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KPJ AMPANG PUTERI

SPECIALIST HOSPITAL

DISASTER MANAGEMENT MANUAL

Definition / terms used in this manual
Internal Disaster:
A condition where need for extra hospital personnel to care for patients and possible
evacuation of them due to an accident within the facility such as fire, explosion, power
failure, bomb threat, structural collapse, radiation.

External Disaster:
A Disaster which occurs outside the hospital, when there is a disproportionate amount of
hospital staff to care for the incoming Emergency Room patients or victims.

Code yellow standby alert:

A period where preparation for a possibility of the code yellow alert.
Usually precede the alert. All services should decide personnel pool to sign in to the
control room.

Code yellow:
Impending disaster. Initiation of Disaster response plan should be executed.

Code yellow stand down alert:

Disaster is finished. To discontinue the disaster response plan, all casualties have been
treated. Disaster treatment area can be dismantled.

Control room:
A room located in the A&E service where action cards are placed. Internal coordination
and internal Communication related to disaster takes place.

Command centre:
A centre where coordination of all activities related to disaster and external
communication takes place.
Press release area.

Action cards:
A card, which is printed with a specific task and responsibility for specific a team and
will be given to the team member, upon reporting duty to the control center

Triage tag:
A colour coded tag which is tagged to the patients based on their clinical condition and
functions to aid in the communication and to ensure correct patient directed to the
correct zone.

MD : Medical Director
DMD : Deputy Medical Director
CEO : Chief Executive Officer

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GM : General Manager
CNO : Chief Nursing Officer
DCNO : Deputy Chief Nursing Officer
MO : Medical Officer
HOS : Head of Service
UM : Unit Manager
FEMS : Facility & Engineering Medical System
SPD : Special Diagnostic Service

Section 1.0

1.1 Introduction

Disasters are the destructive events that disrupt the infrastructure and normal
function of a community or society. They may be natural or man- made. In the
large scale destructive event, the greatest challenge to the healthcare provider is
manage the large number of casualties who require rapid evaluation and
intervention.

Risk of disaster is a measure of the expected losses due to a hazardous event of

a particular magnitude occurring in a given area over a specific time period. Risk
is a function of the probability of particular occurrences and the losses each
would cause.
Level of disaster risk is depends on, nature of the hazard, vulnerability of the
element which are affected and economic value of those elements.

Hazards in disaster are defined as the phenomena that pose a threat to people,
structures or economic assets and which may cause a disaster. They could be
man made or naturally occurring in our environment.

For KPJ APSH disaster risks that have been identified are:
 Internal Disaster
o Fire
o Explosion
o Power failure
o Bomb Threat
o Structural Collapsed.
o Flood
o Amok / fight / assault
o Infant/ Child Abduction

 External Disaster.
o Landslide
o Flood
o Structural collapse

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o Massive motor vehicle accident

o Epidemic

1.2 Definition of disaster:-

1.2.1 Internal disaster: A need for extra hospital personnel to care for patients
and possible evacuation of them due to an accident within the facility such
as fire, explosion, power failure, bomb threat, structural collapse, radiation
leaks and flood.(For management of fire outbreak in KPJ APSH- please
refer to KPJ APSH Fire and Safety Manual )

1.2.2 External disaster: A disaster which occurs outside the hospital, when there
is a disproportionate amount of hospital staff to care for the incoming
Emergency Room patients or victims.( For management of epidemics in
KPJ APSH – Please refer to KPJ APSH Prevention and Control of
Infection Manual)

1.2.3 At KPJ Ampang Puteri Specialist Hospital Disaster shall be declared when
there are five (5) or more requires urgent treatment simultaneously.

1.2.4 Responsibilities of the Team Leaders and team members in this manual to
cater for Disaster management anytime of the day. Throughout the
Disaster Management all APSH members shall comply with the control
standard precautions.

In this manual, disaster shall be addressed as Yellow Alert / Disaster.

People involved in this disaster are addressed as victim / casualty.

1.3 Objectives of Emergency and disaster response plan:-

1.3.1. To establish hospital Disaster Action Plan (manual)

1.3.2. To initiate and coordinate trial practices in place.
1.3.3. To provide awareness program for all staff to ensure smooth disaster
management in event of disaster.
1.3.4. To provide integrated emergency services which are capable in
evacuating, rescuing and resuscitating.
1.3.5 To establish integrated disaster team, medical staff and allied personnel.
1.3.6 To prepare adequate resources and supplies for large number of
casualties.
1.3.7 To establish system to communicate with defense organization, press and
public.

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Section 2.0
2.1 Emergency and Disaster Preparedness Committee

Objective:

2.1.1. To review KPJ APSH’s Emergency and Disaster Response Plan / Manual
2.1.2 To conduct awareness and training program for all staff.
2.1.3 Organize and coordinate Disaster Drill annually.
2.1.4 To conduct meeting minimum twice a year.

