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MAJOR INCIDENT. Dr. Baha Al- Wakeel FRCP Consultant and honorary Senior Lecturer North Middlesex University Hospital-London. North Middlesex University Hospital, London. . /.
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MAJOR INCIDENT Dr. Baha Al-WakeelFRCP Consultant and honorary Senior Lecturer North Middlesex University Hospital-London
/ • “Any occurrence which presents a serious threat to the health of the community, disrupts the 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 services or health authorities.” • Major incidents are classified: • Compensated and non compensated according to the load and capacity. • Simple and compound according to the infrastructure status.
CATEGORIES OF MAJOR INCIDENTS Big Bang : The incident will produce immediate casualties and place pressure on ambulance services and receiving hospitals. Rising Tide: a problem creeps up gradually, such as occurs in a developing infectious disease epidemic. Cloud on the Horizon: preparatory action is needed in response to an evolving threat elsewhere, even from overseas. Headline News: a wave of public or media alarm over a health issue, as a reaction to a perceived threat, may create a crisis even if the fears prove unfounded. Internal Incidents: the hospital may be affected by its own internal major emergency such as a fire, breakdown of major equipment or utilities service failure.
EXAMPLES OF TYPES OF MAJOR INCIDENT Wide scale flooding Industrial explosions Acts of terrorism Chemical incidents Transport accidents Severe weather Boscastle flooding in August 2004 Buncefield oil storage depot fire in December 2005 Terrorist London bombings in July 2005
AIMS OF THE MAJOR INCIDENT PLAN Serve the local community . Provide, at the hospital, a graded and measured reaction. Ensure, as far as practicable, that an internal incident is contained.
MAJOR INCIDENT ALERT MESSAGES Message 1.Major Incident Standby Message 2.Major Incident Declared – Activate Plan Message 3.Major Incident Stand Down or Cancelled
THE SCENE RESPONSE • It is important to bring about order to the chaotic scene. Management and support priorities: • Command • Safety • Communications • Assessment • Triage • Treatment • Transport
COMMON OBJECTIVES OF EMERGENCY SERVICES • Save life • Prevent escalation of the incident • Relive suffering • Protect the environment • Protect property • Rapidly restore normality • Assist any criminal investigation or enquiry
INITIAL INFORMATION TO BE PASSED FROM THE SCENE (ETHANE) • Exact location: grid reference • Type of incident: rail, chemical, road • Hazards: current and potential • Access: from which direction to approach • Number of casualties: and their severity type • Emergency services: present and required
THE LONDON EMERGENCY SERVICES LIAISON PANEL (LESLP) Consists of representatives from the following agencies: • Metropolitan Police Service • London Fire Brigade • City of London Police • British Transport Police • London Ambulance Service(NHS Trust) • HM Coastguard(London) • Port of London Authority • All London Local Authorities • Established in 1973, the group meets once every three months and is chaired by the Metropolitan Police. The role of the LESLP is to establish the correct procedures for a collaborative approach to dealing with major incidents within London. A major incident could be anything from a terrorist attack to a natural disaster.
INITIAL RESPONSIBILITIES OF AMBULANCE SERVICES • Establishment of forward control • Saving of life • Relief of suffering • Liaison with other emergency services • Determination of the receiving hospitals • Mobilisation of necessary additional medical services • Provision of communications for NHS resources at the scene • Provision of casualty clearing station • Determination of priorities for treatment and evacuation (triage) • Arrangement of means of transporting the injured
BODY AREAS THAT MUST BE PROTECTED Head Face/eyes Ears Body Hands Feet
MINIMUM CLOTHING REQUIREMENTS Hard hat, with visor or additional goggles Ear defenders Warm underclothing Fire retardant suit High visibility jacket, marked appropriately Heavy duty gloves Latex gloves Oil and acid resistant boots
MOBILE MEDICAL TEAM Mobile Medical Team Doctor (team Leader) Doctor Nurse Nurse
MOBILE SURGICAL TEAM Mobile Surgical Team Surgeon (team Leader) Anaesthetist Scrub Nurse Anaesthetic Nurse
EXAMPLE OF EQUIPMENT CARRIED BY MOBILE MEDICAL TEAMS • Advanced airway • Difficult airway • Cricothyroidotomy • Advanced breathing • Chest drains • Chest drainage bags • Advanced circulation • High flow cannulas • Pressure infusors • Advanced drugs • Local and regional anaesthesia • Opiate analgesia • General anaesthesia • Advanced trauma • Traction splints • Surgical equipment • Cut down equipment • amputation
COMMAND LINES Gold Silver Bronze
THE CORDONS AT A MAJOR INCIDENT In Ambulance parking point Site Casualty clearing station Ambulance loading point Inner Cordon Outer Cordon Out
SCHEMATIC REPRESENTATION OF A CASUALTY CLEARING STATION Priorities 2 (urgent) Ambulance loading point Priority 1 (immediate) Triage Area Priority 4 (expectant) Priority 3 (delayed) Body Holding Area
TRIAGE AND EVACUATION MAP Triage Sieve Triage Sort Incident site Casualty Clearing Station Ambulance Loading Point Receiving Hospital 1-Immediate 1-Immediate 2-Urgent 2-Urgent Receiving Hospital 3-delayed 4-Expectant 4-Expectant Receiving Hospital Body holding area Dead Temporary Mortuary
THE TRIAGE SIEVE Y Walking Priority 3 (delayed) N N Airways Dead Y Below10 or over 29 Respiratory rate Priority 1 (immediate) Over 2 s 10-29 Capillary refill Priority 2 (urgent) Under 2 s
TRIAGE PRIORITIES • The priorities to be used are: Immediate: Red / Immediate Urgent: Yellow / Urgent Delayed: Green / Delayed Dead: White / Dead Expectant: Green / Red “flashes” Contaminated Green / Yellow “flashes”: Biological and chemical contaminated casualties must not be allowed to enter the hospital unless decontaminated.
