This week I am talking in Manchester at the 14th Annual Critical Care Symposium. This is an amazing meeting organised by the legendary Dr Chithambaram Veerappan, a critical care doc based in Oldham, just up the road from Virchester. Owing to a diary cock up of epic proportions, and after deep, deep apologies to the organising committee I’m only there on Friday talking on major incident planning and helping to run a workshop on the use of social media in critical care medicine.
I’ve only got 20 minutes or so on major incidents and so we will have to be brief so I thought that we should go for a top tips approach. These are based on the in hospital response to an exceptional event although many will be applicable to the prehospital environment too, they are not designed to be comprehensive but rather ask you to stop and think about what we are really trying to achieve on what is admittedly a faily evidence light topic1. I hope that they do make you stop and think for a moment and perhaps prepare better for the next event.
If you’re not at the conference this week then please read on and share the #FOAMed tips. If you want to know why I’m giving this talk then skip to the end where I’ve outlined my journey in major incident planning
1. Have a Plan2
This seems pretty obvious, but you’d be surprised. back in 1996 I looked at pretty much every major incident plan in the UK and looked to see whether they had the required components for an effective major incident response3. It’s hardly ground breaking science, but the results were rather concerning. Few plans were comprehensive and many revealed some rather interesting approaches (the duty dermatologist as on scene medical officer was a favourite) to managing a major incident. It did generate a flurry of activity at the time and even got me an interview on Radio 4, but disappointingly when the work was repeated 10 years later by Wong4 little had changed. In 2017 it’s unclear where we are across the country, though there is no doubt in my mind that certain areas, notably London, have improved as we must recognise that much has changed over the last 20 years. For example, when we started our projects back in the 90’s it was essential that each hospital could provide a mobile medical team. With the development of PHEM in the UK this is increasingly less of a requirement (thankfully), but it still remains in many plans.
Of course no plan will be effective unless people know about it, have read it and can use it. So everyone should go out and read the plan today right? Well yes in an ideal world but if major incident planning has taught me anything it’s that you have to be a realist. On the day of a major incident most people in the hospital will either never have read the plan 5,6–8, will have forgotten the plan or may be too embarrased to reveal that they have not yet got round to it. The point is that we are always going to struggle to resolve this and thus we should expect and plan for it. Action cards are the obvious solution and they are a widely adopted solution. There is varierty though and although they’ve been around for ages in a variety of formats I do think they can be improved. When setting up the HMIMMS course we looked at many different types of action card and subsequently designed those that allow staff to function as normally and as safely as possible (see tip number 5). Action cards should incorporate information on what is required of each person, but also how they fit into the system of care during the major incident response. You can see an example of a well designed action card for a critical care lead clinician below (click on the link for the CC Nurse). The cards incorporate where the staff fir into the overall plan, what their priorities and how a major incident response builds. Note that it is not micro managing what they do as clinicians, but sets the relationships and the priorities for the response. We must and should expect that clinicians can do the clinical job that they are tasked to deliver. Our role as planners is to try and make their clinical role as easy as possible under exceptional circumstances.
Your task – Find and read your action card. is it fit for purpose? Does it make sense?
2. Have a structure that reflects reality.
Hospitals are incredibly complex organisations, and each is complex in it’s own way. Major incidents add an additional level of complexity which is felt most keenly during the inital reception phase and initial management of patients. It is therefore nuts to try to simultaneously completely restructure a hospital’s processes at the same time as receiving casualties. The aim should usually be to try and continue normal processes wherever possible, for example, don’t put a nurse from a medical ward in charge of the minors end of the ED during a major incident. Everyone will end up getting confused and patient care will suffer. In a major indident always try and do ‘more normal’ as opposed to ‘something completely different’.
So the principle is that normal processes should take place, but some understanding and description of how to get things done will help everyone. HMIMMS uses a three hierachy model to demonstrate the links between key decision makers within the medical, nursing and managerial hierachies. The medical hierachy is shown below.
We have kept the number of essential decision making roles to a minimum to allow the hierachy to be expand and collapse depending on the size of the hospital and the build up to a response, we call this a scalable hierachy (see point 5 below).
Some structure is important but keep it to a minimum and try to make it look like normal working practice. on the action cards outline the key relationships for everyone using a diagram. Make sure that everyone understands who they report to and who they are responsible for.
