Major incidents

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Major incidents

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:

• provide a safe and secure environment for the assessment and treatment of patients

• provide a safe and secure environment for staff that will ensure the health, safety and welfare of staff, including appropriate arrangements for the professional and personal indemnification of staff

• provide a clinical response, including provision of general support and specific/specialist healthcare to all casualties, victims and responders

• liaise with the ambulance service, local Primary Care Organizations (PCOs) including GPs, out-of-hours services, Minor Injuries Units (MIUs) and other primary care providers, other hospitals, independent sector providers, and other agencies in order to manage the impact of the incident

• ensure there is an operational response to provide at-scene medical cover using, for example, BASICS and other immediate-care teams where they exist; members of these teams will be trained to an appropriate standard; the Medical Incident Commander should not routinely be taken from the receiving hospital so as not to deplete resources

• ensure that the hospital reviews all its essential functions throughout the incident

• provide appropriate support to any designated receiving hospital or other neighbouring service that is substantially affected

• provide limited decontamination facilities and personal protective equipment to manage contaminated self-presenting casualties

• acute Trusts will be expected to establish a Memorandum of Understanding (MOU) with their local Fire and Rescue Service on decontamination

• acute Trusts will need to make arrangements to reflect national guidance from the Home Office for dealing with the bodies of contaminated patients who die at the hospital

• liaise with activated health emergency control centres and/or on call PCO Officers as appropriate

• maintain communications with relatives and friends of existing patients and those from the incident, the Casualty Bureau, the local community, the media and VIPs.

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.

The timing of an exercise is also of importance. If possible, it is preferable not to advise personnel exactly when the exercise will take place, as forewarning will inevitably create a false state of preparation and readiness that will not truly reflect the response to a ‘real’ incident. However, there is a need to ensure that exercises do not unduly disrupt the normal functioning of the service, so an acceptable compromise must be reached when planning and informing staff of exercises. The organization and enactment of full or ‘live’ exercises are expensive in terms of time, personnel and resources, and these factors make exercises of considerable financial cost. Combining exercises with other services and agencies, many of which also have statutory requirements to exercise, can keep costs to a minimum. It may be that in some circumstances other forms of exercise, which may be more cost-effective and appropriate in meeting response and training needs, should also be considered.

Small-scale exercises allow part of the plan to be examined in detail, utilizing skill and task-specific activities, but do not always highlight problems that may occur when influenced by the activity of other departments or organizations. Table-top exercises allow a greater range of activities to be scrutinized in detail, but are largely theoretical and may not highlight logistical problems or poor skill levels resulting from inadequate training.

In addition to table-top exercises, using computer video serious gaming technology, can create a near reality likeness to an actual event. Knight et al. (2010) developed serious gaming technology to support the decision making involved in triaging patients. The benefit of this technology compared with large exercises is that it is cheaper in terms of resources, and the student can revisit the situation again.

Given that each method has limitations, perhaps there is a case for exercise and training to make use of a combination of these techniques and not to be reliant upon one method.

The hospital should carry out an internal communications/call-in exercise at least every six months and exercise communications systems between themselves and the ambulance service at regular intervals. Exercising of plans also provides an opportunity to review procedures and make amendments in the light of lessons learned from testing implementation. Lack of practice in implementing the plan allows deficits, inconsistencies, and errors to go undetected until a major incident occurs.

While selection, training, and motivation can be expected to create greater resilience in staff involved in major incidents than among the rest of the population, there is also evidence that staff are not completely immune to adverse effects of trauma work (Alexander 2005). Staff may be exposed to:

It is important, therefore, to ensure staff have sufficient rest, exercise and opportunity to talk, when they feel able to do so, to those whom they trust (Alexander & Klein 2011).

Major incident alerting procedures

In the event of a ‘big bang’ major incident it is likely the ambulance service will be the first to become aware of the incident. In this case they will be responsible, on confirmation of the incident, for alerting all appropriate partners within the health community. That noted, there are plenty of examples of major incidents, such as the Omagh bombing in Northern Ireland in 1998 (Lavery & Horan 2005) and the Canterbury earthquake in New Zealand in 2011 (Dolan2011a,b, Dolan et al 2011) where patients presented to the ED some minutes before the first ambulances.

The acute trust should be alerted by one of two messages: either ‘major incident standby’ indicating a major incident may need to be declared, or ‘major incident declared – activate plan’, indicating that the major incident plan should be implemented and all appropriate action should commence.

