Background: Lack of knowledge of an NHS trust’s major incident policies by clinical staff may result in poorly coordinated responses during a mass casualty incident (MCI).
Aim: To audit knowledge of the major incident policy by clinical staff working in a central London major acute NHS trust designated to receive casualties on a 24-h basis during a MCI.
Methods: A 12-question proforma was distributed to 307 nursing and medical staff in the hospital, designed to assess their knowledge of the major incident policy. Completed proformas were collected over a 2-month period between December 2006 and February 2007.
Results: A reply rate of 34% was obtained, with a reasonable representation from all disciplines ranging from nurses to consultants. Despite only 41% having read the policy in full, 70% knew the correct immediate action to take if informed of major incident activation. 76% knew the correct stand-down procedure. 56% knew the correct reporting point but less than 25% knew that an action card system was utilised. Nurses had significantly (p<0.01) more awareness of the policy than doctors.
Conclusion: In view of the heightened terrorist threat in London, knowledge of major incident policy is essential. The high percentage of positive responses relating to immediate and stand-down actions reflects the rolling trust-wide MCI education programme and the organisational memory of the trust following several previous MCI in the capital. There is still scope for an improvement in awareness, however, particularly concerning knowledge of action cards, which are now displayed routinely throughout clinical areas and will be incorporated into induction packs.
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Lack of knowledge of a major incident document could result in a less than adequate response at a time when resources may be stretched. For the NHS, a major incident is defined as “any occurrence that presents a 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 trusts or primary care organisations”.1 Within this definition, the levels of major incident for which NHS organisations are required to arrange emergency planning include major, mass and catastrophic.1 A mass casualty incident (MCI) can be further defined as a “much larger scale event, affecting 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”.1 Published studies have highlighted problems related to the awareness of hospitals’ major incident policies and the role of NHS staff within a major incident.2–4 One study at a teaching hospital in London where doctors were interviewed found that a simple intervention such as a single information sheet increased the awareness of the reporting point from 4.4% to 78%.5 The same study showed that doctors in only two out of 38 hospitals with emergency departments had read their hospital’s major incident policy.5
Another study questioned a total of 179 registrars from 34 different hospitals throughout Great Britain;6 47% had not read their hospital’s major incident policy/plan.6 Only 54% of the registrars questioned felt confident in their role in a major incident.6 They also reported that 25% of hospitals that responded did not hold any teaching sessions for junior and middle-grade doctors.6
A third study questioned duty consultants and trainees in anaesthesia, general and orthopaedic surgery from a total of 17 hospitals in the South East Thames region.7 All consultants and 77% of trainees knew of major incident plans in their hospital, but only 39% of trainees had been given any major incident plan literature and less than a third of staff had attended a major incident plan orientation session.7
These studies all highlight the need for hospitals to promote greater awareness of their major incident policy.
Our own institution is a central London teaching hospital designated by the London ambulance service as the one of the hospitals able to receive casualties on a 24-h basis in the event of a major incident and can be notified by the ambulance service to be a receiving hospital.8 Following this hospital’s involvement with the major incident of 7 July 2005, the aim of this audit was to determine awareness of the hospital’s major incident policy and to audit NHS professionals on their knowledge regarding this important document.
The response to a major incident for this particular London hospital was published in a handbook, made available to all NHS professionals employed by the trust via the hospital’s intranet.8 The document stated that employees had a duty of care and were responsible for their actions during a major incident and that they must have read the main section of the policy document and any action cards that were relevant to them.8 It also stated that this was important as there would be no time to read the policy during an incident.8
A 12-point proforma was designed and verified by the physician in charge of clinical governance at our institution. The questions asked are shown in box 1.
Box 1 Questions asked of all NHS professionals involved in the audit
Have you read the major incident policy document?
How many times a year is the hospital put on major incident standby?
If you are at home and see the hospital being used as one of the receiving hospitals during a major incident what should you do?
If you receive a call saying “major incident activate plan—report to staff reporting point”, where should you go?
Which action cards could you be allocated by the coordination team?
After involvement with a major incident what should you do?
The proforma was distributed via e-mail and by hand to all health professionals perceived to be involved in a major incident at this particular hospital. This list totalled 307 and was obtained from the trust.
