MAJOR INCIDENT PLAN 2007

Transcription

1 Appendix 2 Welsh Ambulance Services NHS Trust Ymddiriedoath G.I.G Gwasanaethau Ambiwlans Cymru MAJOR INCIDENT PLAN 2007 Including Hazardous Substances; Chemical, Biological, Radiological and Nuclear Incidents. DRAFT FOR BOARD RATIFICATION September

2 ISSUED September 2007 PLAN NUMBER of THE MAJOR INCIDENT PLAN IS A CONTROLLED DOCUMENT. THEREFORE IT IS A REQUIREMENT OF THE TRUST THAT THE KEEPER OF THIS DOCUMENT COMPLETES THE FOLLOWING: Name of Keeper: Signature of Keeper: Date received: AMENDMENTS DATE SECTION SIGNATURE Following receipt of this plan or following any amendment made: Please photocopy this amendment page and return the photocopy to the: - National Staff Officer Ambulance HQ St Asaph LL17 0WA Page 1 of 106

3 CONTENTS Pages PAGE TITLE 1 CONTROLED DOCUMENT PAGE 2 CONTENTS OF THE PLAN 3 EXECUTIVE SUMMARY 4 INTRODUCTION 9 WELSH AMBULANCE MAJOR INCIDENT RESPONSE 9 DEFINE A MAJOR INCIDENT / SCALE 12 STANDARD MESSAGES / FIRST ACTIONS OF THE SERVICE 13 METHANE 13 STEPS BRIEFING 15 POST INCIDENT ACTIONS 16 INITIATION OF A MAJOR INCIDENT 18/19 COMMAND CHART / COMMUNICATIONS CHART 20 AMBULANCE STRUCTURE 25 MEDICAL STRUCTURE 26 STAFF HEALTH and WELFARE / DEBRIEF 27 ROLE OF OTHER SERVICES 33 ACTION CARDS CONTENTS LIST 34 CONTROL ACTION CARD 36 MOBILE COMMUNICATIONS UNIT ACTION CARD 37 FIRST VEHICLE ON SCENE 39 SUBSEQUENT CREWS TO SCENE 40 FORWARD INCIDENT OFFICER 41 AMBULANCE INCIDENT COMMANDER 43 GOLD COMMANDER 44 CASUALTY CLEARING STATION OFFICER 43 LOADING OFFICER 46 SAFETY OFFICER 47 EMERGENCY PLANNING OFFICER 48 PARKING OFFICER 49 RENDEZVOUS POINT OFFICER 50 AMBULANCE CBRN OFFICER 51 HOSPITAL AMBULANCE LIAISON OFFICERS 52 EQUIPMENT OFFICER 53 CONTENTS OF APPENDICES 54 APPENDIX 1 SITUATION REPORT (SITREP) 55 APPENDIX 2 BRIEFING FORMAT 56 APPENDIX 3 TRIAGE in CPPE 57 APPENDIX 4 TRIAGE SIEVE 59 APPENDIX 5 TRIAGE SORT 60 APPENDIX 6 EQUIPMENT RESOURCES FORM 61 APPENDIX 7 HAZARDOUS SUBSTANCES 65 APPENDIX 8 CBRN MOBILISATION ALGORHYTHM 67 APPENDIX 9 PRACTICAL DECONTAMINATION 70 APPENDIX 10 CHEMICAL INCIDENT SAFETY ASSESMENT FORM 73 APPENDIX 11 ARRANGEMENTS FOR RADIOACTIVITY 76 APPENDIX 12 GOLD COMMANDERS LIAISON CHART 77 APPENDIX 13 MEDIA GUIDANCE 78 APPENDIX 14 GLOSSARY OF TERMS 83 APPENDIX 15 BIBLIOGRAPHY OF REFERENCE MATERIAL 85 APPENDIX 16 MASS and CATASTROPHIC INCIDENT CONSIDERATIONS 87 APPENDIX 17 DECISION LOG Page 2 of 106

4 EXECUTIVE SUMMARY The delivery of an effective service in the event of a major or serious incident is one of the seven strategic themes outlined within the Trusts strategic modernisation document Time To Make a Difference. As a Category 1 Responder the Trust works in partnership with a raft of colleagues, from the Welsh Assembly Government, the other Emergency Services, Local Health Boards, Local Authorities, Acute Trusts, and volunteer groups to ensure the most effective professional response to a major disruptive challenge. This partnership working ensures that the Trust is able to identify and react to both National and Local issues, to provide response and resilience where and when required. Time To Make a Difference (TTMD) identifies within the overarching theme of Civil Protection; Emergency Preparedness whose five goals will ensure that the Trust can meet its obligations to the people of Wales in this regard. These goals provide evidence that the Trust understands and accepts its responsibilities under legislation, with particular emphasis being placed upon the Civil Contingencies Act and the NHS Emergency Planning Guidance. During this stage of transition and integration between the roles of NHS-Direct Wales and that of the ambulance service, it has been deemed appropriate that the two individuals plans which support the response of each of these specialities remain as stand alone though mutually dependent documents. However, over the preceding months and ahead of the next annual review my intention will be bring together the response arrangements of the two specialities into an organisation wide plan. The Trusts Major Incident Plan, specific to the ambulance service role, has been written to encompass the requirements set out in the first of the five goals which is stated as: To ensure preparedness for an effective response to any major disruptive challenge or emergency situation : (TTMD, January p.47) Objectives 1. To assess the risk of emergencies occurring which underpin and inform the development of contingency plans. 2. To assess those contingency plans against a framework that tests adequacy of capabilities to meet identified risks. 3. To maintain plans which describe how the Trust will meet the three key components of the Emergency Planning duty, identified as preventing an emergency occurring; reducing, controlling or mitigating the effects; and to develop plans which can provide alternative actions. The Trust continues to work with the four Local Resilience Forums across the Principality to ensure that hazards, both static and transient are identified and that a joint partnership approach has been undertaken in their mitigation and or removal. Alan Murray Chief Executive Officer Page 3 of 106

5 1.0 INTRODUCTION 1.1 Integrated Emergency Management and Key Organisations Civil Contingency Planning arrangements need to be integrated both within and between organisations. This has been incorporated into legislation within the Civil Contingencies Act Organisations should work both individually and in collaboration with each other on certain key activities. The following six activities are fundamental to an integrated approach: Anticipation Assessment Prevention Preparation Response Recovery management There are a number of organisations that will almost always be involved in a Major Incident and others that do not come so readily to mind, but to ensure an integrated response all aspects of a Major Incident must be considered. (see Roles of other Services Page 23). 1.2 Pre - Response Planning All serious incidents should be undertaken using practices that are as close to the normal method of operation as possible as this will ensure that this will make it easier to operate when under the stress of a Major Incident. As expectations and assumptions are response arrangements will be thought out well in advance and effectively coordinated- UK Cabinet Office Emergency Review August To ensure that the Welsh Ambulance Services NHS Trust (WAST) follows best practice it is incorporating as its introduction underpinning material from the NHS Emergency Planning Guidance This takes into account the principle of cross border co-operation that is the cornerstone of mutual aid assistance in the event of Wales requiring assistance from other UK ambulance services. This is expanded on where necessary throughout the document. Cognisance has also been taken of the information outlined in the Cabinet Office, Civil Contingencies Secretariat document Responding to emergencies Draft Guidance. Dec In addition the Risk Registers of the 4 Local Resilience Forums have been used to provide a comprehensive background to the Services Pre-response planning. Page 4 of 106

6 1.3 Objectives of this plan. The WAST must ensure that it has a Major Incident plan that has been adopted as policy and authorised by the Chief Executive of the Trust. The plan must: define the responsibilities of the Trust, the operational objective and the process for implementation of the plan state the process for declaring a Major Incident state the role of the first personnel arriving at the scene of the incident identify the actions of the control room for deploying resources and notifying the appropriate staff and partner agencies identify the command structure that the trust will put in place during an incident state the messages that are used for notifying hospitals and other NHS agencies of a Major Incident identify additional NHS and medical resources available for use by the WAST for delivery of immediate medical care at the scene including maintenance of a Medical Incident Commander (MIC) pool. identify the systems in place for dealing with casualties, including the triage system, casualty clearing stations, labelling and documentation and use of supplementary non ambulance transport identify the strategy for the management of the media identify the potential use of voluntary aid societies and cars identify other special contingencies such as mutual aid arrangements or special incidents identify arrangements for Chemical, Biological, Radiological and Nuclear (CBRN) incidents WAST has also ensured at the planning stage that they: fulfil the requirements as a Category 1 responder under the Civil Contingencies Act ensure that the Trust s own escalation plans for dealing with pressures recognises the higher-level requirements of a Major Incident including suspension of nonemergency work establish and maintain working relationships with other emergency services the utilities local commercial organisations and other key stakeholders take into account the needs of vulnerable groups of patients including children train and exercise as an organisation with partners to an agreed schedule develop a command and control structure that allows appropriate linkages to local resilience arrangements are represented at local, regional and national resilience forums be responsive to Local Health Boards (LHB), and accountable to HCW? implement national policy and guidance in the local context develop contingency plans for business continuity especially in the event a protracted incident Page 5 of 106

7 These planning requirements are met by the National Emergency Planning Group in co-operation with locally based Ambulance Officers, with specific reference to those hazards identified in the Community Risk Register. 1.4 The roles and responsibilities of WAST The Ambulance Trust forms part of the National Health Service response to a Major Incident. It is principally geared to the immediate clinical needs of those directly or indirectly associated with the incident(s) and their subsequent transportation to established treatment centres. The WAST is primarily responsible for the alerting, mobilising and co-ordinating at the scene of all primary NHS resources necessary to deal with an incident, unless the incident is an internal health service incident. The WAST works to ensure that it is capable of responding to Major Incidents of any scale in a way that delivers optimum care and assistance to the casualties that minimises the consequential disruption to healthcare services and that brings about a speedy return to normal service provision. This is done by ensuring the WAST works as part of a multi-agency response across organisational boundaries. 1.5 The key responsibilities of the WAST is: Strategic Objectives the saving of life, in conjunction with the other emergency services to instigate a command and control structure to protect the health, safety and welfare of all health service personnel on site to co-ordinate the NHS communications on site and to alert the main 'receiving' hospitals for the receipt of the injured to carry out a health service assessment for the incident to instigate a triage process when required to treat and transport casualties to provide clinical decontamination of casualties and to support mass decontamination to mobilise the UK national reserve stock through the Welsh Co-ordinating Centre to maintain adequate emergency cover throughout other parts of the WAST area to reduce to a minimum, the disruption of the normal work of the Service to alert and co-ordinate the work of the Voluntary Aid Societies enabling them to provide services appropriate to the incident and as may be required. to make provision for the transport of the Medical Emergency Response Incident Team (MERIT) if this is an agreed function for the WAST. Tactical and Operational establish a tactical and operational command structure have the facility to call on an ambulance tactical advisor who has expertise to provide advice on matters relating to the Major Incident plan and the required response of the trust if appropriate Page 6 of 106

8 allocate a Safety Officer who has responsibility to protect the health and safety of ambulance and NHS personnel on site co-ordinate and manage the on site NHS response alert other emergency services provide a nominated member of staff to communicate with receiving hospitals usually known as the Hospital Ambulance Liaison Officer provide on site ambulance communications and a Communications Officer ensure that a log of all actions and communications are kept instigate the use of a casualty clearing station when required instigate the use of a recognised triage sieve and sort on all patients prior to evacuation from scene arrange and maintain the required personnel to provide optimal levels of treatment of casualties at the site arrange and maintain the most appropriate means of transporting the injured to the receiving hospitals have the facility to deploy and provide sufficient bulk equipment (including oxygen) to meet the requirements at the site provide clinical decontamination of casualties that includes dirty side triage and limited hot zone clinical intervention support public mass decontamination by maintaining health presence at the mass decontamination units provide post incident welfare and debriefing for its entire staff involved in the incident to establish a joint plan with the police for the arrangement of the deceased and ensure that ambulances are not deployed for removal of the deceased, the WAST can only be concerned with the transport of live casualties. Medical staff will assist with confirmation of death at an appropriate time. 1.6 Patients Patients will be at their most vulnerable following a Major Incident / Accident, it is the responsibility of all staff to provide appropriate levels of care and protection at this time. This is particularly important for those children and vulnerable adults with a physical or mental impairment who find themselves involved in the incident either as direct victims or as witnesses. The psychological trauma that they suffer may well be out of all proportion to the actual physical trauma that they have received, which can result in a delay in treatment. The close relationship that the WAST has with local Social Services providers will assist in the protection and treatment of these patients. In addition patients whose first language is not English or Welsh must be considered, the ASA Multi-Lingual Phrase Book v3 has been available to all staff to assist in this. Where possible the early involvement of the Police or Local Authority Social Services Department should be sought to ensure the continued safety and wellbeing of such patients. Page 7 of 106

9 1.7 Planning and Training The first step to an incident response starts with preparedness and planning for high risk locations. It is important that WAST carries out contingency planning taking account of identifiable risk areas and risk events in and around their geographical area. This is the responsibility of the Emergency Planning Officer or their equivalent. The WAST must provide its staff with incident action cards that reflect the salient responsibilities listed in the trusts Major Incident plan in an aide memoir format. The WAST continuously trains front line staff and officers, including control room staff who will be involved in responding to a Major Incident on the Major Incident policy and procedure. Exercises for front line staff and officers, including control room staff who will be involved in responding to a Major Incident must undertake a live exercise every three years, a table top exercise every one year and a test of communications cascades every six months which will be in line with national guidelines. In addition Communications systems must be tested at least once a month. 1.8 Warning and Informing the Public in the Event of an Emergency The Civil Contingencies Act 2004 places statutory duties on Category 1 responders (such as the Welsh Ambulance Services NHS Trust) to communicate with the public, as follows: 1. The public be made aware of the risks of emergencies and how category 1 responders are prepared to deal with them if they occur 2. The public be warned and provided with information and advice as necessary at the time of the emergency These duties can be discharged collectively with other partners, through the Local Resilience Forums, which are the framework for delivery of the civil protection capability, as well as by the Trust itself. A recent example of this in action was when the West Midlands Ambulance Service NHS Trust appealed for the public to reduce unnecessary demand on the service when it was experiencing severe difficulties in the widespread floods. The Welsh Ambulance Services NHS Trust will fully engage with partners through the relevant Local Resilience Forums to ensure that this duty is complied with. Furthermore, the Trust will maintain a capability to communicate with the public in isolation, if required, using the appropriate channels, as described in the relevant policy. Reviewed following consultation August 2007 By David G. Jones RSO. On behalf of the National Emergency Planning Group Page 8 of 106

