Publication Date March 2015 September 2015 and six-monthly thereafter.

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2 DOCUMENT CONTROL Document Title Owner & Contact Details Scottish Government Sponsor Department NHS Scotland: Mass Casualties Incident Plan NHSScotland Resilience Scottish Government, St Andrew s House, 1 Regent Road, Edinburgh EH1 3DG Tel: nhsscotlandresilienceteam@scotland.gsi.gov.uk Health and Social Care Directorates (Health Workforce and Performance Directorate) Publication Date March 2015 Review Date September 2015 and six-monthly thereafter. Reader Information Box Target Audience NHS Chief Executives, Directors and Senior Managers Chief Officers, Health and Social Care Partnerships NHS Resilience Leads Regional Resilience Partnerships Scottish Government Directorates Document Purpose Description Superseded Documents Action Required To set out how NHSScotland will respond in the event of a single or multi-site major incident with mass casualties (as defined in Preparing For Emergencies, Guidance for Health Boards in Scotland, 2013). Sets out operational arrangements- roles and structures-that will be put in place to ensure that the NHS in Scotland responds effectively to a major incident with mass casualties. Corresponds to Mass Casualties Incidents: Framework for Planning guidance issued by Scottish Government in 2009 Mass Casualties Incidents- A Framework for Planning, NHSScotland, Scottish Government, May 2009 NHS Chief Executives and Chairs of Health Board Resilience Committees should consider the contents of this document, assess their capabilities and prepare to meet the requirements as set out in this plan in the event of a Mass Casualties Incident being declared.

3 Contents 1. Introduction 1 2. Scope and Context 2 3. Legislation 3 4. Types of Patients 4 5. Declaring an Incident 6 6. Responding to a Declaration: Role of Responding Territorial Health Board 7 7. Responding to a declaration: Role of Neighbouring and other Health Boards 8 8. Treatment Centres for Minor Injuries 9 9. Reporting and Coordinating Capacity and Patient Information NHS Coordination: Strategic Health Group Scottish Government and the Strategic Health Group Patient Tracking Voluntary Organisations Multi Agency Coordination Communications Finance Recovery 20 Annexes Annex 1: NHS Annex 2: Escalation Flow Chart 22 Annex 3: Medical Commander- Role and Function 23 Annex 4 (i): Hospital Capacity Reporting Part 1 25 Annex 4 (ii): Hospital Capacity Reporting Part 2 26 Annex 5: Tactical Medical Adviser 27 Annex 6: Mutual Aid Agreement 29 Annex 7 (i): Chair Strategic Health Group 32 Annex 7 (ii): Role of the Strategic Health Group 33 Annex 7 (iii): Strategic Health Group-Meeting Template 34

4 1. INTRODUCTION 1.1 Scottish Government Guidance Preparing For Emergencies (2013) 1 defines a mass casualties incident 2 as: A disastrous single or simultaneous event(s) or other circumstances where the normal major incident response of several NHS organisations must be augmented by extraordinary measures in order to maintain an effective, suitable and sustainable response. 1.2 By definition, such incidents typically result in a large number of casualties and have the potential to exceed the local capacity of a Health Board to respond, even with the implementation of its major incident plans. However the number and type of casualties likely to overwhelm a Health Board will vary depending on local resources. 1.3 Mass Casualties Incidents fall into two main categories: Those that result from no-notice incidents (Big Bang), e.g. Train Crash; and Those where a surge in the number of casualties occurs over time (Rising Tide), e.g. Pandemic Flu. 1.4 This plan focuses on no-notice/big bang incidents. A different approach to planning and response will need to be adopted by the local Health Board(s) in whose area a mass casualties incident occurs in order to optimise resources and provide the best possible health care in these circumstances. 1.5 Doing more of the same is unlikely to be adequate the Health Board and its staff will need to adopt a different approach to planning and response for such incidents in order to optimise and provide the best health care available under the circumstances. 1.6 Some of the characteristics that distinguish a Mass Casualties Incident (MCI) from a more typical major incident are its likely scale and numbers. In addition to greater numbers of casualties there will be a higher probability of fatalities, and incidents could occur at multiple sites. There will also be significant media and public information challenges Responding effectively to a mass casualties incident(s) requires an integrated approach to service delivery by one or more Health Board(s) working in tandem and in partnership with other category 1 and 2 responders. In planning their response to these types of incident, Health Boards will need to ensure business continuity and the on-going provision of services for patients who require urgent medical attention but not associated with the incident(s). 1.8 The abbreviation MCI will be used hereafter in this document. 1 Preparing for Emergencies- Guidance for Health Boards in Scotland, Scottish Government, NHSScotland Resilience, Extracted from Mass Casualties Incidents: A Framework for Planning, NHS Scotland, Scottish Government, Preparing for Emergencies Guidance, 2013, Sections 7.47 to

