MUH Major Incident Plan - Emergency Department

"A major incident is any occurrence which presents a serious threat to the health of the community and which is likely to cause such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance services or health boards".

The Role of the Mercy University Hospital

Mercy University Hospital is a designated 'supporting hospital' and may have to receive and treat patients redirected from other receiving hospitals if necessary. It may also be required to send staff and supplies to other hospitals or to undertake any other routine services on behalf of Cork University Hospital which will be the major receiving hospital for the City and Region. However, the hospital may be called upon to accept casualties directly from the site of an incident. For the purposes of this plan it is assumed that the hospital will receive 20 casualties for admission, including ICU cases and a larger number of minor casualties.

This plan outlines the basic common actions which will be required in all cases and concentrates upon initial actions. The system is based upon the use of this procedure and ACTION CARDS for key personnel which are reproduced in the appendix.

MUH Major Incident Management Team

In any Major Incident the hospital's responses and actions will be managed and overseen by the Major Incident Management Team. This Team comprises the following people:

a) Senior Nursing Officer

This role will be undertaken by the Senior Nurse on duty in the hospital who will obtain a briefing from the Senior Nurse in charge of the Emergency Department. He / She will maintain this role until relieved by the Director of Nursing.

The Senior Nursing Officer will ensure that sufficient nurses are called in to duty and that major incident bed management procedures are operating. He/She will also set up the hospital Major Incident Control Room in the Ground Floor boardroom using the Major Incident Trolley in the Director of Nursing's office and following the instructions therein.

b) Senior Medical Consultant

The Consultant Physician on call will be the Senior Medical Consultant responsible for leading the clinical response to the incident.

c) Senior General Manager

The Deputy Chief Executive Officer (DCEO) will be responsible for coordinating all support service and administrative staff and for dealing with press and other enquiries from relevant institutions. Out of hours this function will be performed by the Senior Nurse on Duty in the hospital until relieved by the DCEO.

d) Incident Staff Manager

A member of Staff delegated by the Senior General Manager will undertake this role (usually the Human Resources Director). The primary role will be to co-ordinate the arrival of off-duty Staff and volunteers and manage the Staff waiting area located in the small staff canteen on the Ground Floor of the Catherine McAuley Block opposite the main canteen.

e) Chief Executive Officer

The CEO will assume a strategic role. He will liaise with senior managers across the Hospital, with hospitals in the vicinity and with the Southern Health Board, Department of Health, An Garda Síochána and Defence Forces. The critical role of the CEO is to ensure the 'second phase' response by identifying when senior staff need to be relieved due to fatigue and that the hospital does not exhaust all of its resources immediately.

Major Incident Folders And ACTION CARDS

All Departmental Directors and Department Managers must ensure should that there is a Major Incident Folder in each department which will contain copies of Action Cards, a copy of this policy and procedure, copies of any departmental action plans, staff contact lists and useful telephone numbers and email addresses. A common red ring binder will be issued to all departments for this purpose with a copy of this policy and a central list of useful telephone numbers. Individual staff call lists and other relevant departmental information will be the responsibility of the departmental manager to insert. The existence and contents of these folders will be audited routinely and by means of administrative incident exercises. The Major Incident File must be stored in a prominent place in the Department and all staff departmental staff should know where to find it. It is essential that staff contact lists are kept up to date at all times.

Identity Cards

In any incident improper access to hospital departments for both understandable and malicious reasons by relatives, visitors, members of the press and undesirables is quite common. For this reason it is vital that all members of staff possess and wear in a visible position their identity cards. Heads of Department must ensure that all staff have Mercy Hospital Cards, the only exception are NCHDs who may have CUH or UCC cards and Student Nurses who will have a UCC card. Identity cards will also be required for staff to gain access to the IDL site for parking during an incident.

Notification

In the first instance a call will probably be made to the hospital designated Emergency line, situated in the Emergency Department. The Receptionist of Nurse taking the call will establish the following information and record using the Major Incident Communications Duplicate Book which should be stored adjacent to the Emergency line.

• Type of incident
• Location of incident
• Estimated number of casualties
• Time of incident
• Nature of injuries
• Estimated time of arrival;
• Which other hospitals (if any) have been alerted
• Name of person giving the information

The Senior Nurse in charge will notify the Switchboard by means of EXTENSION 5300 and confirm that the Hospital's Major Incident Policy is to be activated giving the following message:

"A Major Incident warning has been received for an incident at .....(place) which occurred at .....(time). Please initiate the Major Incident Procedure". 

