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Author: Jonathan Hurley  / Code: SLO7, SLO8, XC1 / Published: 15/07/2015

In this article, we’ll look at a typical major incident plan and what it contains. Understanding a major incident plan is part of the curriculum outcome for major incident management, and major incidents may be examined in the FCEM OSCE or SAQ.

We looked at what a major incident is and some of the ways it can be defined in the first article in this series. We also touched on the legislation that means we have to plan for major incidents.

The typical major incident plan will have several parts:

  • The core major incident plan which sets out the organisational arrangements for major incidents and explains these in detail
  • Action cards which explain what each person’s role involves when a major incident is declared
  • Specialist plans which deal with specific issues – for example, incidents involving hazardous chemicals, children or large amounts of patients with burns

We’ll look at each of these in a bit more detail.

The Core Major Incident Plan

Having a written major incident plan is a legal requirement and part of the NHS guidance on emergency planning. It has two functions: to act as the official organisational policy on major incident planning and to be a reference document for staff on the actions required during a major incident.

If a major incident has been declared and you have not read the major incident plan, then this is not the time to start reading it!

Plans will often start with some definitions of major incidents and the rationale for planning. This will often include details about the way that the Trust board delegates planning responsibilities and who the accountable officer and planning lead are.

Notification of Incidents

Next the plan will contain some details about how major incident alerts are received from external agencies, and the procedures for declaring a major incident within the organisation. Usually the ambulance service will contact switchboard to inform them of a major incident alert. The telephonist taking the call will record the details and then will verify the alert by calling the ambulance control room back.

Once it has been confirmed, key members of staff within the trust will be alerted through a call-out cascade. During the cascade, telephonists will contact a small number of key staff to inform them of the major incident. Those staff will then contact others within their area, and so on until everybody is informed.

Three messages may be received by switchboard relating to a major incident. These are:

  • Major incident standby
  • Major incident declared, activate plan
  • Major incident cancelled

When a standby message is received, a core group of management and operational staff are informed within the hospital. This allows them to be ready to step up the response if an activation message is received, but does not call in all staff yet.

The activate plan message is given when an ambulance service requires a hospital to move to its full major incident response. At this stage the Emergency Department is cleared and staff and equipment made ready to deal with patients.

If, after an assessment at the scene, it turns out that there does not need to be a major incident response then a cancelled message will be passed.

Within a hospital a fourth message, major incident stand down, may be issued when the hospital response is complete. This will come from the hospital control team as only they can decide when the hospital response is finished, and the hospital phase of an incident may last well beyond the end of involvement at the scene.

Organisation of a Major Incident Response

Major incident plans will set out the way that teams are organised during a major incident. Teams can work at one of three levels:

  • Strategic – this is at Chief Executive and Trust board level. The strategic team – as there is only one within the trust – has the ability to approve release of funds for equipment and supplies; they also work with other regional agencies to oversee the impact of the incident on the wider community. Also known as the gold level.
  • Tactical – these teams oversee and coordinate teams providing patient care. They maintain an overview of the situation within the hospital and can make decisions about allocation of resources. They liaise with tactical teams in other services to share information. This level is also known as the silver level.
  • Operational – at this level, front-line teams may be involved in direct patient care – for example treatment teams in the ED or theatres – or in providing essential resources to allow this to happen – for example sterile supplies departments and laboratory services. This is the bronze level.

There will be some form of hospital co-ordination team which acts as a hub, overseeing other teams and maintaining control of the incident. They function at the tactical level. This team often exists day-to-day outside major incidents, controlling the normal surges and pressures in a hospital, and is usually made up of senior clinicians, nursing staff and managers. They coordinate the activities of the operational teams, and liaise with the strategic team to ensure a two-way flow of information. They will keep details of bed availability and patient flow throughout the hospital.

Operational teams work in many different places. Within the ED, a triage team will assess arriving patients and decide on their triage category. Usually this is a senior nurse and a senior doctor at the ED entrance. Treatment teams provide direct clinical care. How these are organised depends on your own department, but often involve a senior doctor and nurse overseeing a number of other doctors and nurses in delivering care. We’ll look at triage in another article, but there will usually be a treatment team for each category of patients – immediate, delayed and minor.

Definitive care will be delivered by theatre teams (co-ordinated by a senior surgeon) and medical teams (co-ordinated by a senior physician). Critical care will be co-ordinated by a senior ITU clinician. Other support services will also have their own operational teams – labs, radiology, catering, portering and blood transfusion to name but a few.

Action Cards

During a major incident staff are allocated to roles; the role itself is more important than the person doing it. Action cards are a list of the key tasks that a person performing a specific role must do. There will be an action card for each key role identified in a trust’s major incident plan. The exact roles will differ from trust to trust, but the format of the action cards will be similar. Most include space for logging the time when tasks are completed. When a more senior or appropriate person arrives, the role and action card may be handed over and the original person redeployed elsewhere.