5 2. SCOPE AND CONTEXT 2.1 This document sets out arrangements for NHS Scotland to respond collaboratively to a MCI in Scotland. Set in the context of Preparing For Emergencies (2013), it describes how the Health Boards that are designated as Category 1 or Category 2 responders under the Civil Contingencies Act will cooperate to respond effectively to a nonotice/big bang incident that exceeds the capacity of responding Health Board(s). 2.2 This document provides a response framework for Health Boards, with other responders, to combine their capabilities while allowing each hospital s major incident plan to address internal capacity, staffing and resource issues within their Board and / or within local multiagency arrangements. This plan is predicated on Health Boards having in place: Major Incident Plans that are scalable and tested through periodic exercising; Escalation plans; An up-to-date record of their capabilities; A mutual aid agreement with relevant partners; and C3 arrangements at Board-level and a control and coordination facility within major (receiving) acute hospitals. 4 Civil Contingencies Act (CCA) 2004 and the CCA 2004 (Contingency Planning) (Scotland) Regulations

6 3. LEGISLATION Equality and Diversity 3.1 Equality is about creating a fairer society where everyone has the opportunity to fulfil their potential, while diversity recognises and values difference in its broadest sense. In developing emergency preparedness plans, Health Boards must be mindful of their duties under the Equality Act The Equality Duty requires public bodies to consider the needs of all individuals when developing policy, delivering services and in relation to employees. It encourages public bodies to understand how different people will be affected by their activities so that services are appropriate and accessible to all and meet different people s needs. Human Rights 3.3 Health Boards must uphold the UK Human Rights Act (1998) in delivering services which requires that account is taken of a range of factors including the dignity of individuals receiving treatment; end of life considerations; prioritisation of treatments and transparency in relation to decision-making as well as an individual s preferences 5. 5 See Preparing For Emergencies Guidance, 2013, Sections 3.5 to 3.8 3

7 4. TYPES OF PATIENT 4.1 A MCI results in a number of patients who can be broadly placed into three priority groups (see Table in 4.2 below) 6 : People who are seriously injured as a direct result of the incident, who require immediate treatment and need to be admitted to an acute hospital (P1 and P2); People with less serious injuries, who while needing assessment and treatment, do not need to be admitted to hospital. Such casualties 7 may be attended to at the scene, in Emergency Departments or in a P3 setting 8. They may require ongoing monitoring, support or follow in the community which may be arranged by agreement with NHS 24 (see Annex 1); People affected by the incident who may not be physically injured but require information, advice and reassurance. This group includes the so-called worried well and those who have been psychologically affected by an incident The triage categories that will be applied at the scene by paramedics and medical staff are outlined in the table below. Triage Categories Priority Groups Order of Treatment Description of casualties needs P1 1 Immediate Immediate Life-saving procedures required P2 2 Urgent Intervention required within 4-6 hours P3 3 Delayed Less serious cases who do not require treatment within the times given above 4 Expectant Casualties whose injuries are so severe that they either cannot survive or would require so much input from the limited resources available that their treatment would seriously compromise the treatment of large numbers of less seriously ill casualties. Dead Dead Dead Source: MIMMS: Hodgetts, Mackay-Jones. 6 See also Appendix 7 in Preparing For Emergencies (2013) which outlines the planning assumptions and casualty triage scenarios 7 In this document the word casualty refers to patients who are alive; it does not include fatalities. 8 See Emergency Treatment Centres / access points in Preparing For Emergencies (2013) section See Preparing Scotland, Planning for the Psychosocial and Mental Health Needs of People Affected by Emergencies,

8 4.3 Responding Territorial Health Boards 10 (THB) should ultimately plan to address the needs of patients in all three priority groups well beyond the end of the immediate response to the incident(s). 10 Responding Territorial Health Boards refers to the Boards in whose area(s) the incident(s) first occurred. 5

9 5. DECLARING A MAJOR INCIDENT WITH MASS CASUALTIES: ROLE OF THE SCOTTISH AMBULANCE SERVICE 5.1 Following an at-the-scene assessment of the (casualty) impact of the incident, Scottish Ambulance Service (SAS) may declare one of the following: A Major Incident Standby ; or A Major Incident ; or A Major Incident with Mass Casualties. SAS will then establish a Major Incident Control (MIC) facility within the Ambulance Control Centre (ACC) and stand up the National Command, Control and Coordination Centre (NCCC), which is their strategic oversight facility. In parallel, NCCC will notify Scottish Government NHS Resilience Unit of the type/status of MI declaration in accordance with normal practice. 5.2 Also, in line with normal practice ACC, in the following in sequence, will: 1. Inform local designated receiving hospitals of casualty numbers and type, according to the information available; 2. Notify the Responding THB through the Single Point of Contact (SPOC); 3. Notify the Scottish National Blood Transfusion Service (SNBTS) and NHS 24; 4. Notify THBs neighbouring the Responding THB(s) of the type/status of the declaration during the initial stages of the major incident in anticipation of the need for mutual aid; 5. Inform all other THBs should the scale of the MCI indicate the likelihood for national mutual aid. 6

