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Author: Jonathon Hurley / Codes: XC1 Published: 15/10/2014

If I say ‘major incident’ to you, what comes to mind? I bet most people will have visions of scenes from Casualty or ER, with an upturned train or industry up in flames, and hoardes of injured patients making their way to the ED via ambulances whose crews manage to keep their hair perfect despite crawling in wreckage….

In the real world major incidents can take many more forms, and be a lot less glamorous. In this article, I’m going to look at some definitions of major incidents, the legislation behind them and think about what the ‘typical’ major incident plan looks like.

So what is a major incident? Simply put, it is any incident that requires an extraordinary response from health services – ambulance services, primary care, community services and hospital Trusts. Incidents can also become major incidents for other agencies – police and fire services, local authorities and public health services among others; a major incident for one agency might not be a major incident for another however.

There are lots of factors that might turn an incident into a major incident. Take location: the Grayrigg train crash in 2007 happened in a remote area of Cumbria which was incredibly difficult to access. Temporary roads had to be constructed to allow emergency services to get to the scene. If this had happened in a built-up area, location would have been less of an issue – particularly if there had been a lot of ‘walking wounded’ who could easily be evacuated.

This brings us on to the number of live casualties. There is an important distinction to make between live casualties and fatalities – fatalities are the responsibility of the police and local authorities and won’t involve the ED at all. Live casualties are what concerns us in the ED – these are the patients we’ll be receiving from the scene. The Lockerbie plane crash in 1988 was a major incident for the police and fire services – there were 270 fatalities and wreckage was spread over a huge area. Local casualty departments, however, were not impacted – there were no survivors at all.

Time and day can influence whether an incident is a major incident or not. There might be enough staff in the department during the day to cope with the demands of an incident – but overnight the number of staff drops and the department may not be able to cope. The same goes for staffing variations during the week. The explosion at Buncefield Oil Refinery in December 2005 occurred on a Sunday – if this had been during the week, the surrounding industrial estate would have been full of people at work and the number of potential casualties would have been much higher. A lot of these would have been through fume inhalation – most people associate traumatic injuries with major incidents, but they can equally lead to a lot of medical casualties who require different resources from health services.

Thus the type of casualties can determine whether it is a major incident. Most of our departments can handle medical and surgical patients – but what about children, major trauma or burns? These tend to be looked after by local and regional networks with limited bed capacity. Most hospitals can usually handle a decent number of medical or surgical patients – bring a small number of serious burn cases in, though, and they soon become overwhelmed. I’ll talk more about these specialist services in a later article.

How do major incidents occur? The typical Casualty-esque incident – the train crash, industrial explosion or stadium collapse – is a ‘short sharp shock’: the big bang incident. A large amount of resources are needed for a relatively short amount of time, and the incident comes to an end in an easily defined way. Some incidents may occur over longer periods – infectious disease epidemics, staffing crises, capacity problems – and these are the rising tide incidents. These might need a large amount of resources over a longer time, and can easily cause problems with burn-out of staff or shortages of equipment.

Sometimes public or media alarm over a health issue causes a headline news incident: think about the number of ‘worried well’ that engaged with health services during the influenza pandemic. These sort of incidents also have the potential to cause issues for the health service for a long time after – like the MMR scare in the 90s. Another common kind of incident is the internal incident. Most EDs will have these at varying intervals, most often in relation to capacity and overcrowding in the ED. As hospitals usually have the same teams co-ordinating internal incidents and major incidents, they are usually lumped together in one plan with varying levels of activation.

Another sort of incident is the cloud on the horizon. This is a predictable incident based on risks in the local area – chemical plants, sports grounds, motorways, railways and anything else that might lead to a major incident. These kind of incidents can be planned for ahead of time, so that there is a coordinated response from all of the emergency services if anything happens.

While we’re talking about planning, it’s worth thinking about why we bother planning for major incidents? EDs are used to dealing with uncertainty and rapid changes in numbers of patients, so why not just wing it when a major incident happens? For a start, there’s a legal duty to plan for major incidents. This comes from the Civil Contingencies Act 2004 which classes the NHS as a category 1 responder. This means it has a duty to plan and prepare for major incidents alongside other category 1 responders – the police, fire service, local authorities, HM Coastguard, port health authorities and the Environment Agency. Other legislation dealing with sports grounds, chemical plants and other specific kinds of risks requires businesses to work with emergency services to plan for incidents. NHS England publishes a set of core standards which it expects hospital Trusts to meet, and some of these relate to emergency planning.

What does a Trust need to do to prepare for major incidents? Buy-in starts with the Trust board, and an accountable officer. They will often with an emergency planning lead who will have day-to-day responsibility for planning. This lead will usually chair an emergency planning group made up of staff from different specialties, who will each have their own departmental plan which links in with the over-arching Trust major incident plan. They need to have an education programme to inform staff about the major incident plan, and they need to arrange exercises to test the plan. They also liaise with neighbouring Trusts and agencies through Local Health Resilience Partnerships (LHRPs.)

• Emergency Preparedness Framework, NHS Commissioning Board (2013)
• Core Standards for Emergency Preparedness, Resilience and Response, NHS England (2014)
• Civil Contingencies Act 2004

About the Author
Jonathon Hurley is an ST4 trainee in Emergency Medicine in the Northern Deanery. His specialist interests include education, simulation and major incident preparedness.