NHS England region. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. An incident that requires NHS England National Command and Control to support the NHS response. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. Command and Control History has clearly demonstrated that the need for an established and practised command, control and coordination arrangements, thus ensuring a successful outcome. National guidance is available on command and control which can be found in the NHSE Command and Control Framework. Command, control and coordination arrangements for evacuation and shelter should be site specific and integral to existing organisational command and control processes for major incidents. Status: Live Next review date: 11/2018 Page 10
In addition to current incident response arrangements for evacuation and shelter, it is important to consider: Warning and informing that may or may not be required for an evacuation The possibility that crucial parts of the organisations infrastructure may be lost, e.g. command suite, power and/or the ability to communicate A secondary location for command suite Ability to provide command, control and coordination in and out of hours Role of external agencies Tracking patients, staff and equipment An ability to provide internal support/response with the need to also have an outward facing focus for supporting multi-agency and stakeholder liaison The need to ensure that additional people are available for media liaison, thus allowing incident commanders to focus on incident response Maintaining links with other NHS organisations Tactical Coordination Groups (TCG) During an evacuation and shelter incident it may become necessary to request and establish a TCG. This will help to coordinate the response and management of those being evacuated and for other agencies to consider and take appropriate steps to coordinate any off-site response and any impact upon the wider community. The TCG will allow access to additional capability that may be required by NHS organisations during a response to an evacuation and shelter incident and allows engagement with voluntary agencies. The TCG representatives for health will be the CCG on call at the time. A Strategic Coordination Group (SCG) may also be established and it will be the responsibility of the NHSE Director On Call to attend. Please see Appendix A for activation flow chart. Health Economy Tactical Coordination Groups (HETCG) If the incident is of sufficient scale, the local health economy will be asked to participate in a series of teleconferences. This process will used to facilitate information gathering and dissemination, tactical objectives and system assurance. A Battle Rhythm (briefing/update and meeting frequency) will be agreed during first contact between NHS organisations. The HETCG may be facilitated by the CCG or NHSE. It is important to note that organisations should always work together when dealing with these incidents and it recognises that, in some instances, conversations may have taken place before the initial HETCG takes place which should also be fed back to ensure joined up working. Status: Live Next review date: 11/2018 Page 11
EPRR Response Structure The diagram below indicates the EPRR Response Structure that is to be used by health and non-health during incidents. NHS England National & DH NHS England Regional NHS England DCO ICC Health Economy Tactical Coordination Group (HETCG) NHS Funded Organisations Shelter Health organisations will need to develop site specific plans that identify possible places to shelter, including holding areas that may be appropriate to local needs. Furthermore, organisational links to other healthcare partners (including independent providers) and the Local Resilience Forum(s) will also be an important part of this work. In the initial stages of evacuation a number of shelter in place locations should be considered to include options for on-site and healthcare and non-healthcare premises off-site. On-site shelter points should take into account local fire compartment planning. Off-site shelter points should reflect an area of safety, away from the health care organisation, where patients/people can wait until they are either re-directed to another health setting, hospital or conveyed home. Patients should be clinically fit to be placed in these locations (see page 16 for Healthcare Evacuation Triage Priorities) Common choices for off-site shelter points may be: - Other Health Premises - Churches - Town Halls - Community Centres Status: Live Next review date: 11/2018 Page 12
Health helping Health Where possible NHS funded organisations should work together to accept any evacuees during incidents as they will have the skills, equipment and infrastructure to provide care to these patients. The choice of shelter should be agreed in advance through assistance from each organisation s Emergency Preparedness, Resilience and Response (EPRR) Officer, other health partners and, where appropriate, the Local Authority. Shelters can mirror the concept of an ambulance casualty clearing station where patients are held whilst awaiting triage and transport. Where short-term shelter is required, health organisations should have plans in place which reflect the Cabinet Office - Evacuation and Shelter Guidance. Care Homes It is important to note that some patients may end up in Care Homes around the geographical area of the