10 2.0 WELSH AMBUILANCE SERVICE MAJOR INCIDENT RESPONSE 2.1 It is recognised that the Ambulance Trust is the gatekeeper to other NHS services, therefore in the initial stages of a Major Incident the WAST provides an essential link between the NHS and the many other agencies that play a part. It is therefore imperative that the WAST rapidly identifies and declares a Major Incident, or the potential for a Major Incident. 2.2 Defining a Major Incident - Department of Health Emergency Planning Guidance 2005 This section describes various definitions of emergencies and Major Incidents as they may apply to NHS organisations, the varying scale of Major Incidents and the alerting mechanism to be used in the event of a Major Incident. 2.3 Definition: NHS Major Incident For the NHS, Major Incident is the term in general use. The Civil Contingencies Act guidance on emergency preparedness states; that the Act, the regulations and the guidance consistently use the term emergency, but there is nothing in the legislation that prevents a responder from using the term Major Incident in its planning arrangements for the response. For the NHS, a Major Incident is defined as: Any occurrence that presents serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance services or primary care organisations. 2.4 Definition: the Civil Contingencies Act 2004 The Civil Contingencies Act 2004 defines an emergency as: An event or a situation which threatens serious damage to human welfare in a place in the UK, the environment of a place in the UK, or war or terrorism which threatens serious damage to the security of the UK. The definition is concerned with consequences rather than the cause or source. With the implementation of the Civil Contingencies Act, the term emergency may be used instead of incident. NHS organisations may continue to use the term Major Incident, but need to be aware that the term emergency will become common parlance for many of their partners. In this document however the common NHS terminology of Major Incident has been retained. Page 9 of 106

11 A Major Incident is any event whose impact cannot be handled within routine service arrangements. It requires the implementation of special procedures by one or more of the emergency services, the NHS, or a Local Authority to respond to it. A Major Incident may arise in a variety of ways: Big Bang serious transport accident, explosion, or series of smaller incidents. Rising Tide -developing infectious disease epidemic, or a capacity/staffing crisis. Cloud on the Horizon a serious threat such as a major chemical or nuclear release developing elsewhere and needing preparatory action. Headline news public or media alarm about a personal threat. Internal incidents fire, breakdown of utilities, major equipment failure, hospital acquired infections, violent crime. Deliberate - release of chemical, biological or nuclear materials. Mass casualties. Pre-planned - major events that require planning - demonstrations, sports fixtures, air shows etc. 2.5 Definition: the scale of a Major Incident in the NHS NHS organisations are accustomed to normal fluctuations in daily demand for services. Whilst at times this may lead to facilities being fully stretched, such fluctuations are managed without activation of special measures by means of established management procedures and escalation policies. The levels of incident for which NHS organisations are required to develop emergency preparedness arrangements are: Level 1 - Major The WAST and other acute trusts are well versed in handling incidents such as multi-vehicle motorway crashes within the long established Major Incident plans. More patients will be dealt with than usual but it is possible to maintain a normal level of service. Level 2 -Mass - much larger-scale events affecting potentially hundreds rather than tens of people, possibly also involving the closure or evacuation of a major facility (for example, because of fire or contamination) or persistent disruption over many days. These will require a collective response by several or many neighbouring trusts. Level 3 - Catastrophic - events of potentially such proportions that they severely disrupt health and social care and other functions (for example, mass casualties, power, water, etc) and that exceed even collective local capability within the NHS. In addition, there are pre-planned major events that require planning, for example, demonstrations, sports fixtures, air shows, etc that may also require a response. Page 10 of 106

12 For further information on Level 2 and 3 incidents please see Appendix 16 page 83. Page 11 of 106

13 3.0 STANDARD MESSAGES TO BE USED BY NHS ORGANISATIONS 3.1 To avoid confusion about when to implement plans, it is essential to use these standard messages: 1. Major Incident standby This alerts the NHS that a Major Incident may need to be declared Major Incident standby is likely to involve the participating NHS organisations in making preparatory arrangements appropriate to the incident, whether it is a big bang, a rising tide or a pre planned event. 2. Major Incident declared activate plan This alerts NHS organisations that they need to activate their plan and mobilise additional resources. 3. Major Incident cancelled This message cancels either of the first two messages at any time. 4. Major Incident stand down All receiving hospitals are alerted as soon as all live casualties have been removed from the site. Where possible, the Ambulance Incident Commander will make it clear whether any casualties are still enroute While WAST will notify the receiving hospitals(s) that the scene is clear of live casualties, it is the responsibility of each NHS organisation to assess when it is appropriate for them to stand down. 3.2 First actions of the WAST WAST must: Deploy an initial response from its service that should include appropriately trained officers and effective communications for command and control. Ensure that the first responders understand their responsibility is for command and control by taking the key command positions (including Ambulance Incident Commander (Tactical also known as Silver), Parking Commander, Primary Triage Commander or their equivalents until relieved. Ensure that the first responders at the scene provide a structured situation report (Sitrep) using METHANE (or CHALET) or equivalent report: Page 12 of 106

14 3.3 METHANE METHANE is the Situation Report (SITREP) taught and used in WAST, METHANE stands for: M E T H A N E Major Incident declared (or hospitals to standby) Exact location Type of incident brief details of types and numbers of vehicles, buildings, aircraft, etc, involved Hazards, present and potential Access and egress Numbers and types of casualties Emergency Services present and required 3.4 CHALET However, CHALET is included here for the sake of completeness and information C H A L E T Casualties numbers and types of casualties Hazards present and potential Access and egress including best routes for emergency vehicles Location of incident Emergency services present and required Type of incident 3.5 SAFETY STEPS 123 REMEMBER the general safety advice: Use SAFETY Self Scene - Survivors Specifically in the case of incidents of collapse with unknown cause consider; Safety Triggers for Emergency Personnel - STEPS Step 1 One casualty Step 2 Two casualties Approach using normal procedures Approach with caution, consider all options, do not discount anything, report on arrival and update Control Step 3 Three casualties or more Do Not approach the scene. - Withdraw Contain Report Isolate yourself and send for specialist help Page 13 of 106

15 Ensure that a log of all communications and actions has been commenced Declare a Major Incident based on the criteria in the definition Ensure that the nearest appropriate receiving hospitals are aware of the incident and appoint a dedicated person to communicate with hospitals throughout the incident 3.6 Additional actions as the incident progresses: 1. Under our obligation to warn and inform our partners ensure that other emergency services and health service agencies as appropriate are alerted. They may include National Blood Service, Emergency Bed Bureau services, NHS Direct, etc. 2. Determine whether a Medical Incident Commander (MIC) and Medical Emergency Response Incident Team (MERIT) are needed and make sure that there are arrangements to transport them to site. 3. Establish and maintain communication links between the site and the rest of the NHS. 4. Dispatch a Hospital Ambulance Liaison Officer (HALO). 5. Establish a full command structure by also appointing the following roles as appropriate: Ambulance Incident Commander Forward Incident Officer Tactical Advisor, Primary Triage Officer Loading Point Officer Casualty Clearing Officer Communications Officer Medical Incident Commander Forward Medical Incident Officer Safety Officer Secondary Triage Officer Parking Officer Equipment Officer Hospital Ambulance Liaison Officer 6. The WAST ensures that protective clothing and head protection is provided that clearly identifies the Officer s role. 7. Establish a triage SIEVE and SORT process with appropriate labelling. Casualty labelling system (pages 52-54) It is essential that all casualties are processed through a triage system and appropriately labelled. Labels must clearly identify - triage category injuries noted treatments provided/drugs administrated Page 14 of 106

16 The WAST must adopt a triage system at a Major Incident and label casualties with the following codes: Priority Description Colour 1 Immediate Red 2 Urgent Yellow 3 Delayed Green Dead/Lifeless Deceased White or Black 8. Determine the need for other medical or voluntary agencies that may support the WAST. 3.7 Briefing There is a responsibility to ensure that a comprehensive briefing is given to all staff that attend the incident, both ambulance and other medical staff. In addition the other emergency services and other attendees may require to be briefed on the actions and procedures of the service. In order to ensure that the brief given is both comprehensive and consistent the Ambulance Services Association (ASA) SORT course briefing system will be used. This is consistent with the Police Public Order briefing format. (i.e. IIMARC see appendix 2) 3.8 Post Incident Actions (see page 22) Once a Major Incident has been declared the WAST has a responsibility to ensure that a number of important activities take place. These can be split into two groups. "Operational activities" include the procedural and administration needs of the service. "Post traumatic activities" include the psychological management of the staff involved in the incident. Post incident, WAST has a duty to ensure that operational procedures are carried out to restock and maintain the fleet. Debriefing is a very important process in order for the WAST to gain from lessons learnt (positive or negative), make recommendations for change to partners and adapt service protocols if needed. The WAST has an obligation to assess their compliance with emergency planning requirements and must review, improve and test their plan on a regular basis. Lessons identified must not be ignored. It is incumbent on WAST to realise that all staff and management colleagues exposed to a Major Incident may become vulnerable to post traumatic stress - concern for individual members of staff should be highlighted with the staff member and a support worker for risk assessment where necessary. Post incident the WAST has a moral and legal duty to consider staff's psychological needs after exposure to a potentially traumatic incident. Additionally it makes economic sense to avoid loss of valuable personnel to the effect of psychological trauma. With the use of support workers, those who need support after an incident should be referred for early intervention. Page 15 of 106

17 4.0 INITIATION OF THE MAJOR INCIDENT PLAN 4.1 Although the initial call will normally come from one of the emergency services, it is also possible that such a call could come from any source and, consequently, it may not always be clear to the Ambulance Control Centre (ACC) whether the incident is one of major proportions. Therefore, ambulance officers of all ranks and ambulance crews have standing instructions to report back to the ACC immediately they consider that an incident, to which they have been sent in the ordinary way, could be a Major Incident. It is important that such information should be concise and accurate. (Ref Situation Report, METHANE). As soon as reports indicate that a major incident may have occurred (the number of casualties may not be easily determined at the outset), the most senior officer available will initiate the Major Incident Plan. The call can however be made by any member of staff who believes that the criteria in the definition has been met. Any occurrence that presents serious threat to the health of the community disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, the WAST or primary care organisations. It is be better to bring the Major Incident Plan into operation early and possibly unnecessarily rather than to delay doing so with consequent risks to the injured. The Major Incident Plan is generic in nature to allow for a full raft of incidents. However, individual service site specific plans have been compiled to cover sites identified through Community Risk Registers (CRR s) and indicate the initial action to be taken by the Ambulance Control Centre and by the ambulance crew/officer(s) at the site. The role of each service manager/officer and extent to which those managers/officers/staff not on duty are to be called out. Incidents have, more latterly, become more complex, larger and longer in duration (Prof. Scanlon, 1996). However the use of a single over arching Major Incident Plan based upon the normal working patterns and procedures of the service is held to be the safest and most efficient way of undertaking our response. This is supported by sec 5.74 of Emergency Preparedness - Civil contingencies Secretariat the key to effective arrangements is to apply sound principles founded on experience to the problems in hand (Responding To Emergencies Civil Contingencies Secretariat- 2005). 4.2 Mutual Aid from other Ambulance Services. The UK ambulance services have a Memorandum of Understanding that allows for the provision of mutual aid in the case of major or catastrophic incident. There are 4 main principles that govern such aid. Page 16 of 106

18 1. Mutual aid Mutual aid to a major or catastrophic incident will be provided by any ambulance service at the request of the Trust in whose geographical area the incident occurs (hereafter called the Host Trust). 2. Authority and Responsibility The Host Trust will have authority to requisition resources from a neighbouring Trust. It follows that the Trust receiving such a request will have a duty to supply mutual aid on request. 3. Primacy The Host trust will always have primacy at the scene and all resources deployed in pursuance of mutual aid will at all times act under the command of the Host trust. 4. Self activation Self activation by Trusts or individual members of staff must not take place under any circumstances. As per the National ASA Mutual Aid arrangements. Page 17 of 106

19 Figure 1 COMMAND CHART TRUST BOARD HEADQUARTERS EXECUTIVE GOLD COORDINATING GROUP MULTI AGENCY STRATEGY GROUP at designated location. TACTICAL SUPPORT GROUP SILVER TACTICAL COMMAND MEDICAL INCIDENT COMMANDER NURSING INCIDENT COMMANDER IF APPROPRIATE BRONZE OPERATIONAL COMMAND MEDICAL EMERGENCY RESPONSE INCIDENT TEAM (MERIT) Page 18 of 106

20 FIGURE 2 COMMUNICATIONS CHART Hospitals Unitary Authorities Welsh Blood Services Local Health Boards NHPS HEPA / WAG CHaPD / HPA GOLD COMMANDER Other Regional Ambulance Controls + NHS-D AMBULANCE CONTROL CENTRE (ACC) Mobile Communications Unit Ambulance I/C Medical I/C Nursing I/C Rendezvous Point Equipment Parking Point Loading Point Casualty Clearing Safety Medical Emergency Response Incident Team Forward Incident Commander Forward Response Team Triage/Treatment /Transport INCIDENT SCENE Page 19 of 106