Responses were collected electronically or by depositing completed proformas at a designated collection point. Data were collected over a period of 2 months (December 2006 to February 2007). A reminder was sent via e-mail to all participants after one month and individual members of staff were re-contacted at various hospital teaching forums occurring throughout the 2-month period.
A total of 307 profomas were distributed to members of staff who could be involved with a major incident. The total number of personnel who replied to the document was 105 (see fig 1), thus the reply rate was 34% (307/105 replies). There was reasonable representation from all disciplines ranging from nurses to consultants (see fig 1). This audit showed that from the NHS professionals questioned in this study, 41% had read the major incident document; 48% of staff knew the average number of times the hospital was put on major incident alert per year (see table 1); 70% of staff knew the correct immediate action to be taken if informed of the hospital’s involvement in a major incident (see table 1) and 56% knew the correct reporting point for staff during a major incident (see table 1). Less than 25% of people questioned knew which action card they would be allocated during a major incident (see table 1); 76% of personnel knew the correct stand-down procedure during a major incident according to the hospital’s policy (see table 1).
All of the above results are illustrated in table 2, which shows analysis by profession and grade.
When comparing awareness among different grades and professions of staff, two-sided Fisher’s exact test to test the difference among proportions between doctors and nurses was also performed. Nurses were found to be significantly more aware of the hospital’s major incident policy compared with doctors (20/25 vs 39/75, p = 0.009) (see table 3).
Recent events have highlighted the need for hospitals to be alert to the threat of major incidents and staff to be wholly familiar with major incident protocols. The aim of this study was to assess the awareness and familiarity of staff with such protocols within an institution that had recently been involved in a major terrorist incident. Of the healthcare professionals assessed in this study, the proportion that had read the major incident policy in full was low. Despite this, however, a good majority of the multidisciplinary study cohort were aware of the immediate actions to take during a major incident (see table 2). We believe that the high percentage of positive responses relating to immediate and stand-down actions reflected our rolling trust-wide MCI education programme and the organisational memory of the trust following several previous MCI in the capital.
In contrast to the other studies discussed,5–7 this audit, for the first time, ascertained awareness from all members of the major incident multidisciplinary team, including all levels of healthcare professionals. The results highlight that the awareness of major incident plans needs improvement among all the groups assessed.
It is a trust-wide requirement of all personnel at our institution to read the major incident policy, which is clearly outlined in the policy document itself.8 It is evident, however, that various members of staff who had not read the document were unaware of this fact. This will now be routinely highlighted at hospital induction and should improve awareness at our particular institution.
It may be suggested from this study that having a printed document of the hospital’s major incident policy as the sole method of communication to staff is not the best way of informing and alerting hospital staff to its contents. We suggest that it should be used as an adjunct to training days and other more active applications that require participation and involvement of hospital staff.
An interesting observation of this study was that nurses were significantly more aware of the major incident policy compared with doctors. This is likely to represent a difference in the training regimen between the different healthcare professionals. Healthcare groups in our institution who have a paucity of training opportunities will now have increased exposure to major incident planning in their core training.
A major weakness of this study was the poor reply rate obtained among participants. This could be attributed to the non-automaticity of the proformas with a need to e-mail/post/hand deliver the replies to the designated collection point. For future audits of this kind we recommend that proformas are on-line, which would improve the ease of data collection.
In view of the heightened terrorist threat in London, knowledge of major incident policy is essential. This study showed, for the first time, that the multidisciplinary team involved with a major incident was aware of the immediate actions needed to be taken during an MCI, as a result of our hospital’s educational programme, despite a lack of awareness of the major incident policy document itself. There is, however, scope for improvement in awareness, particularly regarding the knowledge of action cards, which are now displayed routinely throughout clinical areas and will be incorporated into induction packs. A range of further recommendations has also been suggested by the authors, incorporating the introduction of briefing sessions during hospital induction, awareness days as well as the requirement to read the document being stipulated at trust induction and also on the hospital’s intranet among clinical and non-clinical areas.
Major Incident Alert—is your NHS trust prepared?
Competing interests: None declared.
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