2.2 Hospital Major Incident (Disaster) Management Committee

2.2.1 Objectives:

2.2.1.1 Actively participate in the event of disaster in the hospital.

2.2.1.2 The members of the committee are:

1) Chief Executive Officer
2) Operation Manager
3) Medical Director ( Clinical Advisor)
4) Chief Nursing Officer
5) Deputy Chief Nursing Officer
6) All Head of Services / Unit Managers.
7) All Employees

2.2.2 Staff Responsibilities:

Committee Members.

2.2.2.1 Advisor / Chairman / Main coordinator ( Chief Executive Officer /

Medical Director)

 To approve for declaration of code yellow

 To ensure establishment of standard operational disaster policy
and disaster committee and to chair the committee.
 To ensure the respective team members are aware of their
responsibilities and carry out their full responsibilities.
 To empower the respective team leaders which the authority to
implement the policy.

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 T o ensure all staff familiar with the hospital disaster response plan
and aware of own role in the event of disaster.
 To ensure a drill is carried out once a year.

In the event of disaster

 To approve declaration of the disaster – CEO / MD

 To activate hospital a disaster action plans and supervises the
organization of the hospital facilities to cope with the incident.
 To take charge of the command center.
 To ensure there is sufficient of emergency drugs, perishables and
medical/surgical supplies.
 To liaise with the networking hospital and allied agencies e.g.
police, fire brigade and etc.
 To handle press, VIP, and others.
 To conduct meeting with hospital disaster management committee
at least once daily
 To schedule post-mortem and ensure necessary team are involved
during discussion.
 To follow up post mortem report
 To lead the debriefing and submit full report of the incident to Chief
Operating Officer of KPJHB.

2.2.2.2. Clinical Coordinator–General Manager (GM)/ Chief Nursing

Manager( CNO) / Deputy Chief Nursing Officer( DCNO)/Unit
Manager (UM) /Unit Manager On- Call)

 Has overall responsibilities for the organization and the

implementation of the disaster plan
 Responsible for developing a keen sense of disaster awareness
through the hospital
 To take charge on all matters related to clinical issues and patient
management.
 Organize the deployment of clinical staff – (CNO)/(DCNO) ,non-
clinical : support staff / outsource service – (GM)

In the event of a disaster.

 To coordinate the respective medical and nursing personal and to

ensure they carry out their responsibilities in an orderly manner.
 To report all activities to the chairman and act as an advisor to the
chairman
 To ensure all head of services and supervisor and adhering to the
policy.

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 To collect reports from the various team leaders and make

summarized copy for the chairman.
 Attend the “Post - Mortem” meeting as scheduled.
 Organize specific treatment zones for various types of casualties.
 Issue instruction related to the clinical duties in managing incident.

2.2.2.3 Commanding Officer (Medical Officer (MO) On Duty/ Unit Manager

A&E / Unit Manager On-Call )

 To familiarize him / herself with the hospital disaster plan.

 To be aware of the teams involved in the event of a disaster.

In the event of disaster.

 To ensure all staff are familiar with the hospital disaster policy and
are aware of their role in the even of disaster.
 To ensure, by rotation, staff participates in disaster drill as
organized by the hospital.
 To prepare details report of event that occurring during
management of disaster
 To attend post Mortem as scheduled.
 To ensure smooth traffic flow in the hospital premise during the
period of yellow alert.
 To report progress of disaster management to the main
coordinator/ chairman from time to time.

2.2.2.4 Head of Services / Unit Managers

2.2.2.5 To ensure all staff are familiar with the hospital disaster policy and are
aware of their role in the period of yellow alert.
 To ensure all staff participates in disaster drill as organized by the
hospital.
 To keep staff’s current address and latest telephone number.
 To ensure department has an update version of the hospital
disaster policy accessible at all times.
 To attend post mortem as scheduled.

NOTE:

In the event of disaster, team leader at the respective unit will participate /
activate the disaster response plan upon approval from CEO / MD. The second
person (Senior Staff) will take charge of the unit.

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2.3 Staffing During Disaster Period.

The need for staff mobilization and deployment is depending to the need
of resources during the period of disaster.
During period of yellow alert (disaster), if internal staff deployment is
adequate to cater for the victims, deployment of staff on duty will be done
(refers to the External Disaster Activation Phase procedure)
Shall more man power or resources is needed which internal deployment
is not adequate to cater for the victims, staff that is off duty and on leave
must be prepared for the call- back.
During the period of yellow alert, all staff must be prepared for extra and
long working hours.
If additional staffing requires more than the available staff, the
Management of KPJ APSH may seeks another alternative such as
deployment of staff from another Klang Valley KPJ hospitals.

2.3.1 Call- back staff

 All Head of services are responsible to keep updated staff contact
number in their respective unit and human resources service.
 All staff is responsible to update any changes in their contact number
and address to Head of services and Human Resources Service.
 During period of Yellow alert, all staff must be prepared to be call- back
if the need arises.
 The staff will be contacted by their respective head of service via their
mobile number or their resident telephone number.
 The call- back staff should report duty to the hospital within reasonable
time frame.

