RESPONDING TO EMERGENCIES: PART 1
INTRODUCTION
NHSSCOTLAND
1.1 Whether manifesting itself as a sudden, unexpected peak in demand for its services, as an unpredicted loss in its operational capabilities or however, and whatever the cause may be, an emergency does not alter the statutory purposes of NHSScotland which remain the securing of improved health for people in Scotland and the prevention, diagnosis and treatment of illness. Under Scottish Ministers, overall responsibility for the management of NHSScotland to achieve its purposes lies with the Scottish Executive Health Department. Close contact is maintained with the other UK Health Departments, with professional bodies and others at the national level to enable co-ordination and mutual support both across the NHS as a whole, and with other public services in Scotland.
1.2 NHS Boards NHS Boards are accountable to the Scottish Executive Health Department for the overall assessment of health needs of all people within their geographic areas, and for arranging for those needs to be met. This strategic function, together with their specific responsibilities for public health within their geographic areas, and for the registration and inspection of private health care facilities, gives NHS Boards an overall leadership role in regard to health and the functioning of the NHS within their areas. It involves working in close partnership with local authorities and securing the collaboration of others with a part to play, both routinely and in emergency, in safeguarding and improving the health of people in the area.
1.3 Centrally Managed Services Certain specialist services needed either by NHS Boards to provide specialist or technical support, or by the Scottish Executive Health Department to furnish national objectives are managed on a central basis by Special Health Boards or by NHS National Services Scotland. As at para 1.3 above, these bodies' responsibilities include that of overcoming the effects of any emergency which might affect the demand for or continuity of the services they provide.
EMERGENCY PLANNING
1.4 Aim The aim of emergency planning within NHSScotland is to ensure that essential health care needs are met effectively when normal services become overloaded, restricted or non- operational for whatever reason.
1.5 Scope An emergency is something which arises unexpectedly, and which requires urgent action to resolve. The NHS faces many emergencies in the course of its routine activities. While each separate instance requiring urgent NHS action might in itself be unexpected, that such emergencies will occur is an expected characteristic of meeting health care needs. To provide a basis for emergency planning it is thus necessary to differentiate between such "routine" emergencies and those which require abnormal action.
1.5.1 Routine Emergency A routine emergency is defined as one which can be met within the normal capacity and procedures of those faced with it. It is one which places no abnormal demand upon health care services.
1.5.2 Major Emergency A major emergency is defined as a situation, either arising or threatened, which requires the special mobilisation and/or redeployment of staff or other resources with consequent interruption to routine activities.
1.5.3 Major Incident This is a widely accepted term used by the emergency services to describe any emergency that requires the implementation of special arrangements by one or more of the emergency services, the NHS or the local authority.
Note: While a major incident might constitute a major emergency, as defined above, for one or more parts of the NHS, it may have no or only limited health care implications.
1.5.4 While this guidance applies to the management of all emergencies, it concentrates on Major Emergencies and Major Incidents. Locally determined arrangements for dealing with Routine Emergencies should conform to the guidance to the maximum extent, so that should such an emergency escalate, the reinforcement and support of local arrangements from elsewhere will be the easier.
1.6 Planning Objectives Amongst the first to become aware that an emergency has arisen or is imminent are likely to be members of the NHS engaged on their routine activities. The process of emergency planning should:
1.6.1 Assist staff to react positively by providing them with specific instructions as to what to do. The scope and nature of these instructions will depend on an individual's particular role and position, but maximum benefit will be obtained by their issue in the form of a personal aide-memoire, check list or action card.
1.6.2 Provide advice and information to enable the NHS response to be appropriate, structured, co-ordinated and managed effectively from the outset of the emergency.
1.6.3 Enable the NHS response to be co-ordinated with the responses of others to form a single combined response to the emergency.
PRINCIPLES
1.7 Focus Emergency planning and management should focus on what needs to be done to respond to the emergency rather than on its cause. Whatever, whenever and wherever the emergency, the NHS must be prepared to:
1.7.1 Deal with new patients whose number, condition or location precludes treatment under routine arrangements.
1.7.2 Take steps to safeguard the health of the population at large from possible adverse effects of the emergency.
1.7.3 Continue to provide necessary treatment, care and services for existing patients.
1.8 Integration While planning should be directed principally towards response to an emergency, that is not the start point. Planning should be based on hazard/risk assessment and be a continuous process. Study of past emergencies suggests there are four distinct but overlapping phases in successfully managing an emergency: 1.8.1 Prevention This phase encompasses measures adopted in advance of an emergency and which seek either to prevent it occurring or to reduce the severity of its effects.
1.8.2 Preparedness Identification and preparation of resources, the maintenance of skills and of alerting, mobilising and operating procedures must be underpinned by regular training and exercises.
1.8.3 Response The urgent action phase. Its priorities are to save life, prevent escalation, relieve suffering and to facilitate subsequent return to normality.
1.8.4 Recovery This phase will encompass all activities necessary to provide that return to normality, both for those affected by the emergency and for those responding to it. It should include identification and assessment of longer term, consequential or delayed effects of the emergency and planning for those to be effectively handled as routine activity. Analysis of the response and identification of lessons learned, which complete the management of one emergency, should contribute to the prevention and preparedness phases of the next.
Thus emergency planning and management should not be regarded as activities relevant exclusively to emergency response but should be integrated into an organisation's overall planning and management arrangements.
1.9 Flexibility Emergency response will need to vary just as the nature, circumstances and effects of the emergency will vary.
1.9.1 To plan separately and in detail for each possible foreseen contingency is less effective than to develop a single plan providing a general framework for response to any emergency, foreseen or not. Amplification or variation needed for specific foreseen events should be incorporated within the general framework.
1.9.2 No emergency plan can cover every eventuality. Over-prescriptive emergency arrangements will constrain individuals' resourcefulness, initiative and improvisation which resolution of any emergency is likely to require.
PLANNING RESPONSIBILITIES
1.10 Just as the assessment of routine health care needs and securing the provision of health care services to meet those needs are responsibilities of NHS Boards to lead, so too is planning for NHS response to potential needs consequent on major emergencies occurring within their areas. Similarly, routine responsibilities of and other operators of health care and support services for the detailed planning, management and operation of the particular services each is established, required by contract, or has otherwise undertaken to provide, includes responsibility for overcoming the effects of any emergency which might threaten the continued provision of those services, or which might require those services to be altered.
1.11 Thus while detailed operational emergency planning is a matter for the managers of individual operational units, each NHS Board is required to maintain an overall, strategic, plan for NHS response to a major emergency occurring in its area. This should:
1.11.1 Define the roles and tasks to be undertaken by each NHS organisation both generally and under specific circumstances.
1.11.2 Establish arrangements for the control and co-ordination of NHS emergency response.
1.11.3 Specify operational procedures to be used to the extent necessary to ensure smooth integration of plan components to be delivered by different units/sub-units/ NHS Trusts.
1.12 Inter-Agency Co-ordination It is important that NHS emergency planning is co-ordinated with that of the emergency services, local authorities and other organisations at the local level. The risks and consequences of different types of emergency should be assessed jointly. Such joint planning should, for instance, cover response to potential major incidents, contingencies consequent on large crowds at sports, entertainment or other events, and the handling of emergencies foreseen as a consequence of severe weather or of industrial or other local hazards. All agencies with a part to play in emergency response should practice together putting their plans into action so that they become accustomed to each other's working arrangements prior to an emergency. Particular attention should be given to the development, exercising and inter-service co-ordination of alerting mechanisms and flexible, resilient communications systems for use in an emergency. A combined response is likely to be more effective than a number of separate ones.
1.13 National Co-ordination While the initial response to, and management of, health care aspects of a particular emergency will remain the responsibility of the NHS Boards and the NHS service providers in whose area it occurs, the scale of the emergency, its nature, geography or other factors may require general or specialist assistance or support from outwith the area. To facilitate this, the emergency plans of all NHS Boards and NHS service providers must be compatible, use the same terminology, and some emergency procedures must be standard. Similarly there is a need to ensure that overall NHS arrangements are co-ordinated with other Scottish organisations, interlock with those of the NHS throughout the UK, and with those of other Government departments. The organisational and procedural framework necessary to meet these various needs is contained in the subsequent parts of this guidance.
