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The NHS Emergency Planning Guidance 2005: underpinning materials
Immediate medical care at the scene of a major incident
Contents
1.
Introduction..................................................................................................2
2.
Planning for an incident –
the organisation and management of immediate medical care at the
scene ............................................................................................................2
3.
Planning for an incident –
the organisation of Medical Emergency Response Incident Teams .......4
4.
Planning for an incident –
employment of personnel providing immediate medical care at the
scene ............................................................................................................5
5.
The Roles and Responsibilities of the Medical Incident Commander ....6
This material should be read in conjunction with the NHS Emergency Planning
Guidance 2005. All material forming the Guidance is web based and is prepared
primarily to be used in that format. The web-based versions of Guidance
including underpinning materials has links to complementary material from other
organisations and to examples of the practice of and approaches to emergency
planning from the NHS in England.
The web version of the Guidance is available at
www.dh.gov.uk/emergencyplanning
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1. Introduction
1.1.
This section describes the arrangements for the organisation of
immediate medical care at the scene of a major incident also known as
pre-hospital care. It also describes the roles and responsibilities of the
Medical Incident Commander (MIC) and describes proposed revised
arrangements for the organisation and management of immediate
medical care at the scene and those providing it by giving responsibility
for this to Ambulance Trusts rather than Acute Trusts. It also describes
revised arrangements for the organisation of Medical Emergency
Response Incident teams (MERITs) formerly known in some areas as
Mobile Medical Teams (or their equivalent). Strategic Health Authorities
(SHAs) will be accountable for ensuring that effective arrangements are in
place for the provision of the Medical Incident Commander role and the
organisations of MERITs or their equivalents.
2. Planning for an incident – the organisation and management
of immediate medical care at the scene
2.1.
SHAs will be accountable for ensuring that Ambulance Trusts and Acute
Trusts including Foundation Trusts work together to provide a model for
immediate medical care at the scene and the organisation of Medical
Emergency Response Incident Teams (MERITs) or their equivalents
appropriate to the area. The models developed will vary around the
country taking into account of, for example, the number of accident and
emergency departments in an area and the distance between them, the
availability of appropriately trained immediate care clinicians from
organisations such as the British Association for Immediate Care
(BASICS) and the organisation of ambulance services.
Whatever model is adopted it should ensure that at the scene it is possible
to
• Triage
• Treat
• Provide appropriate specialist interventions including, for
example, services for children and access for Burn
Assessment Teams (BAT)
It should be clear that the role embodied by a Medical Incident
Commander (MIC) and that provided by a MERIT team are separate. The
MIC function is to work in partnership with the ambulance services to coordinate the delivery of resources at the scene. The function of the
MERIT or equivalent team is to provide additional resources at the scene.
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Strategic Health Authorities (SHAs) will be accountable for ensuring that
effective arrangements are in place for the provision of the Medical
Incident Commander role and the organisations of MERITs or their
equivalents and will be performance managed to ensure delivery.
The delivery of these functions will require healthcare communities to work
collaboratively to ensure an efficient and effective service. In some
instances two or more health communities may work together across
borders to ensure a timely and effective response. The model developed
must allow flexibility to provide skills required by an incident.
SHAs, Ambulance Trusts and Acute Trusts are encouraged to look at
different models used across the country.
2.2.
The increasing complexity of major incidents suggests that the Medical
Incident Commander (MIC) has an increasing and pivotal role in the
clinical management at the scene of an incident where the ambulance
service is taking a lead role for health. The MIC will also work in support
of ambulance colleagues in a ‘rising tide’ incident.
2.3.
It is proposed that the traditional capability for every casualty receiving
hospital to provide a trained MIC should be discontinued in favour of a
Medical Incident Commander pool arrangement. These arrangements
have been very effective in areas that have implemented a pool and
should now be considered best practice and are recommended to all
ambulance services.
2.4.
It is proposed that each Ambulance Trust should be responsible for the
recruitment, selection and training of MICs who would become members
of the pool of practitioners any or all of whom could be called upon in the
event of a major incident. MICs can be drawn from a variety of clinical
disciplines including anaesthetics, accident and emergency, general
practice, and public health. Those offering their services to the pool of
MICs must be willing to undertake appropriate preparation and training.
Ideally the pool will be comprised of experienced clinicians with at least
seven years' postgraduate experience and a good understanding of the
pre- hospital environment and the clinical, managerial and leadership
skills required. Whenever possible they should themselves be accredited
immediate medical care practitioners and hold an appropriate, recognised
qualification. They will be required to attend training exercises regularly
and be physically fit enough to cope with the rigours of a hostile
environment.
2.5.
The intention is that by incorporating the MIC pool into ambulance service
arrangements, their competencies can be continuously updated, their
training integrated with the other agencies and be able to participate in
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exercises undertaken by other agencies and be well briefed about local
issues and plans for example, COMAH sites and airport and prison plans.
2.5
The Ambulance Service will mobilise the Medical Incident Commander
pool for major incidents that have been declared as required. The role of
the Medical Incident Commander (MIC) is to provide support to the
Ambulance Incident Commander by co-ordinating Medical Emergency
Response Incident Teams and doctors at the scene of a major incident
and to provide treatment of casualties as requested by the Ambulance
Incident Commander. The Medical Incident Commander pool may also
be requested to provide support to the Ambulance Service strategic
command as required.
Where there are large numbers of casualties, other pool members should
be mobilised initially to fulfil other roles such as Forward Medical Incident
Commander, Triage Doctor or to have clinical roles alongside paramedics.