2.3.2 Release of staff during the yellow alert period

If the External disaster takes place in areas where staff and family live the
management of KPJ APSH will assist the staff concern to attempt to
ascertain staff family member’s safety and well being by:
 Assist staff to make telephone call to their family members if the
telephone service is not interrupted.
 If staff’s family is contacted via phone, staff will expected to check :
o Their family member’s condition.
o Location.
o Family member’s safety.
o Ability to function without staff member’s presence for at
least 24 hours.
 If the staff family member is not contactable via phone the
management of KPJ APSH will release staff to personally check on
the well being of their family and housing before reporting duty
again to the hospital.

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 Respective Head of service is responsible to arrange and

coordinate for temporary replacement.

2.3.3 Disaster Victim Leave.

KPJ APSH will allow staff to on compassionate leave up two (2) days in the
event the staff is a victim of Disaster as follows:
o Compassionate leave is available to staff who sustained severe or
catastrophic damage or loss of their primary personal residence / has
been ordered to evacuate that residence, or has been quarantined
within their residence or community by Government Officials as a
results of such an event.
o This leave also will be granted to staff if, due to such event, the staff no
longer has access to public transportation, which is documented by the
appropriate government agency, when the staff routinely relies on
public transportation to commute to and from work.

If staff requires time beyond the two (2) compassionate leaves, then staff
shall request the use of other paid leave (annual leave) or unpaid leave if the
staff has exhausted all paid leave via the Head of service.
A verbal request can be made to the head of Service if the staff is not able to
come to the hospital, the documentation will done once staff resume duty.

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Section 3.0

EXTERNAL DISASTER MANAGEMENT

3.1 HOSPITAL ACTIVATION PHASE

3.1.1 INITIAL RESPONSE / RECEIVING MESSAGE.

3.1.1.1 Upon receiving the call, the operator will transfer the call to A&E
service
3.1.1.2 Information received and analyzed by the Medical Officer on duty.
Medical officer will record the following information:

 Identification of the caller

 Time of activation made
 Nature of the incident
 Exact location
 Time of incident
 Estimation no of casualties
 Estimation of casualties being send to KPJ APSH

3.1.1.3 Once all the above information is obtained, the medical officer on duty
will discuss with Unit Manager A&E (during office hours) / Unit
Manager on call (after office hours) to analyze if disaster plan is to be
activated or the existing on duty staff is able to handle the cases and
casualties. The recommendation of Medical Director / Chief Executive
Officer / Chairman of Disaster Management Committee is to be sought

3.1.1.4 On deciding to activate the disaster plan, a “Stand By” will be declared
by Chief Executive Officer / Medical Director. All disaster team will be
asked to be on “Stand By”. The teams can be notified by the Unit
Manager on Call / A&E

3.1.1.5 All teams will be stand by wherever they are and wait for further
instruction.

3.1.1.6 Depending to the event there after, if situation under control / false
alarm –Stand Down will be declared by the commanding officer upon
confirmation by Chief Executive Officer / Operation Manager.

3.1.1.7 On confirmation, Yellow alert (Code Yellow) will be declared.

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3.1.2 Activation of the call up staff

3.1.2.1 Chief Nursing Officer Manager / Unit Managers / Unit Manager On Call
/ Head of services will call up staff on call or available to come to the
hospital.

3.1.2.2 Medical Officer on duty to call second Medical Officer to come to the
hospital.

3.1.3 Setting up of Control Room

3.1.3.1 A Control Room must be established in the hospital where the
coordination of all clinical activities and internal communication.

3.1.3.2 Location: Unit Manager on Call Room.

3.1.3.3 The respective team will report duty to the control center and will be
summoned to their respective area and function.

3.1.4 Command Centre

3.1.4.1 A Command Center must be established in the hospital where the
coordination of all disaster related activities.

3.1.4.2 Location : 1st floor conference room

3.1.4.3 Function as a main communication center and source of all in

formations and press statement.

3.1.4.4 The coordinator, commanding officer, team leaders of all team will be
reporting to the control room from time to time.

3.2 PREPARATION OF PATIENTS RECEPTION.

3.2.1 TRIAGE AREA.

3.2.1.1 Definition of triage

Is a process of assessing and prioritizing of each casualty depending on
severity of injuries and need for medical treatment.

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3.2.1.2 Objectives:
3.2.1.2.1 To ensure all patients / casualties being treated and given medical
attention according to their urgency.

3.2.1.2.2 To ensure patient directed to the correct zone of treatment such as

critical, semi critical and non-critical zone.

3.2.1.2.3 To determine the need for inter hospital transfer if necessary.

3.2.1.3 Triage area

3.2.1.3.1 Triage are will be set up at the ambulance parking bay in front of
A&E service.

3.2.1.3.2 The triage area will be managed by the triage team (team 1)

3.2.1.3.3 All patients / casualties Triage categorization should base on:

Category Colour Condition Emergency Priority

Action
Life or limb threatening death, if
1 Red no rapid intervention. Injuries Immediate Top
affecting airway, breathing, (P1)
circulation
Serious but stable injuries: not
2 Yellow immediate life or limb Urgent Second
threatening. May deteriorate (P2)
without treatment.
Non-serious, minor and stable
3 Green injuries. Deferrable Non – Third
Urgent (P3)

4 Black Death Delayed Lowest

Legend: P1 = Priority 1; P2= Priority 2; P3 = Priority 3

3.2.1.3.4 Stable walk in-patients will be tag with green tag and will be
escorted to the main lobby.
3.2.1.3.5 Critical patients will be with tagged with red tag and will be taken to
the resuscitation area at A&E service and handed over to the
member of team 2.
3.2.1.3.6 All brought in death case will be certified by the triaging doctor and
referred to member of team 4. Team 4 will arranged for last office in
the mortuary.
3.2.1.3.7 Family of the casualties will be directed to the conference room
Anugerah and will be attended by team 5.