10 6. RESPONDING TO A DECLARATION: ROLE OF THE RESPONDING TERRITORIAL HEALTH BOARD 6.1 The Responding THB(s) will rapidly assess its capacity and capability to accept all the casualties from the scene(s). If, after making all reasonable efforts (including requesting mutual aid for small numbers of patients requiring specific treatment), they confirm to Ambulance Control that they cannot accept all the casualties, they and SAS will collectively decide to declare a major incident with mass casualties. See flowchart in Annex Depending on the type, scale and impact of the incident, the Responding THB(s) should: Inform NHS National Services Scotland s National Procurement of any earlyassessed additional requirements; Advise NHS 24 (see Annex 2) that a MCI has been declared and request preparation for a national Helpline to be set up and when it should be activated. The THB should specify the purpose of the Helpline, the type of information, screening and /or advice to be provided, and provide NHS 24 with Q&A s etc. for call handlers. NHS 24 should be prepared to activate the Helpline within 1 hour of receiving the request from the THB; Be prepared to identify and deploy (within 60 minutes of receiving a request from ACC) a suitably qualified senior clinician as Medical Commander (See Annex 3 for further information about role and function) to the Ambulance Control Point, the focal point of NHS Command at the scene(s). However, in view of potential pressures on resources, the Responding THB may request that a neighbouring THB provides / dispatches a Medical Commander to the scene(s). 6.3 The Responding THB will take the lead in: Co-ordinating Health Board(s) response(s) to the incident with SAS; and Setting up the Strategic Health Group (see Section 11). 7

11 7. RESPONDING TO DECLARATIONS: ROLE OF NEIGHBOURING AND OTHER TERRITORIAL HEALTH BOARDS 7.1 Neighbouring 11 THBs that have received notice to stand-by from the ACC should, in readiness: Immediately assess their available capacity; and Be prepared to inform ACC of the outcome within one hour. 7.2 When a Major Incident with Mass Casualties has been declared by ACC, All THB(s) in Scotland should rapidly assess: o Their capacity to accept casualties generally from the incident(s) based on the initial information circulated by ACC, but specifically those with particular types of trauma (e.g. head and neck, burns, cardio-thoracic, paediatrics etc.) and be prepared to submit this information to ACC within one hour (see section 10.2); o The capability (resources) they could offer to the Responding THB(s), if requested; and they should o Prepare to stand up their major incident C3 arrangements. THB(s) whose acute hospitals have been designated as initial receiving hospitals (i.e. those nominated initially to receive patients from the scene of the incident) should: o Activate their major incident plan(s); o Maximise their response capability; and o Stand up their C3 and Hospital Control Room arrangements. At this point, neighbouring THBs may also be tasked by ACC to: o Receive casualties; or o Stand up their pre-hospital medical care services (also known as mobile /site medical teams) or similar facilities in readiness to provide medical support at the scene of the incident, working in tandem with SAS at the Casualty Clearing Station. 11 Refers to those Health Boards adjacent to the boundaries of the Responding Territorial Health Board(s) 8

12 8. TREATMENT CENTRE(S) FOR MINOR INJURIES NHSScotland Mass Casualties Incident Plan 8.1 In order to alleviate pressure on acute receiving hospitals, and Emergency Departments in particular when a MCI has been declared, the Responding THB(s) should: Consider establishing one or more Treatment Centres or appropriate facilities for the treatment and management of P3 patients away from the scene of the incident; Inform Scottish Ambulance Service and NHS 24 of the location, capability and staffing of these units. 8.2 The P3 Treatment Centres: May be located both at and / or away from healthcare establishments; Should be designed to take pressure off emergency departments and allow them to focus on high priority (P1 and P2) patients; Could include community hospitals, minor injury units, survivor reception centre or any other suitable facility. 8.3 When setting up a Treatment Centre, Responding THB(s) should implement their public communication plan (with an emphasis on public messaging) to raise awareness of these temporary arrangements and publicise the NHS 24 Helpline number. NHS 24 may also be in a position to engage with the public and issue advice / information via their social media platform. 9