POSSIBLE LEGAL IMPLICATIONS
1.14 NHS Boards and NHS Managers will be aware that major emergencies tend to attract intense public, media and political interest both as they happen and during any subsequent inquiry. Coupled with the ever greater awareness among the general public, including NHS staff, of the law as a means of seeking redress, it is particularly important that all with responsibilities for NHS emergency response planning and management are aware of potential legal implications. Any significant failure by an NHS Board, NHS Trust or other element of NHSScotland to plan for or respond adequately to a major incident or other emergency could lead to a breach of the law, either civil or criminal. Moreover any failure is likely to generate adverse publicity and criticism at any fatal accident or other public inquiry.
1.15 The point made at para 1.9 above, that emergency planning should be integrated into each NHS organisation's overall planning and management arrangements, is as relevant to the management of possible legal implications as it is to all aspects of managing NHSScotland's services. The Clinical Negligence and Other Risks Indemnity Scheme (CNORIS) [MEL(2000)18 and HDL(2000)02] provides incentives for NHS organisations to manage their liabilities from negligent acts and omissions by their employees and from other risks. CNORIS risk management standards provide useful guidance to preventative measures which NHSScotland organisations should take to minimise the risk of litigation in the emergency planning and response context.
RESPONDING TO EMERGENCIES: PART 2
ORGANISATION
INTRODUCTION
2.1 The purpose of this part is to outline the general organisational framework for overall national and NHS emergency response, and to assist NHS Boards and those who provide and support NHS services to identify those organisations which might, even if they have no routine dealings with them, have a part to play in their own emergency arrangements.
CENTRAL GOVERNMENT
2.2 While immediate response to a major emergency occurring anywhere in the UK will normally be conducted at the local level, government support will usually be required to some degree. In the event of an emergency one department is likely to be nominated to act as "Lead Department". Its tasks are co-ordinating the response of all those departments whose normal responsibilities cover different aspects of the emergency situation, for keeping Ministers and Parliaments informed, and for providing information to the public and media at the national and Scotland levels.
2.3 Scottish Executive Whether or not one of its departments is the overall "Lead Department", the Scottish Executive has a key role in managing response to any emergency in or affecting Scotland. As the department with everyday responsibility for NHSScotland, the Scottish Executive Health Department will continue at all times to provide advice, assistance and guidance to NHS Boards and others as may be needed on health matters. When required the Scottish Executive Emergency Room (SEER) will be activated to provide a focus for inter-departmental co- ordination, to facilitate communication with those controlling response to the emergency locally, for interaction with UK Government departments, for keeping Scottish Ministers informed and for providing information to the Scottish public and media. Further details are at Annex A.
NHSSCOTLAND
2.4 NHS Boards are accountable to the Scottish Executive Health Department for the effective functioning of the NHS within their respective areas, shown on the map at Annex B, both normally and in response to any emergency. Each Board's strategic emergency plan (see paragraph 1.12 above) should identify the roles and tasks to be carried out in its area by the Board and other NHS service providers, and local arrangements for the co-ordination of NHS activity.
2.5 Scottish Ambulance Service The purpose of the Scottish Ambulance Service is to transport to, from and between health care facilities those people who on medical grounds need ambulance care. To meet NHS Board requirements, the service operates a fleet of road and air Accident and Emergency (A & E) ambulances whose equipment and crews enable the transport of patients who may require resuscitation and life sustaining care at the scene of an emergency or in transit. The A & E ambulance fleet can be augmented readily with the less comprehensively equipped ambulances of its Patient Transport Service, regularly used for non-emergency work to support GPs and NHS Boards. The Scottish Ambulance Service operates the Volunteer Ambulance Car Service, and will utilise such further road, rail, air or sea transport resources as its purpose may require. For further details of the Scottish Ambulance Service see Annex D.
2.6 NHS National Services Scotland/Special Health Boards Some essential support services are managed centrally by NHS National Services Scotland or by Special Health Boards, to meet the collective needs of NHSScotland as a whole. Within the NHS NSS, the head of each Division is responsible for ensuring that both routine and emergency demands for its services of the Scottish Executive Health Department, and individual NHS Boards are met. Certain Divisions of NHS National Services Scotland are by their nature crucial to effective NHS emergency response; these include the Scottish National Blood Transfusion Service (see Annex E) and Health Protection Scotland (HPS) (see Annexes M and P). Brief details of the services available from, and contact details of, remaining NHS NSS Divisions and other centrally managed NHS services in Scotland are at Annex F.
2.7 The Private Sector As an extension of their statutory responsibilities for the registration and inspection of private hospitals etc., it is recommended that NHS Boards should maintain information on all private sector health care facilities and services operating in their areas which might provide assistance to the NHS in an emergency. When making or reviewing arrangements for the provision by a private sector supplier of a NHS service or its support under contract, NHS Boards should give due regard to the continuity or extension of that service in the event of a major emergency.
LOCAL GOVERNMENT
2.8 In addition to their duties to maintain particular services and to help people in distress, local authorities have an important supporting, co-ordinating and facilitation role. This extends from being a focal point for local emergency planning, through providing support and assistance to the emergency services, NHS and others involved in emergency response, to co-ordinating the activities of all involved in dealing with the wider effects of an emergency and, not least, leadership of local efforts to return to normality. Further details of local authorities, their roles and services are at Annex G.
EMERGENCY SERVICES
2.9 Police The police have a key role in all situations of major emergency. At and around the scene of a major incident they will control access and co-ordinate the activities of all responding. There and more generally, police assistance and support is likely to be invaluable to NHS emergency response; similarly the police will rely on NHS assistance in their tasks of identifying the dead, investigating the cause and circumstances of death and physical injury, and in collating casualty information. Further information is at Annex H.
2.10 Fire The first concerns of the fire service are the rescue of people trapped in a fire or in wreckage or debris, and the prevention of further casualties by extinguishing fires, making structures safe and dealing with released chemicals and other contaminants. Because its fire-fighters are trained, disciplined and organised to work together in teams, the fire service can play a useful part in a wide variety of emergency situations. Information on the assistance it can provide in an emergency involving chemicals is contained within Annex M.
2.11 Ambulance See paragraph 2.6 above and Annex D.
2.12 Coastguard HM Coastguard is primarily responsible for co-ordinating marine search and rescue within the UK search and rescue sector. It mobilises, organises and despatches resources to assist people in distress at sea, including those on offshore oil and gas installations, and on the shoreline. It makes use of lifeboats of the Royal National Lifeboat Institution together with such ships and aircraft as are available. Through its close links with the military Rescue Co- ordination Centres, the resources of the Royal Navy and Royal Air Force can be called upon. HM Coastguard itself provides cliff rescue expertise and, by contract, search and rescue helicopters based at Stornoway and Shetland. NHS Boards whose areas include coastline should liaise with HM Coastguard on the NHS response to an offshore emergency. A separate branch of The Maritime and Coastguard Agency, the Counter Pollution Control Branch, has responsibility for dealing with pollution from ships at sea and for co-ordinating shoreline clean up. For further information about the management of offshore emergencies see Annex I.
2.13 Mountain Rescue Mountain rescue services are normally mobilised through the police. Services are provided by the Royal Air Force, by some police forces and by local volunteer groups. NHS Boards, in association with the Scottish Ambulance Service, should maintain liaison with mountain rescue services which operate within their areas.
INDUSTRIAL/COMMERCIAL/OTHER ORGANISATIONS
2.14 Any industrial or commercial organisation may play a direct part in response to an emergency if its personnel, operations or services have been involved. Others, whether routinely doing business with an NHS organisation or not, may be able to provide support to an NHS emergency response by applying their equipment, services, skills or specialist knowledge.
2.15 NHS Suppliers Companies supplying goods and services to the NHS are essential to the operation of its health care services. In establishing and reviewing contracts with suppliers, NHS managers should take account of possible extra demands an emergency might make and of difficulties suppliers might need to overcome to ensure delivery. The development of contingency arrangements to overcome any failure to supply goods and services of a "mission critical" nature should be considered.
2.16 Essential Services Particular attention should be paid to utility and other essential services, both as regards their supply to NHS facilities and the dependence of patients in the community on them. Among these are:
2.16.1 Communications In the event of a major emergency, communications systems will invariably become overloaded and the rapid provision of additional links and capacity is likely to be necessary. NHS Boards should ensure that the management and provision of communications systems to enable co-ordinated interaction and information flow between separate NHS organisations and with the public takes proper account of possible foreseen emergency needs, and that arrangements are in place to meet quickly any unforeseen needs. Further information on communications systems is at Annex L.