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3.2.2 RESUSCITATION AREA (RED ZONE)

3.2.2.1 Cater for all victims with red tag only.

3.2.2.2 Location: A&E service – trauma bay.

3.2.2.3 Manned by team 2.

3.2.2.4 Wards, ICU/ CCU, Operation Theatre will be prepared to

accommodate incoming patients.

3.2.3 SEMI CRITICAL (YELLOW ZONE)

3.2.3.1 Cater for all victims with yellow tag only.

3.2.3.2 Location: A&E service – observation bay.

3.2.3.3 Manned by team 3.

3.2.3.4 Wards, ICU / CCU, Operation theatre will be prepared to

accommodate incoming patients.

3.2.4 AMBULATORY CARE (GREEN ZONE)

3.2.4.1 Cater for non – critical and ambulatory victims.

3.2.4.2 Location: Main Lobby / A&E Green Zone

3.2.4.3 Manned by team 4

3.2.4.5 First aid or appropriate treatment will be given and victims will be
admitted or discharged, depending to the severity of the condition.

3.2.5 LAST OFFICE ZONE.

3.2.5.1 Brought in death will be certified by the triaging doctor and will be
taken to the mortuary by the team 5.

3.2.5.2 Last office will be carried out before allowing the family member to
identify.

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3.2.6 BEREAVEMENT ROOM (CENTER FOR FAMILY OF VICTIM)

3.2.6.1 A non – clinical area which cater for the bereavement family.

3.2.6.2 Location: Dewan Anugerah (First Floor)

3.2.6.3 Manned by team 6.

3.2.7 TEAM MEMBERS

3.2.7.1 TEAM 1 (Triage Team)

3.2.7.1.1 Members:

 Medical Officer ( Team Leader)

 Unit Manager A & E / Unit Manager On-Call
 State Registered Nurse A&E / Premier
 CA A&E /Premier
 Registration clerk
 Medical Record staff
 General Worker A&E /OT
 Driver.

3.2.7.1.2 Responsibilities.

1) To be aware of their role in the event of yellow alert.( as per action

card)
2) Participate in disaster drill.

3) To triage victim according to the treatment priority.

3.2.7.1.3 In the event of yellow alert.

1) To set up triage area at the ambulance parking bay.

2) To establish proper patient flow system.
3) To ensure rapid transfer of victim to the correct zone.
4) To ensure there is sufficient supply of triage tag.
5) To ensure all patients are registered.
6) To ensure documentation and prepare report for the coordinating
officer.

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3.2.7.2 TEAM 2 (CRITICAL CARE & RESUSCITATION TEAM)

3.2.7.2.1 Members:

 Consultants
 Anesthetist on call
 Surgeon on call
 Cardiologist / Cardiac Surgeon On Call
 Unit Manager ICU / Peads
 State Registered Nurse ( A&E / ICU/CCU/ OT/ Peads)
 Care Assistant (A&E /ICU/CCU/ Peads)

3.2.7.2.2 Responsibilities:

1) To be aware of their role in the event of yellow alert.( as per action

card)
2) To participate in the disaster drill

3.2.7.2.3 In the event of disaster:

1) To report to the resuscitation room at A&E service

2) Clear the area or expend to receive the victims.
3) Ensure the sufficient supplies of emergency equipment and emergency
drugs.
4) To conduct primary survey and resuscitation of victims.
5) To conduct secondary survey and determined needs for definitive
treatment.
6) To determine for interdepartmental / wards transfer. To ensure all
victims are registered and enquire mode of payment if appropriate.
7) Ensure appropriate documentation and prepare report for the
coordinating officer.
8) To be with patient until patient may be signed off to person in charge
when admitted to a service

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3.2.7.3 TEAM 3 (SEMI CRITICAL CARE & RESUSCITATION TEAM))

3.2.7.3.1 Members:

 Consultant Orthopedic on call

 Unit Manager 5A / 5B
 Unit Manager OT
 Unit Manager Premier Ward
 State Registered Nurse ( 5A / 5B / A&E/ Medical/ Intervention
Surgery/OT On Call)
 Care Assistant ( 5A / 5B / OT)

3.2.7.3.2 Responsibilities:

1) To be aware of their role in the event of yellow alert.(as per action

card)
2) To participate in disaster drill.

3.2.7.3.3 In the event of yellow alert:

1) To report to the observation room at A&E service.

