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Mark Borthwick, MRPharmS,
Neil McGuire, FRCA, and David Scott, MRPharmS, are from the Oxford
Radcliffe Hospitals NHS Trust
Correspondence to:
Dr Scott
e-mail David.Scott@orh.nhs.uk |
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Recent tragic events in London have shown how difficult it can be to
anticipate and prepare for major incidents, even when the general threat
is known. Yet there is a need to respond effectively to accidents, natural
disasters and terrorist attacks.
How does one prepare?
Most people have no experience of real major incidents so hospital
procedures, including pharmacy plans, may have been written without the
benefit
of first-hand knowledge of what can happen.
Some well-known tragedies have been useful as learning tools because
they highlighted the deficiencies of existing plans; the Kegworth aircraft
crash led to a radical overhaul of the coding system used to prioritise
patients because of the confusion caused by each ambulance authority
using its own colour coding system. More recently, Spanish pharmacists
have reflected on the Madrid bombings.1 Such instances can turn out to
be a silver lining to a dark cloud but they make one all the more keen
to learn before a major incident occurs. Proper preparation is necessary
both for new, inexperienced staff and for established staff who may be
complacent about procedures because of years without a major incident.
Planning and simulation exercises are one partial solution. In Birmingham,
one hospital discovered the deficiencies of its fire evacuation procedures
when it tried it out with volunteers acting as patients. The video of
the resultant chaos was distributed to other hospitals and a television
company made a documentary about the subsequent efforts to correct the
problems and run a more successful repeat exercise.
Other multidisciplinary exercises have been run, generally under the
aegis of the emergency rescue services; one of us (DS) was involved in
an exercise where an empty bus was dropped off a railway bridge. The
wreckage was then packed with actors as casualties and yet more actors
played the part of the press, relatives, etc, to test the ability of
the rescue services and hospitals to cope. In that instance pharmacy
turned out to have little unexpected involvement because the local hospital
already had resident pharmacists and the extra work related mainly to
the supply of fluids and opioids. Not all hospitals would be so fortunate.
However valuable these exercises are, and they are also regularly used
as learning tools in the military environment, they are expensive and
time-consuming to organise and run. There are alternatives that can achieve
many of the same aims, without the time and expense, and that can maximise
exposure of personnel to mechanisms and procedures in limited timescales.
Two years ago two of us (MB and DS) were planning to provide training
for hospital pharmacists who might be involved in emergencies but we
were unable to find published examples of pharmacy-based simulations.
We then discovered that there is considerable expertise in the armed
services in running “table-top” exercises to test the capabilities
of new installations. When a new field hospital or other service is set
up, exercises simulating the anticipated demands are run in order to
identify the problems before they occur. There are no real or acted casualties
but the service providers have to enact their roles in real time under
the control of a simulation co-ordinator who plans the scenario and reveals
the plot to the participants as time elapses.
One of us (NM) is a consultant in our hospital’s intensive therapy
unit and is also a Royal Air Force intensive care doctor with experience
of both real emergencies and table-top simulations, and so was able to
design an exercise for pharmacy. The exercise
The exercise was designed to run in a one- hour session and to cover
the first 45 minutes or so of an evolving emergency that involved many
casualties who required medicinal treatment. The session included a
discussion of lessons learnt and led to quiet reflection afterwards
for those involved.
In a classroom that normally seats about 35, a table-top “gaming” board
was set up with a plan that represented a pharmacy with telephones, faxes
and offices detailed. Stores, including a distant bulk IV fluid store,
were shown with an indication of how long it would take to transport
items between sites. Wards, the emergency department, operating theatres
and neighbouring hospitals were similarly depicted. Movable counters
showed staff of different grades or designations.
Participants were given roles to play, with a brief set of written instructions
on how to play their parts. They were asked to make it as real as possible
but not to stray outside their brief. In general, we chose a junior pharmacist
to act as chief pharmacist because we thought this would help highlight
how the system would work in the absence of senior staff. It also stimulated
the juniors to appreciate the need for leadership, the taking of instructions
as a subordinate and acting independently for the overall effort. It
allowed the scenario to be conducted without threatening more senior
participants. They may not have previously considered such a situation
and gaining a too realistic review of their performance was not the intention.
The idea of these exercises was to subject the system to stress but with
accompanying support and suggestions for the participants. If participants
felt intimidated all of the benefits of learning would be undermined,
with a negative result.
Participants stood close to the table unless they had a timed task to
do (eg, “go to ward 9; this will take eight minutes”), in
which case they would retire to the edge of the room for the set period.
There they could observe the action but were not allowed to participate.
Some participants were designated at random as nurses, doctors or relatives
and they interacted or “telephoned in” when given their cue
from the scenario co-ordinator. A portable recorder produced the ringing
tones that came to be much-loathed. Other participants could hear both
ends of these conversations but were not allowed to respond thus benefiting
from the interaction but not altering it. Some participants were instructed
to be difficult in some particular way to add stress, eg, over the need
to leave immediately for child-care reasons or, more generally because
they did not appreciate the gravity of the situation.
At an appropriate moment a medicines information enquiry was simulated
with a folder of papers that showed what would have been found by a computer-based
search, and the relevant pharmacist was moved to the edge of the room
to digest the contents of the file.
Dispensary workload was simulated with counters that represented different
kinds of work; each was marked with the time it would take to complete. Outcomes
The simulation has been run four times, sometimes with participants
from several hospitals and sometimes with staff from only one. On each
occasion
there has been some hilarity, some tension, some confusion and some
frustration. The varied participants performed well and entered the
spirit of the role-playing, after overcoming initial “nerves”.