The alert will be terminated with either ‘major incident – cancelled’, indicating a stand down from the alert and a halt to the implementation of the plan, or ‘major incident stand down’, indicating that all live casualties have left scene, but some may still be en route to hospital.

In the event of a ‘rising tide’ incident the alert is most likely to come from either the Strategic or Regional Health Authority or from one of the Primary Care Organizations. Acute Trusts may declare a major incident, initiated by the most senior person available in the Trust at that time, and this may result from an incident where casualties self-present prior to the ambulance service being aware. In such cases it is essential that the ambulance service are immediately alerted and updated as a matter of urgency.

The hospital’s response to a major incident alert

The emergency department

The primary responsibility of the ED is the reception and treatment of patients. This will include the establishment of reception areas and treatment areas with appropriate access and egress to control patient flow, and decontamination facilities where necessary. Systems should be implemented to provide clinical records for each patient and for the management of patients’ possessions.

During this stage of the incident, relevant nursing and medical staff will be contacted and deployed to activity predetermined by individual action cards. If additional nursing staff are required by the ED, then an appropriately designated person should initiate a ‘call-in’ procedure. Other involved areas in the hospital will also activate similar procedures, which may also involve the use of personnel from voluntary organizations. It is often advisable to call in staff rostered for the next shift but one in the department, as this allows for an already rostered fresh shift to come in relieving those involved in the initial response and allows the present and called-in shifts an opportunity to rest. This is not always possible as the bulk of the current shift may be rostered for the shift after next, e.g., today’s late shift staff are tomorrow’s early shift staff.

It may also be advisable to distinguish ED nurses and doctors from other staff deployed to the department from elsewhere by the use of identifying tabards. If possible, additional staff deployed into ED should have ED or critical-care experience and should not be utilized in treatment teams without the presence of at least one experienced ED nurse. Nurses from other areas can play useful roles in dealing with minor injuries and in transferring casualties from the treatment areas to admission wards.

Receipt of casualties

Within the ED, all of the patients in the department at the time of the major incident alert should have the situation explained to them and their conditions reassessed. Those awaiting treatment or with minor injuries should be given any appropriate first aid treatment and advised to go home, attend their local community hospital, or see their GP. More seriously injured or ill patients should be rapidly stabilized and transferred to a ward.

It should be borne in mind that during a major incident the ED may still receive casualties who have not been involved in the incident, especially if they make their own way to the department. Moreover, patients involved in an incident may make their own way to the department and these should be included within the documentation used during the incident. In either case, the department should provide facilities to treat them but not confusing them with the casualties involved in the major incident. The department should prepare facilities for the reception and treatment of casualties according to their priority for treatment. This commonly involves the utilization of appropriately identified areas, adjacent to the ED if possible, for the collection and treatment of those with a lower clinical priority. Within the ED and other areas identified for casualty reception and treatment, appropriate types and amounts of equipment should be prepared. To enable this essential equipment to be rapidly available for use, stocks should be held in an easily accessible place within the department, and planning with the central sterile supply department, pharmacy and other departments should enable additional supplies to be quickly procured to replenish the stocks held in ED, such as chest drain packs and controlled analgesic drugs.

Each patient should receive a uniquely numbered identification bracelet and set of records, different to those used by the rest of the hospital. As immediate identification of the casualty may be difficult and time consuming, this unique number will accompany the patient throughout the hospital system. The triage labels used at the incident scene should also be uniquely numbered and, if it is practical to use this number within the hospital as well, tracking of the casualty will be assisted.

In the ED, arrangements should be made to receive and treat casualties with appropriate priority. On arrival at the hospital all patients should be re-triaged, documented and directed to an appropriate treatment area. However, in a mass casualty situation, managing a large number of casualties means that the view of ‘doing the greatest good for the greatest number’ (Jenkins et al. 2008) should be applied; a philosophy which is different in normal everyday ED work.

Triage should be carried out by a triage team consisting of an experienced ED doctor and nurse. If separate entrances have been designated for minor and other categories, due to the geography of the hospital, two triage teams may be needed. Each patient will be assigned a triage category and a unique identification number – preferably the same as on the triage label from the scene. Further identification and documentation of patients will take place as their condition allows, and will be carried out by members of the police documentation team and hospital administrative staff. Information regarding the numbers and identities of patients will be compiled by the police documentation team and relayed at regular intervals to the police’s casualty bureau, where it will be combined with information from the scene, rest centres, mortuary and other sources, such as transport companies’ passenger lists.