2.16.2 Energy While a major emergency may cause loss or severe restriction of electricity, gas or oil supplies, severe disruption of energy supplies could, in itself, constitute an emergency situation for the NHS both in hospitals and in the community. The managers of hospitals and other NHS premises should make and regularly review arrangements to safeguard their health care services against any interruption of energy supply. NHS Boards should consider the need for co-ordinated contingency arrangements to meet additional health care needs arising throughout the community during widespread or longer term disruption of supply. Regular liaison with energy suppliers is recommended.
2.16.3 Water Similar considerations apply to water, not only in terms of its supply but also its quality. Any interruption or impurity of supply is likely to require emergency action by the NHS both in respect of its health care services and to protect the public health. Accordingly NHS Boards should maintain close contact with the water authorities which serve their areas.
2.17 HM Forces Regular and reserve units of all 3 Services have a wide range of skills, resources and facilities which may be of use in the response to a major emergency. Any request for Armed Forces assistance in a major emergency should normally be discussed with the police, or local authority where they are co-ordinating emergency response, and channelled through the Scottish Executive. However, where there is danger to life or when immediate help is essential for any other reason, direct application may be made to local armed forces units or to Headquarters 51 (Scottish) Brigade (Tel: 0131-336 1761) which co-ordinates such matters for all 3 Services. Further details, including indemnity, financial and insurance aspects, are contained in the Ministry of Defence publication Military Aid to the Civil Community (ISBN 0 11 772624 9). Separate arrangements exist for the call-out of search and rescue helicopters (see Annex D) and mountain rescue (see paragraph 2.14 above).
2.18 Voluntary Organisations Members of the Voluntary Aid Societies (British Red Cross Society and St Andrew's Ambulance Association) are trained to provide and support emergency health care. The assistance they provide in an emergency to the NHS should be planned in advance locally with local branches of the Societies and co-ordinated by NHS Boards. The Women's Royal Voluntary Service, Salvation Army and other national and local volunteer organisations, including the Churches, can provide invaluable supporting assistance in an emergency situation. To maximise their effectiveness, their contribution should be planned in advance and agreed locally. Their unplanned assistance is normally co-ordinated by local authorities. Further guidance on the use of volunteers is published in MEL(1998)42 and MEL(2000)04.
RESPONDING TO EMERGENCIES: PART 3
PROCEDURES INTRODUCTION 3.1 The NHS response to a major emergency, and the type and quantity of resources allocated to meet health needs arising from it, must depend on an accurate assessment of those needs and their relative priorities. In a slowly developing emergency this assessment can be led by NHS Boards where co-ordinated action will be put into effect through normal management and provisioning processes. However, major emergencies often occur with little or no warning, many will require urgent response by different elements of the NHS, and a major emergency for the NHS may well be associated with a situation requiring emergency action by other organisations too. Effective and immediate co-ordination of response both within the NHS and with other organisations thus requires the use of standard and familiar procedures and terminology. 3.2 Standard Procedures and Terminology This part of the guidance gives details of standard procedures which should be used throughout NHSScotland in responding to any emergency. Titles and terminology to be adopted as standard appear in Bold Type when they first appear in this guidance. It is based on a suddenly occurring major incident requiring immediate response by the NHS, in collaboration with the emergency services and others, to provide life-saving treatment and care and to limit consequential injury/illness. While no template can exactly match the needs of all situations, it provides a good basis for planning in that few other scenarios demand the same degree of no-notice, immediate and concerted action across the NHS. Adjustments might be needed in particular circumstances, among these are: 3.2.1 Incidents involving chemicals. Additional guidance is at Annex M. 3.2.2 Incidents involving ionising radiation. See Annex J. 3.2.3 Offshore emergencies (including diving incidents). See Annex I. 3.2.4 Incidents involving infectious disease/biological hazards. See Annex P. 3.3 Events abroad have resulted in casualties on a scale unseen by any major emergency in the UK to date. Following the terrorist attacks in the United States on 11 September 2001 as well as in Bali and Spain, it is accepted that the potential for larger patient numbers has increased and that there is a need to be prepared for incidents of a different scale and nature. The Department of Health defines a mass casualty incident as “a disastrous event or other circumstances where the normal major incident response of NHS organisations must be augmented by extraordinary measures in order to cope”. By definition such events have the potential to rapidly overwhelm or threaten to exceed local capacity available to respond, even with the implementation of major incident plans.
3.4 Some of the factors that distinguish a mass casualty from a more typical major incident are its likely scale, duration, intensity and the probability that there will be other compounding factors such as loss of services/infrastructure, shortage of essential supplies or the possibility of civil dislocation. These events are likely to involve greater numbers, both in terms of casualties and fatalities, and could involve either incidents occurring simultaneously, or at multiple sites (either in close proximity or more widely spread). It is also likely that there will be significant media and public information challenges, which should be considered in local planning.
3.5 The basic operational principles for dealing with a mass casualty event will be the same as for a major incident. All NHS organisations must have contingency plans which demonstrate that they fully understand the potential scale and nature of the threats and the actions that may be needed, through involvement in multi-agency risk assessments in their areas. Making better use of existing capacity may involve other novel approaches such as teams going out from hospitals to provide services to patients in the community including non-NHS settings. Local NHS organisations need to survey what is available in their areas in terms of unused hospital capacity and also buildings away from hospital sites which might be used as temporary minor injuries units or vaccination centres. MOBILISATION 3.6 It is impossible to predict how or where information about an occurrence that may constitute a major emergency will first reach the NHS. Similarly, while initial information may leave no doubt that a major emergency exists, more frequently this will not be the case. Thus it is important that all NHS staff should know that if they become aware of a situation which to them seems could develop into a major emergency, they should report it at once to their superior or a nominated person for assessment, verification and initiation of appropriate action. 3.7 Every organisation supplying NHS services, whether primary care, secondary care or support should make detailed arrangements for notifying staff of major emergencies and for the speedy mobilisation of its resources. These should be reported to NHS Boards so that contact details may be included in their emergency plans. 3.8 A major emergency stemming from an event or events outwith NHS premises will usually involve the Emergency Services, and is likely to be dealt with by them as a major incident. A 999 call to an Ambulance Service Emergency Medical Dispatch Centre (EMDC), or information relayed there by another of the emergency services, will be frequently the first intimation to the NHS that emergency plans need to be implemented. Because each Ambulance (EMDC) is equipped with the necessary communications to initiate the NHS response, it is important that all relevant information received elsewhere in the NHS is passed immediately to the nearest Ambulance (EMDC). 3.9 In a major incident involving casualties, initial action by an Ambulance (EMDC) will be to deploy ambulances and crews to the scene, and to alert the appropriate hospitals. Alerting messages will be in the format shown in Annex D. The Ambulance (EMDC) will pass identical messages to those local General Practitioners who are members of Immediate Care Schemes (see para. 3.43) and to others as arranged between the Scottish Ambulance Service and NHS Boards according to the nature and scale of the incident. SITE OF MAJOR INCIDENT 3.10 While a major incident might be confined to a single site, such as the scene of a major transport accident, building collapse or fire, it might also be spread over a wider area involving a number of separate sites. Similarly, for the purposes of this part, the term "Site of Major Incident" should be taken to include any point established at a safe distance from an incident for the reception or collection together of casualties evacuated from it. 3.11 The first ambulance crew to arrive at the scene has as its first duty to assess the situation and notify the Ambulance (EMDC). It should give brief details of the nature of the incident, the approximate number of serious and minor casualties, whether any are trapped and whether or not there are particular hazards present. The vehicle will be used as the initial Ambulance Incident Control Point and to maintain communications with the Ambulance (EMDC). The Ambulance Incident Control Point should be adjacent to the Police Incident Control Point and the Fire Incident Control Point. A crew member will contact the senior police and fire service officers present and identify areas suitable for a Casualty Clearing Centre, Ambulance Loading Point, Ambulance Parking Point and an Equipment/Stretcher Bearer Point. The best access and exit routes to and from the site and suitable rendezvous points for emergency vehicles are also identified in consultation with the police at this stage. Until relieved by an Ambulance Officer, the first crew on the site will fulfil the functions of the Ambulance Incident Officer, that is it will establish arrangements for triage, stabilisation and transport from the site of casualties. 