Preparing for Emergencies- Guidance For Health Boards in Scotland

The document provides strategic guidance for Health Board Chief Executives and NHS Senior Managers on fulfilling their obligations under the Civil Contingencies 2004 and other key legislation underpinning emergency preparedness, response and recovery.

Appendix 7

Planning And Preparing For Mass Casualties Incidents

This appendix provides additional information for Health Board resilience leads to consider when planning for mass casualties incidents (MCI).

Optimising health care in a MCI

The principles of optimising healthcare in a MCI should be that:

People will be:

  • provided with the best care available under the circumstances
  • initially treated by the (category 1 & 2) responders most skilled in their management, as soon as possible after the incident occurs
  • triaged and treated in the first instance, wherever possible or transported to the nearest or most appropriate health care facility, as resources allow.
  • Health care resources will be:
    • re-prioritised to meet the unexpected increase in demand
    • maximised to capacity and/or used intensively and appropriately to save the maximum number of lives, and to minimise morbidity
    • used for seriously ill patients, not related to the MCI, throughout the emergency situation.

Taking account of the challenges

Aside from the significant number of casualties, a 'sudden impact' or 'no-notice' MCI is likely to generate a range of challenges for NHS responders at the scene of a major incident:

  • Location: MCIs, especially transport accidents/collisions, may occur in locations where access and egress for emergency services is difficult. Travel time to the scene itself may be considerable;
  • Scene access: Paramedics may be reliant on specialist rescue capability (e.g. Fire and Rescue) to gain access to casualties or be barred from entering the 'hot zone' until it is deemed safe by Police/Security Services;
  • Transport resources: The large number of casualties may overwhelm the Scottish Ambulance Services' available transport resources;
  • Weather: Severe or adverse weather conditions may affect the actions of first responders, e.g. treatment at the scene, telecommunications;
  • Healthcare capacity and capability: As health boards' capacity is generally based on the assessed/anticipated needs of their local population, the nearest receiving hospital may have insufficient capacity and capability to treat the number of (multi-trauma) casualties and patients and they may need to be transported to another health board or health care facility. Within the receiving hospital, changes in the practice of some health professionals may need to occur through necessity;
  • Time delays: There is a high likelihood that the above challenges will result in time delays for the casualties to access treatment.

Identifying capacity

The following table is intended to assist Health Board resilience planning leads to work with partners on the Regional Resilience Partnership to identify reasonable worst case scenarios for various types of incidents and associated casualty numbers.

The table below can be used to identify the capacity within the Health Board to respond to the potential impact/consequences of various types of incidents and ultimately, capability gaps.

Planning assumptions for mass casualties triage scenarios

Adults Children Risk (description and casualty impact ) Capacity within the Health Board Implications for particular clinical/healthcare services
Priority (P) 1 Immediate (25%)
Priority (P) 2 Urgent (25%)
Priority (P) 3 Walking wounded (50%)

The planning assumptions (triage proportions) identified in the table above (25%-25%-50%) is generally used for a range of risks, although it is acknowledged that the consequences of MCI's will vary greatly.

The number of adult/child casualties for each risk/scenario may exceed Health Board(s) capacity within the local RRP area and the MCI may require rapid capacity-escalation by one or more of the other local Health Boards as well as patient transfers out of the area.

Responding to a mass casualties incident - roles of key agencies and groups

The Table below outlines in general terms the roles and responsibilities of agencies at various levels. It is not intended to be either prescriptive or comprehensive.

Organisation Role Key Actions and Outputs
Scottish Government

Activate SGoRR

Monitoring and surveillance

Inform and advise Scottish Ministers

Provide national coordination

Liaise with COBR, if necessary

Advise and reassure the public

Assess financial and resource implications and/or requirements

Liaise with international agencies, if necessary

Maintains an up-to-date overview of national critical care capacity, derived from Regional Resilience Partnerships

Provides strategic direction for the NHS and the particular health board involved and ensure that all other health boards are in readiness to support

Assesses whether mutual aid is required from other nations in the UK if local capacity and capability is overstretched or inadequate

Assesses the impact of the incident on scheduled work of the board(s) and what action needs to be taken

Obtains advice from Health Protection Scotland/STAC

Maximises available communication channels to inform the public

Manages national debrief and evaluation of events

Local and Regional Resilience Partneships

To engage partner organisations in the development and implementation of a local integrated emergency plan for the LRP/RRP area.

To provide coordinate the responses of members.

To assess the ongoing situation, identify, potentially escalate issues and report emerging issues to SGoRR

To gather information from agencies as part of debrief and learning process and modify plans accordingly

The LRP/RRP has:

Obtained health board partners' agreement to coordinate and/or set strategic priorities for local NHS and healthcare for duration of incident

Ensured that all health boards have an identified Executive-level Director with a clear remit and delegated authority from the Chief Executive to contribute to multiagency strategy-setting and response. The Health Board representative has the delegated responsibility to speak for the combined response of all contributing Health Boards

Ensured that LRP/RRP partners have bi/multi-lateral Mutual Aid Agreements (MAA) that in the case of Health Boards:

  • Are annually reviewed and signed by Chief Executive;
  • Address Clinical Governance issues
  • Have been cross-referenced with local authorities;
  • Are collated to form one MAA for the RRP that is signed-off by the RRP Chair;
  • Are reviewed and tested on an annual basis. Healthcare providers are involved in testing and exercising

Plans and procedures have taken account of the needs of people with disabilities and or those who are vulnerable.