13 9. REPORTING AND CO-ORDINATING CAPACITY AND PATIENT INFORMATION WHEN A MCI HAS BEEN DECLARED 9.1 Having accurate and up-to-date information about hospital and treatment centre capacity is central to the ability to make authoritative decisions on the distribution of patients from the scene and the most effective use of transporting resources. For this to happen, it is essential that all THBs collate and be ready to provide ACC with information on capacity to receive patients, especially in relation to specialist treatment facilities. 9.2 When a MCI has been declared, ACC will ask neighbouring THB(s) likely to receive patients from the incident(s) to: Submit capacity information on Part 1 of a standardised form (see Annex 4(i)) within one hour of receiving notification of a MCI on their ability to receive P1 and P2 patients directly from the scene; and quickly thereafter Collate and submit on Part 2 of the standardised form (see Annex 4(ii) Theatre, ICU, ITU, HDU and specialist units e.g. burn, paediatric ICU, surgical and medical capacity to inform decision making across the healthcare system. It should indicate potential capacity at the following critical care levels of change from normal activity: Level 1 - make available capacity that does not disrupt planned work; Level 2 - make available capacity including cancelling elective procedures 12 ; Level 3 - make available capacity including cancellation of all elective procedures, implement early discharge and reassign non-acute areas for acute use procedures. 9.3 Although ACC requires information to inform decisions on patient distribution from the scene, each acute receiving hospital should utilise the same information for both operational planning and governance purposes. 9.4 All THBs will be required to submit up-to-date, real-time capacity information at regular intervals to ACC (reporting frequency will be determined by the severity of the incident and flow of casualties from the scene) to enable them to determine the most suitable destinations for specific types and categories of patients. 9.5 SAS will allocate a medically qualified practitioner to: Work within the ACC in the national role of Tactical Medical Advisor (see Annex 5); Liaise with acute hospital services; Engage in clinician-to-clinician dialogue; and Assist in the patient-distribution decision-making process. 12 This practice should be applied in line with Scottish Government policy. Refer to Preparing For Emergencies Guidance, Section 6, paragraphs 6.5 to

14 9.6 If NHS Scotland s total resources are likely to be overwhelmed (this assessment will be made by the Strategic Health Group (SHG)) See section 11: The Chair of the SHG will inform the NHSScotland Chief Operating Officer at Scottish Government s Health and Social Care Directorates (HSCD) of the situation; and The Director-General of HSCD / Chief Executive of NHSScotland will advise Scottish Government Ministers on seeking mutual aid from the other UK nations. However, depending on the geographical area of the incident(s), it is possible that casualties may have already been taken to a hospital or care facility South of the Border appropriate to patient need, to avoid any delay or compromise to treatment. 11

15 10. NHS COORDINATION: STRATEGIC HEALTH GROUP (SHG) NHSScotland Mass Casualties Incident Plan 10.1 Following declaration of a MCI, the Chief Executive or nominated deputy of the Responding THB will inform the NHSScotland Chief Operating Officer (SG) of their intention to convene a SHG and set one up within 2 hours. In the event of a multiplesite incident, the first affected THB is expected to convene and chair the SHG The chair will host a meeting/virtual meeting of all NHS Chief Executives or nominated deputies, to agree the NHSScotland (NHSS) strategy for managing the response to the incident(s) and formalise mutual aid arrangements (see Annex 6). The chair s organisation will also provide: The secretariat and ensure appropriate and effective recording / record keeping; ICT / telecommunications facilities and personnel; and A senior Communications Manager (preferably the Board s Director of Communications) to liaise with equivalents in other THBs and SG Health Communications and to engage with the media The SHGs remit (Annexes 7(i) to 7(iii)) will be to: Provide strategic advice and leadership; Develop and coordinate the wider NHSS corporate response to the incident; Activate mutual aid between Health Boards 13, coordinate NHSS assets and monitor implementation / progress. [SAS will advise the SHG of mutual aid or MOU s that have been invoked with other UK NHS Ambulance Services and voluntary providers]; Lead decision-making for the NHSS in collaboration with Scottish Government (SG); Communicate with SG HSCD, Health Boards and the media /the public. The chair will be the talking head on behalf of the Responding THBs / NHS Scotland; Establish and manage a Health Information Cell (see section 13); Engage with appropriate stakeholders; Submit a Commonly Recognised Information Picture (CRIP) to SG NHS Resilience Unit; Ensure that arrangements are in place to effectively track patient transfers between healthcare facilities; Undertake long-range planning, including the recovery phase THBs will be in overall control of their resources /assets at all times during a response to a MCI. 13 Note: UK ambulance service mutual aid will be invoked through existing arrangements and will not be referred to the SHG for decision. 12

16 11. SCOTTISH GOVERNMENT AND THE SHG 11.1 Scottish Government HSCD will delegate a Department Health Official to the SHG to act as a bridge of communication to SG and the NHSScotland Resilience Unit; the latter will provide regular updates on behalf of NHS Scotland to SGoRR. The SHG chair will liaise and work collaboratively with the NHSS Chief Operating Officer and / or Director-General while the SHG is in situ. 13