evacuation, providers must have working relationships with these Care Homes in order to fully understand there capability and resilience to ensure that they can be utilised when needed in an evacuation scenario. Evacuation Levels and Phases For the NHS, there are three primary levels when evacuation may be considered (below). Table 1: The levels when evacuation may be necessary and the implications Level Level 1 Level 2 Level 3 Implication No immediate threat to life or safety, but there is an incident on an adjoining floor or in an adjacent building (advance warning provided) A situation with no immediate threat, but one where the incident is likely to spread, or be prolonged so as to affect patient care in that area, from an adjoining area (advance warning provided) The situation where there is an immediate threat to life or safety (no advance warning provided) The decision to shelter or evacuate should only be taken following a dynamic risk assessment, where the risk to life whilst remaining in-situ has been assessed had deemed a greater risk than evacuation. In certain circumstances, it will be safer to remain in-situ or to invacuate, rather than to evacuate. Phases of Evacuation Status: Live Next review date: 11/2018 Page 13
The need for evacuation and shelter will depend on the circumstances of the incident. The type of incident will also influence the time available for evacuation and whether partial or full evacuation is required. Should evacuation be necessary, advance warning can allow staff and patients to prepare and facilitate an efficient evacuation. Phased evacuation should be considered where different parts of premises are to be evacuated. Evacuation should be undertaken in a controlled sequence with those parts of the premises expected to be at greatest risk being evacuated first. The following stages apply: Table 2: The stages/phases of an evacuation and their implications Stage/Phase Stage/Phase 1 Stage/Phase 2 Stage/Phase 3 Stage/Phase 4 Implication Evacuation of a single ward/department Evacuation of one floor Evacuation of an entire block/building/s Evacuation of an entire site Should evacuation be necessary in one in-patient ward/department there will be a variety of patient dependencies to consider. The evacuation should be based on the concept of progressive horizontal evacuation, with only those people directly at risk from the effects of the incident being moved. This involves moving people at immediate risk to a primary holding area or place of temporary safety (Phase 1). If the incident is not contained to one ward a whole floor may need to be vertically evacuated with patients moved to a lower or upper floor (Phase 2), as appropriate. The occupants may remain in the primary holding area until the incident is dealt with or await further evacuation to another similar adjoining area or down the nearest stairway. This procedure should give sufficient time for non-ambulant and partially ambulant patients to be vertically evacuated down or up stairways as appropriate, to a place of safety. It may become necessary to evacuate an entire block or zone of the hospital (Phase 3). In addition, it may be that more than one block or zone of the hospital is affected leading to the evacuation of the entire site (Phase 4). It is acknowledged that tracking staff during an evacuation is a challenge, however each organisation has a duty of care to know which staff are working within the building at any one time, including contractors. The nurse/person in charge of a patient area should be aware of which staff are on duty as per staff duty rota. The rota can be used to support the nurse/person in charge s local knowledge of staff on duty and should be available at short notice wherever possible. Following any evacuation, it is highly likely that there will be a need to assess and reassess (re-triage) the dependency of patients to assist with the appropriate allocation of patients to onward places of safety, including the potential for medium and long-term shelter, for example, another hospital, a nursing home or their home. Status: Live Next review date: 11/2018 Page 14
Healthcare organisations should have plans in place to repatriate patients that have been evacuated and for providing continued clinical support to these patients as appropriate. Patient Management Triage It is the responsibility of all healthcare staff to do the most for the most during an incident involving the evacuation of patients. In-patient consultant-led speciality teams and nursing staff will pay a key role whilst prioritising their in-patients for interhospital transfer if required. Triage will assist in making decisions for whom to evacuate, in what order, and this should be a dynamic process. Triage will also help to determine the resources required to evacuate and shelter patients, patient mobility, any equipment requirements, the length of time it will take to facilitate the relocation and the type of transport that may be required for off-site evacuation. The triage process will use mobility and dependency to determine the evacuation triage priority, categorising patients into groups; Very Dependent, Dependent, and Independent. In order to aid planned and emergency evacuation, NHS organisations should consider recording a patient s evacuation triage status on admission, any equipment requirements and the staff resources that may be needed. When considering whether to move a patient, there are factors which should be considered which may include difficulty of movement, e.g. the mobility of a patient and what equipment may be needed. Status: Live Next review date: 11/2018 Page 15