On the action card below see how it shows the key organisational relationships for that individual.
Task – Does your structure in the major incident plan reflect reality or is it some fantasy invented by someone who does not understand how your department would need to work in a major incident? If concerned then go have a chat with your emergency planning team.
3. Be normal
If you are unlucky enough to be involved in a major incident then you are going to be stressed regardless of where you are in the hierachy. There is no point in piling on additional stress by then asking you to do a job for which you’ve never done before. Wherever possible the strategy of an effective plan will be to do normal work, but just more of it than usual.
The point here is that all the roles in the hierachies are descriptive of normality and not suddenly made up on the day. For example, in the past a new role of ‘Triage Officer (doctor)’ was typically described as an essential role in a major incident. Their role as a senior doctor (usually nominated to be a Surgeon) was to stand at the front door of the ED and triage the patients. Really? How could putting a clinician who does not work in the ED, into the ED, to perform a role that they’ve never done before, on the presumption that it will be trauma (it might not), whilst displacing the ED triage nurses, who are trained, capable and familiar with the role ever be considered a good idea? Honestly, go and have a look at your plan right now and I’ll guarantee that many of them will still suggest this.
Hospitals are complex and difficult places to work and the days when staff could be easily moved about to fill in gaps are diminishing. Whilst flexibility may be important and in the early stages of an incident may be essential, wherever possible return clinicians and roles to as normal as possible, as soon as possible.
As an example, have a look at your major incident plan call in systems and consider how they are ‘planned’ to work. Many will involve complex paper based telephone lists and yet most of the teams I work in use social media like Yammer or What’s app to keep in touch. In a recent exercise 90% of our EM consultant team responded within 10 mins using What’s app detailing their availability and transport times (in other words faster than the time it would have taken us to make a few phone calls). We must aim for and embrace normal practice like this even if it does not fit with the preconceived planning template.
Task – Within your department how much of the major incident plan is novel or contrary to normal working practice? Can you minimise the novelty and return to normality?
4. Where and When?
Major incidents are no respector of time nor place. Whilst they are inevitably more common in large urban centres they can take place anywhere. This is widely recognised and I think everywhere understands that the response in a geographically isolated location such as Jersey is going to be different to one in Manchester. When we think of geography it’s obvious and intuitive. What is perhaps less obvious is the effect of time on the ability to respond. Most hospitals will be at maximum capacity on a weekday morning. Staff will be present in larger numbers, elective patients will be waiting for their journey to begin, discharges may be planned and off duty staff will be more likely awake. Contrast this with 2am on a Saturday night. Hospital capacity may be high, the ED will already be full, staffing will be at it’s lowest level and those off duty will be asleep, intoxicated, somewhere else, or possibly all three. The point is that we cannot expect the same response at all times of day and night. the starting point of a major incident response is the on site capacity of that hospital when the call arrives (or the patients arrive – as that may happen before the call).
Planning must therefore take account of this to deliver a safe response irrespective of time or geography. Similarly a major incident response must take account of current ED workload as normal care and patient loads will not necessarilly diminsh9,10,11. One major incident I was involved in also required us to manage a lad in the late stages of labour and a child with severe meningococcal septicaemia. Plans must presume a worst case scenario and be deliverable with the minumum on site staff available. Does your plan recognise this?
Task – Would your major incident plan be deliverable at all times during the (24/7) week?
5. Scalable Hierachies.
In the HMIMMS model we recognise that hospitals come in different shapes and sizes, and that the ability to deliver a comprehensive incident response changes as an incident progresses. That’s why we developed the idea of anscalable hierachy to support the initial phases of an incident. We originally called this a collapsible hierachy suggesting that the full picture could be collapsed down to minimal numbers during the early stages of an incident. We now think of it as a scalable hierachy that can be used to reflect the evolution of an incident, but also the scalability if applying this to a smaller hospital or to one with limited on site services. In essence the major incident plan is organised around three groups of staff, the medical teams, the nursing teams and the managerial teams. These are placed into organisational hierachies that clearly show how information and organisation flow during the response.
- Red roles are command and control roles designed to structure and control the flow of patients, information and resources within the response.
- Yellow roles are additional command and control roles that may be used in a large organisation or response (but are not essential to an effective response).