3.12 Medical Incident Officer The role of the Medical Incident Officer is to act as the agent of the NHS Board: to identify the overall health care needs arising at the site and to lead and co-ordinate activity there to meet them. NHS Boards should ensure that a Medical Incident Officer can always be provided when required throughout their areas. Whether from a primary care, hospital, or public health background, the Medical Incident Officer should know the availability and capabilities of health services in the area, have contemporary knowledge of triage, and be familiar with the working methods of the emergency services. Arrangements by NHS Boards for the notification and despatch to the site of the Medical Incident Officer should be made known to the Ambulance (EMDC). 3.13 Co-ordination of NHS Activity On arrival at the scene, the Medical Incident Officer should identify himself to the Police Incident Officer as well as being briefed by the Ambulance Incident Officer. While he will need to move about the site, he should base himself at the Ambulance Incident Control Point where communications with the Ambulance (EMDC), hospitals and NHS control points (see paragraph 3.47) will be located, and in order to maintain a close liaison with the Ambulance Incident Officer. Prior to the arrival of the Medical Incident Officer, the Ambulance Incident Officer should oversee and co-ordinate health care activities at the scene. The Medical Incident Officer should: 3.13.1 Provide guidance on priorities for the treatment and evacuation of casualties. 3.13.2 Formulate a casualty evacuation plan in collaboration with the Ambulance Incident Officer, hospitals etc. 3.13.3 Request the attendance at the site, or at any associated reception centre established, of further medical/surgical, nursing or support staff as required, as well as the provision of specialist advice, equipment or supplies that may be needed. 3.13.4 Advise the Police and other Incident Officers on medical aspects of particular hazards at the site and of action necessary to minimise any health risks to emergency services personnel and other people in the vicinity. 3.13.5 Keep under supervision those in danger of becoming over stressed or exposed to shock, cold, heat, hunger/thirst or fatigue and arrange for their relief where appropriate. 3.13.6 In conjunction with the police (as agents of the Procurator Fiscal) make arrangements for the medical certification of the dead, prior to their subsequent removal under police arrangements. 3.13.7 Remain on site to support police activities even after the final living casualty has been removed. 3.13.8 Keep the NHS Board and involved NHS organisations informed of the situation, the number, nature and condition of casualties, of any particular health risks present and of any other relevant information. 3.13.9 Maintain a record of proceedings to assist any post-emergency inquiry. 3.14 Site Medical Team Alerting and despatch, if required, of one or more Site Medical Teams is the responsibility of the Control Hospital/Board Control Centre (see paragraph 3.19.2) which will have been made aware of the need for their services by the Medical Incident Officer or, prior to his arrival, the Ambulance Incident Officer via the Ambulance (EMDC). A Site Medical Team should be drawn from a pre-arranged complement of doctors and nurses with relevant expertise and equipment that is compatible with that carried by the Ambulance Service. The number and composition of teams, if any, attending a site will depend on the nature of the incident, the number of casualties, the proportion of children, their injuries and on the time clearance of casualties from the scene is expected to take. Teams may deploy from acute hospitals, where practicable other than from those receiving casualties, alternatively teams might for example be based around immediate care general practitioners, community staff and trained ambulance personnel. Their primary task is the assessment, resuscitation, treatment and stabilisation of individual casualties as directed by the Medical Incident Officer. They will also assist him in deciding on priorities for the removal of casualties to hospital for definitive treatment. Site Medical Teams should assist in the operation of Casualty Clearing Centres set up by ambulance personnel, but be prepared to deploy around the site of the incident as casualty treatment needs require. 3.15 Volunteers Planned participation of volunteers in the NHS emergency response (see also para 2.19) should ensure they are fully integrated in all respects into the NHS arrangements. Other volunteers with appropriate skills can provide invaluable assistance at the scene, particularly in the early stages of a major incident before ambulance and other NHS staff are fully deployed. The work of these volunteers should be monitored and controlled by the Ambulance Incident Officer and, on his arrival, the Medical Incident Officer. However, the organisation and assessment of volunteers' potential utility is best done away from the immediate scene, and people offering healthcare skills at the site should normally be directed to the hospital (see paragraph 3.28 below). 3.16 Administration at the Site The Police Incident Officer has responsibility for overall control of access to the site. An early police task will be to restrict entry to the site to essential people and vehicles only. With this in mind, and to ensure the ready recognition of staff working at the site, NHS Boards should pay particular attention to the following when formulating detailed plans: 3.16.1 Personal Identification: In order to obtain access to the site of the incident all NHS staff likely to be deployed must be prepared to provide some proof of their identity. NHS Boards and the Scottish Ambulance Service should arrange for them to be issued with official identification (incorporating photograph) as described in Chapter 24 of the NHS Security Manual. High visibility jackets and protective helmets should be marked to identify the service of origin of the emergency workers and their particular job. 3.16.2 Clothing and Equipment: Individuals should be equipped with clothing, including footwear and headgear, sufficiently robust and weatherproof to withstand working in exposed and hazardous conditions and complying with the relevant British Safety Standards. To assist ready identification of individuals, the predominant colour of protective clothing should be green for ambulance personnel, red for site medical personnel. Equipment, dressings, drugs etc. should be packed in robust containers clearly labelled with their contents. These must be readily man-portable when loaded. All clothing and equipment should be checked regularly for serviceability and expiry date. 3.16.3 Transport to Site: Whenever practicable, Scottish Ambulance Service vehicles should be used to transport Medical Incident Officers, Site Medical Teams and any additional NHS staff required at the site. Should it be necessary for any other vehicle to be used the police should be informed, via the Ambulance (EMDC). 3.16.4 Personnel Management: Working at the site of a major incident may expose staff to personal danger, unusual hazards or particularly harrowing circumstances. NHS employers will thus wish to ensure that subsequent monitoring, screening or follow-up of affected personnel is arranged through the Occupational Health Service. With this in mind, details of staff attendance at a major incident site should always be recorded. All staff should be instructed to report their arrival and departure to the Ambulance Incident Control Point, where this and other administration for NHS at the scene will be co-ordinated. While NHS Employers should regard staff who are required to attend major incident sites as working on normal duties, and thus subject to the provisions of the NHS Superannuation and Injury Benefit Scheme as well as the Industrial Injuries Scheme, they will nevertheless wish to ensure that their staff are adequately protected. In this regard they may wish to consider additional insurance such as that available through the British Association of Immediate Care Schemes (BASICS). CASUALTY CARE AT THE SITE 3.17 Treatment at the site of a major incident will normally be confined to the prevention of further injury and immediate care and stabilisation measures. More advanced treatment should be limited to that necessary for the treatment of trapped casualties or for those whose removal to hospital is delayed for some other reason. 3.18 Triage The purpose of the triage process in a major emergency is to ensure that limited time and other resources available are used to care for those who will most benefit, rather than for those with minor injuries or those who have little chance of survival. The triage system requires each casualty to be assessed, treated and a triage priority category given. Triage is a continuous process and regular re-assessment and review of priority categories at intervals over time will detect alteration in the patient's condition. Casualties should be clearly and visibly labelled with their triage category to indicate their priority for treatment and transfer to staff involved at the site, during transportation and on arrival at hospital. In addition to being a priority indicator, the triage label is the first stage of patient documentation and should be filled in as the opportunity arises by whoever treats the casualty (ambulance staff, doctor or nurse). There is space for the recording of patient identification and personal details, details of injuries, clinical measurements and observations, treatment given and drugs administered. The standard format Casualty Triage Label may be folded and fixed to the patient to give a clear indication of the Triage category. Triage categories, shown on the label by both category number and colour coding, are:
• 1 Red: requires immediate evacuation and treatment to save life.
• 2 Yellow: requires urgent evacuation and treatment but whose life is not in jeopardy.