2) Clear the area or expend to receive the victims.
3) Ensure the sufficient supplies of the emergency equipment and
emergency drugs,.
4) To conduct primary survey victims.
5) To conduct secondary survey and determined needs for definitive
treatment.
6) To determine for interdepartmental / wards transfer. To ensure all
victims are registered and enquirer mode of payment if appropriate.
7) Ensure appropriate documentation and prepare report for coordinating
for the coordinating officer.
8) To be with patient until patient may be signed off to person in charge
when admitted to a unit.

3.2.7.4 TEAM 4 (AMBULATORY CARE)

3.2.7.4.1 Members:

 Consultant :
 Physician on call
 Pediatrician on call
 2 nd Medical Officer

 Unit .Manager Medical

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 SRN Medical / SPD

 Care Assistant Medical / SPD

3.2.7.4.2 Responsibilities:

1) To be aware of their role in the event yellow alert.( As per action card)
2) To participate in disaster drill

3.2.7.4.3 In the event of yellow alert:

1) To clear the lobby area in preparation to accept the victims.

2) To ensure the sufficient supplies aid equipment ,drugs and blanket
3) To treat victims appropriately.
4) To ensure all patients are registered and enquire mode of payment if
appropriate.
5) To ensure proper documentation and prepare report for coordinating
officer.

3.2.7.5 TEAM 5 (LAST OFFICE TEAM)

3.2.7.5.1 Members:

 Unit manager HDU

 State Registered Nurse HDU
 Care Assistant HDU
 Security Officer.

3.2.7.5.2 Responsibilities:

1) To be aware of their role in the event yellow alert.( as per action card)
2) To participate in disaster drill

3.2.7.5.3 In the event of yellow alert:

1) To station at the triage area and accompany the body to the mortuary.
2) To perform last office.
3) To ensure belongings of victims are return to the next of kin or labeled
and keep in the A&E safe till claim by the next of kin.
4) Ensure burial permit is written and instruct the family to report the
police if appropriate.
5) To be sympathetic and caring towards family viewing body.

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3.2.7.6 TEAM 6 (BEREAVEMENT TEAM)

3.2.7.6.1 Members:

 Consultant Psychiatrist
 Nurse Instructor
 Customer Service Officer
 U.M. Maternity / LDR
 SRN Maternity
 CA Maternity
 Dietary Staff
 Security.

3.2.7.6.2 Responsibilities:

1) To be aware of their role in the event of yellow alert.(as per action

card)
2) To participate in disaster drill

3.2.7.6.3 In the event of yellow alert:

1) To be sympathetic and caring towards victim’s family.

2) To provide immediate counseling for the victim’s family
3) To release accurate information to the victim’s family.

3.2.8 RESPONSIBILITY OF OTHER SERVICES

3.2.8.1 Admission / Patient Service

 Do not accept routine non- emergency admission except Obstetric
cases.
 Assign an admission personal to aid with discharge of hospital patients
if necessary.

3.2.8.2 Dietary Service

 Prepare adequate supplies of food for 3 days stock.
 Prepare to serve nourishment to patients / families and personnel
when the need arises.
 Utilize executive cafeteria room as an extra eating space for staff.

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3.2.8.3 Maintenance and Engineering Service

 Maintain full operation of all facilities.
 Ensure water and electricity is available without interruption.
 Be responsible for setting up extra beds in hospital if needed, as well as
transporting storeroom supplies and bringing in extra supplies from other
areas

3.2.8.4 House keeping service

 Be available to help clean receiving area, and clean rooms between cases
in treatment areas.
 Be sure all hallways or traffic areas are clear of cleaning carts and
equipment.

3.2.8.5 Linen Service

 Be responsible to supply extra linen.
 Be responsible to collect soiled linen and top up the clean linen as soon as
possible.

3.2.8.6 Pharmacy service

 Be prepared to supply emergency drugs quickly

 Remained open and assign runner to deliver the drugs to the requested
area.

3.2.8.7 Purchasing Services

 Keep up dated list of suppliers who can deliver extra supplies in a fast
manner.
 Be prepared to supply all teams and services with needed supplies.
 Assigned personnel to be runners to deliver supplies to the requesting
services.
 Contact other Klang Valley KPJ Hospitals, if extra medical surgical
supplies required.

3.2.8.8 Security Services

 Be prepared to control flow of traffic during the yellow alert period.
 Be responsible to control visitor from entering clinical area during the
disaster alert.
 Be responsible to ensure safety of staff / casualties / family.

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3.2.8.9 Additional Bed Space Requirements

 If casualties require admission, empty bed will be utilized first.
 If more spaces required, request consultant in-charge to consider
discharging non - critical patients till bed space available again.
 Finance / billing personnel to assist patients’ discharged.
 Nurse in charge to call / inform relatives of these patients for
transportation.
 Discontinued routine admission till bed space available.
 If necessary, seek assistance from other Klang valley hospital.

3.2.9 Resources for patients transfer:

3.2.9.1 If the casualties requires inter- hospital transfer, the resources for transfer
will be:

 All KPJ Group of Hospital in Klang Valley will the main contact for transfer
of patients and additional supplies.

 If necessary, transfer patients to the other private or public hospitals.

