THE MAJOR INCIDENT PLAN

1. THE MAJOR INCIDENT PLAN ANAESTHETIC DEPARTMENT SMUHT 2004

2. CONTENT • Definitions • Assumptions • Regional command structure • Hospital command structure • Where anaesthetists fit in • What should happen when a major incident is declared

3. DEFINITION A major incident for the Health Service is an occurrence involving casualties, the number, severity, type or location of which would overwhelm resources unless extra resources are called in

4. MAJOR INCIDENT STANDBY something has come to the attention of emergency services which might generate casualties. Switchboard and one or two key people are informed. eg bomb warning warning light in cockpit of plane approaching airport gas leak in local factory SMUHT has 2 – 3 of these per week

5. MAJOR INCIDENT DECLARED • An event has occurred generating casualties of sufficient numbers and/or severity to necessitate extra resources to deal with them eg a bomb has exploded a plane has crash landed toxic gas is affecting local residents There are casualties coming here The major incident plan is activated

6. MAJOR INCIDENT REHEARSAL Part or all of the major incident plan is being rehearsed This could be:- Emergency services only Emergency services and the emergency department (ED) Individual hospital departments All hospital departments And might involve:- Live “casualties” Tactical exercise only (paper / tabletop etc) Call in procedure only As the nearest hospital to an international airport we have an obligation to run regular major incident rehearsals

7. MAJOR INCIDENT STAND DOWN • There are either no more casualties coming here, or the incident has not generated enough casualties to warrant major incident status • There is no longer any need for extra resources and the hospital can return to “normal” working

8. ASSUMPTIONS • Mass casualties • Out of hours • Infrastructure is intact Water Electricity Roads Communications Emergency services

9. COMMAND STRUCTURE • Gold - Strategic • Silver - Tactical • Bronze – Operational Analogous to system emergency services and military use

10. COMMAND STRUCTURE • Gold – Strategic command • highest level of command • in an area remote from the site • regional or National level • involves local council, emergency services etc • communicates with other regions, government, military and silver commanders

11. COMMAND STRUCTURE • Silver – Tactical command • overall control of its’ own bronze areas • one at incident site, one in each hospital • Will be near the “site” and able to see it, but take no part in direct casualty care • communicates with gold, other silver commanders and its own bronze commanders

12. COMMAND STRUCTURE • Bronze – Operational • several on scene and within each hospital • deal directly with casualties • each has commander • Bronze commanders gather information and communicate needs and events to silver commander • Bronze commanders do not take part in casualty care

13. Diagram – scene and hospital

14. WHAT ACTUALLY HAPPENSA. TO CASUALTIES • Triage (resp rate + cap refill or pulse) on scene into:- P1 Immediate life threatening injury – need intervention within 1 hour P2 Potential life threatening injury – need intervention within 4 hours P3 All walking wounded (P4) DEAD • Immediate life saving intervention and retriage (SBP, resp rate and GCS) in Casualty clearing station on scene • Transfer to hospitals in rotation according to need • Of those coming to SMUHT (including those arriving independently), further triage at ED entrance • Coded notes, wristband and belongings bag assigned to all casualties 6. P1 and P2 taken into ED, P3 taken to Fracture clinic

15. WHAT ACTUALLY HAPPENSB. TO HOSPITAL • Emergency services → switchboard→ ED consultant, senior nurse, manager • Major incident declared for SMUHT • Switchboard → call in key people and open phone lines • All cardiac arrest bleeps activated → ED • Silver command set up in ED seminar room • Theatre activity suspended • All well patients sent home • ED prepares to receive stretcher cases (P1 P2) • Fracture clinic prepares to receive walking wounded (P3) • A4 A6 become receiving (MAJAX) wards • “Strollers” becomes Staff Tasking area for all called in staff • Chest research area designated for the Press →

16. WHAT ACTUALLY HAPPENSC. TO ANAESTHETISTS • All trainees fast bleeped to ED • Those able to go will be given designation by acting BCED • Maternity anaesthetist calls on call consultants first then all other anaesthetists to check availability. This takes just > 1 hour • All 4 consultants on call go straight to ED, liaise with BCED and wait to hear from Silver likely nos. + severity of casualties • Make provisional plan depending on above information, ICU bed availability, theatre cases and availability etc. • Decide how many anaesthetists needed now and ask maternity anaesthetist to call them in, then: • 1st O/C consultant stays in ED and becomes Rear Triage Officer 2ndO/C consultant may stay in resus initially then ?theatre?Majax AICU goes to unit CICU goes to unit

17. ANAESTHETIC ROLES We will be needed in Bronze areas:- • Emergency department • Receiving wards • Theatre • Acute ICU • Cardiac ICU and • Transfers in hospital ( radiology) • ?Transfers out of hospital • ?On scene

18. ANAESTHETICROLES REAR TRIAGE OFFICER • Is “gatekeeper” for all casualties needing admission to the hospital – deciding which patient goes where and in what priority • Calls in and receives extra anaesthetists and gives them a place to work • Is responsible for ensuring a debrief is organised and will therefore: • Stay in ED • Continually receive information on ED casualty status • Continually liaise with BCED and BC receiving areas • Need help!

19. ANAESTHETICROLES OTHER CONSULTANTS ON CALL • Liaise with BC and other specialty consultants in your area to decide best way of dealing with casualties • BC will need to know casualty status regularly to inform Silver Control • If more anaesthetists needed, call maternity anaesthetist and/or contact Rear Triage Officer to organise this • Extra equipment, drugs etc should be requested through BC • Ensure all anaesthetists in your area know to communicate all casualty management and movement decisions to BC through you

20. OTHER THINGS PARKING • Consultants on call – Helipad or ED visitors car park • All others – wherever you are directed or wherever you can but avoid front of hospital MOBILE PHONES • May not work – cell overload CONTAMINATION • Responsibility of fire service – should not need to be done in Hospital

21. OTHER THINGS DEBRIEF • Important • NOT a psychological counselling session! • Should be done on day of incident before people go home – also at some point after the incident • Should be run by one person • Thank you to involved staff • Give facts of what has happened and what is likely to happen next • Be aware that some people WILL be distressed (including you). They should ideally not be going home alone and should be followed up • The psychiatry department has very sensible advice leaflets

22. OTHER THINGS THE PRESS • Will be there before you are • Be suspicious of anyone without SMUHT identification • Be aware they have extremely sensitive microphones • There is an area and press liaison officer designated for them and they are given regular updates • If stopped by the press, politely but earnestly say you cannot talk to them as you are needed to treat casualties • If you are to give an interview check your appearance ask what the first question will be and have an answer ready if on TV ensure your watch can be seen or stand with a clock behind you

23. SUMMARY • Meaning of “ Major Incident” • Command structure within SMUHT • Where anaesthetists fit in • Rear triage has key role • All should be identifiable • Needed in several locations • Know who is in charge of your location • Communicate with that person • Know your limitations