17 12. PATIENT-TRACKING 12.1 At the initial stages of the incident, NCCC, as standard practice, will collate and submit aggregated casualty information from scene to Scottish Government NHSScotland Resilience Unit SGoRR and the Strategic Health Group (SHG), using agreed SitRep formats The SHG will establish a Health Information Cell (HIC) within 3 hours of its first meeting. The HIC will: Perform an information-coordination function on behalf of the SHG; Co-ordinate patient information and patient transfers between healthcare facilities and other key information; Be the focal point for conveying information on a patient s whereabouts to families / relatives or a contact point for the latter; and Liaise with the Police Casualty Bureau in relation to patients in the care of NHSScotland The SHG chair will: Make available IT / telecommunications equipment; Designate an appropriate 14 Health Board to coordinate the HIC and to receive, process, coordinate and share patient transfer information with designated staff / points in other Health Boards only; Request, if necessary, subsidiary resources (IT staff) from NHS National Services Scotland and other Health Boards. (A provisional / stand-by database and reporting pro-forma for use in such instances is under consideration / development) 12.4 All THBs will be required to: Collate information on all casualties received from the scene (by ambulance and self-presenters) and subsequent/secondary patient transfers to healthcare facilities and submit it to the Health Information Cell (HIC); Identify an appropriate individual to gather and submit patient information from the Board to the HIC, and to act as the single point of contact for the latter A Police Scotland Casualty Bureau (CB) may also be established and will also hold information on casualties. The SHG will decide on an appropriate level of information sharing with the CB, in line with agreed protocols and guidance from the SHG Chair s Caldicott Guardian. (see section 13.2) When a decision has been made to stand down the SHG, the Chair will request the HIC to undertake a final check to ensure that appropriate information regarding patients whereabouts has been communicated to the patients local THB 15. It will then be the responsibility of the local THB to ensure that next-of-kin / relatives of the patient are 14 It is recognised that a Health Boards contribution will be proportionate to its capabilities. 15 This applies to patients domiciled in the UK. Information regarding non-uk domiciled patients will be communicated via the relevant authorities and in line with existing procedures to their country of residence with the assistance of the FCO. 14

18 kept informed of any subsequent transfers in relation to that patient, and the arrangements for following up the patient if necessary. 15

19 13. VOLUNTARY ORGANISATIONS 13.1 SAS will invoke its MOU with British Red Cross (BRC) and St Andrews First Aid (SAFA) to support the ambulance service, if necessary, during a major incident. In these circumstances, BRC and SAFA will act under the direction of the Ambulance Incident Commander at Scene or other location to be determined. British Red Cross ambulances may be utilised by the SAS to support routine emergency or urgent demand in preference to activities at the scene As part of their major incident plans, THBs or the Local/Regional Resilience Partnerships may also have arrangements with BRC/SAFA or other voluntary organisations and the Local Authority which they call upon to support acute hospitals in the discharge process, to transport patients and / or to provide practical and emotional support at Family and Friends Reception Centres or P3 treatment centres. 16

20 14. MULTIAGENCY COORDINATION 14.1 In line with existing arrangements, strategic level multi-agency coordination of the response and recovery to the incident will be achieved through the Local/Regional Resilience Partnerships that will have been established by this point Responding THBs will be expected to participate in these arrangements, delegating a Director/ senior manager to attend meetings and keep abreast of jointagency developments. The THB representative will be expected to update / keep the Chair of the SHG appraised of partners progress and any potential implications for the NHS. 17

21 15. COMMUNICATIONS 15.1 The Regional Resilience Partnership(s) will agree a multiagency public communications plan with all agencies affected by the MCI. The NHS contribution to this multiagency arena will be made via the SHG to avoid any risks associated with conflicting messaging and unilateral statements Information about the number and condition of casualties will only be issued by or with the endorsement of the SHG and Scottish Government. 18

22 16. FINANCE 16.1 During and following a MCI costs associated with responding to the incident(s) will need to be identified, monitored and documented, so that discussions may subsequently take place between relevant parties in relation to recovery of monies. Therefore, all Health Boards involved in the responding to the incident(s) should have arrangements in place that enable them to track incident-related expenditure. 19

23 17. RECOVERY 17.1 Recovery from an incident on this scale and magnitude may take longer for the NHS than other organisations as the impact on capacity is likely to be felt for some time The impact on each Health Board may vary and as such the recovery period will differ. Once the initial incident has been declared a MCI, Health Boards should consider how they would return to business-as-usual within a reasonable time frame Health Boards major incident plans should address recovery arrangements and the SHG will use the local recovery plans to develop a longer-term plan for NHSS Some injuries and illnesses may require weeks, months or years of hospital or outpatient treatment followed by long term follow up care. Operations and other treatments will have been postponed to cope with the mass casualties incident and as the NHS operates close to capacity it might take a considerable time to allow this backlog to be dealt with. There is also the possibility that some of those involved could develop incident related conditions at a later date. Staff would also be involved with subsequent enquiries and other legal proceedings. 20