Patient care

Treatment may be facilitated by organizing available staff into ‘treatment teams’. A treatment team can consist of two doctors and two nurses. At least one of the nurses should be an ED nurse. Each ‘immediate priority’ patient will require one treatment team for their care in the department. However, one team should be able to manage the care of two or three urgent priority patients, and the area designated for delayed priority (‘minor’) patients should be manageable using two teams. The medical and nursing staff in ED should aim to treat, stabilize and transfer immediate and urgent casualties out of the initial treatment areas as rapidly as possible, to allow treatment of the maximum number of casualties. However, in reality, the number of immediate and urgent patients that a hospital will be able to accept will be limited by the number of intensive care, high-dependency care and operating theatre spaces available.

While casualties in the minor area may be initially regarded as having a low priority, their conditions may change. It is therefore important that at least some of the nurses allocated to this area are suitably experienced and are able to re-triage casualties into higher categories when required and arrange for their transfer to a more appropriate treatment area as necessary, especially as areas designated for the treatment of minor injuries may be geographically separated from the main ED treatment areas, such as an outpatients department.

Transfer teams will also be required to transfer critically ill patients from the treatment area to critical care areas or to the operating theatres. These teams may consist of a doctor and a nurse, preferably both with critical care experience, and preferably two porters, as medical and nursing staff are needed for patient care and should not be pushing trolleys. The transfer of non-critical casualties to their admission destination can be facilitated by a nurse and a porter. In order that there is continuity of care for casualties and of record keeping and handover, it may prove useful for one nurse to remain with the patients in immediate and urgent categories during their stay in the ED. However, the practicality of this arrangement will depend upon the number of casualties involved and the number of nurses available. It may be that this role should be fulfilled by a nurse drafted into the department from elsewhere in the hospital. During a major incident the knowledge and skills of the emergency nurse are at a premium, and if their numbers are limited then they are probably best utilized in the care of critical casualties and in a resource and organization of care role, making use of other hospital nurses drafted into the department.

Hospital response

The hospital will establish a Hospital Coordinating Team (HCT) typically made up of a senior clinician, a senior nurse and a senior manager. The primary function of the HCT is to manage the hospital’s response and ensure effective deployment of staff.

If the hospital is to receive patients, it is also likely that routine operating lists will be suspended and as many intensive care and high dependency spaces as possible made free. In addition, it may be thought necessary to clear as many beds as possible in other wards by means of early discharges and by transferring patients to other, unaffected hospitals – the use of the voluntary aid societies and their vehicles may be indicated for this task as the ambulance service is unlikely to be able to support this activity. The Civil Contingencies Home Office Act (2004) now places statutory responsibilities on primary care organizations to cooperate with other responders to an incident and to have a plan in place. It should be possible, in theory at least, for beds to be made available in a major incident but there is a reliance on primary care organizations having plans for some surge capacity in the event of such an emergency.

Restriction of access

Maintaining security, controlling access to the hospital and the containment of casualties, relatives and the media in specified areas of the hospital are vital tasks essential to the effectiveness of the hospital’s response. Full security and containment arrangements must be in place as soon as possible after the hospital has received notification to activate its plan.

If possible, access to all involved areas should be limited to one entrance and egress to one exit. All other entrances should be locked or closed by security personnel. Only those staff with appropriate identification should be allowed into the hospital, the ED and associated treatment and collection points. Major incidents cause a convergence of individuals and groups on the hospital, focusing upon the ED. Well-meaning and interested hospital and non-hospital nursing and medical staff, various volunteers and voluntary groups will cause a disrupted and confused response and their access must be prevented.

It is advisable that hospital staff do not leave their own departments or come to the hospital until they are requested to do so via the recognized communication channels. A decision will also have to be made whether or not to use non-requested, non-hospital medical, nursing and other volunteers who offer their services. The potential legal ramifications of using possibly unqualified impostors and/or the possibility of negligence claims resulting from their practices may well outweigh any useful function that they may be able to perform.

The media

The media, which will no doubt have gathered at the hospital, should be provided with regular and accurate press releases. The media are under pressure during a major incident to meet deadlines and if they do not receive adequate and appropriate information they may set about seeking it out for themselves. It is not uncommon for members of the media to attempt to gain access to patients/relatives in ED and other clinical settings such as ITU and wards by pretending to be members of staff. Walter (2011) notes, however, that news reporting, particularly live from the scene, may give vital information to the more remote commanders and to the wider health response before the normal communication channels can generate a properly informed report. The needs of the media should be addressed in ways that will not compromise the emergency response of the hospital and its staff or the confidentiality of casualties and relatives. Only designated members of staff, who preferably have been prepared for this role, should address the media and only statements prepared in consultation with the appropriate emergency services and approved by the hospital’s major incident coordination team should be released. Any access to casualties and staff should be very carefully controlled, with ground rules being agreed and consent obtained before any interviews take place.