HOSPITAL AND EMERGENCY SERVICES The ambulance service is responsible for distributing casualties to and between receiving hospitals. Trusts must keep the ambulance service informed of their immediate and continuing capacity to receive, admit and treat patients. This is particularly important for critical services which may be in short supply, such as intensive care and operating theatres.
MAJOR INCIDENT RECEIVING HOSPITALS • Listed Hospitals: Hospitals listed as being adequately equipped to receive casualties on a 24 hour basis. • Receiving Hospitals: The hospitals selected by the London Ambulance Service to be one of those in line for receiving casualties resulting from a Major Incident. • Supporting Hospitals: Hospitals, whether listed or not, which can offer support to the First Receiving Hospital by any or all of the following means: • Accept overflow casualties from the incident when the First Receiving Hospital can accept no more (such hospitals will also be referred to as Receiving Hospitals). • Accept transfers of existing casualties from Receiving Hospitals to allow extra space for admission of casualties..
RECEIVING TRUST 5 MAJOR ROLES To provide the clinical facilities to respond appropriately. To liaise with the ambulance service, other hospitals and agencies in order to manage the impact of the incident. To maintain communications with relatives and friends of existing patients and those from the incident, the local community, the media and VIPs. To provide on site medical care and advice. To ensure the hospital continues all its essential functions throughout the incident.
STRATEGIC LEVEL MANAGEMENT - GOLD COMMAND • Liaise with the NHS London Co-ordinating Team and Health Protection Advisor (HPA). • Liaise with Chief Executives of linked Trusts, and the Local Authority as necessary. • Accompany any Minister or other VIP round the Trust during the period of a Major Incident. • Liaise with the Cabinet Office (if appropriate). • Advise the Hospital Control Team on any issues from any of these agencies.
HOSPITAL CONTROL TEAM (HCT) – SILVER COMMAND During normal working hours, the HCT members will be: • Action card A1: Executive Director on Call • Action card B1: Medical Director (or designated deputy). • Action Card C1: Director of Nursing (or designated deputy).
HOSPITAL CONTROL TEAM (HCT) – SILVER COMMAND Outside normal working hours the HCT members will be as follows, until the HCT team as described above, arrive on site: • Action card A1: Site Manager until the on call manager and/or Executive Director on call arrives on site. • Action card B1: Senior Medical Practitioner / Medical Registrar (until an A&E consultant or the Medical Director arrives on site). • Action Card C1: Senior Nurse from ICU (until the Director of Nursing arrives)
ACCIDENT AND EMERGENCY (A&E)DEPARTMENT – Bronze Command • It is important to remember, despite the possibility of a large number of critically injured and ill casualties arriving during a Major Incident and the busy and stressful conditions that often pertain, that all casualties must be treated with due regard to consent, confidentiality and infection control. They must be afforded as much privacy and dignity as conditions will allow.
STAFF ASSEMBLY AREAS Hospital Control Team will assemble in the Seminar Room, A & E department. Medical staff and On-call doctors should report to the Junior Doctors Mess, Ground Floor Surgical Block. All other staff volunteering or not required in their department should report to the Academic Centre Lecture theatre.
STAFF IDENTIFICATION All hospital staff who normally wear uniforms at work, must attend hospital in uniform during a Major Incident, if possible. Non-uniformed staff, like all uniformed staff, must wear their identity card at all times.
MAJOR INCIDENTS INVOLVING CHILDREN • In any of these circumstances, the HCT will, in consultation with the Paediatric Manager, elect: • A Paediatric Medical Consultant; • A Paediatric Senior Nurse Manager; • A Paediatric Ward Manager.
MEDIA MANAGEMENT Key points to consider; • Only the HCT or designated media lead should speak with the media • Patient confidentiality must be maintained at all times.
STAFF WELFARE CONSIDERATIONS • Notify your family.Call them regularly. • Ensure you take your identification badge, cards, keys, mobile phone, pager, map book, torch and coat with you.Ensure you bring any personal medication or dietary requirements with you. • You should not work for longer than 8 – 12 hours without going off duty. Please ensure you take regular breaks. • Counselling and support will be available during and after an incident. This can be arranged by contacting your line manager.
HOSPITAL PRESSURE POINTS • There are several areas of the hospital which provide specific pressure points or “bottle necks.” These have their own Action cards as part of the plan and include: • Theatres • X-Ray • Transport • Blood Transfusion Service • ITU / HDU • Telecommunications
VOLUNTEERS (Individuals not normally employed by the Trust) • Volunteers should be directed to the Seminar Room 3, Academic Centre, Lower Ground Floor Tower Block. • An adjacent seminar room in the same corridor can be used for any necessary people overflow. • A Volunteer Co-ordinator should be assigned to organise these persons for relevant tasks throughout the hospital, when asked for additional personnel by a member of the Hospital Coordinator Team.
MAJOR INCIDENT TRAINING • A live exercise (or live testing of the plan) every three years. • A table-top exercise to test particular parts of the plan without disrupting the work of the hospital. Results of exercises will be logged with the Major Incident Committee and reported to the Patient Safety & Quality Committee. Actions arising from tests and reviews will be monitored for progress by this group. • A telecommunications and switchboard exercise every six months, with telecommunications checks monthly.