24 NHS 24: SPECIAL HELPLINE SERVICE NHSScotland Mass Casualties Incident Plan Annex 1 1. Upon request from a Health Board, NHS 24 can provide a unique 0800 telephone number to enable information provision during the acute phase of a major incident when the call volumes have the potential to be too great for the local Health Board to manage e.g. large number of individuals affected, or high press activity leading to large numbers of 'worried well' or concerned relatives. All such information must be co-ordinated with Scottish Ambulance Service. 2. A standard request will be in place for 7 days, but can be extended depending on the volume required. 3. Normal helpline operating hours will be from A Helpline provides a single point of contact for the public affected by the incident to access consistent information and potential appropriate sign posting to local services. The service is provided by non-clinicians who are used to working within a health information environment and will provide the information as required by the Health Board including the application of simple protocols to filter types of callers. In certain circumstances, some information can also be captured and shared with the Health Board if there are certain individuals that need to be contacted/followed up. 5. Prior to the line being activated NHS 24 requires Q&As related to the incident from the requestor, with as much information as possible to cover questions the public might ask (these can be amended once the line is open) along with copies of any letters/press releases which have been sent. There should also be a single contact point for NHS 24 to communicate with at the Health Board; a single point of contact at NHS 24 will also be provided. 6. For routine requests NHS 24 can set up a helpline within 6 hours. 7. However, upon receipt of the required information from the Health Board, NHS 24 could in exceptional circumstances set up a helpline within an hour. 8. NHS 24 can provide daily reports on call volumes and will monitor the activity on the helpline to ensure adequate resourcing and to influence the decision to extend the service or not. 9. If a Health Board wishes to trigger a helpline, their Public Health department should send an to alert@nhss24.scot.nhss.uk with details of the request along with contact details and someone from NHS 24 Health Information Services will be in touch. 10. This service is provided free of charge to NHSS Health Boards. However in exceptional circumstances where NHS 24 may have to engage additional resources costs may be cross-charged. 21

25 Health Board Ambulance NHSScotland Mass Casualties Incident Plan Escalation Flow Chart Annex 2 Call received by Ambulance Control Yes Is this a Major Mass Casualties Incident? No/Don t Know Implement Plan Yes Dispatch PDA? Dispatch: Resources Command Team Notify NHS/Response Partners SITREP confirms Major/MCI No Tactical Medical Advisor to ACC Medical Advisor to Scene NCCC Refine Information/ Intelligence Scene/ACC Manage with local NHS Board Major Incident Plan Implement MCI Plan No Is incident manageable within Health Board Area? Yes Establish Strategic Health Group Establish Scale Mutual Aid Neighbouring Health Boards Establish Health Information Cell Create Capacity without disruption to plan Mutual Aid Regional SG HSCD Create capacity by cancelling elective work Create capacity by cancelling early discharge etc Mutual Aid National Mutual Aid UK sought by SG 22

26 ACTION CARD NHSScotland Mass Casualties Incident Plan Annex 3 MEDICAL COMMANDER Role Description A Medical Commander provided by a territorial Health Board will attend the scene of a major incident. The term Medical Commander has been used in this paper to describe a role also referred to elsewhere as Medical Incident Officer, Medical Incident Advisor and Medical Incident Commander. A Medical Commander will a hospital-based medical practitioner or General Practitioner; When deployed by their Health Boards, Medical Commanders will work collaboratively with the Ambulance Command Team as a structured, cohesive unit; The activities of a Medical Commander will be coordinated by Ambulance Control; Ambulance Control will activate a Medical Commander through an agreed single point of contact within a Health Board; Task Health Boards will deploy a Medical Commander to be at Ambulance Command normally within 60 minutes of the MCI activation. During a major incident, a Medical Commander will Be based at the Ambulance Control Point (at the scene), normally with the Ambulance Incident Commander; Operate within the outer cordon of the incident. Function The Medical Commander will: Be the senior clinician / medical practitioner and inform / assist decision-making by ambulance service tactical command at the scene and within ACC; Enable the Ambulance Incident Commander and Tactical Medical Advisor (SAS staff at Ambulance Control) to identify appropriate facilities across Health Boards or Hospitals to suit the health care needs of the patients generated by the incident; Identify points or locations to be established for the treatment and management of P3 patients; Provide information to the host Health Board 16 and manage medical staff communications to avoid duplication and parallel information; Provide reassurance as part of the command structure; Ensure that suitably trained, skilled and experienced medical staff: Provide medical interventions where likely to improve survival or clinical outcomes in cases where the interventions required are over and above 16 The Board in whose area the incident has occurred. 23

27 the current levels of ambulance service clinical practice; Save life and improve outcomes through the effective and direct use of senior medical staff to triage, treat and provide specialist or critical clinical interventions; and Contribute to risk assessments and the safety and welfare of responders by ensuring that medical staff can operate within appropriate areas with suitable PPE. 24

28 Mass Casualties Incident Hospital Capacity Reporting Part 1 NHSScotland Mass Casualties Incident Plan Annex 4(i) Please complete one pro-forma per Acute Hospital. Complete all fields. If nothing to report or information requested is not applicable, please insert Nil or N/A. Return the completed proforma to SAS Ambulance Control, Cardonald by to: xxxxxxx@xxxxx.nhs.uk Health Board name Hospital name Contact Tel. Number Inc. Extension Name and designation of person completing report Current A&E capacity P1 Date Time Contact P2 Other Treatment Centre(s) & capacity By location P3 Please fax completed form to: Updates to be sent to Ambulance Control Centre at XX intervals until advised otherwise. 25