• 3 Green: evacuation and treatment may be delayed. This category includes the lightly injured, walking wounded and others whose condition would not be affected by delay. • White: dead - clearly labelling the dead saves time and makes further involvement by Health Service staff unnecessary. The triage label has space for a note by the doctor pronouncing death, the time and for police information. HOSPITAL RESPONSE 3.19 Hospital Classification: While every type of hospital, health centre or other NHS healthcare facility may have a part to play in response to a major emergency, the following classification of hospitals is used in NHS emergency plans: 3.19.1 Designated Receiving Hospital A hospital designated by an NHS Board in its Emergency Plan to receive casualties. It has the facilities to receive and treat patients who are seriously injured or critically ill on a 24 hour a day basis. 3.19.2 Control Hospital A Designated Receiving Hospital nominated by a NHS Board to provide, on its behalf, immediate co-ordination of all NHS activities connected with response to a major emergency until any separate Board Control Centre (see paragraph 3.47 below) is activated. 3.19.3 Support Hospital A hospital (acute or otherwise) which in an emergency can receive casualties or other patients in support of Designated Receiving Hospitals or provide staff or other resources to support them. 3.20 The detailed emergency plan for each Designated Receiving Hospital should describe arrangements for preparing for, receiving, assessing, resuscitating and treating casualties arriving as a consequence of a major incident or in other major emergencies, and should detail emergency procedures, including those for hospital management and control and the rearrangement of routine work to accommodate the immediate and longer term effects of the influx of emergency patients. The emergency plans of Support Hospitals and other NHS facilities should similarly prepare them for their assigned roles in a major emergency. 3.21 Emergency Plan Activation As indicated above (paragraphs 3.6 – 3.9) notification of a major incident will normally be passed to the hospital by the Ambulance (EMDC), but information might also be received from the police or elsewhere. Alternatively the first indication that an emergency exists may be the arrival of casualties at the A&E Department. However news of a major incident or other emergency arrives, hospital management will wish to ensure that effective procedures are in place for it to be assessed, verified if necessary and for activation to the degree necessary of the hospital's emergency plan. 3.22 Hospital Control The effective operation of the hospital's emergency plan is dependent on central control and co-ordination of the hospital's activities with those of other agencies involved. This is best effected from a Hospital Control Room equipped with the necessary internal and external communications. The Hospital Control Centre should be manned by a Hospital Control Team which normally would include a senior doctor, specifically appointed by the Chief Executive to be the Hospital Medical Controller, a Senior Nursing Officer and other officers to oversee control of their particular functions. The role of the Hospital Medical Controller is one of overall responsibility, in consultation with other members of the team, for arranging and co-ordinating the hospital's response to the total need for patient care. The Hospital Control Centres in Designated Receiving Hospitals should include provision for the Ambulance Liaison Officer, and for liaison with the police. The importance of accurately recording the time and details of events and of information received by the hospital, of decisions taken, instructions issued and reports made cannot be over emphasised. 3.23 Hospital Preparation Hospital emergency plans should detail: how staff are to be alerted; the manning, equipment and transport where required of a Site Medical Team (see paragraph 3.14 above); how the Accident and Emergency Department is to be prepared and augmented in terms of staff, equipment and supplies; how resuscitation rooms, holding and waiting areas, pre-operative wards, operating theatres, recovery wards and all supporting departments are to be manned, equipped, organised and managed for what might be a protracted period of intense activity. Such arrangements should be well practised drills. Information as to the nature and demands of the major emergency should be disseminated from the Hospital Control Centre as it arrives to aid the preparation by all hospital departments. Care should be taken to keep existing patients informed, particularly as to any changes to routine made necessary by the hospital's response to the emergency. 3.24 Freeing Resources The cancellation of routine admissions, out-patients clinics, treatment sessions and operating lists may have to be considered by the Hospital Control Team in order to free resources for emergency use. Patients may need to be transferred to other hospitals or nursing homes, and relatively fit patients may need to be discharged to continue their care in the community. All such decisions must involve discussion between the Hospital Medical Controller, his or her counterpart in other involved hospitals, with general practitioners and with the Ambulance Service. Any significant interruption to normal activity should be reported to the NHS Board for their action as necessary. 3.25 Capacity The greatest constraint on capacity is staff, and NHS organisations need to have plans to bring in additional staff within their local area. Such plans must, however, recognise the possibility of transport and communication disruption. These plans should also recognise the fact that staff (or their families) may well be victims of any incident, particularly if it is in the locality. This could potentially have a considerable impact on staff attendance and this must be taken into account in planning.
3.26 Staffing contingency plans should also focus on pre-identifying (and enhancing) the emergency care potential/skills of all staff, directing staff effort to key emergency roles, and sustaining activity levels well beyond the initial response phase. They should also consider further training which would be required by those who will play a leading role in responding to and managing such an incident. This must include command and control and leadership training across the full spectrum of NHS organisations.
3.27 Staffing contingency plans will include identifying part-time staff who are willing to work additional hours (including staff employed by other organisations), including independent sector providers, qualified non-practising staff and those who have recently retired.3.28 Access to the Hospital Every NHS Board needs to develop procedures for implementing rapid action to protect the capacity available by ensuring it retains control over access to its facilities. This may require planning for security measures to ensure access can be restricted to a pre-designated point(s) of entry. 3.29 Where possible all casualties from a major incident should enter the hospital at the same access point. A separate access point for casualties' relatives, together with a separate waiting area for them should be made available so that they as well as casualties may be protected from media and other unwelcome attention.
3.30 It is possible that in the early stages of an incident, NHS organisations find themselves faced with considerable numbers of people who self present to Accident & Emergency or Primary Care facilities. This could represent a significant challenge and organisations must consider how they would handle such an eventuality. It should not be assumed that the Police will be able to provide assistance and NHS Boards are advised to have local discussions about public order and control issues which may be associated with this level of self presenting. They should consider how they would handle such an influx of potential casualties, taking into account that casualties may also be contaminated. Plans must properly address safety for staff, patients and visitors.
3.31 It is likely that the current preparations for decontamination of small numbers of casualties at most hospitals would be put under severe strain by the scale and circumstances of mass casualty incidents with contamination. To deal with this NHS Boards should develop a mass casualty plan in collaboration with the police and fire services to address crowd management and triage procedures, to avoid cross contamination and unnecessary attendance at Accident & Emergency departments and admissions to hospital. 3.32 Casualty Reception A senior physician or surgeon with relevant experience should be designated Casualty Receiving Officer and charged with the medical supervision of casualty reception, assessment and primary treatment. The Casualty Receiving Officer will need to maintain close liaison with the Hospital Medical Controller, both to receive up-to-date information on casualties expected, and to ensure that the necessary secondary treatment, expertise and facilities are made available. During the early stages of a major emergency the number and type of casualties are often unknown. The rate at which they arrive and their treatment needs will vary with the type of incident, its location(s) and available means of transport. Casualties may well have left for hospital before the establishment of fully organised site medical facilities. It is, therefore, most important that every casualty should be assessed on arrival at the hospital, be given an individual triage priority category, and documented such that casualties from a major incident site can be readily differentiated from other patients. Arrival assessment will effectively update any priority classification given during triage at the site or in transit to the hospital. Casualties who are dead on arrival at the hospital should be certified dead by a doctor as soon as possible and taken to police-arranged mortuary facilities once established. 3.33 Casualty Flow and Treatment Following triage, casualties should be moved according to their priority classification and treatment needs to separate Resuscitation (priority 1); Urgent (priority 2) or Minor (priority 3) treatment areas for primary treatment. Throughout their progress through Casualty Reception and Primary Treatment areas, patients should be monitored and their triage priority category reassessed at regular intervals. It is an important principle in the management of a large number of casualties that patients should remain in Primary Treatment for as short a period as possible before being moved on to a Secondary Treatment area. Special arrangements must be made in Casualty Reception to help people involved in the emergency who are uninjured but who are suffering from emotional distress. Similar support for casualties will also be required as part of their ongoing treatment. 3.34 Patient Documentation On arrival at hospital, casualty documentation should be raised on all casualties whether with major, minor or no physical injuries and irrespective of whether they have been labelled and documented previously. Hospital labels and associated patient documentation for use in a major emergency situation should be serially numbered, the number being readily identifiable as being associated with the major emergency rather than routine activity. The continuity of patient records is particularly important in a major emergency and any labels or documentation completed at a site or en route to the hospital, should be retained with the patient's case notes. To provide information for the Police Casualty Bureau and for any subsequent investigation, there should be immediate communication between hospital staff and the police documentation team about numbers of casualties, their identification, known relatives and addresses and subsequent information about casualties' condition and disposal. 3.35 Social Workers Mobilisation of social workers may be required at an early stage both to provide support to casualties and their relatives and to assist in the early release of existing patients. Their role is particularly important should individual family members become patients in different hospitals. Liaison between hospital staff and local authority social work departments will be necessary to provide assistance with emergency living accommodation, finance, counselling and longer-term support. 