Healthcare Evacuation Triage Priorities Evacuation Priority Evacuation Priority 1 Evacuation Priority 2 Evacuation Priority 3 Category Very Dependant Dependant Independent Triage Card Colour (if used) Red Yellow Green Definition a. patient is on assisted ventilation b. patient is of such a weight as to require the assistance of 3 or more staff to effect evacuation c. patient cannot be disconnected from 1 or more pieces of apparatus for more than 60 seconds d. patient is connected to life support machinery e. patient is unconscious and in life threatened state f. patient requires more than 7 minutes to be disconnected from 1 piece of equipment g. patient is undergoing surgery h. patient has undergone major surgery under general anaesthetic i. patient requires 2 staff to effect evacuation j. patient can only be moved on his/ her bed k. patient is in critical condition/attached to more than 1 piece of apparatus l. patient is unconscious m. patient is under section mental health act n. patient is blind or deaf or has other extra-ordinary communication needs a. patient can only move on his/her bed b. patient is connected to 1 piece of apparatus ( e.g. drainage bag) c. patient must be moved in a wheelchair by another person d. patient requires more than minimal assistance or is unwilling to be dressed in adequate clothing requiring therefore 1 or more persons to assist e. patient has dementia to the extent that they cannot be left without supervision f. patient can walk unaided for less than 5 metres g. patient has severe sight impairment or severe hearing impairment a. patient can mobilize by him/herself in a wheelchair b. patient can walk unaided at less than normal pace c. patient has significant sight or hearing impediment d. patient can walk at same speed and for same distance as a member of staff e. patient can get out of bed and dress in adequate clothing with none or minimal assistance
The following are factors to be considered: The time taken to move particular patient s vs moving other patients on the ward/clinic. Risk to the patient through/whilst being moved Risk to the patient remaining in situ. This has been articulated in the following simple algorithm that illustrates the principles to be used. Evacuation and Shelter Aide Memoire Tracking/Identifying Patients for Evacuation During evacuation, tracking is necessary to monitor the movement of all patients, staff and equipment from an originating department or ward to a place of safety (even if interim measure), other health location or outside of the area. Health organisations should ensure that a robust mechanism of evacuating a patients notes with each patient, including electronic notes where appropriate exists. Patient notes should be where possible gathered up and evacuated with the patient.
This responsibility remains with the clinician caring for that patient at the time. Triage labels can also be used to document important information relating to those patients, if appropriate. Health organisations should ensure a mechanism for tracking patient movements by implementing a dedicated command role with action card and tabard. Any member of staff (clinical or non-clinical) can perform the role of a Tracking Officer. It is critically important that all departments keep a log of all of their own patients and staff in order to communicate this information to the Tracking Officer as soon as they have been evacuated. An existing triage card system may be adapted for evacuation purposes using the principles set out in the Healthcare Evacuation Triage Priorities (Table 3). A patient and staff tracking proforma should be designed to note persons accounted and/or unaccounted for. Moving Vulnerable Patients What makes a person vulnerable, or become vulnerable in an emergency will vary from person to person, from one type of emergency to another. This highlights a point that it is not necessarily only hospital patients that are vulnerable, sensory impairment and the patients with a disability. It is also recognised that some people may become vulnerable because of their inability to cope with changing circumstances or the need for support with communications when explaining the evacuation process. Health organisations should determine the potential scale of requirements of evacuation and sheltering patients and other vulnerable people on their premises, which should be estimated in advance without divulging information about individuals. This information can be fed into planning process for resources and equipment. In the context of evacuation within a healthcare setting, the main groups of clinically vulnerable patients are likely to be being cared for in locations such as: Critical care (adult, children, neo-natal and others) Infectious disease and isolation units Operating theatres and their associated recovery areas Mental health, including secure units, and intellectual and developmental disabilities units Children s wards and units Cancer treatment wards, outpatient units Renal dialysis units, renal wards, outpatient units and associated areas Cardiac treatment wards, outpatient units and associated areas Bariatric wards and units Please note that the above list is for purposes of illustration only and is not intended to be exhaustive. Status: Live Next review date: 11/2018 Page 18