29 Mass Casualties Incident Hospital Capacity Reporting Part 2 Annex 4 (ii) Please complete one pro-forma per Acute Hospital. Complete all fields. If nothing to report or information requested is not applicable, please insert Nil or N/A. Return the completed proforma to SAS Ambulance Control, Cardonald by to: xxxxxxx@xxxxx.nhs.uk Health Board name Hospital name Contact Tel. Number Inc. Extension Date Time Contact Name and designation of person completing report Facility ICU HDU CCU Trauma Burns Theatres Paediatrics Capacity available Capacity Issues If Yes, please explain: Do you have capacity issues with any particular type of patients? Capability Issues If Yes, please explain: (Is there any category of patients that you are unable to deal with?) Please fax completed form to: to: Updates to be sent to Ambulance Control Centre at XX intervals until advised otherwise. 26

30 ACTION CARD Annex 5 Task Call Sign: Tactical Medical Advisor Ambulance Control Action Card Description Time The Tactical Medical Advisor will work as an integral part the national Major Incident Control structure established within the Ambulance Control Centre (ACC). The role of the Tactical Medical Advisor is to ensure, as far as practicable, that the distribution of patients across Health Board areas, the hospitals and facilities in those areas and those within other administrative areas, is appropriate to the needs of the patients generated by the incident. The Tactical Medical Advisor will liaise with the Ambulance Command Team, medical staff within Health Board and hospital control or co-ordination teams and, where required, individual clinicians, to ensure the most effective use of NHS facilities and resources in the interests of patient safety and clinical care. 1 On notification of a major incident / mass casualty incident, attend the ACC to establish the role of Tactical Medical Advisor. 2 Obtain a briefing from the Major Incident Control (MIC) Team Ascertain the pattern of patient distribution already undertaken and that anticipated by the MIC, based on information obtained from the scene and from receiving hospitals. Establish the medical staffing at scene and requested by the ambulance service and advise the MIC on requirements. Through the MIC, establish contact with the Medical Incident Advisor, if present, or other medical staff acting in such a role. Through the MIC, establish contact with each Health Board and hospital control or co-ordination team in every area likely to receive patients from the incident(s). Collate information on capacity and capability at each site. Through the MIC, establish contact with individual clinicians or networks and the establish capacity and capability to receive patients requiring evacuation or transfer to specialist centres. Assist to influence the most effective use of resources through the avoidance of secondary transfers during the response phase. 27

31 Act on the advice of the MIC and Ambulance Tactical Advisor on procedures and facilities agreed between the statutory services, ensuring that accurate and comprehensive records of decisions, actions and outcomes are maintained. Liaise with Health Boards and hospitals about the suspension or postponement of routine activity to allow the ambulance service to redeploy non-emergency patient transport service resources. Interpret STAC or other specialist advice on public health, health protection, toxic releases, countermeasures, protective equipment and control of infection, as required. Maintain, through the MIC, Ambulance Control Point (ACP), Medical Incident Advisor, and Ambulance Liaison Officers at Hospitals and through dialogue with medical staff within Health Boards and hospitals, an overview of the pattern of patient distribution, working with the above to find solutions to an issues arising. Ambulance Control Centre Caledonia House 140 Fifty Pitches Road Cardonald Glasgow G51 4EB 28

32 Annex 6 MUTUAL AID AGREEMENT BETWEEN HEALTH BOARDS IN SCOTLAND Introduction 1. This is a mutual aid /partnership agreement between the Health Boards listed in the table at the end of this paper. Its objectives are: To respond as quickly and effectively as possible to requests for assistance from another Health Board, or Boards, at the time of a major / mass casualties incident; and To enable assistance from another Health Board, or Boards, to be provided where that is reasonable and practicable, for the benefit of people affected by the incident. 2. This Agreement is made under the terms of the Civil Contingencies Act 2004 (Contingency Planning) Regulations It is not a legally binding contract and does not imply any obligation on the part of the signatory organisations to provide specific aid. Scope of the Agreement 3. Health Boards are required to make thorough preparations to respond to major incidents, in accordance with their statutory duties and relevant national guidance. If a major incident occurs, they should make every reasonable effort to deliver an effective response using local resources. Despite thorough preparations, it is possible that an incident could occur that is so large, complex or unusual that it exceeds the capacity of a single Health Board to respond adequately. In such situations the Health Board should request mutual aid from another Board or Boards. 4. Mutual Aid is the provision of staff, equipment or services required by another Health Board, in order to provide the best possible care for the greatest number of patients. This includes: The agreed transfer of patients for specialist treatment and/or care; The agreed redirection of other patients to a different Health Board; and The agreed provision of other health services to support the needs of other boards, e.g. laboratory investigations. 5. Health Boards will provide mutual aid, as far as is reasonable and practicable, when: Requested by another Health Board, and The capacity of the requesting Health Board to deliver care would otherwise be exceeded because of the incident(s), and It is expected that providing aid would significantly improve the health outcomes of people affected by the incident(s), and No serious adverse health effects are likely to result for other patients. Requesting and Providing Mutual Aid 6. When requested by a Health Board that is managing an emergency, other Boards will provide information about their current and projected ability to provide mutual aid. Boards will ensure that this information, including their current and potential acute capacity, can be provided at short notice. 29

