BJA Education, 16 (10): 329–333 (2016)

doi: 10.1093/bjaed/mkw006
Advance Access Publication Date: 6 May 2016
Matrix reference 1I02,
2A02, 2C07, 3A10

Hospital response to a major incident: initial

considerations and longer term effects

Downloaded from http://bjaed.oxfordjournals.org/ by Syed Zeeshan Javaid Hashmi on December 17, 2016
C Johnson MBBS FRCA FFICM RAMC1 and J F Cosgrove MBBS FRCA FFICM2, *
1
Specialist Registrar in Anaesthetics and Intensive Care Medicine, James Cook University Hospital,
Middlesbrough TS4 3BW, UK and 2Consultant in Anaesthetics and Intensive Care Medicine, Freeman Hospital,
Newcastle upon Tyne NE7 7DN, UK
*To whom correspondence should be addressed. Perioperative and Critical Care, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK. Tel: +44 191 2231059;
Fax: +44 191 2231180; E-mail: joe_cosgrove@hotmail.com

major incident, the trust was able to cancel non-urgent elective

Key points
• Read your institution’s major incident plan.
• Practice the major incident plan—clinical and non-
clinical staff.
• Command, control, and communication are essen-
tial components of management.
• Consider how your department would manage on-
going care of mass casualties.
• Staff will require physical, social, and psychological
support during and after a major incident.
All NHS providers in the UK are required by law to prepare for
large-scale emergencies and major incidents.1 A health-related
major incident is described as any occurrence presenting a serious
threat to the health of the community. It is likely to involve disruption
of services and require the implementation of special arrange-
ments by hospitals, ambulance, and primary care trusts.2 For
hospitals, this manifests itself as the major incident plan which
focuses on a specific trigger e.g. the London bombings in 2005
were external major incidents that immediately created more
than 700 casualties.3 Communications from ambulance control
generally activate hospitals’ major incident responses. Prehospi-
tal response subsequently directs casualties to local emergency
departments, although more recently NHS trusts have activated
internal major incidents because of overwhelming service pres-
sures e.g. in January 2015, a demand for in-patient beds out
stripped availability at Peterborough Hospital.4 By declaring a
operations and emphasize the need for local primary care trusts,
social services, etc. to expedite the discharge of medically fit pa-
tients requiring non-clinical support.
With respect to (the more usual) external major incidents,
the majority of hospitals have plans based on prehospital inci-
dents that tend to deal with events in the emergency depart-
ment and immediate care of severely ill or injured patients.
This may only be for a 6–8 h period; however, there are the so-
called consolidation and recovery phases of a major incident
(Fig. 1) that can impact upon the NHS trust for days, weeks,
and months afterwards. These phases are inconsistently dealt
with and historically NHS trusts have put little resource into
such longer term effects; however, recent experiences such as
the London 7/7 Bombings have brought experience and data to
strategic planning.5,6
The hospital major incident plan
Each institution is likely to have a variation on a standard major
incident plan and it is important that staff likely to be engaged
by a major incident have read it and where possible participated
in simulation training: it is too late to do so once a major
incident has been declared. It is impossible to make detailed
plans for every eventuality, so a flexible framework can enable
responses to multiple forms of major incident. This begins with
an understanding of the four basic major incident alerts
(Table 1) and the generic outline of a major incident plan
which involves preparation for arrival, freeing of resources, and
deployment of staff. Subsequent organization and management
involves the arrival of casualties, assessment of injuries, and initial
treatment.