21 5.0 AMBULANCE STRUCTURE 5.1 Definition of Roles and Responsibilities In the event of a Major Incident operational staff of the WAST will undertake those roles required at the incident. 5.2 Strategic Coordinating Group The central Gold Command usually held at Police Headquarters chaired by a senior Police officer and attended by the senior officers/ managers of all the relevant agencies. The officers / managers attending must be able to make strategic decisions relating to their agencies. 5.3 Gold Commander The senior Ambulance Commander who has responsibility for the strategic command of the incident. This officer or their representative will liaise with the senior officers of the other emergency services at the Gold Coordinating Group held at Police Headquarters. The Gold Commander will not attend at the scene, as tactical decisions are the role of the Ambulance Incident Commander. The Ambulance Incident Commander will continually update the Gold Commander. A flow chart indicating some of the individuals and organisations that the Gold Commander will be expected to liaise with during and following an incident is given at appendix 12. The Gold Commander will require administrative assistance to facilitate this role. 5.4 Ambulance Incident Commander (Silver) Initially this will be the first Senior Ambulance Commander on scene he/she will be responsible for the tactical management of the incident scene and the continual updating of ACC. All requests for staff, equipment, transport, and medical support by the Forward Incident Commanders, Medical Commanders or other services will be channelled through this officer to ensure unity of command and that an accurate log of all such requests is maintained. He / she must have cognisance of any relevant SOP relating to equipment and location. The Ambulance Incident Commander is supported in the role by the Medical Incident Commander and if appropriate a Nursing Incident Commander. 5.5 Forward Incident Officer (Bronze) The first member of staff who will undertake a management role at the scene. This officer s early and continuing SITREP s are vital for the correct management of the incident. The focus of this role is the Triage, Treatment and Transport of patients to the Casualty Clearing Station. He /she reports directly to the AIC. Page 20 of 106

22 He/she has the responsibility of managing the immediate incident site with the resources at hand. Requests for additional staff, medics, equipment, etc. are directed to the ACC at first and then through the Mobile Communications Unit for Silvers attention when it is established. If the incident site is geographically spread or if communication around the site is difficult, more than one Forward Incident Officer can be deployed. The call signs will then have numerical suffixes (this applies to all the roles at scene). 5.6 Parking Officer An officer with responsibility for liaising with the Police to ensure that the area designated for ambulance parking allows easy access to the Ambulance Loading Point. That vehicles are correctly parked and ready to proceed to the Loading Point as requested. To ensue that the correct grade of staff and type of vehicle are sent forward as requested. The Parking Officer also has the responsibility to ensure that staff are wearing appropriate Personal Protective Equipment (PPE) prior to entering the site. 5.7 Loading Point Officer The officer who has responsibility for ensuring that patients receive the most appropriate transport with the correct level of ambulance aid provided, the logging of such patients, and the passing of the information to the Mobile Communications Unit. A close liaison is needed between the Forward Incident Officer and the Loading Officer to facilitate safe efficient removal of the casualties from the scene to the CCS, and with the Parking Officer to ensure the correct vehicle and crews are appropriately tasked. 5.8 Equipment Officer The officer with responsibility for the setting up of the Operational Support Unit (OSU) and the issuing and logging of equipment, and to maintain a resource log for the information of the AIC. To source and obtain specialist equipment required at scene. At the close of the incident to ensure that all ambulance equipment is returned. 5.9 Casualty Clearing Officer (medical /ambulance) A suitably qualified member of the ambulance or medical team may undertake this role. To liaise with the medical staff at the Casualty Clearing Station to triage and co-ordinate the treatment and prioritise the evacuation of live casualties to the most appropriate receiving hospitals 5.10 Emergency Planning Officer / Tactical Officer The duty of this officer is to advise the Ambulance Incident Commander of any specialist personnel or equipment that may be necessary to assist in the Page 21 of 106

23 management of a Major Incident. This officer will advise on the expertise available through outside agencies e.g. Local Authority, Military Aid, Voluntary Aid Societies. To provide a link with these agencies as part of his/her normal duties. To arrange the internal structured debrief following an incident, to ensure that the results of such a debrief are provided for a review of our plans and procedures Rendezvous Point Officer This Officer has the responsibility for the rendezvous point and initial briefing of staff regarding incident and safety procedures. To ensure that there are communications with both the Ambulance Control Centre, and the Mobile Communications Unit from the rendezvous point. Staff will be directed to the rendezvous point and will from there be tasked into the scene having been informed of the radio channel to be used Safety Officer This officer is responsible for the overall safety of all Ambulance, Medical, Voluntary Aid Societies and Civilian volunteers. To ensure that safe working practices and a safe working environment is provided for these staff. Liaison with the Safety Officer of the other services is essential. A sound working knowledge of the operational environment is vital to ensure a holistic approach to the safety considerations, which must be undertaken Ambulance Control and Communications Officer. The ACC Officer who oversees the communications aspect of the incident from within the communications centre. This officer should move to a separate consul and with the aid of a scribe where possible, follow the initial flow chart for implementation of the Major Incident Plan. To ensure the implementation of any specific ACTION PLAN in place in relation to the incident or incident site. To ensure keeping of an accurate log of all radio transmissions to and from the site and any subsequent telephone calls and their content. To call in such assistance to the ACC as he/ she believes is required to ensure the efficient handling of both the Major Incident and the ongoing domestic commitment. To ensure the early passage of information to all relevant personnel both emergency services, wide NHS and civilian organisation Communications Officer The Communications Officer who oversees the operation of the Mobile Communications unit (MCU) at the scene. Page 22 of 106

24 5.15 Patient Care Services Manager This manager has the responsibility of maintaining as far as is possible the contractual obligations of the service, during the period of the incident. A close liaison with the PCS will allow them to provide the large transport vehicles which can be utilised in either providing a shelter facility at the site or for the transport of the walking wounded or evacuees to hospital or rest centre. This manager is also in contact during working hours with the Ambulance Hospital Liaison officers and can quickly retask these staff Hospital Ambulance Liaison Officer An Officer/s or Manager will attend the Hospital Co-ordination Centre to liaise with the Hospital Co-ordination Team (HCT). They will provide updated information to the AIC regarding the hospitals ability to receive patients and to convey any requirements that the HCT have of the service. They will act as the communications conduit to and from the hospital to the AIC, ACC and vice versa Support Services / Fleet and Estates The Support Services and Fleet Department will have in place a callout system to ensure that in the event of being required during non-office hours, they will be able to staff their respective departments. Provide assistance as required by the Tactical Support Group Ambulance Control Centre - (ACC) The role of the ACC is to provide the resource to deliver and operate the MOBILE COMMUNICATIONS UNIT at an incident or specified event if required. Their role is an integral part of the services Warning and Informing strategy as they will co-ordinate requests from the Mobile Communications Unit to notify Hospitals, request Medical Teams (MIC and MERIT), inform Welsh Blood Service (where applicable) inform local Unitary authorities, Local Health Boards and others. All transmissions from the incident site to the ACC and from the ACC to other services etc in regard to the incident must be logged at the ACC in the event of an inquiry following the incident. The log can also provide evidence for the validation of the Major Incident Plan, and also to pinpoint any weaknesses within the operation or plan in order that training in these areas can take place Mobile Communications Unit - (MCU.) The role of the MCU at the scene of any major or serious incident or at any event where local control is required is to: Page 23 of 106

25 Provide on-site communications for Health Service staff at scene. (see Fig. 2) To act as the Incident Command Post. To provide a central location for the logging of all events and requests made, pertinent to those staff. To provide the Ambulance Control Centre (ACC), with continuous updates from scene. To pass to ACC, requests from scene for specialist assistance, equipment, transport etc Operational Support Unit (OSU) The role of the OSU is to provide additional equipment on site to the Ambulance and Health Service staff involved at the incident scene. This support will include the provision of shelter and provision of medical consumables at the scene. This will include airway management equipment, fluid replacement, wound dressings and extrication equipment. Medical teams must provide any specialist equipment that they require when they arrive at scene or arrange that it be made available from hospital stores for carriage to scene SPECIALIST UNITS 5.22 Special Operations Response Team (SORT) The SORT team is a specially trained group of staff that will provide a decontamination facility either at scene or at a hospital using NHS Chemical Personal Protection Equipment (CPPE) and decontamination units. They will also assist in the distribution of the POD s if required. The SORT team will also be part of the National Response to a CBRN incident. To provide additional support to the SORT team the Operational Support Unit will always be deployed at the same time as the SORT team Bronze CBRN The Bronze Commander with specific responsibility for the SORT team and the Decontamination area. He /she reports to the AIC and Forward Incident Officer and is specifically trained in CBRN and decontamination safety issues. In conjunction with the Fire Safety Officer he/she will have the responsibility for the safety of the SORT team and other NHS staff within the decontamination zone, the location of the unit and the water supply for the Decon unit and waste water management 5.24 MEDIA It must be remembered that the Media will be in attendance at an incident in a very short time. Requests for statements should be directed to the senior police officer Page 24 of 106

26 present. This will ensure that all statements made in these early stages are coterminous. Speculation as to cause, effect or patient numbers etc. is to be actively discouraged. Remember that in an age of long lens photography your actions and your patients treatment and welfare can be observed from a long way off, try where practicable to maintain the dignity of your patients from such intrusion. The Trusts Media representative should be contacted as soon as possible in order to ensure that the service is properly represented in any future media broadcasts or paper format. This will include requests for help, return to work of staff etc. The Media have a job to do and will require where possible statements to be made in order that they can meet their broadcasting schedules. They will appreciate regular updates for example hourly; this should remove some of the pressures of doorsteping staff at the scene. (See Appendix 13) 6.0 MEDICAL / HOSPITAL STRUCTURE 6.1 Medical Incident Commander The Medical Doctor with overall responsibility, in close liaison with the Ambulance Incident Commander, for the management of the field Mobile Medical Team at the scene of a Major Incident. He/she should not be a member of a mobile medical team. He/she will be located with the Ambulance Incident Commander and act as part of the Tactical Command group. 6.2 Medical Emergency Response Incident Team (MERIT) These are medical teams, which can be called to the incident scene. They are requested by the Ambulance Incident Commander (AIC) or, on the advice of the Medical Incident Commander (MIC). They will work under the direction of the Medical Incident Commander. The make up and skill level of the teams to be as agreed by the EPSG-Wales. (Ref. NHS Wales Emergency Compendium Section 18). 6.3 Nursing Incident Commander A Senior Nursing Officer who may be called to the scene to undertake responsibility for the co-ordination and liaison with the Ambulance Incident Commander and Medical Incident Commander for the nursing component of the Mobile Medical Teams that works at the incident site. He/she may be located with the Medical Incident Commander. This is only available provided in the Central and West area. Page 25 of 106

27 6.4 BASICS / Medserve Doctors Where this scheme is in operation it provides a number of pre-hospital immediate care trained Doctors who have experience of working with the WAST on a day-today basis. These Doctors are equipped to provide advanced trauma life support and drug therapy over and above that can be provided by the WAST paramedics, they will attend at the scene with their own medical and personal protective equipment. BASICS trained Doctors will also have undertaken a Major Incident Medical Management Support (MIMMS) course to equip them to act as the Medical Incident Commander. 7.0 POST INCIDENT ACTIONS 7.1 Staff Health and Welfare The WAST take their responsibilities in this area very seriously and have used the guidance given in Dealing with Disaster (revised version3) June 2003 section and The NHS Planning Guidance 2005, Ambulance section page 11. to provide both physical and psychological support to their staff. Specific issues are outlined below; 1. Anyone who suffers injury or contamination at the Incident site must report this to the Ambulance Safety Officer. 2. Staff suffering injury or contamination must seek medical aid as soon as possible either at scene or at a Casualty Unit or other medical facility. 3. Continued health care is available through the services contractual agreements with the Occupational Health Departments. 4. Post traumatic stress disorder is a real concern for all those who work within the Emergency Services; therefore confidential professional help is available to any member of staff. 5. Staff should be aware that some posttraumatic stress reaction is the norm following an abnormal event. If however, these reactions persist longer than 4 to 6 weeks staff should be encouraged to seek confidential help. 6. Supervisory Officers have a duty to monitor all staff following an incident and to ensure that they are aware of the professional expertise available. 7.2 Structured Debrief. In order to ensure that the incident is not just filed away and forgotten, a Structured Debrief will be held with all those staff that had input into the incident. This will allow lessons learned to be fed back into the organisation, changing policies and procedures as required. Page 26 of 106

28 In addition the results from this in service debrief will be taken forward to any multiagency debrief to ensure a more robust and effective response in the future. 8.0 ROLES OF OTHER SERVICES (Civil Contingencies Secretariat document Responding to emergencies Draft Guidance. Dec 2004). Category 1 Responders 8.1 Police (CAT 1) The police will normally co-ordinate all the activities of those responding at and around the scene of a land-based emergency. The saving and protection of life is the priority but as far as possible the scene must be preserved to provide evidence for subsequent enquiries and possibly criminal proceedings. Once life saving is complete, the area will be preserved as a scene of crime until it is established as otherwise (unless the emergency results from severe weather or other natural phenomena and no element of human culpability is involved). Where practicable the police, in consultation with other emergency services and specialists, should establish and maintain cordons at appropriate distances. Cordons are established to facilitate the work of the other emergency services and support organisations in the saving of life, the protection of the public and the care of survivors. Where terrorist action is suspected as causing an incident, the police will normally take additional measures to protect the scene. These include establishing cordons under the Prevention of Terrorism Act and carrying out searches for secondary devices. They also take initial responsibility for safety management at such incidents for those working within cordons. The police oversee any criminal investigation. Where a criminal act is suspected they must undertake the collection of evidence, with due labelling, sealing, storage and recording. They facilitate inquiries carried out by the responsible accident investigation bodies, such as the Health and Safety Executive or the Air or Marine Accident Investigation Branch. The police process casualty information and have responsibility for identifying and arranging for the removal of the dead. In this task they act on behalf of HM Coroner who has the legal responsibility for investigating the cause and circumstances of any deaths involved. Survivors or casualties may not always be located in the immediate vicinity of a disaster scene, it is therefore important to consider the need to search the surrounding area. If this is necessary the police should normally co-ordinate search activities on land. Where the task may be labour intensive and cover a wide area, assistance should be sought from the emergency services, the military or volunteers. Page 27 of 106