 The KPJ APSH administrator will contact the receiving prior to the transfer.

 Consultant in- charge to receiving doctor contact through telephone

should take place prior to transfer

 Ask the contacted hospitals to provide emergency ambulance services to

pick up patients form KPJ APSH.

 Additional ambulance services may be acquired from other private

ambulance services or Red Crescent / Public Defense Agency (JPA) /
Bomba.

3.30 Transfer - out Procedure:

 Refer to procedure admission, transfer and discharge of patient (KPJ
ASHW 342- ACC. 4)

3.3.1 Communication during Period of Yellow Alert.

3.3.1 The management of KPJ APSH is responsible to ensure PABX system is
functioning well.

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3.3.2 The telephone operators must keep relevant agencies contact numbers
and keep the updated number.

3.3.3 During the period of yellow alert:

3.3.1 Internal communication will be taking place via:
 Walkie-talkie - will be provided by the FEMS service to all teams and
also to the Commanding Officer.
 Internal telephone
 Personal Mobile Phone ( if necessary)
 Fax system
 Email
 SMS drop system
 Runner

3.3.2 External Communication will be taking place via:

 Hospital Direct Telephone line ( for certain areas)
 Hospital line via operators.
 Fax system
 Email
 Runner / dispatch.
 Television

3.4 Requirement

3.4.1 Action Card

 Definition: A card, which is printed with a specific task and responsibility for
specific a team.
 The card will be given to the team member, upon reporting duty to the control
center.
 The card should be kept in the control center and accessible to the team
member at all time.
 The card should be long lasting and waterproof.
3.4.2 Triage tag

 Definition: A colour coded tag which is tagged to the patients based on their
clinical condition and functions to aid in the communication and to ensure
correct patient directed to the correct zone.
 Use international / standard colour coding: Red / yellow / green / black.
 Should be durable and waterproof and kept in the A&E Service

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Sample Triage Tag

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3.4.3 Medical / surgical supplies

 All services should keep the minimum stock of 3 days medical / surgical
supplies in own unit
 Purchasing Service should have adequate stock of medical surgical supplies
to cater for disaster victims in the period of yellow alert.
 Indent books will be provided to the each Disaster team, which can be used
only during the yellow alert period.
 The Requisition Book will be kept in the command Center

3.4.4 Emergency trolleys

 Team 2 will obtain the emergency trolleys from Cardiac Catheterization
Laboratory, Diagnostic & Imaging Service and Endoscopy room.

3.4.5 Trolley / Drip stand

 All trolley from the Cardiac Catheterization Laboratory, and Endoscopy room
and all trolley from wards and Units.

3.4.6 Wheelchairs
 From all the wards and main lobby

3.4.7 Walkie –talkie

 Walkie - talkie should be provided to each team, commanding officer,
chairman /administrative personnel and security officer.

3.4.8 Extra linen

 To use linen from linen department.
 To get extra linen from the wards.

3.4.9 Mortuary sheet / body Identification Tag.

 Team 5 to obtain the sheet from purchasing department.

3.5.0 Food / beverages

 Dietary Service to supply food for the casualties and family /(staff whenever
necessary)
 Maintain adequate supplies of food minimum for 3 days stock.

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3.6 ACTION CARD FOR:

3.6.1 TEAM 1 (Triage Team)

Members:
 Medical Officer ( Team Leader)
 Unit Manager A & E
 State Registered Nurse( A&E / Premier )
 Care Assistant ( A&E / Premier )
 Registration clerk / cashier
 Medical Record staff
 General Worker (A&E / OT)
 Driver

Responsibilities.
1) To be aware of their role in the event of yellow alert.
2) Participate in disaster drill.
3) To triage victim according to the treatment priority.
In the event of yellow alert.
1) To set up triage area at the ambulance parking bay.
2) To establish proper patient flow system.
3) To ensure rapid transfer of victim to the correct zone.
4) To ensure there is sufficient supply of triage tag.
5) To ensure all patients are registered.
6) To ensure documentation and prepare report for the
Coordinating officer.

3.6.2 TEAM 2 (CRITICAL CARE & RESUSCITATION TEAM)

Members:
 Consultants
 Anesthetist on call
 Surgeon on call
 Cardiologist / Cardiac Surgeon On Call
 Unit Manager( ICU / Peads)
 State Registered Nurses (A&E / ICU/CCU / OT / Peads)
 Care Assistant (A&E /ICU/CCU / OT/Peads)

Responsibilities
1) To be aware of their role in the event of yellow alert.
2) To participate in disaster drill
In the event of disaster:
1) To report to the resuscitation room at A&E service
2) Clear the area or expend to receive the victims.

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3) Ensure the sufficient supplies of emergency equipment and

emergency drugs.
4) To conduct primary survey and resuscitation of victims.
5) To conduct secondary survey and determined needs for definitive
Treatment.
6) To determine for interservices / wards transfer. To ensure all
victims are registered and enquire mode of payment if appropriate.
7) Ensure appropriate documentation and prepare report for the
Coordinating Officer.