- Green roles that deliver care/support in a manner typical of normal practice
The expandable hierachy supports the natural evolution of a major incident response. It also allows the same structure, with the same terms and same roles to be deliverable across a range of hospital sizes and structures. In the intial phase of an incident all the red roles must be filled, and are filled from whoever is the most senior person in that job, on site, at the time of the incident. Red Roles always get filled before green roles, and yellow roles are added last as the incident response progresses or in larger hospital responses. Scalable hierachies exist for nursing, medical and managerial roles as an overall planning tool, but in contrast the action cards themselves show how an individual relates both within and between hierachies.
Task – Are your action cards and strucutres able to flex and expand as an incident develops or are they designed around the myth that everyone will already be in the hospital?
6. Regionalisation is a blessing and also a problem
The last 10 years in the UK have seen major changes in the way that we organise healthcare. The most obvious of these for major incident planners are the changes around major trauma networks. The role of major trauma centres in a traumatic major incident is clearly obvious and there are good reasons why this should be done. London makes a good case for the ability of a group of trauma centres to come together to deliver a coordinated response6, but this cannot be the case in all areas, notably those who are geographically isolated from other centres.
We have also risked deskilling non MTCs in the management of major trauma patients. Major trauma systems are designed to prevent patients with serious injury ending up in anywhere apart from the MTC. This may not work in a major incident and thus we need to build collaborative systems between organisations to assess, coordinate and retrieve patients who end up ‘in the wrong place’ through no fault of their own. Consider this not just from an anatomical injury perspective but also from how we have changed our approach to imaging, investigations and critical care capacity.
Patients are highly likely to end up in the ‘wrong’ place. Our current MTC systems have great systems to get the right patient to the right place but in a major incident that capacity, especially for for air transport, may be rapidly exhausted and may be better used to distribute staff and resources11.Neuro, PICU and cardiac are entirely separate beasts these days. Have you thought about what would happen if the local childrens hospital was the site of a major incident? Or even if not, ambulance crews are unlikely to separate parents and children at the site of any incident? Critically ill children would arrive at your doorstep. Transport services would likely be overloaded and unable to help. How would you cope? Do you have paediatric vents? Do you have paediatricians? Are your nurses trained? You can and should think about these problems as part of your planning process.
Task – Look at the geography of your region. How and where could an incident take place and where would the patients go? How will you manage those in the wrong place?
7. The all hazards approach
I understand that the best time to sell earthquake insurance is just after an earthquake. This makes no sense of course as the liklihood of an earthquake diminishes after a big one. As humans this is common as we succumb to an availability bias based on what we see and experience. Major incident planning can be a bit like that. In the UK at the moment we are all very exercised against terrorist threats. Many conferences and meetings are aimed at ensuring that we can respond to another car attack, Mumbai type attack or some other atrocity. This is of course perfectly fine and natural but it should not distract from the most important aspect of major incident planning, that of a generic, all-hazards approach. We must not only expect the expected, which is currently a terrorist attack, but also ensure that we can respond well to all types of incidents. Transportation incidents, mass gatherings and natural disasters are still going to happen and probably (well hopefully really) with a greater frequency than those in the current Zeitgeist.
Use a common language to plan and respond to major incidents. The MIMMS and HMIMMS courses use the CSCATTT system. This helps us understand the priorities in planning and in response. This system is used across the world in the many countries that the ‘IMMMS family of courses are taught.
Remember that a major incident is defined as an event when the need exceeds the capacity so look at your systems and capacities and look for the pinch points. Look for injury patterns that would challenge you, or patient groups such as paediatrics and burns.
Task – Ask yourself whether you plan would respond to all hazards and look for areas where you have the least capacity to respond (patient type of pathology). How will you address these problems?
8. As fast as we can and only just in time.
Hospitals no longer sit around with excess capacity. Wards are full, operation lists are maximised, critical care beds are at a premium and our emergency departments overflow under normal pressures. A key role for the critical care clinician will be to determine which patients are likely to benefit the most12. Such triage decisions are essential to maximise the response to a major incident and are a familiar task for many critical care clinicians. Such decisions are most likely taken in consultation with surgical and anaesthetic colleagues.