29 8.2 Fire Service (CAT 1) The primary role of the fire service in a major emergency is the rescue of people trapped by fire, wreckage or debris. They will prevent further escalation of an incident by controlling or extinguishing fires, by rescuing people and by undertaking other protective measures. They will deal with released chemicals or other contaminants in order to render the incident site safe or recommend exclusion zones. They will also assist the WAST with casualty handling and the police with recovery of bodies. The fire service is likely to take the lead on health and safety issues for personnel of all agencies working within the inner cordon however, safety of staff should normally be resolved and agreed between relevant agencies at the scene following an appropriate risk assessment. Any conflicts over responsibility for safety should be raised and resolved at multi-agency meetings. The fire service will manage access to the inner cordon under their Incident Command System, liaising with the police and discussing who should be allowed access. It is expected that other agency workers attending the scene come issued with the appropriate level of personal protective equipment and that they are adequately trained and briefed. However, in the event of any situation which is, or which is suspected to be, the result of terrorism the police will assume overall control and take initial responsibility for safety management, but the main responsibility for rescuing people and saving lives remains with the fire service. Although the health service is responsible for the decontamination of casualties, the fire service will in practice often undertake mass decontamination of the general public in circumstances where large numbers of persons have been exposed to chemical and biological substances. This is done on behalf of the health service, and under the direction of the WAST following a Memorandum of Understanding between the Office of the Deputy Prime Minister and the Department of Health. 8.3 The Maritime and Coastguard Agency (MCA) (CAT1) The MCA is an executive agency within the Department for Transport. The MCA s Directorate of Operations consists of separate but integrated branches HM Coastguard (responsible for Search and Rescue [SAR], Prevention and Response); the Counter Pollution and Response Branch; the Press Office; Survey and Inspection Branch (ensures that the UK Fleet meets the correct safety standards and Port State Control of non UK ships); an Enforcement Branch (carries out investigations and prosecutions following breaches of Merchant Shipping legislation); and a Technical Services Branch. The primary responsibility of HM Coastguard is to initiate and coordinate civil maritime search and rescue (and in some cases maritime incidents resulting from an air accident) within the United Kingdom Search and Rescue Region. This includes mobilising, organising and dispatching resources to assist people in distress at sea, in danger on the cliffs or shoreline, or in danger in inland Page 28 of 106

30 areas due to flooding. Local coastal safety committees based on police force boundaries ensure effective co-ordination of resources between police and coastguard for land based incidents on or adjacent to coastlines. The Counter Pollution and Response Branch is responsible for dealing with pollution at sea and in conjunction with local authorities, for the shoreline clean-up. It also has responsibility for approving Oil Spill Contingency Plans for Ports and Harbour Authorities and provides appropriate training. 8.4 Unitary Authorities. (CAT1) Each local authority manages a civil contingency planning function. Civil protection (or emergency planning) personnel act as a hub to coordinate the planning, training and exercising within local authority departments. The effectiveness of this hub is fundamental to the discharge of related community responsibilities in an emergency, whatever the cause. Local authority planning is carried out in close cooperation with the emergency services, utilities, many other industrial and commercial organisations, central government departments such as the Ministry of Defence or Department of Health, other statutory organisations such as the Environment Agency, and many voluntary agencies. The principal concerns of local authorities in the immediate aftermath of an emergency are to provide support for the people in their area. Generally they do so by co-operating in the first instance with the emergency services in the overall response however, they also have many specific responsibilities of their own. They will use the resources of local authority departments to mitigate the effects of emergencies on people, property and infrastructure and play a key role in co-ordinating the response from the voluntary sector. They also endeavour to continue normal support and care for the local and wider community throughout any disruption. In incidents involving multiple fatalities, the coroner s office will liaise with the local authority on the establishment of temporary mortuaries. As part of the local response, plans should already have been agreed for opening additional spaces at existing public or NHS mortuaries and/or establishing temporary mortuaries. These plans should include how to locate staff. As the emphasis moves in time from immediate response to recovery, the local authority will take a leading role to facilitate the rehabilitation of the community and restoration of the environment. Even a relatively small emergency may overwhelm the resources of the local authority in whose area it occurs. Against this possibility plans need to be made which will, in appropriate circumstances, trigger arrangements for mutual aid from neighbouring authorities, delivering cross boundary assistance if required. Arrangements may range from simple agreements offering whatever assistance is available in the event of an incident to more formal arrangements for the shared use of resources. This could include the use of vehicles, equipment and people. (Payment arrangements may need to be included in any agreement). Page 29 of 106

31 8.5 The Environment Agency (EA) (CAT1) The EA has primary responsibilities for the environmental protection of water, land and air in England and Wales. The devolved administrations for Scotland and Northern Ireland have similar respective responsibilities. The EA has key responsibilities for maintaining and operating flood defences on certain specified rivers and coastlines. Whenever necessary, the EA s role is to provide remedial action to prevent and mitigate the effects of the incident, to provide specialist advice, to give warnings to those likely to be affected, to monitor the effects of an incident and to investigate its cause. The EA also collects evidence for future enforcement or cost recovery. It also plays a major part in the UK Government s response to overseas nuclear incidents. Category 2 Responders 8.6 Commercial and Industrial (CAT 2) Industrial or commercial organisations, including the utilities, may play a direct part in the response to emergencies if their personnel, operations or services have been involved. Organisers of large outdoor and indoor events such as sporting competitions, folk festivals, pop or classical concerts will also have a role in the response to an emergency. Industrial or commercial organisations may give support by providing equipment, services or specialist knowledge. While many private sector organisations contribute to the wider response, many businesses fail as a result of various types of major emergency storm, flood, fire, terrorism, product contamination or pressure group activity. Experience shows that those businesses which have considered potential hazards and have prepared response plans ( which often need be no more than a few pages in length) have a much greater chance of surviving than those who are unprepared. Other Responders 8.7 Military. (Support CAT1 when necessary) A Ministry of Defence (MOD) pamphlet14 sets out the conditions under which military assistance is provided including the financial aspects. In broad terms there are three categories of Military Aid to the Civil Community (MACC) Category A: Category B: Category C: Assistance to the civil authorities in dealing with an emergency such as a natural disaster or Major Incident. Short-term, routine assistance on special projects of significant social value to the civil community. The full-time attachment of volunteers to social service (or similar) organisations for specific periods. Page 30 of 106

32 Both the operational and financial responsibility for dealing with all categories of civil emergencies lies with the civil authorities and assistance is undertaken under their direction. Service personnel and materials are not earmarked or put on standby to meet any civil emergency or other task. Consequently, although civil authorities may produce contingency plans in conjunction with service headquarters and units, such plans do not guarantee that a service response will necessarily be available. 8.8 Voluntary Services There are a great number of volunteer organisations working in Wales. The majority of whom are contactable through the Unitary Authorities Emergency Planning Officer. Requests for assistance stating the problem rather than a specific request for an organization will often deliver a swifter and more positive response. Specific Organisations with whom we have day-to-day dealings such as the British Red Cross and the St John Ambulance will endeavour; 1. To provide assistance and support to the various emergency services. 2. To provide an agreed level of support to the unitary authority in respect of Rest Centre cover. 3. To provide communication links. However it must be remembered that a number of the volunteer organisations and Territorial Army regiments (e.g. Field Hospital Units) rely heavily on NHS staff to provide their members. This could result in expectations of help and assistance not being achieved in the event of a large scale emergency as potential volunteers are required to provide cover within their employing organisations. 9.0 THE NATIONAL HEALTH SERVICE (other than the Ambulance Service) 9.1 The NHS resource in an area should decide upon a lead responder who will attend at all CAT 1 meetings to represent their members, but in addition members with a specific interest should represent themselves at relevant meetings. 9.2 National Public Health Service The NHS makes public health advice available to the emergency services, NHS organisations and the public on a 24-hour basis. This advice is crucial for the control of communicable diseases and for public health concerns relating to hazards in chemical, biological, radiological and nuclear incidents 9.3 Acute Hospitals Hospitals with Major Accident and Emergency Departments have been designated as potential casualty receiving hospitals. They respond to requests from the WAST Page 31 of 106

33 to receive casualties for medical treatment and also provide appropriately trained staff to act as Medical Emergency Response Incident Team (MERIT) Medical Incident Commanders. (see Medical / Hospital staff at scene). Other hospitals provide support to receiving hospitals by taking patient transfers etc. 9.4 Primary and Community Care Services The provision of primary and community care support is a crucial aspect of the NHS response. These services cover a range of health professions including General Practitioners (GPs), community nurses, health visitors, mental health services and pharmacists, many of whom would need to be involved following a Major Incident. Local Health Boards should therefore be involved in the emergency planning processes. 9.5 NHS Direct - Wales. NHS Direct are an integral part of the WAST, who report through the Health Department of the Welsh Assembly Government. They provide standard algorhythm response to telephone health advice requests generated by the general public. They are one of the first points of contact for WAST in the event of a major or serious incident, as they will be a resource in the event of a Major or Serious incident to disseminate medical and / or health advice to members of the public. This could result in fewer casualties calling for WAST or attending at Hospitals who may be heavily involved in dealing with an incident. 9.6 The Local Health Board (LHB) (Cat 1) The LHB play a fundamental role in terms of co-ordinating the NHS response across a wide area by representing the NHS within the Strategic Co-ordination Group as well as being the primary co-ordinators of Primary care Services. Page 32 of 106

34 ACTION CARDS Communications 1) Ambulance Control Centre - ACC 2) Mobile Communications Unit - Mobile Command Unit Operational Roles 3) First vehicle on scene a: Attendant b: Driver 4) Subsequent vehicles at scene 5) Forward Incident Officer (Bronze / Operational) 6) Ambulance Incident Commander (Silver / Tactical) 7) Gold Commander (Strategic) 8) Casualty Clearing Officer 9) Loading Point Officer 10) Safety Officer 11) Emergency Planning Officer 12) Parking Officer 13) Rendezvous Officer 14) Bronze CBRN 15) Hospital Ambulance Liaison Officer 16) Equipment Officer Page 33 of 106

35 ACTION CARD 1 Action by Ambulance Control Centre (ACC) The Senior Control Officer on duty will assume overall responsibility within the ACC for the Major Incident and ensure that the following actions have been taken. 1. He/she will ensure that a log is maintained of all messages and nominate the channel to be used by all responding vehicles. 2. Dispatch initial attendance of ambulances and relevant on-call officer. Inform the other Emergency Services. 3. Inform the crews that the attendant of the first ambulance to arrive at the scene is responsible for the duties of the Acting Ambulance Forward Incident Commander until relieved by a Senior Officer. (To avoid confusion, the first vehicle to report at the scene must be informed by Control that they are in fact, the first vehicle present). Control must also inform other vehicles en-route of location and identity of first vehicle at scene. 4. Instruct crews of all vehicles deployed to the incident to switch their radios to the designated channel and advise them of the receiving hospitals. 5. Dispatch/alert Ambulance Officers as appropriate. 6. Consider dispatching the Mobile Communications Unit if reports received indicate that the incident will continue for a long period of time, is of large proportions or underground. 7. Dispatch a Medical Incident Commander to the scene. 8. Notify the nearest listed hospitals that they have been nominated as the receiving hospitals for the incident. Warn all hospitals local to the incident that they may receive self-referral patients. 9. Inform the Health Emergency Planning Advisor Welsh Assembly Government, The Local Health Board on call officer, the National Public Health Services on call officer, NHS Direct Wales and the relevant Unitary Authority Emergency Planning Officer. 10. If a Medical Emergency Response Incident Team (Merit) are needed at the incident, notify the appropriate hospital and task transport to convey. All names of medical and nursing personnel deployed at the scene must be given to the Mobile Communications Unit and the Ambulance Safety Officer. 11. Inform Police, as appropriate, giving the names of receiving hospitals. Page 34 of 106

36 12. Inform the Gold Commander of all information received - maintain contact with the AIC and implement his/her requirements. 13. Dispatch Officers to fulfil all the key roles at the scene and the receiving hospitals with the appropriate communications equipment. 14. Mobilise the required resources for the incident by: Deploying available ambulances to rendezvous points in consultation with the AIC. Deploying appropriate specialist resources to the scene (e.g. SORT Teams, POD s, Control and Operational Support Unit s) Authorising suspension or adjustment of non-urgent work in affected areas, in consultation with the PCS manager, whichever is immediately available. Split crews and retain personnel due to go off duty to crew additional vehicles. If necessary and practicable, increase staff (by transfer or recall) at ACC. 15. Dispatch at least one multi-seat PCS vehicle to the scene for early evacuation of P3 (walking) casualties. 16. Training Officers and students to be dispatched to the scene as available and necessary. 17. Seek assistance, if required, from adjacent ambulance regions and / or services to provide cover in denuded areas or to attend the scene. 18. Alert the Blood Service of any likelihood of increase demands for blood (if applicable). 19. Notify Fleet Manager / on call mechanic to facilitate operation of vehicles during long-term operation. 20. Unitary Authority Emergency Planning Officer to alert voluntary organisations as required, refer to control list for details. 21. Give the appropriate stand down message at the appropriate time to all participating agencies alerted during the operation, with either; Major Incident Cancelled. Major Incident stand-down. 22. Notify hospitals that a site is cleared of casualties, this message must include an estimate of the number of patients still en route to their hospital. 23. At the conclusion of the incident prepare a report for the Director of Ambulance Services. Page 35 of 106

37 ACTION CARD 2 Mobile Communications Unit - Mobile Command Unit (MCU) 1. Collect the appropriate Mobile Communications Unit, confirm the location of the incident and proceed to site. 2. In liaison with the AIC set up the Mobile Communications Unit at a safe location in close proximity to the other Emergency Services Control Units (a minimum distance between vehicles not to be less than 10 metres). 3. Carry out procedures for setting up the Mobile Communications Unit and implement communication checks. 4. Issue hand portable radios as required, indicate appropriate channels. 5. If the AIC is not in attendance, work in liaison with the acting AIC. 6. Inform Control of the exact location and magnitude of the incident. 7. The Officer in charge of Mobile Communications Unit will ensure that effective communications exist between the Mobile Communications Unit, staff working on site, other Emergency Services and the ACC. 8. Ensure that all ambulances arriving and leaving the scene are duly logged. 9. To provide the Bronze Loading with destinations of casualties removed from the scene. 10. At the conclusion of the incident, prepare a report for the Director of Ambulance Services. Page 36 of 106