Planning by health organisation should include managing mental health patients, if applicable, especially those requiring specific security and/or pharmaceutical measures. Consideration should also be given to the sheltering of immunosuppressed patients in a different location (shelter) to infectious patients. Plans should include how medications can be obtained from alternative organisations when planning for on or off-site shelters in non-clinical facilities. NHSE North Midlands has arrangements in place to release certain medicines in an emergency. Where a health organisation cares for patients in critical care units, a prescriptive form of evacuation and shelter planning should take place. Organisations should ensure that a system is in place to evacuate patient equipment and that the patient shelter location has sufficient resources to maintain vital critical care equipment. A Personal Emergency Evacuation Plan (PEEP), a pre-determined plan to work from/make reference to in the event of evacuation, should be completed for any patient who may need assistance to evacuate. For patients being cared for in Mental Health and Intellectual and Developmental Disabilities settings, consideration should be given to including specific needs such as the communication needs of the patient, the number of staff required to escort the patient and the potential destination following evacuation. Transport Health organisations will need to consider transport to support the evacuation and shelter and any subsequent re-shelter. This may need to form part of a mutual aid agreements. As well as vulnerability, particular attention will need to be given to: Transport of patients on site between buildings Transport of patients to places of shelter on site, e.g. to a holding area Transport of patients from one healthcare site to another hospital or healthcare site Transport of patients to places of shelter off site Health organisations need to link with local partners and LRFs to ensure that several organisations are not dependent on the same transport providers. Health organisations should identify possible sources of transport including: Statutory ambulance service (based on clinical need) Patient transport services Commercial NHS Internal services Buses e.g. accessed via local authority and commercial Voluntary agencies Others Status: Live Next review date: 11/2018 Page 19
Relevant requirements and command arrangements should be written into private ambulance transport contracts for use in an emergency and any transport decisions should be linked to the triage evacuation priorities process. Communications It is important to communicate with the public, specifically to ensure that the public is made aware of the risks of emergencies and that information and advice is supplied where necessary. Responders are required to: During planning - to warn and inform the public of any imminent or actual dangers that health organisations are preparing for and the types of potential responses During responding - communication arrangements should be appropriate to needs of the audience Communications should come from a single source that is regarded as authoritative and that represents the response. A consistent message is important and will reduce the risk of miscommunication and/or conflicting messages. Reference should be made to the Cabinet Office - Evacuation and Shelter Guidance (Page 48, (2014 version)) for characteristics of messages and considerations to be taken when communicating with internal and external stakeholders. While planning for communications during an emergency, responders must consider disruptions to infrastructure. Effective and robust business continuity procedures to ensure systems are in place to communicate both internally and externally, regardless of the emergency. The use of communications equipment already in place in the building will assist the incident response due to familiarisation but consideration should also be given to patient communication and any back up resources, such as radios and/or the use of runners in relaying messages. Special consideration should also be given to the use of social media in this situation. Whilst it offers a useful way of getting information direct to people, social media may form part of a communications plan which should also involving multi-agency partners to ensure only official information is consistently broadcasted. Equipment to Support the Movement of Patients Where progressive horizontal evacuation is used, non-ambulant patients should, where possible, be evacuated by bed or by wheelchair with any equipment required for their welfare and their medical notes. When/if the need for vertical evacuation is identified, alternative equipment may be necessary if evacuation lifts are not provided. Examples of such equipment include evacuation sheets, ski pads, evacuation chairs, stretchers etc. Status: Live Next review date: 11/2018 Page 20