Similarly we no longer hold large stocks of equipment with hospital supply chains operating ‘just in time’ processes which are lean and cheap. The lack of a stockpile of equipment is a problem for devices such as ventilators or monitors, but in reality these can often be sourced from other departments in a hospital. Plans for rapidly increasing the availability of key equipment at short notice should be in place13. This is especially important for critical care14 related items, surgical devices and drugs. Critical care bed availability, and staffing is rarely at anything but near maximum capacity and is a good illustration of why critical care clinicians must be involved in major incident management. Key questions for the critical care team might include questions around how an incident involving large numbers of surgical patients might be managed by relocating to an environment with more access to urgent services. Would you be better to use recovery as the ‘Hot’ ICU so patients could go back and forth as needed, with transfer to the real ‘cold’ ICU only when predicted not to need further acute intervention? Making the best use of resources from a CC perspective invovles creating flow reflecting the needs of the patient types in the incident. It is unlikely that many patients will be immediately dischargeable from an ICU environment as you point out.
Task – Consider how you would equip and staff to facilitate the resuscitation and stabilisation of patients with severe illness or injury.
9. Train your brain before your body
You may have been involved in multi-agency exercises at some point in your career. These are quite a bit of fun when all emergency services get together to walk through a simulated major incident. There is usually a lot of activity around these events, a fair bit of press interest and a feeling that we are getting things done. In truth these exercises are not the only way to prepare and we should arguably be spending much more time training in smaller units and in different ways. As we advocate an approach to major incident planning that encourages normality there is no reason, rather there is EVERY reason, why you should train as a department or team. You need very little to do a table top exercise or to run a workshop on possible scenarios, ideas or challenges.
Make it fun, ALWAYS make it multiprofessional and do it in your own department on a real day with realistic intercurrent requirements. You’ll be amazed at how many problems and difficulties you can detect and manage just by getting a group of clinicians and managers together to think things through.
Task – ask yourself when was the last time you ran a workshop/tabletop in your department on major incident strategies and plans. If never or whenever – go plan one now.
10. Plan for what people are going to do, not what you want them to do
This is really a quote by Eric auf de Heide who wrote the book ‘Disaster Response’ back in the 80s. Even though it’s an old book and much in the world has changed it encapsulates everything that I’ve learned about responding to major incidents. We have to plan for what people are going to do, and what they can do, rather than any imaginarium in the mind of the planner.
As a quote it fits with two other quotes that were on the front of my platoon commanders handbook back in the days when I was with the British Army. Use these to sense check your major incident plans.
‘A failure to plan is a plan to fail’
‘No plan survives contact with the enemy’
Task – Get your major incident plan out and sense check it. Would it really work? Would you be able to do what it says at 0200 on a busy Saturday night as well as 0900 on a Thursday. Would people follow it? Is it a good plan? Would it survive contact with reality?
Look after yourself and look after anyone else who becomes involved in a major incident response. Patients, carers, staff and bystanders will typically find these events stressful. Never forget to be kind, to ask how people are feeling and to listen. Formal debriefs will happen, but never forget the power of informal support, a kind word and a simple question such as ‘how are you getting on’.
I became interested in major incident planning when I was awarded a research fellowship from the Royal College of Surgeons of England. The fellowship was funded from Hillsborough charities who wanted us to look at major incident plans for children, which at that time were rudimentary.
I expect you will all know of the Hillsborough disaster and the subsequent enquiries that have sought to find out what happened on that terrible day when in April 1989 at the FA Cup semi final between Liverpool and Nottingham Forest. A day that should have been a celebration of football but which turned into a horrific tragedy. When the horror of over 700 injured and 80 dead became clear 44 ambulances were despatched yet only one was allowed into the ground. No satisfactory plan was in place to deal with such an catastrophe either in the ambulance service or at the local hospitals. I vividly remember the profound effect it had on me as I helplessly watched events unfold on the TV as I was revising for 3rd year med student exams in Manchester. Take a moment to remember the real impact of major incidents, on families, patients and the victims of these tragic events. Clearly we have a duty to do our very best for those involved on what may be the most tragic and challenging day of their lives.
The fellowship founded my interest in major incident planning and led myself and colleagues to examine UK Major Incident epidemiology15, planning1617 and other specialist incidents18,19,20,21,22,23,24,25,26,27. The project delivered several papers and helped inform UK major incident planning. I am incredibly grateful to the Hillsborough charity and the Royal College of Surgeons for the opportunity to work on this project.
References and further reading