There have been many lessons learnt and a strong determination from
all involved to think ahead. Many found the experience sobering and
have resolved to read their own department’s emergency files,
in some cases for the first time.
As far as we were concerned, the exercises went well; the participants
learnt a lot and could see the real-life application of the skills learnt
in a somewhat artificial exercise. The benefit of having an experienced
person to design and co-ordinate the exercise was apparent although the
fourth session was run by the two non-military authors proving that,
with a little practice and guidance, exercises could be run by any hospital
or department with minimal effort. The session could fit into a study
day or into a slightly extended lunchtime seminar slot and with proper
planning requires only minimal props and equipment. Since these exercises,
at least one department has rewritten their major incident protocols
to incorporate the lessons learnt. Recommendations
The Panel contains some suggestions that may or may not be applicable
to any one situation or institution.
Recommendations
· Ensure your incident plan is well known in the department and
is written in bullet point format as an aide-memoire. Detailed annexes,
for example, the trust policy on various matters, should be attached
where necessary but should not interrupt the flow.
· Write actions in the order they would need to be performed, without
waffle. The time available to read in a real incident will be short
and distractions numerous. (One hospital provided a pharmacy incident
plan and it took four hours to extract the information to make an
action card suitable for use in an emergency by someone unfamiliar
with it.)
· Consider revision sessions or drills for staff every six to 12
months. Check telephone numbers and contact details in the incident
plan.
· Clear the decks early on. Do not wait until a situation has fully
developed and their are lots of casualties before taking action.
Start preparing as soon as there is a warning of a possible major
incident and reorganise staff and priorities. This may require some
effort but the price is worth paying; at least staff will be better
prepared for the real thing.
· Communicate the department’s aims and
priorities clearly and frequently to your own staff as the situation
unfolds.
· Ensure an experienced person is managing the workload in the dispensary,
assigning priorities and balancing existing patient needs with those
of the newcomers. This person should not be the person co-ordinating
the response to the emergency but the two people need to talk frequently.
· Assign specific staff to deal with other tasks that are not in
the major incident plan but which are necessary to keep the hospital
running.
· Rather than use telephones, dispatch one or more experienced technicians
or pharmacists on a tour of wards to explain the new priorities and
to prioritise the work to focus on discharge drugs so that beds can
be cleared if necessary.
· Have a plan to cope with the likelihood of the telephone and bleep
systems being jammed.
· Plan in advance how to locate and summon staff when communications
are difficult, or when most staff are off duty. Consider having lists
of staff home and mobile telephone numbers, which can be held by
several staff members at home as well as in the department. Then,
the pharmacist on site can ask the first person he or she finds at
home to use their home telephone to call for reinforcements. A formal
cascade system may be used but it should not be one that could get
blocked if someone is not contactable. Consider using mobile telephones
as well as, or instead of, hospital telephones and consider sending
a junior runner to find staff who are on low-priority wards.
· In most incidents with multiple casualties,
there will be an increased need for IV fluids and analgesia in
emergency departments, operating
theatres and critical care areas. Some areas that are not normally “critical” may
be redesignated as such in an emergency. Consider an immediate supply
of fluids and analgesics, including opioids and perhaps anaesthetics,
to some or all of these areas, without waiting for a request. Paperwork
can be sorted on delivery or afterwards. The nature of these deliveries
can be discussed with medical staff when writing major incident procedures.
· Consider how existing patients can be rapidly and efficiently
discharged if necessary. Some incidents may need only a few discharges;
others will need whole wards cleared or patients relocated to areas
such as the physiotherapy gymnasium or classrooms. Perhaps discharge
medicines could be dispensed from inpatient prescriptions under the
supervision of the ward pharmacist and confirmed later. Perhaps some
patients could be sent, with their inpatient chart, to a GP with
a note asking the GP to prescribe appropriately; the chart could
be returned at the next outpatient appointment or when the incident
is over.
· Consider giving FP(10) prescription pads to outpatient departments.
· Ensure there are lists of important medicines and their locations,
including at other hospitals or depots, with access details and telephone
numbers that are up to date.
· Remember that the central control room for the major incident
has details of military or government contacts who can arrange for
personnel or materials that may be needed from outside the NHS; this
may be especially important for terrorist attacks and chemical accidents.
· Keep the central control room informed of any major developments
relating to your work, including expected supply problems. Control
can advise or help with obtaining transport and escorts when the
roads are blocked.
· Be aware that members of the press or public may telephone any
hospital number they can find, by-passing switchboard; you may get
such direct calls. |
Conclusions
There are no clear-cut right and wrong ways of handling emergency incidents;
in each of the exercises the pharmacy response was controlled in
different ways by their respective chiefs. The usefulness of the specific
content
of the exercises will only be as good as the prophetic abilities
of the person designing the scenario, but the broader messages have wide
applicability.
Feedback from participants suggests these exercises were extremely
valuable and we recommend that departments set up their own group
exercise or
collaborate with neighbouring hospitals in order to run one. Local
emergency co-ordinators or military sources may be able to suggest
suitable simulation
designers who can use pharmacy input to create and run an exercise
tailored to test the
service.
Reference
1. Obeid I. Practical implications of disaster preparedness for a hospital
(European Association of Hospital Pharmacists congress report). European Journal of Hospital Pharmacy Practice 2005;11:20. |
The
Pharmaceutical Journal