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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

MAJOR INCIDENT

Dr. Baha Al-WakeelFRCP

Consultant and honorary Senior Lecturer

North Middlesex University Hospital-London

slide3
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  • “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
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
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
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
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
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
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
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
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
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
BODY AREAS THAT MUST BE PROTECTED

Head

Face/eyes

Ears

Body

Hands

Feet

minimum clothing requirements
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

Mobile Medical Team

Doctor (team Leader)

Doctor

Nurse

Nurse

mobile surgical team
MOBILE SURGICAL TEAM

Mobile Surgical Team

Surgeon (team Leader)

Anaesthetist

Scrub Nurse

Anaesthetic Nurse

example of equipment carried by mobile medical teams
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
COMMAND LINES

Gold

Silver

Bronze

the cordons at a major incident
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
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 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
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
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
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
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
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
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
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 command1
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
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
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
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
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
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
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
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
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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
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.