Major Incident – Acute Care Guide

by Gareth Patton, Mike Donald & Russell Duncan, updated in 2020 by Fergus Taylor.

Blue Car Crash A Major Incident is a confirmed/threatened situation, which requires special mobilisation and / or redeployment of staff and other resources with consequent interruption to routine service.

Key Points:

Report directly to your own speciality.
Stay out of the Emergency Department (unless you work there or are asked to attend)
Every task from resuscitation to discharging patient on the wards is vital.
Do not give out information over the phone – redirect these calls.
Communication is the key!

A major incident could be anything from a plane crash, major road traffic collision, terrorist attack, chemical incident or even off shore event from which casualties may be produced. Fortunately though, the frequency of such events is very rare. This infrequency however leads to unfamiliarity and confusion when these events do occur. NHS Tayside has in place a Major Incident Policy which can be referred to in such an event. This is a lengthy and detailed document, of which those who have roles and responsibilities will be aware. Below is a brief guide to what ought to happen and what you should do.

The Hospital service may be notified as a ‘standby’ or formally declared. The declaration will usually be made by the Scottish Ambulance Service in a call to the Hospital switchboard. On receiving such a message, switchboard will contact the relevant pre-designated personnel in each service included in the response. These persons then activate a ‘cascade’ to recruit more of their own staff – medical, nursing and support thereby keeping the phone lines at switchboard clear.

Burning Tree A pre-hospital site medical team comprising of Emergency Medicine and Anaesthetic staff may be deployed to the scene to assist the Ambulance Service in the set up of a Casualty Clearing Station and to provide advanced pre-hospital medical support. The ‘Medical Incident Officer’ (off-duty Emergency Medicine Consultant) will deploy to the scene and liase with Ambulance, Police, and Fire Service Incident Officers co-ordinating the on scene NHS response. Ninewells Hospital is the Designated Receiving Hospital for Major Incidents occurring within Tayside.

Casualties enter via the Emergency Department ambulance entrance only. This ensures that triage can be re-performed on patient’s arrival by the ‘Casualty Receiving Officer’ and directed to the most appropriate part of the ED. It also ensures that details of all patients entering the receiving hospital can be recorded and their subsequent movements logged.

In the ED teams will be prepared to receive each casualty. Each resus bay will be manned by a team of staff from the EM and Anaesthetic departments. Overall activity and decision making will be made by Senior Staff leading each speciality. Only the Lead for specialities such as Anaesthesia, General Surgery, and Orthopaedics should be present in the ED. They will then communicate directly with their own teams once clinical decisions have been made.

The casualties that come through the ED will then be moved / admitted to the most appropriate destination – Ward 7 (Casualty Receiving Ward), Theatre or Mortuary. This presents a challenge to the receiving wards(s) to clear beds into which patients will be admitted. Each inpatient speciality should therefore have a senior decision maker identifying patients who are fit for discharge in a bid to free beds.

ambulance_at_night

The hospital wide response will be co-ordinated by the ‘Hospital Control Team’ which will be located in the Board Room on level 10. The Staff here, from medical, nursing, support and management backgrounds will have no direct patient contact. Their roles are to ensure that patient flow within and out of the hospital is as smooth as possible.

What should you do if you are called? If you work in the ED, you should report directly there. If you work elsewhere, you must report to your own direct clinical lead on the relevant ward. Do not enter via the Emergency Department and do not attend the ED unless asked to do so. Try not to take instructions from too many people. This leads to confusion for the person co-ordinating your speciality. Information and instructions should only pass directly up and down the ‘chain of command’. The establishment of a ‘command and control’ system is vital to an effective Hospital response in such circumstances. There is no room for individuals going ‘off-piste’ however well-intentioned this may be.

As in every area of healthcare, communication is the key to success when managing such an incident. When communication breaks down chaos quickly follows!

In addition to the health care response to an incident there will be a police and press response. The primary role of the Police is to preserve the integrity of the scene as a ‘crime scene’. At the Hospital they will be required to gather information regarding numbers of casualties and their details. They are also responsible for co-ordinating liaison with the Press. Medical staff must not speak directly to the Press – it has been known for some members of the Press to try to obtain information using false identities.

It must be stressed however that every duty performed is just as important as any other in the event of a Major Incident. It may seem

Fire Rescue Crew

like you are not doing anything by writing discharge letters or sending bloods away – but if these tasks are not completed they may have significant knock on effects.

Lastly, during a Major Incident response a near normal emergency service for other day-to-day emergencies must continue! GP referrals for emergency admission will continue to be accepted by the Medical and Surgical receiving teams