The switchboard operator receiving this message will the refer to the SWITCHBOARD ACTION CARD held in the switchboard (or at Reception out of normal hours) and follow the actions specified upon it. The Senior Nurse in charge of the Emergency Department will refer to the SENIOR NURSE - EMERGENCY DEPARTMENT ACTION CARD and follow the actions specified upon it.

On-duty Staff not directly involved in Major Incident Alert must Stay away from the Emergency Department unless instructed to go there by the control room.

On-duty clinical and non-clinical staff should

• Continue routine work
• Identify patients ready for discharge, transfer
• Assess workload
• Prepare to release staff and equipment if necessary

Off-duty Staff

• Must not contact Switchboard
• Should stay at home unless unless contacted and attend their next normal shift on time
• Off-duty staff requested to assist in a specific area should go to that area and report to the senior person on duty in that area
• Staff requested to attend to the hospital should proceed to the Staff Waiting Area unless specifically told otherwise and Report to the Incident Staff Manager who will be coordinating staff deployment
• REMEMBER to bring Hospital ID

Day-to-day hospital Activities

The hospital will try to maintain daily routine activities and minimise disruption. However, when an incident is declared all elective admissions will be suspended and all visitors will be asked to leave the hospital.

It is essential that Bed State information is maintained throughout the incident.

Patients already in the Emergency Department

On receipt of Declared alert for a Major Incident the Senior Nurse in the Emergency Department will ensure that non-urgent patients are informed of the situation and that there may be significant delays these patients will be advised to attend one of the other Hospital Emergency Departments in the city or to return on the next day or see their GP. Any non-urgent patients who refuse to leave should remain in the ED waiting areas and should be treated there in order of clinical priority. If patients are moved to the Main Outpatient Department a record must be kept of who has moved.

• A record should be kept of patients leaving the ED in the Emergency Department notes if possible
• Remaining patients should be rapidly seen, treated, or referred on by the ED medical staff
• Non-incident patients waiting to be admitted, for all Specialties, will be transferred to St Oliver's Ward as soon as they can be accepted

Major incident patients admitted from the ED (except ICU)

St Catherine's & St Patrick's Wards will be the initial wards admitting all patients from the incident regardless of insurance category. They should be prepared to admit ten patients each as the hospital's first response. In the first instance, one bay of patients in each ward (6-8 beds) will be transferred to other acute private and public wards.

Key Departmental & Staff Responses

The Emergency Department

The Emergency Department Consultant on duty will assume the role of Lead Emergency Doctor. He / She should collect the Lead Emergency Doctor Action Card from the Control Room and will have the responsibility for the overall arrangements in the Emergency Department and the triage on arrival of patients from the incident: in the Consultant's absence this role will be undertaken by the Emergency Department Registrar or in his/her absence by the Medical Registrar on duty. He / She will liaise with the Senior General Manager who will establish the hospital Control Room. The designated Lead Emergency Clinician will liaise initially with the Consultant Physician, Consultant Anaesthetist and Consultant General Surgeon on call. The department will be the access point for all casualties from an external incident where they will be triaged and treated.

Anaesthetic Department

The Consultant Anaesthetist on call should go to the Control room to report his arrival and collect the Lead Anaesthetist Action Card, he should then straight to the Emergency Department and act as Lead Anaesthetist, he should refer to his Action Card and take action as indicated and necessary.

Radiology Department

The Consultant Radiologist on call should go to the Control room to report his arrival and collect the Lead Radiologist Action Card, he should then straight to the Emergency Department and act as Lead Radiologist, he should refer to his Action Card and take action as indicated and necessary. During normal hours the Radiography Services Manager should adopt the role of LEAD RADIOGRAPHER and follow the actions on the Action Card in the Department especially to nominate another Radiographer to be EMERGENCY RADIOGRAPHER who should collect his her action card from the Control Room and go to the Emergency Department immediately. Out of normal hours the Radiographer on call (General) will be the EMERGENCY RADIOGRAPHER and should collect his/her action card from the Control Room and go to the Emergency Department. The 2nd Radiographer on call (CT) will be the LEAD RADIOGRAPHER and should go to the main Radiology Department and report his/her arrival to the Control Room by telephone on extension 5999. He/she should ensure all machines are switched on and should call in one additional Radiologist, the Superintendent Radiographer and 4 additional Radiographers.