336 Foreign Casualties In the event of a major emergency involving people from countries other than UK, international co-ordination and translation facilities will have to be provided, in conjunction with the police and local authority. 3.37 Hospital Chaplains Hospital chaplains have an important role in a major emergency; not only do they offer a ministry to the sick and dying but they provide comfort for hospital staff, patients and their relatives. 3.38 Volunteers In a major emergency situation large numbers of off-duty and former NHS staff and members of the general public often volunteer to help with the response. Chief Executives should work with local branches of voluntary organisations to plan in advance how their support might best be utilised in an emergency. A Volunteer Reception Point should be established and all additional volunteers should be held there until assigned to duties by the respective Voluntary Aid Society senior officers or co-ordinator of voluntary services in accordance with directions issued by members of the Hospital Control Team. Care must be taken to check the bona fides of volunteers and verify any professional qualifications they may claim prior to their employment. Where possible volunteers should be given an armband or a lapel badge indicating their area of expertise: e.g. "trained nurse". They should also be issued with an appropriate identity/security pass to ensure their access and to validate their being in the hospital. 3.39 Hospital Information Centre It will be necessary to establish a Hospital Information Centre at each hospital receiving casualties. This should be separate from but close to the Hospital Control Centre. While the public will be invited to direct their enquiries about the major emergency elsewhere, the hospital will need to respond to patients' relatives referred to them by the Police Casualty Bureau. The establishment of a Hospital Information Centre enables all such enquiries, both by telephone and by personal callers, to be dealt with centrally rather than by diverting ward or switchboard staff from their other duties. Staffing of the Hospital Information Centre can be augmented by the use of specially trained volunteers. 3.40 Media A hospital receiving casualties from a major incident or other emergency will inevitably become a focal point for the media. Hospital arrangements for providing the media with controlled access, authoritative information and briefing should conform to the guidance at Annex O. PRIMARY/COMMUNITY CARE SERVICES RESPONSE 3.41 NHS Boards should establish how best their primary care and other skills and resources might be utilised in a major emergency. Detailed emergency plans, along the lines of those needed for an acute hospital (paragraphs 3.19 – 3.40 above) should be maintained. Chief Executives will wish to ensure that as well as providing for the management of a sudden increase in demand for their services or other assigned emergency tasks, their emergency plans also provide a basis for immediate action necessary to overcome or mitigate anything else which might threaten the services they have undertaken to provide. It should be noted that when a major emergency generates a sudden increase in demand for primary/community services, experience is that that increase in demand may last for a protracted period. 3.42 NHS Board Community Care Partnerships (CCPs) should identify any unused physical capacity which could be brought into use in an emergency. This might include capacity within intermediate care or community settings, or capacity in the independent or private sectors. In the extreme, other less conventional options such as hotels or schools or colleges may also need to be considered.3.43 Site of Major Incident To conserve hospital A & E resources, to support the Scottish Ambulance Service and to improve the availability of immediate care, NHS Boards will wish to encourage and support General Practitioner Immediate Care Schemes in their area. These, either alone or augmented with community nursing staff, should be prepared for roles at a major incident site (see paragraph 3.14 above). 3.44 Support of Hospital Response Provision of direct support to acute hospitals, in the form of skills and resources, might be required in some circumstances. However, support is more likely to be needed by providing treatment and care in the home or community setting for those patients released early or who would normally be treated in hospital. 3.45 Reception Centres Uninjured or apparently uninjured survivors or victims will normally be taken from the site of a major incident to a reception centre where their immediate needs for rest and comfort can be met. Similar reception centres may be established by local authorities to accommodate those evacuated from their homes because of flooding or for other reasons, or to provide refuge to those stranded by, for example, severe weather. NHS Boards should arrange with primary/community service providers to ensure that the medical/dental/pharmaceutical needs of survivors/evacuees/refugees are met and that procedures to do so are developed in collaboration with local authorities. MANAGEMENT OF EMERGENCY RESPONSE 3.46 Arrangements for the detailed management of an NHS organisation's response to an emergency are its responsibility. While these will at the outset best be based on those in routine use, early adjustment may be needed to meet the particular circumstances and demands of a particular emergency and the degree of its impact on continuing normal work. Chief Executives should thus ensure that their arrangements for emergency management provide for the focused operational control of their organisation's response while maintaining overall strategic direction of the organisation as a whole. 3.47 Co-ordination between separate NHS organisations' responses to create a unified Health Service response, compatible when required with the responses of other agencies to the extent that a combined, multi-agency, approach is taken to an emergency in its area, is an NHS Board objective. The degree of leadership and control necessary to achieve it will clearly depend on the nature, scale and demands of a particular emergency. In the early stages of an emergency the delegation of authority to a Designated Receiving Hospital to exercise overall control on behalf of the NHS Board, making it the Control Hospital, might be sufficient. However, the capacity of a Hospital Control Team to exercise an overall strategic co- ordination function concurrently with that of controlling in detail the hospital's operational response may rapidly become limited and establishment of a separate Board Control Centre will then become necessary. 3.48 Strategic Control While the purpose of the Board Control Centre is to provide a focus for the strategic control and leadership of the NHS response to the emergency, and its combination with responses of other agencies, its essential tasks remain those of assessing the needs of people for health care and of arranging for those needs to be met. Clearly new or altered demands will require adjustment to existing priorities for the use of NHS resources, the redeployment or augmentation of those resources, the postponement of less urgent work and the switching of tasks between providers. Activation of a Board Control Centre provides individual NHS organisations with a focal point for arranging whatever additional support and external assistance they might require, both immediately and in the longer term. It also provides a collation point for information about the NHS response to the emergency which will be required by other agencies, the media and by the Scottish Executive Health Department. Relieving those at the front line of such tasks enables them to concentrate on the immediate operational management of their emergency response. 3.49 Board Control Centre As an alternative to using their normal headquarters, NHS Boards may wish to co-locate their Board Control Centre with an Ambulance (EMDC), at a hospital, or with a local authority or police control centre. Activation arrangements, including procedures for any transfer of control from a Control Hospital and re-routing of communications links, should be detailed in the Board's emergency plan. Alerting, keeping informed and standing down health care and supporting services, liaising with neighbouring NHS Boards, the emergency services, local authorities, the Scottish Executive Health Department and responding to requests for information from the media and public are likely to place heavy demands on the Board Control Centre's communication facilities, and Boards will wish to ensure adequate provision of both equipment and training in its use. That the Board Control Centre may be required for a protracted period will have significant staffing implications; Boards are encouraged to develop mutual support arrangements with each other. 3.50 Overall Control Arrangements Achieving the necessary inter-agency collaboration is likely to require appropriately senior NHS Board representation, supported as necessary, at the police, local authority or other control centre at which the responses of all involved are being co-ordinated. Overall control arrangements are illustrated in outline at Annex N. PUBLIC INFORMATION 3.51 Whatever the nature of an emergency, it will inevitably prompt questions to the NHS from the public, and immediate media scrutiny of every aspect of it must be expected. A pro- active approach to the media is recommended which not only meets their needs for regular, accurate information but also enables the media to assist positively the response to the emergency. Annex O provides detailed information on media relations in major emergency situations. AFTER THE EMERGENCY 3.52 Formal Investigations Following a major emergency, it must be expected that a formal investigation into the causes and circumstances of the emergency will be ordered. Initial investigation may be conducted by the police on behalf of the Procurator Fiscal, Health and Safety Executive or other statutory regulatory body. Such investigations and any subsequent Fatal Accident Inquiry or other judicial inquiry may require evidence from anyone involved in responding to the emergency, not least those with management responsibility for that response. Since the formal investigation process may be protracted, it is important that log- sheets, records of events, communications, of decisions taken, and other relevant contemporaneous materials are preserved. 3.53 Debriefing As soon as possible after a major emergency, arrangements should be made by each NHS organisation which played a part to debrief all involved so that lessons learned and any adjustments needed to emergency arrangements and capabilities can be identified. Following debriefing within participating NHS organisations, NHS Boards should submit a consolidated report on the major emergency to the Scottish Executive Health Department (Emergency Planning Unit) for analysis and dissemination of lessons learned to the NHS as a whole. NHS Boards should also co-ordinate NHS participation in inter-agency debriefing initiated, as appropriate, by the police or local authority.
RESPONDING TO EMERGENCIES: PART 4
TRAINING AND EXERCISES
GENERAL
4.1 Effective response to a major emergency will require people knowing what to do and how, when and where to do it. It will require teamwork, may involve special procedures and equipment, and even when not, will require people to carry out their functions in unusual circumstances and under what may be extreme pressure. Training, to ensure that every team member has the knowledge and skills their role in an emergency will need, and exercises, both to validate emergency plans and procedures and to develop the necessary teamwork and give individuals confidence, are clearly essential to the maintenance of emergency preparedness.
TRAINING
4.2 New staff should be fitted for their part in an organisation's emergency plan during their induction. As organisations change, new equipment replaces old, different everyday procedures and practices are adopted, accommodation becomes used for different purposes, so too will emergency plans require adjustment and both individual and organisational training needs should be kept under review. Team leaders and managers should ensure that training is provided so that at all times their staff:
• understand their own emergency roles and the roles of those with whom they need to interact; • are familiar with the systems and procedures of the emergency plan; • know where emergency equipment is kept and how to use it.