38 First Ambulance at Scene (Attendant) ACTION CARD 3A 1. On arrival at scene notify the ACC and state exact location, vehicle call sign and forward control point. Full safety clothing including safety helmet MUST be worn at ALL times. 2. Carry out a reconnaissance of the scene reporting back to Control as soon as possible. 3. Use the Step to ensure your safety. STEP = STEP 1. STEP 2 STEP 3 Steps To protect Emergency Personnel One patient collapsed / showing signs of poisoning treat as normal. Two patients collapsed / showing signs of poisoning treat with extreme caution. Three or more patients collapsed / showing signs of poisoning you should STOP, WITHDRAW AND RE-EVALUATE your safety and investigate the potential cause. 4. Confirm as soon as possible - MAJOR INCIDENT Give SITUATION REPORT. (METHANE) (Ref. Appendix 1). M Major Incident Declared or Standby E Exact location grid reference if possible. T Type of Incident rail, road, air, chemical etc. H Hazards current and potential A Access / egress direction to approach / leave N Number of Casualties and their severity / type E Emergency Services present and required 5. Do NOT attempt to revive or treat patients, initial TRIAGE SIEVE only. 6. Be prepared to brief and remain with the first Ambulance Officer on scene 7. Prepare report for Director of Operations. Page 37 of 106

39 First Ambulance at Scene (Driver) ACTION CARD 3B 1. They should park as near to the scene as safety permits and in close proximity to first Police/Fire responses on scene. 2. Full safety clothing MUST be worn at all times including safety helmet. 3. Roof beacons should be left ON as the first vehicle on scene as it acts as the Ambulance Control Point and should be within easy reach of Police / Fire Forward Control Units. This vehicle will become the focal point for all the patients who can self evacuate from the scene. 4. Provide Ambulance Control Centre with an initial visual report and confirm the attendance of or requirement for other Emergency Services. He / she should also confirm that the attendant has gone forward to undertake a reconnaissance. In liaison with other Emergency Services set up following: - a) Ambulance Control point. b) Ambulance Parking point. 5. The driver should stay with vehicle at ALL times and maintain communication link with attendant and Control. Page 38 of 106

40 ACTION CARD 4 Subsequent Ambulance Crews 1. Approach with care and inform Control of arrival. 2. On arrival at scene ALL blue lights must be extinguished if safe to do so. At a very early stage in the incident contact to be made with the Forward Incident Commander to receive instructions on their deployment. 3. As the incident develops and a Parking Point has been established the attendant is to remain with the vehicle unless instructed otherwise; drivers MUST remain with their vehicle at the Parking Point unless instructed otherwise. 4. Keep radios switched on. Do not use unless specifically called by Control or an emergency transmission is justified. 5. Convey casualties to the hospital stipulated by Ambulance Loading Point Officer, unless otherwise directed by Control. 6. Record information on casualty label, including any drugs given etc. 7. On arrival at hospital, unload, without delay and report to ACC for further instructions. 8. If instructed to return to scene, do so as quickly as possible to the Ambulance Parking Point. Page 39 of 106

41 Forward Incident Officer (FIO) ACTION CARD 5 1. The role of the FIO in liaison and under direct control of the AIC, is to directly manage and co-ordinate the medical activities at the incident or specific site(s). 2. Direct and brief ambulance personnel as needed, consider the use of specialist units. 3. Liaise with the AIC and assist in directing medical / nursing teams as needed. Ensure AIC is aware of such teams on site. 4. Provide flexible managerial control of forward area, keeping the AIC informed at all times. 5. Monitor the working environment for safe working practices and liaise with Ambulance Safety Officer. 6. In liaison with AIC ensure: a) Appropriate access / egress exists. b) Setting up of Casualty Clearing Station. c) Setting up of an Ambulance Loading Point. d) Setting up of an Ambulance Parking Point. e) Setting up of a Forward Control Point. f) Provision of a decontamination facility if required. 7. Maintain contact with other Emergency Services Bronze Commanders. 8. Immediately following close down of Incident, hand any records to the AIC. 9. Prepare a report for the Director of Ambulance Services. Page 40 of 106

42 ACTION CARD 6 Ambulance Incident Commander (AIC Silver) 1. On arrival at Incident, locate Acting Ambulance Incident Commander and obtain all relevant information. Relieve acting AIC and deploy as appropriate. Report arrival to Control and Mobile Communications Unit. 2. Reassess situation and update Gold Commander( when in position) 3. Liaise with Police and Fire Service Silver Commander and maintain overall scene management in conjunction with them. 4. Confirm to Control: M Major Incident declared / standby E Exact location grid reference T Type of incident rail, road, CBRN etc. H Hazard current & potential A Access / egress direction to approach / leave N Number of casualties and their severity /type E Emergency services present and required 5. Establish where appropriate that the following roles have been allocated: a) Forward Incident Officer. b) Communications Officer - Mobile Communications Unit. c) Parking Officer d) Casualty Clearing Officer e) Loading Point Officer f) Safety Officer g) Rendezvous Officer h) Equipment Officer i) Bronze CBRN Undertake or arrange for the following; 6. Brief and deploy ambulance personnel on site. Liaise with the Ambulance Safety Officer regarding issue of equipment relating to staff working at scene. 7. Receive information from the ACC regarding hospitals that are prepared to take casualties to include numbers and types of casualties. 8. Prioritise casualties prior to arrival of back-up services. 9. Update and liaise with Medical Incident Commander on arrival. 10. Request back-up resources as required updating information to Control. Page 41 of 106

43 11. If required, request attendance and then brief and deploy personnel from Voluntary Aid Societies through the organisations Senior Officer on site. 12. If required, consideration must be given to tasking an individual, suitably trained, to provide Air Ambulance co-ordination at the site. 13. When all casualties have been dealt with the AIC will close down the WAST operations and inform Control requesting that a MAJOR INCIDENT - CASUALTY EVACUATION COMPLETE message be sent to the appropriate hospital(s). 14. Arrange collection of all WAST equipment following close down. 15. Arrange retention of all documentation generated at scene. 16. Prepare report for Director of Ambulance Services. Page 42 of 106

44 ACTION CARD 7 Ambulance Gold Commander 1. Report through the ACC and set up liaison with the Ambulance Incident Commander at the scene. 2. Report to or send a representative to the designated Strategic Coordinating Group if applicable. 3. Initiate and maintain as required liaison at executive level with other Emergency Services, Local Health Boards, NPHS HM Forces and Unitary Authorities, and the Health Emergency Planning Advisor Wales. He / she must ensure representation in the Welsh Assembly Governments Emergency Co-ordination Centre Cardiff. 4. Advise the Ambulance Incident Commander of WAST strategy. 5. To liaise with the Trust Executive and following consultation to communicate to the Ambulance Incident Commander such decisions as may effect the long-term tactical operation. 6 To initiate if required the ASA National mutual aid procedures. 7 To act as the focal point for media information in co-operation with the other Gold Commanders. 8 Following the appropriate stand down message from the Ambulance Incident Commander implement the return to normal working. 9 To consider the second phase of the Major Incident from the hospital perspective and the consequences of the disruption to hospital routine. 10. To maintain as far as practicable core service delivery throughout the incident and during its immediate aftermath. 11. At the conclusion of the incident prepare a report for the Director of Ambulance Services/Trust Board. Page 43 of 106

45 ACTION CARD 8 Casualty Clearing Officer 1. Report to the Ambulance Incident Commander / Mobile Communications Unit. 2. Locate or establish a Casualty Clearing Station. 3. Liaise with Medical Incident Commander and initiate triage sort. 4. Determine the medical priority of patients and the priority of their removal from the Casualty Clearing Unit, having regard to the transport and medical facilities available. 5. Ensure all casualties moved to Ambulance Loading Point are displaying the appropriate patient label. 6. Maintain in liaison with the Loading Officer a record of casualty numbers and destinations. 7. In liaison with the Police, designate a temporary body holding point. 8. Update Ambulance Incident Commander as required. 9. Ensure continuity of documentation. 10. Prepare a report for the Director of Ambulance Services. Page 44 of 106

46 ACTION CARD 9 Loading Point Officer 1. Report to Ambulance Incident Commander/ Mobile Communications Unit. 2. Locate or establish Ambulance Loading Point. 3. Call forward ambulances as required from the Parking Officer via Mobile Communications Unit. In liaison with the Casualty Clearing Officer specify the level of transport and continuing care required for each casualty, e.g. Paramedic, Technician etc. 4. Maintain a log of all casualties removed by ambulance. 5. Ensure all patients loaded are displaying appropriate patient labels. 6. Update Ambulance Incident Commander as required. 7. Instruct crews as to the location of receiving hospital. 8. Prepare a report for the Director of Ambulance Services. Page 45 of 106

47 ACTION CARD 10 Safety Officer 1. Liaise with the Safety Officers from other the Emergency Services in particular the Fire Service Safety Officer. 2. Identify specific hazards and / or dangers and notify the Forward Incident Officer (s), the Ambulance Incident Commander and the Medical Incident Commander. 3. Monitor, in liaison with other Officers the number of staff working within the incident boundaries and ensure all WAST personnel and medical staff are wearing the correct high visibility personal protective clothing and safety headgear. 4. Advise Parking Officer and Ambulance Incident Commander of any unforeseen hazards and dangers that may arise and of any protective measures that can be taken i.e. specialist clothing, decontamination procedures. 5. Monitor all work functions where possible for safety and act immediately to correct any errors. 6. Following liaison with the AIC and the MIC and in consultation with the Parking Officer, assist with the briefing of staff prior to deployment to the scene. 7. Identify members of staff who may be feeling the effects of stress and or fatigue. Take action to either relieve stress or relieve them of their duties within the incident. 8. In liaison with Parking Officer monitor periods of duty that staff are working and ensure they receive adequate rest and refreshment. 9. In liaison with the other emergency services in attendance, advise the Forward Incident Officers and the Ambulance Incident Commander if the need to evacuate the scene arises. 10. Where appropriate, provide the Ambulance Incident Commander and the Forward Officers with information regarding methods of treatment for such eventualities as contamination. See Appendix Prepare a report for the Director of Ambulance Services. Page 46 of 106

48 ACTION CARD 11 Emergency Planning Officer / Tactical Advisor 1. Report to the ACC - receive updated information regarding incident. 2. Advise on facilities and support organisations available; a) Vehicles, Equipment, Support Services. b) Hospital and Medical. (NHPS, HPA). c) Unitary Authority. d) Volunteers. 3. Following a SITREP ensure mobilisation of appropriate Mobile Communications Unit and Mobile Equipment Unit/s and staff. 4. Attend scene as appropriate to assist and advise in overall management of resources. 5. Ensure that suitable records are being maintained at all levels. 6. Liaise with Emergency Planning representatives from other Emergency Services and local Unitary Council(s) 7. Provide specialist advice on tactics and procedures at CBRN and Hazmat incidents. 8. Facilitate Service Debrief(s) at suitable time periods and contribute with selected staff to inter-agency debriefing procedures. 9. Collate the WAST Incident Report on behalf of the Service. 10. Review WAST procedures as necessary in light of lessons learnt. 11. Provide a report to the Director of Ambulance Services on the management of the incident to be used as an audit of the Major Incident Plan and current training programme. Page 47 of 106

49 ACTION CARD 12 Parking Officer 1. Report to the Ambulance Incident Commander / Mobile Communications Unit 2. Inform the Ambulance Incident Commander and Mobile Communications Unit when the Parking Point is manned and operational.. 3. Brief staff arriving at the incident of any special areas, hazards for consideration, or safety information received from Bronze Safety 4. Ensure that staff are wearing the appropriate Personal Protective Equipment. 5. Specific equipment checks of vehicles arriving on scene as per the Equipment Resource form (See appendix 3) and redeployment of this equipment to the incident equipment site as required by the Equipment Officer. 6. Continuous update of Mobile Communications Unit of: - a) Status of crews e.g. paramedic, qualified ambulance persons. b) Arrival of Operational Support Unit/s and / or Decontamination Units. c) Arrival of vehicles with teams of staff e.g. Training Centre staff. d) Arrival of SORT team. d) Arrival of Basics / GPs. e) Arrival of Medical / Nursing teams. f) Arrival of Voluntary Aid Societies, and organisations. g) Maintain record of the same. 7. Ensure that measures are taken to retain staff at the Parking Point to move ambulances to the Loading Point as required. 8. Ensure that ignition keys remain in vehicles at the Parking Point and are not retained by crew staff for security. Consider removal of ignition keys to secure location at Parking Point for reissue to crews leaving scene. 9. Direct ambulance and medical staff from the Parking Point to the scene as required. 10. Ensure all vehicles arriving and leaving the scene are duly logged. 12. Prepare a report for Director of Ambulance Services. Page 48 of 106

50 ACTION CARD 13 Rendezvous Officer 1. To allocate in consultation with the Ambulance Incident Commander the location of the Rendezvous point. 2. To ensure the safety of staff and vehicles at the Rendezvous Point. 3. To liaise with the Parking Officer and the ACC. 4. To inform the Parking Officer of staff and vehicles that are available for deployment to scene. 5. To ensure that the appropriate staff are deployed to the Parking Point. 6. To ensure that staff have full personal protective equipment. 7. To ensure that all vehicles have medical gasses and fuel prior to being tasked. 8. To ensure that crews are aware of the location of the incident and the route and direction to take to the incident. 9. Prepare a report for the Director of Ambulance Services. Page 49 of 106

51 ACTION CARD 14. Bronze CBRN 1. To locate and deploy the decontamination unit in consultation with the Fire Safety Commander. 2. To ensure the safety of SORT team members working within the warm zone. 3. To ensure the safety of all NHS staff working within the decontamination zone. 4. To obtain as much information on the potential CBRN product as possible. 5. To decide on the level of decontamination required by those presenting as contaminated. 6. To decide upon the Triage methods to be used in the warm zone, to ensure that the Fire Service understand rescue triage. 7. To request through the AIC any specialist information or equipment required. 8. To decide on the working time in a NHS CPPE suit for SORT team members. 9. To arrange for individual team member times to be logged to facilitate air blower filter changes for staffing CPPE. 10. To arrange for sufficient water supplies to undertake decontamination. 11. To arrange for retention of waste contaminated water and liaison with the Environmental Agency. 12. To ensure the safe decontamination of staff and equipment at the close of the incident. 13. To restock the decontamination unit. 14. Prepare a report for the Director of Ambulance Services. Page 50 of 106