Main Outpatient Department

The Senior Nurse Manager for Outpatients should collect the Action Card from the Control Room. All OPD appointments will be suspended and patients should be told to return home pending the issue of a new appointment. The OPD will also act as the designated 'overflow' area for 'walking-wounded / minor' injuries that are cleared from the Emergency Department. In addition patients refusing to leave the Emergency Department will be transferred to Main OPD.

St Catherine's Ward & St Patrick's Ward

The Senior Nurse Manager on these Wards should refer to the Major Incident Action Card held on the ward. It is important that 6-8 beds on St Catherine's ward are decanted as quickly as possible to prepare to receive potential incident casualties. It is essential that the Senior Nursing Officer initially establishes a Bed State and liaises with the Bed Management Team. It must be ensured that the response is co-ordinate to safeguard against possible 'blockages' restricting patient decanting and that the appropriate care of patients is considered at all times.

St Anne's Ward (Paediatrics)

The Senior Nurse Manager on the Ward should refer to the Major Incident Action Card held on the ward All child casualties under the age of 15 will be admitted to St Anne's ward. Patients between 15 and 18 will only be admitted following consultation with Consultant Paediatricians and the ward Nurse Manager. On receipt of a notification that an incident has occurred the nurse manager should seek to identify 5 beds of which 2 should be isolation beds for immediate use by child casualties and should report bed availability to the Senior Nursing Officer. The Nurse Manager should liaise with the Paediatric teams with respect to children who might be sent home or whose subsequent planned admission could be postponed. All children who can be discharged should be discharged regardless of the demand for incident admissions due to the possible upsetting nature of injuries to be received in the hospital. This policy will be reviewed after 24 hours.

St Oliver's Ward

The Senior Nurse Manager on the Ward should refer to the Major Incident Action Card held on the ward St Oliver's ward will be utilised for non-incident casualties awaiting admission in the Emergency Department or those who cannot be sent home. During normal hours on receipt of a notification that an incident has occurred the nurse manager should liaise with the Medical teams to ensure that all Endoscopy lists are suspended immediately and patients discharged out of the ward as quickly as possible. Out of normal hours the Incident Senior Nursing Officer will decide whether St Oliver's is to be opened and make arrangements for it to be staffed.

Remaining M.U.H. Wards

The Senior Nurse Manager on duty on these Wards should refer to the Major Incident Action Card held on the ward. Do not transfer or discharge any patients unless advised to do so. Prepare the Ward to accept rapid transfers of displaced patients from other areas. In the event of a Major Incident the Senior Nurse on the ward will record on a Bed State Form the ward bed availability ready for the Bed Management team. In the event of multiple casualties requiring admission it may be necessary to use Wards, other than those indicated, to accommodate them.

Operating Theatres

The Senior Nurse Manager on duty should refer to the Major Incident Action Card held in the department.

The Senior Theatre Nurse in charge will be notified of a "Declared or Standby" alert by Switchboard. The Senior Theatre Nurse will liaise with the Senior Nurse in the Emergency Department for an incident briefing. Once the type of incident has been established the Senior Theatre Nurse will determine the level of response and co-ordinate the preparation of theatres, recovery and arrangements with S.D.U. / T.S.S.U and calling in of staff as necessary.

Critical Care Area (I.C.U. /C.C.U.)

The Senior Nurse Manager on duty should refer to the Major Incident Action Card held in the unit.

Switchboard will inform the I.C.U. Senior Nurse who will brief the Consultant Anaesthetist in Charge of the Critical Care Area. He / She will liaise with the Anaesthetist in Charge of the Anaesthetic response, based in the Emergency Department. Available Critical Care beds will be prepared to receive admissions. A Ward round will be conducted to identify patients suitable for transfer to an alternative ward or another hospital.

On call Teams

The on call Surgical, and on call Medical teams will be informed by Switchboard when a Major Incident Alert is declared. It will be the responsibility of the duty Consultants to obtain a briefing from the Senior General Manager and initiate as necessary their team response. The Nurse in Charge of Operating Theatres will have been notified and will liaise as necessary. NCHDs should not remain in the Emergency Department unless instructed to do so by a consultant in the Department.