EXERCISES
4.3 Confidence that an emergency plan is workable, and that staff are appropriately trained and prepared to activate it, requires that it be exercised and tested. It will be appreciated that to test comprehensively an NHS organisation's major emergency plan will affect routine NHS activity and involve other organisations both in and external to the NHS. Therefore exercises must themselves be the subject of careful planning and control. Any NHS emergency exercise must include a mechanism for its immediate termination in the event of a real emergency. It must also include a SAFEGUARD procedure to ensure that any exercise player who receives injury or who becomes ill during it is immediately identified and given appropriate "real" treatment and care.
4.4 A major emergency exercise should benefit all involved. It should:
• Inform and motivate all staff and instil confidence in those with an emergency response role. • Bring together those who will need to form teams, and to jointly develop their organisation and performance under simulated conditions of realism. • Enable assessment of the impact of an emergency on the participating organisation and its ability to continue to provide its full range of services. • Identify training needs, organisational strengths and weaknesses and equipment deficiencies. • Test new additions or alterations to the emergency plan. • Demonstrate, both internally and externally, commitment of the organisation to quality assurance of its emergency preparedness.
4.5 NHS Boards should ensure that all aspects of their major emergency plans are fully exercised at least every 2 years. They will wish to exercise some aspects of their plans more frequently should staff, organisational or other changes make it necessary, and to validate major changes they make to their emergency plans. Liaison between NHS and other authorities on exercise planning should be maintained, and opportunities taken to meet NHS exercise requirements through participation in multi-agency exercises, such as those which some bodies have a statutory requirement to stage.
4.6 As with major emergencies, major emergency exercises should be subjected to formal debriefing with lessons learned being identified, and appropriate amendments to plans being made. Similarly reports on major exercises should be submitted to the Scottish Executive Health Department (Emergency Planning Unit) for analysis and subsequent dissemination to the Service at large of any general lessons or examples of good practice.
RESPONDING TO EMERGENCIES: ANNEX A
THE SCOTTISH EXECUTIVE
A1 The Scottish Executive consists of nine main departments:
Scottish Executive Development Department (SEDD)
Responsibilities include housing, construction, transport infrastructure and roads.
Scottish Executive Education Department (SEED)
Responsibilities include primary and secondary education, children and young people, culture and the arts, the built heritage, architecture, sport and lottery funding.
Scottish Executive Enterprise and Lifelong Learning Department (SEELLD)
Responsibilities include economy, business, and industry including Scottish Enterprise, Highlands and Islands Enterprise, tourism, trade and inward investment, further and higher education, the science base, lifelong learning, training and new deal.
Scottish Executive Health Department (SEHD)
Responsible the NHS in Scotland, for wider aspects of health and community care.
Scottish Executive Justice Department (SEJD)
Responsibilities include Home Affairs, including civil law and criminal justice, social work services group (except community care), police, fire, courts and prisons, law reform, land reform policy, freedom of information and policy in relation to drugs.
Scottish Executive Environment and Rural Affairs Department (SEERAD)
Responsibilities include policy in relation to rural development including agriculture, fisheries forestry, research, the environment, natural heritage, sustainable development, strategic environmental assessments and land-use planning system.
Scottish Executive Finance and Central Services Department (SEFCSD)
Responsibilities include the Scottish Budget, local government finance and European structural funds, resource allocation and accounting, support to the Scottish Parliament and the Scottish Executive Media and Communications Group which handles media and publicity services for the Scottish Executive as a whole.
Scottish Executive Corporate Services (SECS)
Responsibilities include pay and conditions, accommodation, staffing of the Executive, purchasing and IT.
Scottish Executive Legal and Parliamentary Services
Responsibilities include drafting of bills for the Scottish Executive, management of the Scottish Executive's legislative programme, solicitors' services to the Scottish Executive, parliamentary liaison, constitutional issues, freedom of information and data protection.
A2 Under the First Minister and his Ministerial Team, the departmental heads form, with the Permanent Secretary, a management group to ensure policy co-ordination between departments when required, and to superintend a number of groups and directorates which provide common services to all departments.
A3 All Scottish Executive departments with responsibilities for the provision of a service or policy advice in normal times remain responsible with regard to emergencies arising which involve that service or policy area. The nature of the emergency will determine which department co-ordinates overall Scottish Executive response to it; Scottish Executive Justice Department (Fire Services and Emergency Planning Division) will take the lead initially should the nature of the emergency be unclear; this division is also charged with maintaining and activating when required the Scottish Executive Emergency Room (SEER). Irrespective, health aspects of any emergency remain the responsibility of the Scottish Executive Health Department.
Scottish Executive Health Department
A4 The Department, headed by the NHS Chief Executive, comprises a number of Directorates and divisions including one dealing with public health policy.
A5 Performance Management Division While all divisions will assist with those aspects of an emergency relevant to their normal responsibilities, the Performance Management Division, through which routine contact with NHS Boards on strategic issues is maintained, is the focal point for the initial co-ordination of emergency response by the NHS in Scotland and of activity to support it.
A6 Chief Medical Officer The Chief Medical Officer has oversight of public health matters both within the NHS and more widely. In an emergency his office will provide such advice and assistance that the NHS response might require.
A7 Community Care Where the circumstances of an emergency need the specialist services that only social work can provide, the Community Care division will work to provide such advice and assistance the NHS response might require.
A8 Information Needs To enable the timely mobilisation of any support that might be required, not least that Ministers are properly briefed to face inevitable media questioning, it is important that NHS Boards notify SEHD Emergency Planning Unit as soon as possible of major emergencies occurring in their areas. Similarly should SEHD become aware from the media or otherwise of a situation which might constitute a major emergency for the NHS, the NHS Board(s) whose area(s) appear(s) to be affected will be contacted immediately by the SEHD Emergency Planning Unit. Initially SEHD will require a general outline of the situation, what its impact is on the NHS, what is being done, and whether any assistance is required. While the nature, scale and circumstances of the particular emergency, and the degree of public interest it generates, will determine what further information will be called for, NHS Boards should always report significant developments as they occur and keep the SEHD Emergency Planning Unit up-to-date with the NHS response to the emergency.
A9 Multiple Channels While the main communication channel for the NHS involved in emergency response with SEHD should be through NHS Boards to the SEHD Emergency Planning Unit, direct contact between staff in NHS Trusts or Boards and other Branches or Divisions of the Scottish Executive should continue to be made on matters normally dealt with in this way. However this freedom must be kept under review, and should it cause operational problems either for Health Boards or SEHD it will be restricted or withdrawn.
SCOTTISH EXECUTIVE CONTACT POINTS
SEHD Emergency Planning Unit (*)
Tel. 0131-244 2431 Fax: 0131-244 3482 0131-244 2386 0131-244 2429
A10 SEHD Performance Management Division
Branch 1
(Argyll and Clyde, Ayrshire and Arran, Dumfries and Galloway, Greater Glasgow, Lanarkshire).
Tel. 0131-244 2397 Fax: 0131-244 3487
Branch 2
(Borders, Fife, Forth Valley, Lothian, Tayside)
Tel. 0131-244 2389 Fax: 0131-244 3487
Branch 3
(Grampian, Highland, Orkney, Shetland, Western Isles)
Tel. 0131-244 2393 Fax: 0131-244 3487
A11 SEHD Chief Medical Officer (*)
Tel. 0131-244 2836
A12 SE Media and Communications Group - Health Desk (*)
Tel. 0131-244 2968
(*) National Emergency Planning Officer, Duty Press Officer and Duty Public Health Doctor may be contacted out of normal working hours via Scottish Executive Security on 0131-556 8400.
A13 SEHD Emergency Planning Unit
Mobile Phone: 07795-618391 Pager: 07659-108760
OFFICE OF THE SECRETARY OF STATE FOR SCOTLAND
A14 The interests of the Scottish Parliament are represented in the Westminster Parliament by the Secretary of State for Scotland. She and her Ministerial Team report back to the First Minister, Scottish Parliament on matters reserved for the Westminster Parliament that have implications across the UK and therefore Scotland. The Secretary of State has her office in Dover House, London, and this provides a fixed Scottish presence for liaison with the Scottish Executive, the UK Cabinet Executive and all other UK Government Departments.