3.6.3 TEAM 3 ( SEMI CRITICAL & RESUSCITATION TEAM)

Members:
 Consultant
 Orthopedic on call
 Unit Manager ( 5A / 5B )
 State Registered Nurse ( 5A/ 5B / OT On Call)
 Care Assistant ( 5A / 5B / OT On Call )

Responsibilities:
1) To be aware of their role in the event of yellow alert.
2) To participate in disaster drill.
In the event of yellow alert:
1) To report to the observation room at A&E service
2) Clear the area or expend to receive the victims
3) Ensure the sufficient of emergency equipment and emergency drugs.
4) To conduct primary survey victims.
5) To conduct secondary survey and determined needs for definitive
treatment.
6) To determine for interdepartmental / wards transfer. To ensure all victims
are registered and Enquirer mode of payment if appropriate.
7) Ensure appropriate documentation and prepare report for the coordinating
officer.

3.6.4 TEAM 4 (AMBULATORY CARE)

Members:
 Consultant
 Physician on call
 Pediatrician on call
 2nd MO
 Unit Manager ( Med / SPD )

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 State Registered Nurse ( Med / SPD )

 Care Assistant (Med / SPD)

Responsibilities:

1) To be aware of their role in the event of yellow alert.

2) To participate in disaster drill.
In the event of yellow alert:
1) To clear the lobby area in preparation to accept the victims,
2) To ensure the sufficient of supplies first aid equipment, drugs, and blanket
3) To treat victims appropriately.
4) To ensure all patient are registered and enquire mode of payment if
appropriate
5) To ensure proper documentation and prepare report for coordinating
officer.

3.6.5 TEAM 5 (LAST OFFICE TEAM)

Members:
 Unit Manager HDU
 State Registered Nurses HDU
 Care Assistant HDU
 Security Officer

Responsibilities:
1) To be aware of their role in the event yellow alert.
2) To participate in disaster drill

In the event of yellow alert:

1) To station at the triage area and accompany the body to
mortuary
2) To perform last office.
3) To ensure belongings of victims are return to next of kin or labeled and
keep in the hospital safe till claim by the next of kin.
4) Ensure burial permit is written and instruct the family to report to the police
if appropriate.
5) To be sympathetic and caring towards family viewing body

3.6.6 TEAM 6 (BEREAVEMENT TEAM)

Members:
 Psychiatrist
 Nurse Instructor.
 Customer service officer / Public Relation Officer (TL)
 Unit Manager (Maternity / LDR)

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 State Registered Nurse Maternity

 CA Maternity
 Dietary Staff
 Security

Responsibilities:

1) To be aware of their role in the event yellow alert.

2) To participate in disaster mock drill
In the event of yellow alert:
1) To be sympathetic and caring towards victims’ family
2) To provide immediate counseling for the victims’ family
3) To release accurate information to the victims’ family.

ACTION CARDS

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SECTION 4.0 : INTERNAL DISASTERS

4.1 OUTBREAK OF FIRE:

 For management of fire outbreak in KPJ APSH - please refer to KPJ APSH
Fire Safety Manual.

4.2 TREMORS PROCEDURE

4.5.1 Upon warning of event after event occurs, building integrity, critical
infrastructure and other environmental factors must be assessed if hospital
can continue to provide appropriate medical care to patients or should be
evacuated - (FEMS personnel / Bio- Medical Engineering Personnel / HOS
relevant service with assistance from Government Authority)

●No threat to patient / staff safety:

In this situation, it is immediately clear that hospital did not suffer any
significant damage
that would cause decision for evacuation.

● Immediate to patient/ staff safety:

At the other extreme are situations in which the event clearly causes an
immediate life –
Threatening risk to patients / staff, the hospital evacuation should be
done rapidly.

In the event the situations are causing life threatening situation to the patients/
staff, the management of:
Medical Gases : Refers to KPJ APSH Contingency Plan
Power Supply : Refers to KPJ APSH Contingency Plan
Water : Refers to KPJ APSH Contingency Plan
Sanitation : Refers to KPJ APSH Contingency Plan
Alarms / telephone : Refers to KPJ APSH Contingency Plan

Decision for total evacuation or partial evacuation will be made by the CEO /
MD with advised from Government authority.
Once, decision for evacuation and transfer is made, the following instruction:

4.2.1 Evacuation procedure:

a. Need for evacuation will be depending on the decision of Chief

Executive or Medical Director.

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b. If the decision is made to evacuate patients from a ward the

following factors must be taken into account :

c. Evacuation is carried out as quickly as possible yet always

having due regard for the medical condition of the patient being
evacuated and the degree of danger present.

d. Evacuation will be done in systematic manner, where the

patients and personnel closet to the danger first.

e. Immobile patients are evacuated by means of the evacuation

sheets under each mattress and not by moving the beds. Beds
are relatively wide and to cause congestion and delay in the
evacuation procedure. They also cannot be moved down
upstairs. All patients should be evacuation horizontally as far as
possible before a vertical evacuation is considered.

f. All patients are evacuated in a manner such as to cause

minimum discomfort or inconvenience but as quickly as
possible.

g. Patients’ medical and other records, if safe to do so, are to be

collected to facilitate a roll call and also to allow continuity of
medical treatment particularly if the patient has to be moved off
the premises.

h. Roll call if possible will be done before and after the evacuation
by the head of involved Service.

i. Patients are to be moved to safer area while waiting to be

transferred to other facilities

j. Under no circumstances should lifts be used during an evacuation

exercise.