Doctors on call

The following Consultants will go to the Control room to collect their action card and establish the nature of the incident and determine the level of response required by their teams and ascertain whether further Consultant support is required. They should then take the action given below:

• Medical Registrar on call Go to Emergency Dept. and act as Lead Doctor until relieved by an ED Registrar or EM Consultant
• EM Consultant on call Go to Emergency Department and act as Lead Emergency Doctor
• Consultant Anaesthetist on call: Go to the Emergency Department to assist in triage and treatment as necessary
• Registrar Anaesthetist on call Go to Emergency Department to assist in triage and treatment as necessary
• Consultant Radiologist on call: Go to the Emergency Department
• Consultant Paediatrician on call Go to the Emergency Department
• Consultant General Surgeon on call: Stay in the Control Room until required to go elsewhere
• Other Consultants: Report to the Control Room before going to their department or elsewhere as directed
• The emergency medicine Consultant in conjunction with his Colleagues will assess whether further Consultant support is required as part of the incident response and inform the Control Room
• The medical, surgical, anaesthetic and other on call teams should go to the Emergency Department only when alerted to to so

Bed Manager / Night Superintendent/ ADONs

The Bed Management Team will be informed by Senior Nursing Officer. All available staff will proceed to the Admissions Unit to confirm roles and to organise the team response. The primary function will be to establish the Bed capacity of the hospital and to facilitate the patient transfers and discharges to free up bed space rapidly and safely. The team will ensure that 'all wards' are informed and that ward rounds are conducted, initially on the dedicated 'take wards': the team will collect all the Bed State Forms from the wards and hand them over to the Senior Nursing Officer. It will be their responsibility, in conjunction with the Senior Nursing Officer, to ensure that staff are allocated to the Relatives area.

Laboratories & Blood

The Laboratory Technicians on call will be notified by the switchboard. They should each go to their laboratories and immediately call an additional technician to duty. They should ensure that all machines are operating fully and that the necessary supplies of stationery are available to deal with the requests which will be received. Any routine test requests which can be postponed should be delayed. The switchboard will also call the Chief Laboratory Scientists who will assess the need for further staff and action. The Technician covering Haematology should immediately notify the Blood bank of an emergency requirement for 10 units of Group O+ and ten units of Group O- to meet expected surgical demands.

Pharmacy

Switchboard will notify the Principal Pharmacist and on call duty pharmacist. The pharmacy manager/ on call pharmacist will report their presence to the Control Room and then check drugs requirement for the Emergency Department before commencing to co-ordinate the department response and obtain additional stocks of drugs if required for all wards.

Social Work Team

The Principal Social Worker will be informed by Switchboard and will contact the Control Room. for instruction and briefing.

Other essential services

To be contacted by switchboard and / or the controls room will include:

Physiotherapists, Security, Support Services, C.S.S.D., Admissions Office, Medical Records, Pastoral Care

Press Management

In a Declared incident it will be the responsibility of the Senior General Manager to manage the hospital's response to the media.

Ambulance & Garda Liaison

The Gardaí and Ambulance service will establish a 'Gardaí & Ambulance Liaison Room' in the ground floor pastoral care office. In the event of an extended Major Incident Gardaí will establish a full information bureau elsewhere.

Forensic Evidence - Every major incident is a potential scene of crime. All staff involved in major incident response must ensure that they take appropriate measures to preserve potential evidence in order that any subsequent investigations by the police or other agency(ies) are not jeopardised.

Confidentiality

Staff must be aware that they must honour their duty of confidentiality to individual patients when co-operating with the police. Staff should not normally disclose personal information without the patient's consent. NOTE: In the abnormal situation of a major incident, the duty of confidentiality is not lifted.

Stand Down Procedure

Stand Down will be declared by:

Ambulance Service - the call will be received by the Control Room the Incident management Team will initiate the Stand Down procedure through Switchboard: notification will be given to all those on the call-out list. If the stand down call is received elsewhere it should be communicated to the Control Room at once.

Major Incident Management team: - the Incident Management Team may decide to declare "Stand Down" once all casualties are in hospital, the full extent of the incident is known and systems are in place throughout the hospital to deal with the ongoing situation.