Major Incident Medical Management and Support Alna JP Robb

Major Incident Definition ‘events that owing to the number, severity, type or location of live casualties require special arrangements to be made by the health services. Main type of incidents are: stadia, civil disorder, transport, industrial. The majority of major incidents result in fewer than 100 casualties. Disproportionately large number of casualties seen in stadia related injuries, when may be expected to plan for up to 200 casualties. However terrorist threats have been present in UK for around 40 years 31 year review of major incidents occurring between 1968-1999 was conducted. ( defined as 25+ people had attended hospital of whom 6 or more had suffered serious injury) A total of 115 major incidents were identified. Although major incidents are perceived as rare the overall incidence over this period was 3-4 major incidents a year, but not all data was complete. In recent years data is more reliable and an estimate of 4-5 major incidents occurred per year when data collection is know to be complete

Are we ready for a major incident? Several studies carried out- 1996, and 2002( UK) Conclusions-The actual level of preparedness could be significantly improved The present preparation for major incidents in most hospitals is poor Few major incident plans conformed to guidance Planning for the despatch of qualified personnel from hospital to the scene of a major incident is flawed

Disasters are different! The most severely injured of mass casualties may have to be set aside and treated LAST, so as to more effectively apply the limited resources to many more. Evaluations of casualties must be rapid, decisions must be accurate ‘Minimal acceptable care’ is the standard in this setting Planning for major incidents is essential Like politics, all incidents are LOCAL Medical care is the primary goal of any major incident response

Trauma Physical trauma is the most common and most likely affliction of major incident casualties. 80% of all disasters in history involve traumatic injuries amongst the casualties. Blast injuries is amongst the most common mechanisms of mass casualty disasters currently, yet most healthcare staff have little understanding of this trauma Communications failure is the most common disaster response pitfall

Structured approach to the pre-hospital response Management and Support Principles Command Safety Communication Assessment Triage Treatment Transport This is the ‘ABC’ of major incident management Safety- staff, situation, Survivors- protecting those with clinical skills, and the environment in which these clinical skills can be practiced so that any care at all can be given to patients Communication failures frequently occur between the scene and hospital, and within the hospital itself. Importance of predictable failures- e.g. overwhelming call volume freezing the hospital switchboard are recognised and solutions identified before the plan is activated. Rapid assessment to estimate size and severity of the casualty load is essential, to determine the initial medical response. Continuing assessment will relate to the hazards that arise and the adequacy of medical resources ( the right people, with the right skills and equipment to treat the casualties) Triage- the sorting of casualties into priorities for treatment. The process is dynamic and can be repeated at every stage to detect change Treatment- ‘do the most for the most’. The actual treatment delivered will reflect the skills of those providers, the severity of the injuries, and the time and resources available. Transport- not all people will turn up by emergency ambulance- some may arrive by their own or unconventional transport ( e.g. bus)

Pre-hospital Hospital involvement in the pre-hospital phase is generally confined to the provision of a Medical Commander or Mobile Medical Team. If possible, the hospital receiving major casualties from a major incident should not provide staff for these roles. Individuals who may be tasked to go to the scene as MC or MMT must be specifically trained in these roles

Goal The standard goal of providing the greatest good for each individual patient must change in a major incident setting to the greatest good for the greatest number. Rationing of limited resources

Triage ‘To sort, prioritize according to need – The major determinate of casualty flow The major determinate of casualty outcome An evolving process that must be done multiple times What is the trigger? -number of ambulances/ casualty clearing centre/ hospital resources/ ITU beds ( local V regional sources/ time continuum of event

TRIAGE Triage Sieve Quickly sorts out casualties into priority groups, using cards that are colour coded Priority 1/ T1 Immediate RED Priority 2/T2 Urgent YELLOW Priority 3/T3 Delayed GREEN Dead WHITE or BLACK Triage sort- used when further resources arrive, using the Triage revised trauma score (TRTS), based on three parameters: respiratory rate, systolic BP and GCS

Sequence of events Rescue- decontamination Triage Evacuation Definitive treatment. Challenges- 80-90% are not critically ill Need to identify the small minority of critically injured patients from among the great majority

Treatment Casualty clearing station and ambulance loading point Triage sort, assessment, treatment and stabilisation are carried out by ambulance staff and medical teams as they arrive on scene. Once sufficient resources have arrived on scene then patient documentation starts Patients them conveyed to hospital

Transport Ambulances, Patient transport vehicles and buses can be used to transport patients to hospital. 50% will arrive in first hour 75% in 2 hours 75% go to or are sent to nearest hospital First to arrive will be non critical

Triage Accuracy Triage accuracy – major impact on casualty outcome Errors- under triage/ over triage Critical injuries not assigned to immediate ‘Critical care is a process, not a place’

Phases of the hospital major incident plan Pre-hospital Reception Definitive Care Recovery

RECEPTION The hospital must be prepared for its clinical and administrative functions and the casualties themselves must be received. Key Clinical Areas Reception area (Emergency Department) Staff reporting areas Theatres Intensive Care Wards Body holding area Usually the reception phase lasts hours, but it may last days in very protracted incidents. Minor casualties may present before the seriously injuries if the seriously injured are entrapped.

Preparation: Administrative Hospital Co-ordination Team, lead by Medical Co-ordinator: - Senior Emergency Physician, Senior Nurse, Senior Manager. They are not involved in patient care Hospital Coordination centre Hospital Information centre Discharge/ Reunion area Press area

Collapsible Hierarchies Concept The system used to delegate staff in major incidents during a major incident response is termed the collapsible hierarchy. The roles within a major incident may be grouped under three headings Clinical roles Nursing roles Management roles

Major Incident plans must contain the same core roles and responsibilities that need to be carried out as part of the response. e.g.- all plans must identify staff for the resuscitation of Priority 1 casualties. Plans include: Action cards that cover all the responsibilities within a hospital. It is vital that a major accident plan is capable of being initiated by a small number of staff. A small number of staff may take control of a large number of tasks until further help arrives.

MANAGEMENT Hospital Coordination Team Medical coordinator Senior Nurse Senior manager Senior Emergency Physician Adequate administration and support staffing is essential Accurate administrative documentation of casualties is a considerable challenge Property – robust storage and identification system

DEFINITIVE CARE All treatment given after casualties have passed through the receiving areas is considered to occur during the definitive care phase. This distinction is somewhat arbitrary as for some casualties there is a continuum between procedures started during reception/ immediate treatment and definitive care. May last weeks or even months depending on injuries sustained Provision of surgical and intensive care services, but may include medical cases requiring care

RECOVERY The Medical coordinator will decide the phasing of the stand down of the hospital medical response, and will inform staff accordingly. Likely that extraordinary activity will continue for some days after the reception phase has finished, and decisions about stand down and rostering of staff should be taken with this in mind. All remaining operational issues need to be resolved and normal services restored. Reflection. Psychological well- being of patients and the staff. Audit( and possibly inquiry) must occur