52 Hospital Ambulance Liaison Officer ACTION CARD Proceed to their designated receiving hospital. 2. Confirm arrival with Ambulance Control Centre. 3. Request information from the ACC on the nature of the Incident, approximate number of casualties and the extent of hospital resources required. 4. Liaise with appropriate Managers at hospital. 5. Provide information to Ambulance Control Centre regarding the bed state at the hospital and support hospitals and other relevant information. 6. Co-ordinate with receiving hospital the requests for transport for patients needing transfer or discharge. 7. Maintain a log of all patients brought into hospital (Appendix 5). 8. Supervise arrangements for the arrival of helicopters at the hospital. 9. When incident is closed, deal with recovery of ALL ambulance equipment and return to its source. 10. Prepare a report for the Director of Ambulance Services. Page 51 of 106

53 ACTION CARD 16 Equipment Officer 1. In liaison with the Ambulance Incident Commander and the Loading Point Officer site the Operational Support Unit Record all equipment issued and to whom the issue was made. 3. Liaise with Hospital Ambulance Liaison Officer via the ACC to obtain specialist equipment from the receiving hospitals as required e.g. drugs, blood, amputation equipment, etc. 4. Liaise with the Ambulance Incident Commander and the Forward Incident Officer/s regarding the equipment state at the scene, requesting the deployment of other Operational Support Unit s to the scene if appropriate. 5. Arrange for the transportation of equipment as required by the Ambulance Incident Commander. 6. In liaison with the Ambulance Incident Commander and Safety Officer consider the provision of refreshments. 7. Ensure the safe return of all non-disposable equipment issued. 8. At the conclusion of the Incident prepare a report for the Director of Ambulance Services. Page 52 of 106

54 APPENDICES 1. Situation Report (Sitrep) 2. Briefing Format 3. Triage In CPPE 4. Triage Sieve 5. Triage Sort 6. Equipment Transfer Form 7. Hazardous Substances 8. CBRN Mobilisation Flow Chart 9. Practical Decontamination Procedure 10. Chemical Incident Assessment Form 11. Arrangements for Radiation Casualties 12. Gold Commanders Liaison Chart 13. Media Guidance 14. Glossary of Terms 15. Bibliography of Reference Material 16. Example of a Decision Log Page 53 of 106

55 Appendix 1 SITUATION REPORT TIME DATE AS.1 NUMBER. Major Incident declared / Standby Exact location Type of incident Hazards Access / rendezvous point Number of casualties P1 P2 P3 Dead Emergency Services Major Incident: Standby/Declared YES / NO Signed: Name Signed Page 54 of 106

56 BRIEFING FORMAT Appendix 2 The service will use the mnemonic IIMARC in order to maintain continuity through all briefings. This simple system which is also used by the Police started as the basis for all public order briefings where police staff from a number of regions required to be comprehensively briefed prior to engaging at an incident. The information received from the initial and subsequent METHANE reports will assist in forming the brief. Information Name and role what where / how many/ premises / grid reference / landmarks / features etc. Intent What are we here for? State the aim of the service at the incident and repeat for clarity. Method Address each team member and give them a task Actions on- (i.e. what they should do if circumstances change). Administration Confirm the equipment available. Confirm resupply / support arrangements / welfare. Ensure chain of command is understood (roles). New tasks should only be undertaken on command. Time and place of next meeting. Relief staff to be briefed on arrival. Risk Assessment Specific threats. Time in CPPE suits. Filter changes. Communications Confirm radio call signs / indicate other means of communications if required and ensure all staff understand the- Interagency communications. Decision logging (logs will be primary evidence at any subsequent trial / enquiry). Page 55 of 106

57 TRIAGE IN CPPE Appendix 3 To Triage effectively whilst wearing NHS Chemical Personal Protective Equipment is very difficult as your ability to undertake capillary refill or pulse checks are seriously hampered by the material of the gloves and the noise generated in the hood by the air blower unit. The ASA National Ambulance Services CBRN & Hazmat Faculty has developed a simple Triage procedure which will ensure that those patients that would benefit from decontamination first receive it at the appropriate time. WALKING YES DECONTAMINATE NO RESPONSE TO YES DECONTAMINATE VOICE / PAIN NO YES RESPIRATORY NO DEAD MOVEMENT Page 56 of 106

58 Appendix 4 Triage Sieve. (Mobility + ABC s) Should an incident occur then the MIMMS Triage Sieve will be utilised in the first instance to ensure that all patients are seen and given an initial priority to assist in ensuring that the resources of the service will be targeted at those patients with the more serious conditions. The sieve uses the patients ability to walk, Respiratory rate, and the Capillary refill rate as the criteria. Patients are banded into 3 categories, denoted by a number and a colour; P1 red Immediate P2 yellow Urgent P3 green Delayed Dead white The sieve is a quick snapshot of the patient at the time that he or she is triaged. Remember triage is a dynamic process and must be carried out continually, each patient being visited and revisited to ensure the stability of his or her condition. WALKING Yes P3 (delayed / green) No No AIRWAY DEA D (try simple airway manoeuvre) Yes Yes DEAD RESPIRATORY <10 or >29 P1 (immediate / red) RATE over 120 PULSE under120 P2 (urgent / yellow) Capillary refill can be used in place of pulse rate, but is not as accurate due to outside influences (temperature, skin discoloration, bad circulation etc.) Capillary refill Over 2 seconds = P1 Capillary refill Under 2 seconds = P2 Page 57 of 106

59 Appendix 5 TRIAGE SIEVE TRIAGE From the French word to sort. The allocation of a priority to any patient at the scene with regard to their clinical condition based upon their: Airway - Breathing - Circulation and ability to Walk. The PRIORITY is based upon the patients need for surgical or medical intervention within a specified time scale. Triage ensures = The greatest good for the greatest number. The WAST utilises the cruciform triage card to ensure effective means of patient triage. This card is described below. Cruciform Triage Table PRIORITY COLOUR TREATMENT TIME ONE Red card immediate treatment TWO Yellow card 2 to 4 hour THREE Green card 4 hours plus White card Dead Priority ONE Priority TWO Priority THREE DEAD Non ambulant. Respirations under 10 or over 30 per minute. Pulse over 120 beats per minute (bpm). Non ambulant. Respirations between 10 and 30 per minute. Pulse under 120 bpm. All walking patients irrespective of injury. Triage is a dynamic process, patients can be reprioritised at any time. Any patient whose breathing is not restored following a simple airway manoeuvres e.g. chin lift, jaw thrust. Circulation can also be measured, but not as accurately, by the speed of capillary refill, i.e. over 2 seconds Priority ONE. under 2 seconds Priority TWO. THIS TRIAGE SIEVE IS RECOMMENDED IN THE MIMMS MANUAL Page 58 of 106

60 TRIAGE SORT Triage Sort also known as Secondary triage and is carried out at the Casualty Clearing Station. It uses the Triage Revised Trauma Score as the basis for providing a triage category for the patient. TRTS is based on the physiological assessment of the patient. The TRTS utilizes the scores of; Respiratory rate 0 4 Systolic blood pressure 0 4 Glasgow Coma Score 0 4 Total The values are given using the following criteria. Respiratory rate = 4 >29 = = = 1 0 = 0 Systolic BP >90 = = = = 1 0 = 0 Glasgow = 4 Coma 9 12 = 3 Score 6 8 = = 1 0 = 0 The addition of the scores gained above equals the Triage priority; SCORE PRIORITY 1 10 T1 11 T2 12 T3 0 T4 REMEMBER THAT TRIAGE IS A DYNAMIC AND CONTINUAL PROCESS Page 59 of 106

61 Appendix 6 EQUIPMENT RESOURCE FORM EQUIPMENT FOR TRANSFER TO EQUIPMENT POINT AT A MAJOR INCIDENT SITE FROM ATTENDING AMBULANCES. Registration number of vehicle Equipment received by Equipment received - YES NO Spinal Board Head restraint and straps Orthopedic stretcher Cervical collars (no. and sizes enter below) Fracture immobilisation equipment (type) Portable Oxygen / Oxygen masks Defib. Blankets Carry sheet Signed Date Page 60 of 106

62 HAZARDOUS SUBSTANCES Appendix 7 CBRN and Hazardous Substances Incidents CBRN (chemical, biological, radiological or nuclear) will be used to identify specific terrorist deliberate release scenarios where the intent is deliberate, malicious and or murderous. Hazmat on the other hand is a generic term to cover a great many different types of hazardous material incident. This section of the Major Incident Plan is intended to provide a reference for staff prior to them becoming the first responders to an accidental or deliberate release of CBRN / Hazmat substances. First responders must ensure that information on a suspected incident is relayed via a SITREP to the Control to ensure that properly trained staff can be deployed as quickly as possible toward the scene. See page 10 STEPS The subject is covered in depth in the ASA Pre-Hospital CBRN Handbook. General Advice for All Hazardous Incidents 1. Approach from upwind / uphill. Keep vehicle at least 400mts back initially. 2. Provide an initial SITREP to control. 3. Identify whether the incident is CBRN or Hazmat. 4. Request a CBRN Tactical advisor be informed. 5. Move to Joint services RV point; confer with the other emergency services at scene. 6. Inform the ACC of HAZCHEM markings, TREM card information, if available at the scene. 7. Confer with POLICE and FIRE Services and request any information that they have from their Controls regarding the substance / substances at scene. Take safety advice form the Fire Incident Control Officer. 8. If available request that the Decontamination Unit be deployed to the scene. Request this level of protection early into the incident - they can always be stood down if not required. (Ref. ASA Pre-hospital CBRN Handbook, Strategic National Guidance Home Office). 9. Do not commit yourself to rescue or treatment unless you are properly equipped and trained in decontamination procedures. Ambulant patients should be advised to Strip-Bag-Seal their outer clothing and be provided with Disrobe packs (held by the Fire Service) or blankets in the early stages of the incident. 10. All contaminated clothing, dressings, or equipment to be contained in sealed plastic bags, which are to be clearly marked. Disposal of these items to be arranged following specialised advice. 11. Continuous SITREPS with additional information gained from the other services on scene will allow the WAST CBRN/Hazmat Tactical advisor to make a value judgment with regard to response. Page 61 of 106

63 Background Millions of tonnes of chemicals are manufactured in the UK every year. It is estimated that 90 million tonnes of chemicals are moved around the country annually. A great many of these chemicals are considered to be hazardous to human health and the environment. Toxic chemicals are in use in every village, town and city in the country. They are used in swimming pools, dry cleaners and breweries to mention but a few. Two of the earliest chemical warfare agents, phosgene and chlorine, are also commonly used in industry and leisure facilities. As a consequence to this large amounts of these chemicals are stored and transported around the country. The threat of terrorist attack with a purpose made weapon of mass destruction (WMD) does exist and current threat assessments by the Security Services indicate that several Terrorist organisations still see this as a viable means of attack. Indeed if we look around the world we see that terrorists now tend to attack what can be considered soft targets due to their lack of security and high media value As a result of this all NHS Trusts Ambulance and Acute Trusts have the ability to decontaminate patients using the DH decontamination units (PLYSU) and RESPIREX personal protective equipment. CBR (N) / Hazmat Hazards. Hazardous substances are everywhere. The materials that surround us provide the basis for our lifestyle, but they can prove to be deadly when released unchecked. CBR (N) material can be dispersed into the air that we breathe, the water we drink, or on the surfaces we physically contact. Dispersal methods may be as simple as placing a container in a heavily used area and opening the container or as elaborate as detonating an improvised explosive device. There is also the very real risk of accidental spillage due to road or rail accident, or by fractured chemical pipeline. Evidence has shown that the transportation of chemicals has historically been safe, as incidents are uncommon. However, incidents are more likely to occur during the loading/unloading phase. They are also more likely where large quantities of chemicals are stored, where there is the potential of human error or even terrorist attack. Chemical incidents are characterised by the rapid onset of medical symptoms (minutes to hours) and often-observable environmental indicators (coloured residue, dead foliage, strong odours and dead insect and animal life). A biological hazard is A health hazard created when a person comes into direct contact with a pathogenic micro organism which can cause disease. The onset of symptoms from a biological release may require days to weeks to become evident and generally there will be no environmental signs to indicate that a release has occurred. There are also many sites where a biological incident can occur in the workplace. These sites include hospitals, laboratories and commercial premises. Page 62 of 106

64 With regard to radiological and nuclear material, the onset of symptoms may not be experienced for days to years and there typically may be no characteristic signs. Radiation is unrecognisable to the senses, is colourless and odourless and is present in our everyday lives. It is also commonly found in larger quantities within industry, research and medicine. Radioactive material is transported around the country in trains and tankers using sealed containers. The military are also responsible for holding large stocks of radioactive material. Industrial hazard recognition Remember that an early SITREP will greatly assist you in obtaining specialist information, equipment and personnel. As in all Major Incident type scenario it is better to ask early and stand it down rather than ask for it later and then try to play catch up. There are a number of sources where information can be gained with regard to any substance encountered. They are: The vehicle. The driver. The manufacturer. The haulage firm. The Fire service. Ambulance Control. The Military. Pre-Hospital CBR (N) / Hazmat Planning Doctrine The pre-hospital CBR (N)/ Hazmat planning doctrine is based upon the following; Casualty decontamination is and remains the responsibility of the Health Service. DH and NHS Wales and all ambulance service have agreed a nationalised response using generic procedures, equipments and philosophies. Specialist Ambulance teams are trained in the use of decontamination procedures to be used in the NHS Decontamination units and NHS PPE equipment. Other staff will have received an awareness package in the subject. Hospital Trusts are responsible for decontamination at their sites regardless of the provision. Each service can provide a position to provide a credible local response for the first 60 minutes of any incident. Page 63 of 106