Health care organisations should ensure that all very dependent in-patient beds (see triage section) have ski sheets under the mattresses, or equivalent drag mattresses, or rapid casualty evacuation sheets should be available to aid the swift evacuation of patients. On wards with dependent patients where ski sheets (or equivalent) are not used under each mattress, there should be an adequate supply of drag mattress or rapid casualty evacuation sheets available for emergency use. Health care organisations should, if caring for them, make adequate provision of bariatric evacuation equipment that can be deployed as needed. Health organisations should ensure that all evacuation equipment is tested on a regular basis. Site Management The security of a building is of principle concern while it is being evacuated. Use of the lockdown process for controlling the movement and access, both entry and exit of people around building or area is an effective way of achieving this (see NHSE EPRR Lockdown Guidance for NHSE and the NHS in England). Recovery and Repatriation The principles of recovering from emergencies are: Recovery is an enabling and supportive process, which allows individuals, families and communities to attain a proper level of functioning through the provision of information, specialist services and resources Effective recovery requires the establishment of planning and management arrangements, which are accepted and understood by recovery groups and agencies and the community Recovery management arrangements are most effective when they recognise the complex, dynamic and protracted nature of recovery processes and the changing needs of affected individuals, families and groups within the community over time. The management of recovery is best approached from a NHS community development perspective. It is most effective when conducted at the local level with the active participation of the affected community and a strong reliance on local capacities and expertise. Recovery is not just a matter for the statutory agencies - the private sector, the voluntary sector and the wider community will play a crucial role. Recovery management is most effective when agencies involved in human welfare have a major role in all levels of decision-making which may influence the well-being and recovery of the affected community National Recovery Guidance can be found at: https://www.gov.uk/government/publications/emergency-response-and-recovery Status: Live Next review date: 11/2018 Page 21
Both business continuity and recovery planning should be considered as close to the beginning of a response as possible, ideally during the evacuation itself, although it will be dictated by the circumstances at the time. Early consideration of recovery and patient repatriation options including the strategic opportunity to plan for a new normality will ensure a smooth transition through each phase of the incident. Recovery should be led by a senior director, independent of the Incident Management Team. There are four main areas to consider, Humanitarian, Economic, Environmental and Infrastructure. Humanitarian Economic Environmental Infrastructure Patient repatriation/return Ongoing patient care Updates to patients, families, and visitors Displacement of staff to other healthcare sites, both within and outside the Trust [welfare, travel costs, providing managerial support and visibility Psychological support Insurance Incident costs Landlord / tenant agreements & responsibilities SLAs with partner agencies / Trusts Provision of supplies / equipment where Trust inpatients are in other healthcare Trusts Budget arrangements Site clean-up requirements [Pollution or contamination specialist companies required] Waste Repair / rebuilding site Consideration of leased modular buildings / trailers to provide specific areas, such as treatment rooms, Operating Theatres and Imaging facilities Site security The recovery plan should include activation and triggers for moving from incident response to recovery and to normality, i.e. repatriation of patients. This should also be cognisant of multi-agency involvement and agreements that may relate to evacuation. Status: Live Next review date: 11/2018 Page 22
Training and Exercising Training and exercising to enable an organisation to respond appropriately should be incorporated into each organisations training and exercise program. Equality and diversity Equality and diversity are at the heart of NHS England s values. Throughout the development of the policies and processes cited in this document, we have given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited in under the Equality Act 2010) and those who do not share it. Status: Live Next review date: 11/2018 Page 23
Appendix A Incident Response Flowchart Incident Contact Emergency Services and CCG via On Call arrangements No Do you need to evacuate? Yes Keep updating relevant partners of situation Situation Change Utilise EPRR Incident Level (P.11) Activate TCG and HETCG ID sources of shelter, health to health and others Patients moved to holding area or other sites dependant on triage priority Patients Transferred onto other Health care premises TCG To support the health economy with Access to Voluntary Organisations Access to Rest Centres Transport Arrangements Social Care (evacuations from or support from) Working together HETCG To coordinate the health economy response As per the Incident Response Plan for the North Midlands + Transport arrangements Health care provision to nonhealthcare setting holding centres Tracking of patients, equipment etc. Capacity reviewing and management This flowchart should be used in conjunction with: NHSE NM Evacuation and Shelter Framework EPRR Framework 2015 NHSE NM Incident Response Plan Status: Live Next review date: 11/2018 Page 24