Tim Morse and Tim Kilner

Chapter Contents

Introduction

Incidents involving large numbers of injured individuals are not as uncommon as people may like to believe, although over the years the profiles of these incidents have changed. Incidents are often associated with industry, transportation, mass gatherings, and terrorism. Carley & Mackway-Jones (2005) found on average, 3–4 major incidents occurred in the UK every year from 1966 to 1996 (range 0–11). Table 3.1 lists a few examples of incidents occurring over the last 20 years in the UK.

At a local level the threat of a major incident occurring in the UK has often been viewed as remote; however, the terrorist events in New York and Washington on September 11th 2001 that killed 2996 people, the Madrid bombing that killed 191 people and injured over 1700 and on the London Underground attack on 7th July 2005, which killed 52 and injured over 700 people certainly heightened awareness and the increasing terrorist risk. Consequently, major incident planning has assumed a greater priority than previously, although there may still be an element of denial by assuming that such events will happen elsewhere (Lennquist 2012).

By their very nature, major incidents are unpredictable, the only certainty being that at some time, somewhere, the unexpected will happen. But when it does, the health services must be able to respond rapidly, mobilizing additional human and material resources. Procedures must also be in place to make the most efficient use of those resources in the given circumstances. Achieving this requires the health services to be proactive in the planning of emergency management measures, thus reducing the need for reactive management in an extremely stressful situation. The Emergency Department (ED) provides the focus for the hospital’s patient-care activity during the response to an incident.

This chapter discusses the role of the health services in contingency planning and service provision for major incidents. Consideration will be given to hospital-based activity, both in general terms and specifically in relation to in-hospital emergency services. The on-scene response to a major incident is considered in Chapter 1.

In England the primary source of guidance to assist the NHS in planning a response to a major incident is contained in the Department of Health Emergency Preparedness Division (2007) Mass Casualties Incidents: A Framework for Planning, which is influenced by the requirements of the Civil Contingencies Act 2004 (Home Office 2004). Guidance for Scotland, Wales and Northern Ireland is issued by the Health Departments of each of the Administrations.

Definition

Guidance from the Department of Health (HSE1996a,b) defines a major incident as: ‘any occurrence that presents serious threat to the health of the community, disruption to service, or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance trusts or primary care organizations’.

This definition reflects the departure from the view that major incidents only result from the ‘big bang’ scenario such as a rail collision or a building collapse. Guidance now recognizes that major incidents can also occur in a variety of different ways (NHS Management Executive 1998, National Audit Office 2002), such as

Planning

Each NHS organization must have a major incident plan based upon risk assessment, cooperation with partners, communicating with the public, and information sharing. It is the Chief Executive’s responsibility to ensure such a plan is in place and to keep the Trust Board up to date with the plan (Department of Health Emergency Preparedness Division 2005, 2011).

The plan should outline actions for the acute Trust to discharge its responsibilities, namely:

The very nature of major incidents brings together diverse groups of professionals in large numbers, each group having distinct roles and responsibilities. When faced with the complexities of a major incident, it is unrealistic to expect such a large multidisciplinary team to function in an effective and coordinated manner without detailed prior planning. It is therefore essential that planning assumes an appropriately high priority.

Training

There is an expectation that staff understand the role they would adopt in a major incident, have the competencies to fulfil that role and have received training to fulfil those competencies. There is some evidence to suggest that staff are not entirely familiar with the action they should take in a major incident (Carr et al. 2006, Milkhu et al. 2008, Linney et al. 2011). It is suggested that acute Trusts should consider providing annual training and development for staff to enable them to meet these expectations. There is also a requirement for all NHS organizations to undertake a live exercise every three years, a table-top exercise each year and a test of communication cascades every six months (Department of Health Emergency Preparedness Division 2005). However, despite these exercises their must be a recognition for acute hospital trusts to coordinate their role with the surrounding primary healthcare organizations, as they may also lack in preparedness (Day et al. 2010).

Large-scale exercises serve a number of purposes:

However, large exercises do not allow detailed scrutiny of any one aspect of the plan; rather, there is a superficial overview of the plan as a whole. Large-scale exercises should be as realistic as possible in all respects and be based upon the more likely incidents that may occur locally, to gain full benefit from testing the emergency response and making the experience as meaningful as possible.