4.2.2 Resources for patients transfer:

 All KPJ Group of Hospitals in Klang Valley will the main contact for
transfer of patients and additional supplies.
 If necessary, transfer patients to the other private or public hospitals.
 The KPJ APSH administrator will contact the receiving hospital prior
to the transfer.
 Consultant in- charge to receiving doctor contact through telephone
should take place prior to transfer.
 Ask the contacted hospitals to provide emergency ambulance
services to pick up patients form KPJ APSH.

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 Additional ambulance services may be acquired from other private

ambulance services or Red Crescent / Public Defense Agency (JPA)/
Bomba

4.2.3 Transfer - out Procedure:

 Refer to procedure admission, transfer and discharge of patient (KPJ
ASHW 342- ACC. 4)

4.2.4 Report
>All personnel involved should records and report the detailed if the event
that has taken place.
>Comprehensive report should be submitted to the CEO/GM and
Emergency Preparedness Committee.

SECTION 5: OTHER TYPES OF INTERNAL EMERGENCY

5.1 POWER FAILURE

>In the event of power failure, staff on duty should inform head of service.

>Dial 1000 to inform the control room and request for presence of security
personnel at the scene to control and divert the flow of visitors.

>All clinical services are to ensure that essential power supply is activated
immediately.

>Notify Facility And Engineering Management System personnel if the

essential power supply failed to activate.

> FEMS personnel shall ensure OT / ICU / CCU is supported by the

Uninterrupted Power Supply (UPS).

> All staff to stay alert, ensure patients monitoring and safety are adhered
to.

5.1.1Transfer – Out Procedure:

> In the event of total power failure, Head of Maintenance and engineering
service will inform CEO / GM / Medical Director / CNO immediately

>Unit Managers will inform consultants regarding the situation and

arrangement shall be made to prepare for transferring of patients to
other hospital immediately

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(Refer to procedure admission, transfer and discharge of patient /KPJ

ASHW 342- ACC. 4)

5.1.2 Report
>All personnel involved should records and report the detailed if the event
that has taken place.
>Comprehensive report should be submitted to the CEO/GM
and Emergency Preparedness Committee.

5.3 FIGHT / ASSULT / RUN AMOK

5.3.1 Any staff upon finding or being informed that a fight is in progress in the
vicinity should:
a. Note location of fight and number of people involve.
b. Should assess the situation.
c. Dial 1000 to inform the Control Room and request for the
presence of Security personnel at the scene immediately.
d. Do not approach / confront the group on your own.
e. Stay calm and keep within the safe distance.
f. Wait for the arrival of the Security Team.
g. Security Officer to inform CEO / GM / Medical Director /
CNO/DCNO if the event is not resolved immediately.
h. Security Officer to seek police assistance if necessary.

5.3.2 Report
>All personnel involved should records and report the detailed if the event
that has taken place.
>Comprehensive report should be submitted to the CEO/GM and
Emergency Preparedness Committee.

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KPJ AMPANG PUTERI

SPECIALIST HOSPITAL

LIST OF TELEPHONE NUMBERS

HOSPITALS TELEPHONE SPEED DIAL
NUMBERS NUMBERS
Hospital Kuala Lumpur (HKL) 2615 5555 7051
Pusat Perubatan Universiti 9173 3333 7062
Kebangsaan Masalaysia
Institute Jantung Negara ( IJN) 2617 8200 7056
University Malaya Medical 7956 4422 7052
Center
Hospital Respiratory 4023 2966 -
Hospital Selayang 6120 3233 7066
Hospital Putra Jaya 8888 0080 -
Pusat Darah Negara 2693 3888 7053
Pantai Hospital Kuala Lumpur 2296 0888 7058
Pantai Hospital Cheras 9132 2022 7064
Pantai Hospital Ampang 4089 2828 7065
Pusat Perubatan Islam 4041 4922 7057
Gleneagles Intan Medical 4257 1300 7055
Centre
Sime Darby Jaya Medical 5634 1212 7059
Centre
Assunta Hospital 7782 3433 7054
Hospital Ampang 42896000 -
Selangor Medical Centre 55431111 -
Sentosa Medical Centre 40437166 7011
Prince Court Hospital 21600000 -
Sunway Hospital 74911919 -
Tung Shin Medical Centre 20721655 -
KPJ Kajang Specialist Hospital 87692999 7012
AMBULANCE SERVICES
Red Cresent 4257 8122 7938
First Ambulance 1300 – 88 – 1919 7939
St. John 9285 5294 7940
MAHA MAS MEDIC Ambulance 40449099
OTHERS
Balai Polis Ampang 4252 2222 7933
Balai Polis AU 2 Keramat 42573322 -
BOMBA 4292 4444 7932

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