Others should be held in reserve as later reliefs. If necessary a senior pool
member can give support as strategic doctor to ambulance strategic
command. A relief MIC and if necessary other clinical practitioners from
the pool can be mobilised later.
2.6.
2.7
It may be necessary to provide a 24-hour a day clinical presence for
some days in some protracted incidents. The MIC pool should have
enough resilience to provide this. It is also a way of rotating staff to
ensure that those in the pool can get some experience at the scene of
incidents.
Planning for immediate medical care at the scene should include
consideration for how to deal with relatives and friends that may try to
access the scene of an incident particularly if the incident involves
vulnerable person including children.
3. Planning for an incident – the organisation of Medical
Emergency Response Incident Teams
3.1.
SHAs are accountable for ensuring that effective arrangements are in
place for the provision of MERITs or equivalent provision.
3.2.
Where there are active immediate medical care teams working regularly
with the ambulance service, these often now include accredited nurses,
and with the new emergency care practitioners being trained by the
ambulance services, the need for the traditional mobile medical team
response is diminishing in some areas. This role can now be undertaken
by others with specific training and experience in pre-hospital care and
this leaves key acute hospital staff available in receiving and stand by
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hospitals. The SHA should decide on the mobile team resources required
to be maintained on call to support them. Equipment may be held by the
ambulance services in a pool arrangement rather than every receiving
hospital duplicating resources.
3.3.
Before the MMT or equivalent provision is mobilised to the scene, the AIC
and MIC should be clear what role is expected of them and that a Mobile
Medical Team is the best way to provide it. Other options, including
mutual aid from neighbouring immediate medical care services may be a
more efficient way of providing extra resources. Mobile Medical Teams
may be trained and employed to provide specific skills at the scene of a
major incident, for example, provision of analgesia.
3.4.
SHAs need to ensure that NHS organisations including Acute and
Foundation Trusts and Primary Care Organisations facilitate
arrangements for recruitment, retention and training of those identified to
provide immediate medical care at the scene of a major incident including
access to training, facilitating leave and cover arrangements and
provision of necessary equipment not provided by the Ambulance Trusts.
3.5.
Acute Trusts can request the attendance of an MIC and other clinical
resources from the pool when they self declare a major incident, for
example in the event of a fire, where their own staff as well as the
patients are victims of an incident.
4. Planning for an incident – employment of personnel providing
immediate medical care at the scene
4.1.
Local arrangements should be in place for the ambulance service to
engage the services of accredited immediate care clinicians to provide
immediate medical care. A memorandum of understanding should be in
place both with members of the MIC pool and with local accredited
intermediate care schemes.
4.2.
Appropriate arrangements need to be made to ensure adequate
professional indemnity and life insurance for all members of the MIC pool
and members of MERIT teams.
4.3.
It is recommended that the MIC be provided at the scene with a loggist to
log all calls received and made and all decisions taken to assist with
incident debriefing.
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5. The Roles and Responsibilities of the Medical Incident
Commander
5.1.
This guidance proposes the following roles and responsibilities for the
Medical Incident Commander:
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To provide professional advice guidance and support to the
emergency services, particularly the ambulance service in assessing
the medical implications and response to any major incident, actual
or potential as well as rising tide and public health incidents
To coordinate and organise the NHS clinical resources (apart from
the ambulance service staff) at the scene of an incident allocating
tasks and roles in close cooperation with the Ambulance Incident
Commander.
To take clinical responsibility for the care of casualties and their
appropriate distribution to receiving hospitals, again in close
cooperation with the AIC.
To provide a doctor for the confirmation of death procedures once
live casualties have been removed from the scene. This is to be
achieved through liaison with the police tactical command and the
senior investigating officer. Liaison with the coroner may be required
To communicate clinician to clinician with the Acute Trusts and
Foundation Trusts who are providing casualty receiving facilities or
on standby to receive casualties. The Acute Trusts should be able to
provide accurate information about each participating Acute Trust’s
capacity for theatres, critical care and bed availability. Clear
information from the MIC about children as casualties and burns
patients is particularly important
To act as an on scene clinical link to the on-call public health, Health
Protection Agency or other strategic advisors. Providing accurate
situation reports and risk or threat assessments
To work closely with the AIC keeping the ambulance control fully
appraised of the situation at the scene
The MIC and AIC should always remain co-located and attend
tactical co-ordinating meetings together
The MIC must ensure that an accurate and detailed log of events and
decisions made are kept. A loggist should be appointed to assist in
this if possible
Before a MERIT or equivalent is deployed to the scene, the MIC and
AIC should agree what their role at the scene would be and that a
MERIT is the best way to fulfil this. Consideration should also be
given, depending on availability, to deploy Immediate Care clinicians
from local and neighbouring BASICS or equivalent schemes
In a CBRN incident the MIC will always stay on the clean side of an
incident and only rarely should it be necessary to deploy a forward
MIC into the contaminated area wearing appropriate PPE. Normally
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the Forward MIC will stay on the clean side to supervise the care of
casualties after decontamination
The MIC should ensure safety and welfare of immediate care staff
and that they are properly cared for
At the end of the incident the MIC should collate reports from all
clinicians at the scene and then prepare a full report about the
incident. The MIC should attend debriefs and ensure that lessons
learnt are shared
The MIC should be prepared to assist the Ambulance Incident
Commander in dealing with media requests and participating in press
conferences
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