33 7. A formal request for the provision of mutual aid shall only be made by the Chief Executive 17 (or their authorised designate) of the Responding Health Board to a Chief Executive of the assisting Health Board. 8. When a Chief Executive receives a request for assistance he/she shall take the appropriate action to respond to the request without delay. This will include considering whether fulfilling the request would be likely to result in serious adverse effects on the health of other patients or on service delivery obligations. 9. When a Health Board agrees to provide mutual aid, the Boards involved shall also agree a review date for the provision. Aid should not normally be withdrawn until either that date has been reached or the need for aid has passed, however the assisting Health Board retains the right to withdraw aid at any time in order to deal with situations affecting its own area. 10. In rapidly changing situations, the requirements for mutual aid and the ability to offer it may change very quickly. To manage such changes effectively, Chief Executives should ensure there is clear leadership and coordination of mutual aid arrangements, with appropriate delegation of authority, to allow provision to be adjusted where this is reasonable and necessary. Staff and Resources 11. The affected Health Board undertakes only to use the staff and resources provided for the purposes for which they have been granted and to ensure that: They are deployed with the appropriate governance arrangements; They are not deployed outside the boundaries of the affected Health Board; and Their statutory entitlements and safety provisions are met, including the provision of food and drink, protective equipment and suitable working arrangements. 12. The affected Health Board must undertake to indemnify the assisting Health Board for any liabilities that may occur whilst the employees of the assisting Board are subject to the control of the affected Board. 13. The assisting Health Board must ensure that: Regular contact is maintained with its employees working for the affected Health Board and that management issues are dealt with appropriately; and All existing insurance provisions are extended to cover mutual aid circumstances. 14. The Chief Executives of the affected and assisting Health Boards undertake to liaise regularly with each other regarding the management of resources, the progress of the emergency and other matters within this agreement. 15. The affected Health Board, receiving mutual aid, agrees to reimburse the assisting Board all reasonable financial costs incurred. This will be done on the termination of the aid and the submission to the affected Board of a documented account for settlement, within 28 days. 17 All references to Chief Executive also refer to an authorised designate acting on their behalf. 30

34 The following Health Boards have agreed to take part in the NHSScotland Health Boards Major Incident Mutual Aid Agreement Health Board Name and designation Signature and date 31

35 Annex 7 (i) STRATEGIC HEALTH GROUP ROLE OF THE CHAIR ACTION CARD Description The role of the chair of the Strategic Health Group is to formalise the mutual aid arrangements and agree an NHS plan for managing the mass casualties incident(s). The meeting will consider the resources, specialities and additional support required. Tasks 1 On notification of a mass casualties incident, initiate a tele-conference with all Health Boards (including ambulance NCCC) and Scottish Government. 2 Chair SHG meeting 3 Formulate strategy 4 Agree actions; allocate tasks 5 Establish a battle rhythm 32

36 Annex 7(ii) STRATEGIC HEALTH GROUP Action Card Description The role of the Strategic Health Group is to activate, monitor and co-ordinate the NHS response to the incident. Tasks 1 Provide strategic advice and leadership; 2 Develop and coordinate the wider NHSS corporate response to the incident Activate mutual aid between Health Boards 18, coordinate NHSS assets and monitor implementation / progress. [SAS will advise the SHG of mutual aid or MOU s that have been invoked with other UK NHS Ambulance Services and voluntary providers]. Lead decision-making for the NHSS in collaboration with Scottish Government (SG). Communicate with SG HSCD, Health Boards and the media /the public. The chair will be the talking head on behalf of the Responding THBs / NHS Scotland. Establish and manage a Health Information Cell. Engage with appropriate stakeholders. Submit a SitRep to SG NHS Resilience Unit. Ensure that arrangements are in place to effectively track patient transfers between healthcare facilities. 10 Undertake long-range planning, including the recovery phase. 18 Note: UK ambulance service mutual aid will be invoked through existing arrangements and will not be referred to the SHG for decision. 33

37 Date: 1 Welcome and introduction 2 Members present, apologies 3 Urgent actions/decisions 4 Actions from previous meetings 5 Situation update / briefing What has happened? What does this mean for us now? What do we need to do now? 6 Review / formulation of future actions STRATEGIC HEALTH GROUP Emergency Meeting Template Venue: AGENDA NHSScotland Mass Casualties Incident Plan Time: Annex 7(iii) ITEM PAPERS / INPUT LEAD Mutual aid requirements Strategic aim Strategic intentions (short, medium, long term) Casualty Information Casualty numbers Casualty categories Casualty specialist treatment requirements Casualty capacities Discharge status Casualty distribution Bed capacity Communications Strategies Staff Public Media Support agency liaison Scottish Government liaison and notifications Recovery management 7 Summary of actions allocated during meeting 8 AOCB 9 Next meeting: 34