65 No basic life support skills will be carried out, other than basic airway opening manoeuvres in any contaminated area and therefore there is no requirement for clinical medical teams to deploy into contaminated, pre-hospital areas. All contaminated casualties will be brought, by the fire service, to a casualty holding area in the WARM zone, for decontamination and will be moved to the COLD zone for subsequent triage and treatment. Although mass casualty decontamination remains the responsibility of the ambulance service, it will be carried out with the assistance and support of the fire service. (Memorandum of Understanding between Office of the Deputy Prime Minister and National Health Service 2003). Robust and national ambulance service mutual aid procedures are be in place and they are agreed by all ambulance services. All ambulance services will support the needs of other ambulance services for CBR (N) trained teams. Existing service Major Incident responses remain the basis of CBR (N) incident management. Page 64 of 106

66 INITIAL CALL CBRN MOBILISATION CHART Appendix 8 Pre-determined generic questions used by all emergency controls questions overleaf = inform Police Control INITIAL RISK ASSESSMENT ON INFORMATION RECEIVED ALWAYS CARRIED OUT BY POLICE (ACR INSPECTOR) Perceived threat level? Moderate or High Nil INFORM CBRN SILVER COMMANDER Low-level response only required CBRN SILVER COMMANDERS RISK ASSESSMENT CARRIED OUT INFORM OTHER SERVICES POLICY SET TO ADDRESS PERCEIVED THREAT LEVEL LOW MODERATE HIGH MEASURED RESPONSE Nominate RVP BRONZE COMMANDERS TO RVP POLICE UNITS cordon and contain AMBULANCE SERVICE to RVP FIRE SERVICE to RVP Page 65 of 106

67 AMBULANCE BRONZE COMMANDER LIAISE WITH OTHER SERVICES BRONZE COMMANDERS AT RV POINT ASSESSED AS LOW RISK BY POLICE SILVER CBRN ASSESSED AS MODERATE OR HIGH RISK BY POLICE SILVER CBRN ENSURE CONTROL HAS INFORMED LOCAL HOSPITALS AND PUBLIC HEALTH PATIENT DECONTAMINATION BY RAPID CHEMICAL RESPONSE UNIT 1. STRIP-BAG-SEAL CLOTHING 2. WASH HEAD FACE AND HANDS 3. CONTAIN WASHING WATER WHERE POSSIBLE 4. DISROBE PACK or PAPER SUIT AND OVERSHOES PATIENT DECONTAMINATION BY RAPID CHEMICAL RESPONSE UNIT AND/OR MOBILE DECONTAMINATION UNIT (DEPENDANT ON NUMBERS AND CHEMICAL INVOLVED) 1.STRIP-BAG-SEAL CLOTHING 2. FULL BODY WASH 3. CONTAIN WASHING WATER WHERE POSSIBLE 4. DISROBE PACK or PAPER SUIT AND OVERSHOES Page 66 of 106

68 PRACTICAL DECONTAMINATION Appendix 9 STRIP BAG SEAL This easily remembered pneumonic is the first priority at the site of a chemical incident. Strip BAG Seal the patient, or get them to strip. Remember over 90% of their contamination will be on their clothing the clothing into a double thickness of clear plastic bags, in order that others can see the contents at a later date the bags against accidental opening, thereby avoiding further contamination Removal of clothing Only those staff dressed in appropriate Chemical Personal Protective Equipment (CPPE) must be involved in doing this. 1. Cut clothing along the midline of the extremities and also along the midline of the upper and lower torso. This allows the patient to be lifted out of their clothing without the outer garments coming into contact with the patients skin. 2. Clothing must be bagged and labelled with the patients number. The bags remain at the rear of the unit for collection and disposal at a later time. 3. Valuables watches, rings etc. will be bagged in a smaller clear bag this will also be marked with the patients number, to await collection. 4. The labelling of clothing and bagging of valuables must be a secondary consideration to the patients medical needs. Evidence gathering is the prerogative of the Police and although we will attempt at all times to assist, it must be noted that it is not our primary function. Ambulant Patients WASH DOWN PROCEDURE Tell the patient to undress trying as far as is practicable to avoid touching the outside of his/her garments, to avoid wherever possible clothing being taken over the head, cut the clothing if necessary. Page 67 of 106

69 Have the patient place their clothing and valuables in the bags provided. Instruct the patient to lean forward into the first shower and thoroughly wash their hair, they should avoid ingesting any of the water and should try to avoid the run off water from their hair contaminating their lower body. Particular attention should be paid to their ears and eyes and they should expectorate any mucus from their noses into a tissue provided. Following the hair wash they should proceed with a full body shower using the sponges provided, working downwards to avoid recontamination of already cleaned areas. Assistance should be given in the cleaning of the patients back, explain the protocol prior to giving such assistance especially in the case of female patients. If possible females will deal with females, males with males; however operational staffing at scene will decide this in the initial stages. Ensure that the patient washes thoroughly in the creases of the elbows, the creases behind the knee, the crease of the buttocks and the genitalia. Ensure that the patient has fully followed all these procedures before being allowed to enter the clean area. The patient will then be handed towels and either a blanket or paper suit and then directed to the clean side reception area. Stretcher Patient (Spinal Board Stretcher) The Fire Service will assist in bringing patients to the Decontamination Unit where they will be triaged by Ambulance staff using the Triage in CPPE method sieve. This will allow staff to prioritise the patients, thereby ensuring the greatest good for the greatest number. Patients will have their clothing removed either prior to entry to (if protection from the elements is available) or having been placed into the unit clothing will be remove as described earlier. The attendants placing the contaminated clothing in bags to be held within the dirty area. The patient will then be washed down, with particular attention being paid to; Avoiding the patient ingesting the washing water and therefore any contaminant through either the mouth or nose. Protect the eyes from direct water jets, wash the eyes with the head turned to the side in order that the washings run away. Ensure that the ears are cleaned. The creases of the elbows, knees, buttocks and genitalia and under the arms are to be cleaned thoroughly. Page 68 of 106

70 Log roll the patient to wash the back of the patient, also wash down the spinal board at the same time to ensure no build up of contaminant. As for Ambulant patients the procedure must be completed thoroughly to ensure the patient is as clean as possible before they are allowed to leave. The patient is then towel dried, covered with a blanket and passed into the clean area. A major consideration will be the time taken to decontaminate patients; non-ambulant patients will take on average 12 minutes to be properly decontaminated in the NHS unit. With only one non-ambulant patient being processed through a unit at a time. Bronze CBRN officers must be mindful of requesting mutual aid at an early stage in the incident. Page 69 of 106

71 HAZMAT / CBRN INCIDENT ASSESSMENT FORM Appendix 10 CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH REGULATIONS 1988 This Assessment should be carried out at any HAZMAT / CBRN Incident and used to ensure that all relevant information has been gathered to ensure the safety of Staff, Patients and others who may be affected by the Trusts activity. Number of persons contaminated... Brief description of incident: CHEMICAL NAME: UN. NUMBER. TRADE NAM PHYSICAL STATE: TOXICITY (gas / liquid / particulate) (very low, low, high, very high) DO YOU HAVE ACCESS TO SAFETY DATA SHEETS YES / NO SOURCES OF EXPOSURE: Inhalation, Absorption, Ingestion, and Injection. TOXIC EFFECTS: (Symptomatology) ANY FIRST AID INFORMATION- Page 70 of 106

72 HOSPITAL INFORMED: YES / NO TIME HAS CONTACT BEEN MADE WITH THE FIRE SERVICE (HAZMAT OFFICER). YES / NO TIME PUBLIC HEALTH INFORMED. YES / NO TIME ARE FURTHER LEAKS POSSIBLE - YES / NO IS PROTECTIVE EQUIPMENT SUITABLE AND IN GOOD ORDER - PROTECTIVE EQUIPMENT (NHS CPPE) WORN - YES / NO YES / NO PARKING OF AMBULANCES, IS IT A SAFE AREA - CASUALTY CLEARING/DECONTAMINATION AREA, IS IT SAFE - OTHER DANGERS - YES / NO YES / NO YES / NO Specify. : = TRANSPORT AND TRANSFER: Have patients been decontaminated - YES / NO IF NO, ANY DANGER TO CREW IN CONFINED VEHICLE - YES / NO HAS CLOTHING BEEN ISOLATED - YES / NO IS VEHICLE VENTILATED - YES / NO DISPOSAL OF CONTAMINATED MATERIAL - IF YES, HOW? : = YES / NO HEALTH/MEDICAL SURVEILLANCE: Is it required - YES / NO IF YES ALL STAFF NAMES TO BE PASSED TO PUBLIC HEALTH AND OR OCCUPATIONAL HEALTH. Page 71 of 106

73 Having considered the information provided on the previous pages, I am of the opinion that: (Ring the appropriate comment.) 1. The risks to health are unlikely. 2. The risk is significant but adequate controls are in operation. 3. The risk is significant and controls need to be applied as follows: - 4. The risk is unknown, the following actions are recommended: - This assessment should be reviewed whenever the above actions are implemented or circumstances change Assessor(s): Name.. Position. Signature.. Date. Page 72 of 106

74 ARRANGEMENTS FOR RADIATION CASUALTIES Appendix 11 Radiation Incidents If Radiation is suspected confer with the FIRE Service who have monitoring equipment on each of their Fire Tenders and be guided by their advice. The following guidance has been taken from The NHS Emergency Planning Guidance 2005 in relation to accidents involving radioactivity. The guidance has been summarised for convenience and placed into the plan. Action at the scene of an incident The treatment of serious life threatening injuries must take priority over all other actions. Whenever practicable, decontamination should be carried out at the scene of the incident using whatever facilities can be made available. Decontamination should proceed where possible, simultaneously with medical treatment. However, should a casualty require definitive treatment at a hospital, the patient should be transported to the receiving hospital prior to decontamination. The hospitals must be informed prior to the arrival of any patient, irrespective of the patient having been decontaminated or not. Transportation In order to reduce the effects of contamination to both the ambulance and its staff, the patient should be placed on and in plastic sheeting. If such sheeting is not available, then ordinary bed sheets are to be used. If the vehicle is not being retasked back into the incident scene, it must be parked away from the hospital receiving area to wait monitoring and decontamination by the radiological service. The Ambulance staff will remain with their vehicle in order that the medical physics department can monitor them and give appropriate advice. Decontamination of Casualties 1. Remove the patients clothing this will remove the majority of contaminant from the patient. Strip- Bag Seal. 2. Double bag all contaminated clothing and seal the bags. Ensure that the contaminated clothing is retained for examination by the appropriate authority. 3. Contaminated casualties should be decontaminated in a supine position to reduce the spread of contaminated water washing over the body. 4. They should not be given food or drink except to permit oral medication, which must be preceded by facial decontamination. Page 73 of 106

75 5. Casualties must not be permitted to smoke until they have been decontaminated and monitored. 6. Ambulance staff at the scene or adjacent RV points must also follow these rules. 7. Decontamination Units, if available, should be tasked to a safe area, near to but outside the hot zone (inner cordon) at the accident site or to the receiving hospital at an early stage of the incident. Role of the WAST 1. The WAST plan allows for the collection and delivery to an appropriate location of the Radiation Monitoring Unit (RMU) Teams, together with their equipment. Protective clothing and sufficient tentage if permanent buildings cannot be used to be arranged through Ambulance Control. 2. Expert advice and assistance should be sought as soon as an incident is recorded. This advice may be available from the Local Health Board, NPHS Local Authority Emergency Planning Officers and especially employees at an incident site. 3. Initialisation through Police Control of a NAIR (National Arrangements for Incidents involving Radioactivity) response, which will provide expertise and monitoring equipment from a local source. 4. Staff should be aware that if attending a known radiological site, they would rarely be required to deal with patients who have been heavily contaminated. The Fire Service / Site Operator will have primacy at an incident site and staff attending should consult with the Fire / Site Safety Commander before entering any contaminated area. 5. At a non-site specific incident, staff should proceed with extreme caution and be directed by the Fire Safety Commander who will have the primary health and safety role within the inner cordon. 6. Alpha and low level Beta radiation contamination will require a simple surgical type mask, gloves, overalls and boots to significantly reduce the contamination risk. 7. Liquid contamination will require the use of the personal protection equipment as issued at chemical incidents, which will include respiratory protection. Radiological Incidents Involving the Military 1. In the event of a Military incident, there could be additional hazards specific to the site or the type of incident. Aviation fuel. High explosives. Explosives contained within ejection seats and other escape apparatus. Page 74 of 106

76 Carbon fibres from burning aircraft. Toxic smoke / dust. 2. The Nuclear Accident Response Organisation (NARO) is the Military arm set up to attend and contain all accidents involving Ministry of Defence nuclear material. The NARO team will ensure cordons are in place, will provide monitoring and safety briefings for all staff who may have to attend at such an incident. On arrival at an incident site, the NARO team are not yet in place, health and safety advice must be obtained from the Fire Service who have the safety remit. Fire Service personnel are trained and equipped to enter areas into which Ambulance Staff should not attempt to enter. 3. The Ministry of Defence will provide medical personnel who will attend at both the incident ground and also at the receiving hospital in the event of casualties having to be admitted to an NHS facility. Page 75 of 106

77 Appendix 12 GOLD COMMANDERS Liaison Chart JHAC NPHS LOCAL HEALTH BOARDS GOLD COMMANDERS OF OTHER EMERGENCY SERVICES H.M. ARMED FORCES TRUST BOARD EXECUTIVE TEAM GOLD COMMANDER WALES GOVERNMENT CO-ORDINATION CENTRE UNITARY AUTHORITIES HEPA / WELSH ASSEMBLY GOVERNMENT AMBULANCE INCIDENT COMMANDER INCIDENT GROUND Page 76 of 106

