Introduction

A major incident is any emergency requiring the implementation of special arrangements by the emergency services and will generally involve large numbers of casualties.1 To respond appropriately to such events, all hospitals are required to keep a major incident plan (MIP) under the Civil Contingencies Act of 2004.2 The plan covers the strategic, tactical and operational management of such scenarios and identifies key commanding members of the emergency team, including the anaesthetic/intensive treatment unit (ITU), emergency medicine, general surgery, and trauma and orthopaedic registrars and consultants.

In 2006, following the 7/7 London bombings, we conducted a survey assessing confidence using MIPs among registrars in specialties that would be expected to respond to a major incident3 and found that many had not even read their hospital’s MIP nor knew where to find it, demonstrating the need for significant improvement. Similar conclusions have been drawn by other studies in the UK.4 5 We concluded by highlighting the importance of educating doctors about MIPs. Since our previous report, several large-scale events (including the Manchester Arena bombing and Grenfell Tower disaster) have demonstrated that major incident planning is more relevant now than ever. We have therefore revisited our earlier research and set out to determine whether there has been a substantive change in knowledge and confidence compared with our original report.

Methods

We identified NHS trusts in England that received more than 30 000 patients through the emergency department in the fourth quarter of 2016/2017 using publicly available data from NHS England.6 In each of these trusts we contacted the on-call registrars (middle-grade doctors in specialty training) in anaesthetics, emergency medicine, general surgery, and trauma and orthopaedics via the hospital switchboard. After gaining verbal consent to participate, we conducted our questionnaire on the phone (online supplementary figure 1). This survey is the same as the one used in our original study and has only three questions in order to maximise response rate. Two contact attempts were made for each individual. Results were then compiled for the group as a whole and by specialty. We determined that three response categories for each question were appropriate for analysis and that the nuance between the ‘in-between’ answers was not substantially different in practice. This also allowed us to compare results with the 2006 paper, where the same process was employed. All data are shown to one decimal place.

Results

We identified 76 NHS trusts in England that matched our search criteria. Two of these were community healthcare trusts, only accepting minor injuries, and were excluded. We then attempted to contact 296 registrars across the 74 remaining hospital trusts. One hundred and eighty-six (62.8%) individuals consented to being included and gave their responses to the survey, while the remaining 110 (37.2%) either did not consent or were uncontactable after two attempts (online supplementary figure 2).

The responses of our survey are detailed in table 1 and figure 1. Trauma and orthopaedics had the highest response rate, while emergency medicine had the lowest. Half of the responding individuals had read their hospital’s MIP, with 46.8% being confident they knew where the guidelines were kept. Only 36% of individuals were sure of the role they would play if an MIP came into effect while they were on call. The greatest number of responses came from trauma and orthopaedic registrars, while emergency medicine registrars were generally the most confident in using the MIP. Results were broadly similar to our previous study, although fewer individuals were confident in their role in the MIP (figure 2).

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Questionnaire responses separated by question and specialty. (A) Responses to ‘Have you read your hospital’s Major Incident Plan?’; a total of 46 individuals (24.7%) had read all, 47 (25.3%) part and 93 (50.0%) had read none. (B) Responses to ‘Do you know where you can access your hospital’s major incident plan guidelines?’; a total of 87 (46.8%) responded yes, 66 (35.5%) were unsure and 33 (17.7%) responded no. (C) Responses to ‘Do you know what role you would play if a major incident plan came into effect while you were on call?’; 67 (36.0%) responded yes, 69 (37.1%) were unsure and 50 (26.9%) responded no.  ITU = Intensive treatment unit

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

Comparison of results with our previous study (Wong et al 3). (A) Responses to ‘Have you read your hospital’s Major Incident Plan?’; 23% vs 24.7% had read all, 30% vs 25.3% had read part, and 47% vs 50.0% had read none (Wong et al 3 vs current study, respectively). (B) Responses to ‘Do you know what role you would play if a major incident plan came into effect while you were on call?’; 54% vs 36.0% responded yes, 27% vs 37.1% were unsure, and 19% vs 26.9% responded no (Wong et al 3 vs current study, respectively).

Discussion

Since 2004 all hospitals in England have been required to keep an MIP, and the importance of planning for such events has been exemplified in recent tragedies. We did not investigate the content of the MIPs as this would not be practical. Instead the purpose of this study was to assess the propagation and effectiveness of this information, and how it is understood by the individuals it involves rather than an evaluation of the MIP itself. We found that just half of the doctors contacted had read their hospital’s guidelines. Of concern, we found no improvement since 2006: indeed fewer individuals were confident in the role they would play if an MIP came into effect while they were on call. Perhaps unsurprisingly, emergency medicine registrars were the most familiar with their hospital’s protocol. They were closely followed by anaesthetics, with surgical specialties being least familiar. Importantly, doctors had no prior warning of our contact, as would be the case in the real-life enactment of an MIP.

Conclusion

We have demonstrated that confidence in using MIPs among registrars in England has not improved since 2006. We have made several suggestions, including the addition of succinct action cards in all trust inductions.