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329
Hospital response to a major incident
Preparations for arrival
This relates primarily to understanding the categorization of
major incident alerts: major incident stand-by, major incident de-
clared, major incident cancelled, major incident stand-down (Table 1).
Freeing resources
Many acute NHS trusts may be functioning at ∼90% capacity
across all services and with a recent decline in the number of in-
patient beds, issues such as dischargeable patients requiring so-
cial care may be significant. Within the hospital specialist
services e.g. intensive care units, operating theatres are often run-
ning at near maximum capacity. Creating space to receive severe-
ly injured casualties can therefore be challenging and in addition
to physical space, there will be a need to increase staffing levels
for the initial surge period and (importantly) for the consolidation
and recovery phases, which could be a period of weeks.7
Part of the major incident response is the expedited discharge
of ward patients and the cancelling of most elective surgery (on-
going surgical emergencies and transplant surgery are usually
exempt, but this will depend upon required theatre capacity).
This process creates space for patient movement within the hos-
pital including internal ‘step-down’ transfers from level-3 (inva-
sive ventilation/multi-organ support) to level-2 care (single organ
support/non-invasive respiratory support) or level-2 to level-1 care
Fig 1 The stages of a major incident. London Emergency Services Liaison Panel.
Table 1 Major incident alerts
Major incident Definition
terms
Major incident An incident has occurred but is within its early stages. It has
standby the potential to escalate and demand the extraordinary
response of the receiving trust
Major incident This cancels a major incident standby call
cancelled
Major incident This can be declared either with or without a preceding
declared standby status. An event has occurred which mandates
that a trusts major incident plan is activated
Major incident The major incident is perceived to be over and a plan to revert
stand down the trust to normal operation will be made
330 BJA Education | Volume 16, Number 10, 2016
(ward-based support), etc. Alternatively (or simultaneously), critic-
al care capacity (level-3 and level-2 beds) can be expanded by util-
izing space in theatre recovery areas and anaesthetic rooms where
there is a familiarity with caring for ventilated patients.
Inter-hospital transfer of patients across a critical care net-
work may be possible/necessary. This will inevitably depend
upon bed availability elsewhere with the major incident and cas-
ualties potentially impacting on more than one acute NHS trust.
Other compounding factors that planners need to consider are
transfer teams and availability of transfer vehicles. The former
usually requires experienced anaesthetic/intensive care doctors
and nurses being taken away from patient care and the latter
will be dependent upon how the local NHS Ambulance service
is coping with the incident. Charitable and private companies
can be utilized for this, as can neighbouring NHS Ambulance
Trusts. Significant communications are therefore necessary in
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both contingency planning and the aftermath of incidents.
Deployment of staff
The time of day that a major incident is declared dictates the
number of immediately available staff. The person in charge of
each clinical area should ensure that staff are allocated according
to need and skill set. The ideal situation for all severely injured
(P1) casualties is that they are received by a trauma team whereby
emergency department staff and surgeons triage and initially
manage individual injuries. Within the team, it is essential that
there is a constant presence of an anaesthetist and trained assist-
ant who will follow the patient through the resuscitation room,
imaging areas, operating theatres, and on to intensive care.
This improves continuity of care and information transfer min-
imizing the likelihood of errors in treatment, particularly the ad-
ministration of drugs, blood, and blood products.
Arrival of casualties
There is a high chance that the arrival of casualties will not be
as controlled and co-ordinated as is intended. Many ‘walking
wounded’ where treatment can be delayed (P3) and uninjured
may self-present or be transported by bystanders. While many do
not require immediate treatment, they pose significant organiza-
tional issues through weight of numbers and the fact that one or
two may be delayed presentations of serious injury. Additionally,
while the priority is to transfer the seriously injured, first their res-
cue may be hampered by access to the scene and consequently
Actions
Confirm that standby action ONLY is required. Initial key
personnel on major incident call out list are contacted
The key personnel are again contacted and stood down
All personnel on the major incident call out list are notified.
They should retrieve their major incident action cards and
proceed to their designated location. As further information
is obtained, actions to create extra space and prepare to
receive casualties are undertaken
Personnel on the call out list are informed that the major
incident plan is being stood down. This may be in
conjunction with a recovery plan to transition the trust back
to normal operational service