78 APPENDIX 13 Information that can be issued: Guidance on Handling Media Enquiries 1. Accurate & brief description of what has happened. 2. General location, including street names as long as this does not identify the patient. 3. Date and time of day. 4. Time of call, response time and arrival time if appropriate. 5. Amount and type of resources used. 6. Use of air ambulance/police helicopter can be confirmed. 7. Number of casualties and whether male or female. 8. Approx age of casualty (e.g. in their twenties) or child/teenager. 9. Brief details of treatment on scene e.g. Treated for injuries sustained. Treated after being taken ill (medical case). 10. As appropriate, preface with words suspected or believed. 11. Whether conveyed or not conveyed. 12. Name of hospital. In some circumstances, while working within these guidelines, there may be opportunities to: Highlight outstanding actions by the crew involved. Information that cannot be issued: 1. Avoid speculation as to how an incident happened (cause). 2. Do not issue names, addresses or other information that could lead to the identification of the patient. 3. Do not issue numbers/names of houses or premises where the incident happened. 4. Do not diagnose or speculate about nature of injuries. 5. Do not release specific medical details. 6. Do not confirm death. 7. Do not indicate whether it was inflicted by another person or self-inflicted. 8. Do not release names of crew involved. 9. Avoid issuing details of incidents unless in a public place (i.e. incidents at houses or business premises should be regarded as confidential). If in doubt, contact the press office. Page 77 of 106

79 GLOSSARY OF TERMS Appendix 14 Ambulance Incident Commander(Silver) The ambulance commander at the scene with tactical responsibility for the efficient running of the incident. He or she will have overall responsibility for the efficient and safe running of the scene with assistance being given by operational (Bronze) officers. Bronze Commanders A title given to appointed ambulance officers who are accountable to the A.I.C. but responsible for the operational management of specific tasks, e.g. casualty loading, triage, parking etc. These functions are often monitoring, managing or administration and may require assistance from other officers or personnel. CHaPD The Chemical Hazards and Poisons Division of the Health Protection Agency. CBRN Chemical-biological-radiological and nuclear substances, this will be used in this document to describe an incident where deliberate, malicious and murderous CBRN components are involved. Cruciform Card (Triage label). The patient report card attached to patients involved at the site of a Major Incident. This card is the only one used by the WAST for Triage Sort. However washable Triage Slappers (coloured plastic coated metal bands) are available on the SORT vehicles for use at a CBRN / Hazmat incident. District Emergency Control Centre A designated centre from where nominated Local Health Board senior officers can coordinate the NHS response to a Major Incident, oversee operations and provide adequate support. Emergency Services The Ambulance, Police, Fire, Coastguard. (Military personnel deployed in support of civil powers are not included in this definition). Emergency Planning Officer The officer employed by the local authority to develop the local authority emergency plan and to co-ordinate assistance to the emergency services in the event of a Major Incident. Executive Team Those board members that would be gathered at Trust headquarters to provide assistance and expertise to the Gold Commander in the event of a Major Incident. Hazchem. The name given to the warning panel that must be displayed at the sides and rear of vehicles carrying hazardous substances. Page 78 of 106

80 Hazmat The term used to describe any accidental release of a hazardous Chemical, biological or Radiological material. Health Desk During a protracted incident the welsh Assembly Government will activate a cocoordinating centre in Cardiff of which the NHS Department will provide a Health desk for communication to appropriate LHB s and NHS Trusts. Health Emergency Command Centre (HECC). A designated centre from where nominated Local Health Board senior officers can coordinate the NHS response to a Major Incident, oversee operations and provide adequate support. H.E.P.A. (Health Emergency Planning Advisor) The officer employed by the Welsh Assembly Government to offer advice and guidance to the NHS Directorate on emergency planning issues. The HEPA will assist and assure Local Health Boards, Trusts produce individual and joint plans and provide liaison and contact with all relevant organisations. Hospital Co-Ordination Centre A designated hospital location within a receiving hospital from where the hospital s response to a Major Incident can be monitored and co-ordinated by hospital senior managers. Hospital Co-Ordination Team A team of hospital senior managers appointed to monitor and co-ordinate the hospital s response to a Major Incident. Hospital Information Centre A centre set up at the receiving hospital to deal with all enquiries about patients admitted from a Major Incident. Hospitals - Listed Hospitals listed by the Health Authority as adequately equipped to receive casualties on a 24 hour basis and able to provide, if appropriate, a Medical Incident Commander and Medical Emergency Response Intervention Team Hospitals - Receiving Any hospital selected by the ambulance service from those designated by a Local Health Board to receive casualties in the event of a major incident. (i.e. hospitals that have a full range of Accident and Emergency facilities.) Hospitals -Supporting A listed hospital nominated to support the receiving hospital in dealing with casualties from a Major Incident. Page 79 of 106

81 Local Health Boards Local Health Boards comprising 22 in Wales with responsibility for the provision of local NHS services, they are split into three regions across Wales each with a designated lead for Major Incident planning and provision (replaced the Health Authorities). LRF (Local Resilience Forum) The arena in which Cat 1 responders meet to discuss and organise their response to an incident in their area. M.A.C.C. (Military Aid to the Civil Community) An arrangement to utilise the resources of the three Military Services to assist local authorities or the Emergency Services. Marshalling Area Area to which resources and personnel not immediately required at the scene or being held for further use can be directed to stand by. Medical Incident Commander A Doctor trained and qualified in pre-hospital medical emergencies who attends to assist the Ambulance Incident Commander with specialist knowledge of the wider NHS. Medical Emergency Response Incident Team (MERIT) A hospital based team transported to the incident site to undertake the specific task of secondary triage and treatment in the Casualty Clearing Station. The team will consist of both Doctors and Nurses who have expertise in assessment and resuscitation. M.I.M.M.S. (Major Incident Medical Management and Support System) A manual accompanied by a training course structured to teach the principles of management and support at a Major Incident to the Health Service staff. M.S.T. (Mobile Surgical Team) Where a requirement for on scene surgery is required, at the request of the M.I.C. a Mobile Surgical Team may be summoned. This request will be task specific and will generally involve surgery for extrication. Once complete the Team will be returned to the hospital that provided them. N.A.I.R. National Arrangements for Incidents involving Radioactivity A local resource of expertise and monitoring equipment contacted via Police Control. National Public Health Service (NPHS) The body with national responsibility for the provision of Public Health medicine and advice in Wales. Works in close cooperation with the Health Protection Agency in England. N.I.C. (Nursing Incident Commander). If requested by the Medical Incident C0mmander, a Nursing Incident Commander may be deployed to the incident to co-ordinate nursing activities. (Please note this facility is only available in the Central and West Region). Page 80 of 106

82 Police Documentation Team A team sent to the receiving hospital by the local Police force to pass casualty information to the Police Casualty Bureau. Police Casualty Bureau A bureau established by the Police at Police HQ to maintain a list of casualties resulting from a Major Incident, including casualties dealt with on site without referral to hospital. A central contact and information point for all records and data relating to casualties. A Force not directly involved in the incident usually opens the Bureau. Post Traumatic Stress Syndrome Stress caused as a direct result of a traumatic event causing physical or psychological symptoms, or both. Rapid Response Vehicles EMS vehicles used to provide rapid access to casualties to initiate treatment prior to the arrival of a paramedic ambulance. Often single manned, some vehicles have the capacity to convey a stretcher patient if necessary. Rest Centre Designated premises where uninjured or evacuated persons can be taken. Rest centres are the responsibility of the local authority. R.V. Point (Rendezvous Point) Point to which all vehicles and resources arriving at the outer cordon are directed S.O.P Standard Operating Procedure. The operating procedure, which has been written for a specific control centre, Mobile Communications Unit, or equipment. This allows for the variance of command and equipment across Wales. The procedures will include all those requirements of the generic plan but will take into account local procedures and sensibilities. SORT The Special Operations Response Team consisting of specially trained staff to deal with CBRN incidents. The Team is trained in NHS CPPE, the deployment of the Decontamination Units and water management. Tactical Advisor CBRN A specially trained officer who will provide an overview and validation to the Silver or Gold commander in relation to any CBRN incident. Tactical Support Group Those officers and managers drawn together at the ACC to provide the Ambulance Incident Commander with a knowledge and support base to enable him / her to undertake the tactical command of the incident. Page 81 of 106

83 TREM Card An information card carried in vehicles transporting hazardous substances or articles. The information on the card informs of the name of the substance, a description of the substance, its hazards, immediate first aid and any protective equipment to be used. Triage A system of prioritising casualties in respect of injuries. The use at incidents of the M.I.M.M.S. triage system ensures the greatest good for the greatest number is undertaken. Triage Primary (Triage Sieve) Undertaken by triage officers or paramedics within the inner cordon where patients are located. Once triaged, casualties are labelled with a triage card. Triage Secondary (Triage Sort) Undertaken within the Casualty Clearing Station by members of the Medical Incident Team or paramedics. The triage label may also re-categorise the casualties once examined. Triage in CPPE The only method currently available of undertaking limited triage whilst wearing NHS CPPE. (A review of Hot Zone working practices is underway). Unitary Authority Emergency Plan A plan developed that outlines the role the local authority has in the event of a Major Incident. U.H.F. (Ultra High Frequency) Radio frequency used by Ambulance Services at the site of a Major Incident by means of hand portable radios operating from an M.C.U. (Mobile Control Unit). V.H.F. (Very High Frequency) Radio frequency used by Ambulance Service in everyday use to deal with normal domestic demand, monitored by the A.C.C. (Ambulance Control Centre). V.A.S. (Voluntary Aid Societies) The three bodies that form the official V.A.S. are the Red Cross, St. John Ambulance and St. Andrews Ambulance. Most V.A.S. personnel are well trained in first aid to assist the WAST at incident sites or to assist local authorities to provide assistance at rest centres. Volunteers Those persons that may be part of a recognized organisation or may as an individual bring specific expertise or ability or a desire to help to the incident scene. They must be carefully vetted and collated as vicarious liability rests with the organisation that accepts and utilises their skills. In addition we have a specific responsibility under the Children s and Young Persons Act to ensure child safety and welfare. Page 82 of 106

84 Appendix 15 BIBLIOGRAPHY Incident Medical Management and Support: 2 nd edition Major BMJ Publishing. ALSG (2001) Ambulance Service Basic Training: IHCD Training Division. Operational arrangements for civil emergencies. : Civil Emergencies Committee. ASA. (1998) Guidance on Chemical Incidents: Chemical Incident Procedures Working Group. -ASA. (1998) National decontamination Handbook ASA (2003) The Civil Contingencies Act Emergency Preparedness Guidance (for C.C.A. 2004) - HM Government Emergency Response and Recovery (for C.C.A. 2004) - HM Government (Replacing - Dealing With Disaster, revised Third edition: Brodie Publishing. Home Office (2003). The NHS Emergency Planning Guidance - Department of Health, Emergency Preparedness Division 2005 The NHS Guidance (1999): Planning for Major Incidents: NHS Executive Emergency Panning Advisory Group Wales. Beyond a Major Incident Department of Health Mass Casualties Incidents- A Framework for Planning Department of Health 2005 Guidelines for Faith Communities when Dealing With Disasters: Home Office. Faith Communities (1997) The Event Safety Guide A guide to Health, Safety and Welfare at music and similar events. : Health and Safety Executive HMSO. (2002) Guide to Safety at Sports Grounds 4 th edition. : HMSO. Department for Culture, Media and Sport (1999) CBRN Incidents: clinical management &health protection Health Protection Agency 2005 Living with Radiation National Radiation Protection Board, 1999 Multi-Agency National Concept of Operations (Edition 1) CBRN Tacticians Forum Sept.2005 Page 83 of 106

85 Guide to Management of Crowd Safety Health and Safety (1996) Prepared for EMERGENCY: HSE Publications. Health and Safety Executive (1997), Dealing with Fatalities During Disasters: Home Office National Working Party (1994) Ambulance Service Operational Arrangements CIVIL EMERGENCIES: Ambulance Services Association 1990 The Easingwold Papers: Scanlon T. Home Office Emergency Planning College (1996). Page 84 of 106

86 MASS and CATASTROPHIC INCIDENTS Appendix 16 The terms Mass and Catastrophic incidents are explained on page 9. The following considerations are not exhaustive, however they indicate the additional problems that might face the WAST in the event of a Mass or Catastrophic incident, Strategic and Tactical Officer will need to be proactive in the realisation and resolution of such considerations. Mass Casualty incidents. Command - WAST will run its Command system as described in the preceding pages. However it is noted that the event will by virtue of being a Mass casualty event will require the Command structure to be in place for a considerable time, early consideration must be given to this. Staff careful use of off duty staff to ensure consistency of service for a considerable period. Use of mixed ability crews to increase capacity. Vehicles Mutual Aid, Voluntary services Local Authority vehicles, private ambulance services, local coach/ transport contractors. Fuel Supplies a consideration as local supplies may be placed in jeopardy by the type of event. Vehicles to refuel at every opportunities when outside effected area. Medical Supplies potential for short term shortages during initial response stage however WAST has a number of units capable of providing backup to the incident scene. Mutual Aid WAST has signed up to the ASA Mutal Aid agreement in which adjacent services will provide staff and vehicles to be placed under the direction of the WAST Silver Officer for use during the incident. This is a reciprocal agreement. Catastrophic Incidents Command By the very nature of a Catastrophic incident HM and Welsh Assembly Government command groups will be initiated WAST must be able to fulfil not only its own Strategic / Tactical (Gold / Silver) commands for a considerable time, but also to ensure appropriate representation at any Assembly led Coordination groups that are established Staff unavailability of staff to respond, due to illness, involvement in the incident or unable to travel to required sites. Vehicles breakdowns overwhelming available spare supplies, vehicles becoming contaminated and having to be removed from service for considerable periods Fuel Supplies inability to obtain sufficient supplies to maintain normal work load Page 85 of 106

87 Medical Supplies supplies run out with no ability to restock from normal suppliers, medical gasses, consumables, servicing and repair of medical equipment. Mutual Aid Unavailable due to pressure within each region of the United Kingdom, staff sent to provide mutual aid that then have to be recalled due to local escalation of demand. Page 86 of 106

88 APPENDIX 17 Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru Welsh Ambulance Services NHS Trust DECISION LOG (Please indicate) Gold Silver Bronze Incident Number Time / Date Incident Commenced Time / Date Incident Concluded This Book Commenced This Book Completed Book Number of Page 87 of 106