A communications strategy

Clearly identified trigger points for escalation to Scottish Government

Territorial Health Boards

To improve the health of the population, address health inequalities and provide high quality services

To work in partnership with community planning partners to protect and address the needs of vulnerable people

To provide specific or specialist health care for casualties and support for responders

To commission services that enhance the health and wellbeing of the local population

Health Board level
There are arrangements to increase and maintain extra capacity in the event of an incident resulting in large numbers of casualties, including procedures for all elective activity, identifying patients available for rapid discharge, supplementing available equipment and making alternative use of specialist/day care facilities

An assessment has been made of equipment and supply issues, notably supply-chains for critical items in an emergency - the option of establishing an emergency store holding a limited stock has been considered

Available capacity in private healthcare sector has been identified

NHS 24's role in providing advice (and triage) agreed so that only the most serious patients attend or are admitted to hospital Account taken of the needs of the population as well as healthcare staff during the recovery phase of the incident and post crisis response

Account taken of the needs of casualties who are vulnerable and/or have a disability

Acute sector
Plans exist for using existing capacity more intensively to create extra capacity for a higher level of dependency

Additional appropriately trained and equipped clinical support can be provided at the scene

Hospital BC plans reflect the need to maintain critical clinical and managerial functions during disruptive challenges

Mitigation of the impact of the incident and other scheduled work and resource availability is considered

There are arrangements for senior clinical managers to temporarily realign treatment protocols to re-prioritise patient care and adapt normal clinical practices, if necessary

Non-acute facilities are identified to supplement maximum bed capacity (e.g. in independent sector) by agreement with local authorities

Unused physical capacity (disused NHS wards) or beds in the independent sector, and options for utilising hotels, local halls of residence etc are pre-identified with local authorities and relevant organisations

There are plans for managing large numbers of people making contact in person or by phone with hospital services

Receiving hospitals have agreed plans with local police to document casualties and details of the deceased and share this information with the Casualty Bureau, ensuring that these plans are integrated with those of the local authorities for providing people with humanitarian assistance and/or using Rest Centres

Arrangements have been made with local authorities and primary care to assist in expediting appropriate early discharges from acute care wards

A cohort of recently retired (medical and nursing) staff are trained/retained to assist in critical care skills and a group of existing staff have been trained and supported to work in different ways in the event of mass casualty incidents

Staff in critical care services are advised/aware that they may have to work in a different way in an emergency and there are action cards to highlight what would be expected of them, backed up by a training programme

Primary care services
Primary care contractors have a clear understanding of what is expected of them during a major incident involving mass casualties, and have business continuity plans to manage the impact of an incident with a large number of casualties affecting their service and staff

Health board/acute sector plans identify how GP's and primary care staff can assist in setting up facilities away from acute hospital services to triage, diagnosis/ treatment and support of patients who are not obviously seriously ill or injured

There are contingency plans, developed in conjunction with relevant local authorities to maintain patients in the community and to reduce/avoid referrals to acute hospital services

Arrangements have been agreed with GPs and community staff so that they can be deployed to supplement acute sector services if required. The arrangements have addressed issues around clinical indemnity and support for practitioners working in a different environment, away from their normal place of work

The emergency care skills of primary care staff have been pre-identified so that they can be deployed/directed to key emergency roles without delay and on a phased/staggered basis during the incident

Scottish Ambulance Service (SAS)

To respond to emergencies, deliver safe and effective person- centred pre-hospital emergency care

To prioritise resources in order to save life and improve health outcomes

To establish command, control and coordination for healthcare activity at the incident site

To continue to deliver pre-hospital emergency care in Scotland, in liaison with partners, coordinated at national level

SAS will:

advise the health board/hospital and Gold command of the potential number of casualties and nature and severity of injuries

act as the focal point of NHS activity, manage healthcare communications and logistics at the incident site(s) and direct ambulance and medical resources at the site

undertake tactical and operational procedures as agreed previously with Scottish Government, emergency services and other agencies, including the deployment of specialised resources

issue, through the RRP Communications Group, and in partnership with the health board, a public information notice advising the public not to place any unnecessary burden on the 999 system and A&E

have plans to increase capacity to provide triage, treatment and transportation for people in keeping with threat assessments, drawing in mutual aid as needed from voluntary aid organisations, and Ambulance Trusts in England, Wales and Northern Ireland and suitable private ambulance providers

place on 'stand-by' a sufficient number of receiving hospitals and specialist units to cater for anticipated/estimated number of casualties, liaising through SGoRR/NHSScotland Resilience to access facilities outside Scotland

plans and procedures that take account of the needs of injured people with disabilities and or those who are vulnerable

NHS National Services Scotland

Through Health Protection Scotland (HPS) Scottish National Blood transfusion Service (SNBTS) and National Procurement (NP)

To protect the health and wellbeing of the population

To ensure uninterrupted blood supply to the NHS is maintained

To ensure the delivery of goods to hospitals and other facilities that are crucial to support the running of NHSScotland

Arrangements are in place to:

provide accurate and timely advice on health protection issues to the NHS, Scottish Government and the public in relation to the incident

provide advice and support to health boards and primary care services on monitoring the long term health impacts of an incident

provide specialist advice to the STAC cell

Uninterrupted blood supply to NHSScotland

Effective arrangements in place to support Health Boards in the supply of goods required


Email: NHSScotland Resilience Unit

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