their arrival in the emergency department may follow the earlier
arrival of P3 casualities, despite the best efforts of organization at
casualty clearing stations.
To minimize delays and further prioritize treatments and care,
an in-hospital triage area should be established within the emer-
gency department. This is usually close to the ambulance bay but
should also take into consideration landing areas of air ambu-
lances. A senior clinician (ideally an Emergency Medicine Consult-
ant) should be the designated triage officer making further rapid
assessments of injury severity and allocating a triage priority:
P1 (immediate life-saving interventions), P2 (interventions within
2–4 h), or P3 (less serious: treatment can be delayed beyond 4 h).
Patients are moved to appropriate treatment areas within the
emergency department. Constant review is necessary as P1/P2
casualties can improve and P2/P3 deteriorate. It is therefore im-
portant to be receptive to changes in triage category with time.8
P3 casualties usually make up the largest number of people
requiring treatment. Many do not require admission but may re-
quire follow-up and contingencies for this will therefore be ne-
cessary. Planning should therefore consider an area outside the
main emergency department where such patients can be triaged,
assessed, and treated. If this can be done, distraction from the
care of the severely injured is minimized.
Nature of injuries
Injury patterns are determined by the nature of the major inci-
dent, although the majority within the developed world involve
trauma from explosions, collisions, and building collapses.
Table 2 summarizes the nature of injuries suffered during the
Madrid and London bombings.8,9 Those close to the bomb are
usually killed outright, meaning the injuries are often a conse-
quence of the blast wave and flying debris.
In summary, it is important to obtain as much information as
possible from the scene before patients arrive at hospital in order
to direct specific treatment priorities (e.g. burns) and to protect
hospital staff and infrastructure e.g. after CBRN (Chemical, Bio-
logical, Radiological, Nuclear) incidents where specialist services,
training, and equipment are required.
Initial treatment: damage control
Standard management of seriously injured casualties from a
major incident now involves damage-control surgery and damage-
control resuscitation.10 Of note, only 51 of 270 P1 and P2 casualties
required surgery in the first 24 h after the Madrid and London
bombs.8,9 Damage-control principles aim to prevent
Table 2 Combined summary of injuries, Madrid and London bombings
Type of injury Critically injured Non-critically injured
population (n=35) population (n=235)
Tympanic perforation 26 (74%) 118 (50%)
Chest injuries 27 (77%) 96 (41%)
Shrapnel wounds 28 (80%) 99 (42%)
Long bone fractures 13 (37%) 16 (7%)
Burns (superficial and 18 (51%) 47 (20%)
partial thickness)
Eye injuries 7 (20%) 42 (18%)
Traumatic brain injury 17 (49%) 33 (14%)
Abdominal injury 10 (29%) 12 (5%)
Traumatic amputations 12 (34%) 14 (6%)
(limbs, digits, ears)
Hospital response to a major incident
hypothermia, acidosis, and coagulopathy, all of which are asso-
ciated with increased mortality. Methods used include:
• early haemorrhage control of visible bleeding,
• limited crystalloid resuscitation with permissive hypotension,
• blood product resuscitation aimed at the clinical condition ra-
ther than laboratory values (ideally guided in part by point-of-
care coagulation testing e.g. TEG or ROTEM),
• active warming of fluids and (where necessary) patients,
• surgery with an endpoint of haemostatic control only,
• stabilization in critical care to normalize temperature, clot-
ting, and pH,
• return to theatre for definitive surgery once physiologically
stable.
Radiological imaging is a valuable tool for assessing trauma pa-
tients and identifying internal injuries; however, damage-control
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surgery should not be delayed by a wait for imaging.
Command and control
Within the UK, local NHS headquarters provide a command and
control framework for major incidents. It follows a similar format
to the prehospital structure.2
Strategic (gold) command
Normally chaired by the trust’s chief executive or nominated
deputy. It is responsible for acting upon the longer term conse-
quences of a major incident e.g. the financial impact, planning
the recovery phase, and return to normal operations. They also
have a role in media liaison and tend to delegate the direct inci-
dent management to tactical command (see below).
Tactical (silver) command
Directed from a designated operating theatre. It determines the im-
pact of the incident on the trust and makes decisions about staff de-
ployment and the use of resources. It delegates the responsibility of
running individual departments to multiple bronze commanders.
Depending on the organization structure within the hospital,
there may be direct communication with tactical command at the
scene of the incident or the local ambulance NHS trust may provide
an Ambulance Liaison Officer (ALO) to the hospital’s operational
command with the emergency department (see below).
Operational (bronze) command
Usually organized on a departmental basis, with commanders
being senior doctors and nurses. Their role is to co-ordinate pa-
tient flow, ensuring tactical command receives timely updates
about patient numbers and resources in use. This is of particular
importance in operating theatres and critical care areas. These
people tend not to be directly involved in clinical care but receive
information from clinical teams that is used to prioritize care.
Communication
Clear communication is essential. In a major incident, traditional
methods of communication (telephones, bleeps, etc.) may fail
either from internal overuse or saturation of the hospital switch-
board from outside calls as people attempt to gather information
e.g. relatives of casualties, staff not yet at work, media organizations.
Communications’ contingencies therefore have to enable the trans-
fer of information between staff for the purpose of clinical care and
also provide information to relatives and media.
BJA Education | Volume 16, Number 10, 2016 331
Hospital response to a major incident

Fall-back plans for internal communications include the use of Visiting dignitaries
handheld radios in key areas by key personnel and the use of run-
Within 24–48 h of a major incident, it is inevitable that dignitaries
ners. This can be the most reliable way of transferring information
will visit the affected area and the injured in hospital. In the UK,
in a chaotic environment. Written messages are carried by run-
such people will almost certainly be Members of Parliament in-
ners and retained as part of the records of the major incident.
cluding Cabinet Members (UK and or devolved nations) and
From a clinical perspective, the most reliable way of accurate
may include members of the Royal Family. There are inevitable
information transfer in a major incident is to have the same clin-
security issues (especially in the wake of a terrorist incident). Ad-
ical team looking after the most severely injured patients from
vice from the Police will be provided under such circumstances
the emergency department through imaging and surgery (see
and consideration should also be given to any potential disrup-
the Deployment of staff section). This maintains continuity and
tion to patient care during an incident’s recovery phase.
minimizes the loss of vital information. Assigning one person to
record keeping on wards and intensive care units can also assist
the flow of information. During the 7/7 bombings, the Royal Lon-
don intensive care unit assigned one doctor to create a database Staff working patterns and welfare
of patients being admitted to intensive care. This included listing
Critical care staff will play a significant role in dealing with on-
injuries, investigations outstanding, and procedures performed.