Medico-legal issues

During the response to a major incident in the hospital or at the scene, nurses must consider a number of legal and professional issues. Major incident scenes are considered to be ‘scenes of crime’ until proven otherwise and consideration must be given to the preservation of forensic evidence. Such evidence, e.g., clothing, debris, etc., may leave the scene with casualties and, as a result, be present in the ED and other areas of the hospital. Every effort should be made to collect and preserve this evidence in collaboration with the police. Of course, in all circumstances, preservation of life takes priority over the preservation of evidence.

Criminal investigations and prosecutions, civil actions, official inquiries and inquests are all possible following a major incident. Some of the staff involved in the management of the incident is likely to be required to provide statements and/or give evidence. It should also be remembered that all documentation completed during the incident can be used not only as a source of evidence to explain what happened, but possibly also to suggest negligence.

Although staff are working under considerable pressure at the time of an incident, all documentation should be adequate, clear and accurate (Carvalho et al. 2011). Nurses should consider that the pressures of a major incident do not remove their professional accountability for practice, and they may well be asked to justify the actions that they took, both inside and outside the ED, at a later date. Staff should also be aware that the plan, including any action cards, is a written document and, as such, essentially becomes an approved policy document of the organization and provides standards and descriptions of expected activities against which the actions of staff may be judged by any investigation, whether internal or external.

Aftermath

During and in the aftermath of a major incident, it is important to recognize that both casualties and staff may be psychologically and/or spiritually affected by events that are outside the normal range of experience. As a consequence they may be at risk of developing post-trauma stress reactions and doubting long-held beliefs (Firth-Cozens et al. 2000).

Hospital major incident plans must include arrangements to provide patients, relatives, and staff with appropriate psychological and spiritual support during and after the event. Psychological support may be provided by appropriately trained personnel from the mental health professions or other statutory or voluntary bodies. Religious representatives from the major groupings should also be available, as well as a contact list of representatives from a broad range of spiritual beliefs so that individual needs may be met as far as is possible. Both psychological and spiritual support should be available from the outset and throughout the incident. Follow-up services such as psychological debriefing should also be made available to all of those involved as part of the plan.

References

Alexander, D. Early mental health intervention after disasters. Advances in Psychiatric Treatment. 2005;11(1):12–18.

Alexander, D., Klein, S. Major incidents. In: Smith J., Greaves I., Porter K., eds. Oxford Desk Reference: Major Trauma. Oxford: Oxford Medical Publications, 2011.

Carley, S., Mackway-Jones. Major Incident Medical Management and Support: The Practical Approach in the Hospital. Oxford: Blackwell Publishing, Advanced Life Support Group; 2005.

Carr, E.R.M., Chatrath, P., Palan, P. Audit of doctors’ knowledge of major incident policies. Annals of the Royal College of Surgeons of England. 2006;88(3):313–315.

Carvalho, S., Reeves, M., Orford, J. Fundamental Aspects of Legal, Ethical and Professional Issues in Nursing, second ed. London: Quay Books; 2011.

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Dolan, B., Esson, A., Grainger, P., et al. Earthquake disaster response in Christchurch, New Zealand. Journal of Emergency Nursing. 2011;37(5):506–509.

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Knight, J.F., Carley, S., Tregunna, B., et al. Serious gaming technology in major incident training: A pragmatic controlled trial. Resuscitation. 2010;81:1175–1179.

Lavery, G.G., Horan, E. Clinical review: Communication and logistics in the response to the 1998 terrorist bombing in Omagh, Northern Ireland, Critical Care, 2005. [9, 401–408].

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Milkhu, C.S., Howell, D.C.J., Glynne, P.A., et al. Mass casualty incidents: Are NHS staff prepared? An audit of one NHS foundation trust. Emergency Medicine Journal. 2008;25(10):562–564.

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Smith, A.F., Wild, C., Law, J. The Barrow-in-Furness legionnaires’ outbreak: qualitative study of the hospital response and the role of the major incident plan. Emergency Medicine Journal. 2005;22(4):251–255.

Walter, D. Communication. In: Smith J., Greaves I., Porter K., eds. Oxford Desk Reference: Major Trauma. Oxford: Oxford Medical Publications, 2011.

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