Practice the major incident plan—clinical and non-clinical staff.
Command, control, and communication are essential components of management.
Consider how your department would manage ongoing 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 arrangements 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. Prehospital response subsequently directs casualties to local emergency departments, although more recently NHS trusts have activated internal major incidents because of overwhelming service pressures e.g. in January 2015, a demand for in-patient beds out stripped availability at Peterborough Hospital.4 By declaring a major incident, the trust was able to cancel non-urgent elective operations and emphasize the need for local primary care trusts, social services, etc. to expedite the discharge of medically fit patients requiring non-clinical support.
With respect to (the more usual) external major incidents, the majority of hospitals have plans based on prehospital incidents that tend to deal with events in the emergency department 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 stages of a major incident. London Emergency Services Liaison Panel.
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.
An incident has occurred but is within its early stages. It has the potential to escalate and demand the extraordinary response of the receiving trust
Confirm that standby action ONLY is required. Initial key personnel on major incident call out list are contacted
Major incident cancelled
This cancels a major incident standby call
The key personnel are again contacted and stood down
Major incident declared
This can be declared either with or without a preceding standby status. An event has occurred which mandates that a trusts major incident plan is activated
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
Major incident stand down
The major incident is perceived to be over and a plan to revert the trust to normal operation will be made
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
Preparations for arrival
This relates primarily to understanding the categorization of major incident alerts: major incident stand-by, major incident declared, major incident cancelled, major incident stand-down (Table 1).
Many acute NHS trusts may be functioning at ∼90% capacity across all services and with a recent decline in the number of inpatient beds, issues such as dischargeable patients requiring social care may be significant. Within the hospital specialist services e.g. intensive care units, operating theatres are often running at near maximum capacity. Creating space to receive severely 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 (ongoing 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 hospital including internal ‘step-down’ transfers from level-3 (invasive ventilation/multi-organ support) to level-2 care (single organ support/non-invasive respiratory support) or level-2 to level-1 care (ward-based support), etc. Alternatively (or simultaneously), critical care capacity (level-3 and level-2 beds) can be expanded by utilizing 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 network may be possible/necessary. This will inevitably depend upon bed availability elsewhere with the major incident and casualties 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 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 assistant 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 minimizing the likelihood of errors in treatment, particularly the administration 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 organizational 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 rescue may be hampered by access to the scene and consequently 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 emergency department. This is usually close to the ambulance bay but should also take into consideration landing areas of air ambulances. A senior clinician (ideally an Emergency Medicine Consultant) 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 important 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 require follow-up and contingencies for this will therefore be necessary. 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 incident, 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 consequence of the blast wave and flying debris.
Combined summary of injuries, Madrid and London bombings
Type of injury
Critically injured population (n=35)
Non-critically injured population (n=235)
Long bone fractures
Burns (superficial and partial thickness)
Traumatic brain injury
Traumatic amputations (limbs, digits, ears)
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, Biological, 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 hypothermia, acidosis, and coagulopathy, all of which are associated 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 rather 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, clotting, and pH,
return to theatre for definitive surgery once physiologically stable.
Radiological imaging is a valuable tool for assessing trauma patients and identifying internal injuries; however, damage-control 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 consequences 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 incident management to tactical command (see below).
Tactical (silver) command
Directed from a designated operating theatre. It determines the impact of the incident on the trust and makes decisions about staff deployment 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 patient 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.
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 switchboard 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 transfer of information between staff for the purpose of clinical care and also provide information to relatives and media.
Fall-back plans for internal communications include the use of handheld radios in key areas by key personnel and the use of runners. This can be the most reliable way of transferring information in a chaotic environment. Written messages are carried by runners and retained as part of the records of the major incident.
From a clinical perspective, the most reliable way of accurate information transfer in a major incident is to have the same clinical team looking after the most severely injured patients from the emergency department through imaging and surgery (see the Deployment of staff section). This maintains continuity and 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 London intensive care unit assigned one doctor to create a database of patients being admitted to intensive care. This included listing injuries, investigations outstanding, and procedures performed. The after-action review held this document to be extremely useful 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 officer 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 reunite casualties with friends and family.
As stated, a hospital's main focus in a major incident is the receipt and resuscitation of large numbers of seriously injured casualties 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-opening 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 admission and treatment is beyond a period of a few hours (see below).
After the initial period of damage control resuscitation and surgery, the majority of the critically injured will be further stabilized 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 operating 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), comparable 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 emergency 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 related to the aftermath of a major incident.
Within 24–48 h of a major incident, it is inevitable that dignitaries will visit the affected area and the injured in hospital. In the UK, such people will almost certainly be Members of Parliament including Cabinet Members (UK and or devolved nations) and may include members of the Royal Family. There are inevitable security issues (especially in the wake of a terrorist incident). Advice from the Police will be provided under such circumstances and consideration should also be given to any potential disruption to patient care during an incident's recovery phase.
Staff working patterns and welfare
Critical care staff will play a significant role in dealing with ongoing care. Rotas may have to be organized and split i.e. casualties 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 initial 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 incident. 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.
Providing clinical care to casualties is the comparatively ‘easy’ part of in-hospital major incident management. The organizational response required is wide reaching and the impact of receiving 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 institution can respond to provide both effective care and organization in the incident's aftermath.
Declaration of interest
In 2015 Dr Cosgrove received a grant of £5000 from the Hillsborough Family Support Group to develop guidance pertaining to the provision of Events Medicine Services. This includes major incident contingency planning.
. 11 March 2004: The terrorist bomb explosions in Madrid, Spain—an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital. Crit Care 2005; 9: 1