The after-action review held this document to be extremely use-
ful in organizing subsequent care.5
With respect to relatives, the media, and the general public:
ambulance services assign liaison officers to the NHS trust;
they will be party to all communications about casualties and
their management. Similarly, the police designate a liaison offi-
cer who works with a hospital representative in disseminating
information in a consistent, co-ordinated manner to the media,
etc. Advising people to use dedicated help-lines or specific links
to social media can also ease telecommunications overload on
the hospital switchboard. A dedicated police team will also re-
unite casualties with friends and family.
Aftermath
As stated, a hospital’s main focus in a major incident is the re-
ceipt and resuscitation of large numbers of seriously injured cas-
ualties with a concurrent increase in capacity. After the 7/7
bombings, the Royal London Hospital stood down from a major
incident 5 h post-event with the emergency department re-open-
ing to trauma.5 At this point, the operating theatres were working
at full capacity and the critical care unit had not received its full
complement of patients from the incident.5,8 Such actions have
the potential to further overload pressured systems. Thus, the
ongoing care of the patients admitted from the incident should
form part of a major incident plan as the impact of their admis-
sion and treatment is beyond a period of a few hours (see below).
Ongoing care
After the initial period of damage control resuscitation and sur-
gery, the majority of the critically injured will be further stabi-
lized in critical care. To identify missed injuries, they should
undergo secondary and tertiary trauma surveys and more in-
depth and specific investigations (laboratory, radiological, etc.).
They are likely to require multiple transfers to radiology and op-
erating theatres with an associated prolonged intensive care
length of stay. After 7/7, the intensive care at the Royal London
had a 12 day median length of stay (maximum 22 days), compar-
able with the median of 10 days after the Madrid bombings.8,9
Furthermore, the Royal London Hospital required an additional
180 h of operating theatre time beyond elective and other emer-
gency work. There were inevitable disruptions and cancellations
to accommodate the increased need with subsequent knock-on
effects for elective surgical waiting lists. Planners must therefore
be aware of this impact and be able to review figures of elective
and usual emergency work to assist in contingency planning re-
lated to the aftermath of a major incident.
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going care. Rotas may have to be organized and split i.e. casual-
ties and usual workload. The requirement for extra staff may
result in significant change to shifts for weeks afterwards.
The psychological wellbeing of all the staff involved in the ini-
tial response and the aftermath of a major incident is paramount.
This is particularly relevant to intensive care staff as they will
have to interact regularly with the sickest survivors and their
families. All staff should therefore be encouraged to participate
in de-briefing exercises and be offered counselling and support
as required.
De-brief and future preparedness
This is arguably the most time-consuming part of a major inci-
dent. It will include action reports, follow-up, debrief, and even
preparation for inquests, etc. (Fig. 1). The process may take
months to years and lessons learned in individual cases should
be disseminated throughout the medical community to improve
on responses when other major incidents inevitably occur.
Summary
Providing clinical care to casualties is the comparatively ‘easy’
part of in-hospital major incident management. The organiza-
tional response required is wide reaching and the impact of re-
ceiving even a relatively small number of critically injured
casualties has implications for an Acute NHS Trust lasting for
weeks/months after the incident.
The key is to plan, be flexible within the plan, and to train staff
in advance so that if and when a major incident occurs, the insti-
tution can respond to provide both effective care and organiza-
tion in the incident’s aftermath.
Declaration of interest
In 2015 Dr Cosgrove received a grant of £5000 from the Hillsbor-
ough Family Support Group to develop guidance pertaining to
the provision of Events Medicine Services. This includes major
incident contingency planning.
MCQs
The associated MCQs (to support CME/CPD activity) can be
accessed at https://access.oxfordjournals.org by subscribers to
BJA Education.

332 BJA Education | Volume 16, Number 10, 2016


Podcasts
This article has an associated podcast which can be accessed
at http://www.oxfordjournals.org/podcasts/bjaed_Prehospital
and Hospital Major Incident Management_Dr Cosgrove_
BJAEducation_Oct2016.mp3
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