RESPONDING TO EMERGENCIES: ANNEX B
NHS BOARD AREAS IN SCOTLAND
B1 Contact details for NHS Boards are listed below:
B1.1 Territorial Boards
NHS Board/Address General Emergency Planning Officer Manager Argyll & Clyde Tel: 0141-842 Tel: 0141-842 7277 Ross House 7200 Fax: 0141-840 4556 Hawkhead Road Fax: 0141-848 [email protected] PAISLEY 1414 PA2 7BN Ayrshire & Arran Tel: 01292- Tel : 01292-885854 Boswell House 611040 Fax: 01292-286762 7-10 Arthur Street Fax: 01292- [email protected] AYR 610636 KA7 1QJ Borders Tel: 01896- Tel: 01896-825521 Newstead 825500 Fax: 01896-823401 MELROSE Fax: 01896- [email protected] TD6 9DB 823401 Dumfries & Galloway Tel: 01387- Tel: 01387-272704 Grierson House 272700 Fax: 01387-252375 The Crighton Fax: 01387- [email protected] Rankend Rd 252375 DUMFRIES DG1 4ZJ Fife Tel: 01334- Tel: 01592-226840 Springfield House 656200 Fax: 01334-657579 CUPAR Fax: 01334- [email protected] Fife 652210 KY15 5UP Forth Valley Tel: 01786- Tel: 01786-457261 33 Spittal Street 463031 Fax: 01786-446327 STIRLING Fax: 01786- [email protected] FK8 1DX 471474 Grampian Tel: 01224- Tel: 01224-633030 i. General Manager 663456 Fax: 01224-645647 Summerfield House Fax: 01224- [email protected] 2 Eday Road 404014 ABERDEEN AB9 1RE ii. Emergency Planning Emergency Planning Manager Aberdeen City Council 1 Queens Gardens ABERDEEN AB15 4YD Greater Glasgow Tel: 0141-201 0141-201 4554 PO Box 15329 4444 0141-201 4733 Dalian House Fax: 0141-201 [email protected] 350 St Vincent Street 4401 GLASGOW G3 8ZY Highland Tel: 01463- Tel: 01463-704970 Beechwood Park 717123 Fax: 01463-235189 INVERNESS Fax: 01463- [email protected] IV2 3HG 717666 Lanarkshire Tel: 01698- Tel: 01698-281313 x6316 14 Beckford Street 281313 Fax: 01698-423134 HAMILTON Fax: 01698- [email protected] ML3 0TA 423134 Lothian Tel: 0131-536 Tel: 0131-536 9198 Deaconess House 9000 Fax: 0131-536 9195 148 Pleasance Fax: 0131-536 [email protected] EDINBURGH 9009 EH8 9RS Orkney Tel: 01856- Tel: 01856-873535 i. General Manager 885400 Fax: 01856-873319 Garden House Fax: 01856- [email protected] New Scapa Road 885411 KIRKWALL KW15 1BQ ii. Emergency Planning Emergency Planning Officer Orkney Islands Council School Place KIRKWALL KW15 1NY Shetland Tel: 01596- Tel: 01595-744739 i. General Manager 696767 Fax: 01595-690846 Brevik House Fax: 01596- [email protected] LERWICK 696727 ZE1 0RB ii. Emergency Planning Shetland Islands Council Emergency Planning Executive Services Department 11 Hill Lane Lerwick Shetland ZE1 0HA Tayside Tel: 01382- Tel: 01382-496386 i. General Manager 561818 Fax: 01382-424003 Gateway House Fax: 01382- [email protected] Luna Place 424003 Technology Park DUNDEE DD2 1TP ii. Emergency Planning Kings Cross Clepington Road DUNDEE DD2 1TP Western Isles Tel: 01851- Tel: 01851-702526 i. General Manager 702997 Fax: 01851-702320 37 South Beach Fax: 01851- [email protected] STORNOWAY 704405 Isle of Lewis HS1 2BB ii. Emergency Planning Emergency Planning Officer Comhairle Nan Eilean Siar 21 South Beach STORNOWAY Isle of Lewis HS1 2BJ
B1.2 Special Health Boards
Scottish Ambulance Service Tel: 0131-446 Tel: 0131-446 2626 i. Chief Executive 7000 Fax: 0131-447 7338 Headquarters Fax: 0131-446 [email protected] Tipperlinn Road 7001 EDINBURGH EH10 5UU ii. Emergency Planning Risk and Emergency Planning Dept DSDA Engineer Park (Stirling) Building 135 Forthside Stirling FK7 7RR State Hospitals Board for Tel: 01555- Scotland 840293 State Hospital Fax: 01555- Carstairs 840024 Lanark ML11 8RP
RESPONDING TO EMERGENCIES: ANNEX C
HEALTH EMERGENCY PLANNING AUTHORITIES IN NEIGHBOURING COUNTRIES
ENGLAND Tel: 0171-210 5769/5771 Department of Health Fax: 0171-210 2670 Emergency Planning Co-ordination Unit (Out of hours via switchboard 0171-201 Room 603 5371) Richmond House 79 Whitehall LONDON SW1A 2NS NHS Executive Northern Region Tel: 0191-258 1159 Interlink House Fax: 0191-273 7070 Scotswood Road NEWCASTLE UPON TYNE NE4 7BJ NORTHERN IRELAND Tel: 01232-524783 Department of Health Personal Social Fax: 01232-489537 Services (Out of hours via Northern Ireland Office Emergency Planning Unit Duty Officer 01232-520700) Room 401 Dundonald House Upper Newtonards Road BELFAST BT4 3SF
RESPONDING TO EMERGENCIES: ANNEX D
SCOTTISH AMBULANCE SERVICE
GENERAL
D1 As one of the Emergency Services, the Scottish Ambulance Service receives 999/112 telephone calls from the public and usually provides the first NHS response to a major incident. It provides life-sustaining immediate care to casualties at the scene together with transport, and care in transit, of patients to, from and between health care facilities.
D2 Accident and Emergency Service National targets exist for response to 999/112 calls by an Accident and Emergency ambulance, and the level of cover necessary to meet those targets, both routinely and in a major emergency, is determined by the Scottish Ambulance Service in consultation with NHS Boards to take account of local priorities and resources. Operational flexibility to meet unexpected demands in any one area, likely in a major emergency, is achieved through a national command and control organisation which enables resources to be rapidly redeployed across Scotland as required. The Scottish Ambulance Service maintains mutual support arrangements with NHS ambulance services in the North of England.
D3 Patient Transport Service The ambulances and crews of the Patient Transport Service, in a major emergency provide invaluable extra resources and flexibility to the Scottish Ambulance Service. While funded, provided and stationed where best to meet the routine needs of individual NHS Trusts for the non-emergency transport of patients, such is the strategic importance of their emergency support role that it is recommended that NHS Trusts keep NHS Boards and the Scottish Ambulance Service informed of any proposals to change their use of these services.
D4 Auxiliary Services Auxiliary Services may be provided by:
D4.1 Voluntary Aid Societies The volunteers and resources of the British Red Cross and St Andrew's Ambulance Association are frequently deployed at major sporting and other events to provide first aid, often in conjunction with the Scottish Ambulance Service, and may be able to provide similar assistance at the scene of a major incident. In areas where such support is likely to be required the Scottish Ambulance Service should develop detailed plans with those local branches of the societies able to provide it, keeping NHS Boards informed.
D4.2 Private Ambulance Services While some private ambulance services are well run, with suitably trained and qualified staff, others are not. Even in emergency the use of private ambulance services should be considered very carefully; decisions on their use should be left to the Scottish Ambulance Service.
D4.3 Additional Transport When necessary the Scottish Ambulance Service will take steps to supplement its ambulance fleet to fulfil its purposes. Four-wheel-drive vehicles, boats, trains, buses and even horses have been used by the Scottish Ambulance Service in the recent past. The Service may in an emergency seek NHS Board assistance in acquiring appropriate additional transport.
D5 Air Ambulance Service To supplement its road ambulances, the Scottish Ambulance Service operates a 24 hour a day, seven days per week fixed wing and helicopter air ambulance service to transport those patients whose condition and need for urgent transfer make air transport necessary. Should its own resources be insufficient, or unable to meet requirements, the Scottish Ambulance Service will make arrangements for use of RN, RAF or HM Coastguard Search and Rescue (SAR) helicopters or other aircraft.
MAJOR INCIDENT PROCEDURES
D6 The Scottish Ambulance Service maintains detailed standard procedures for all aspects of its operations. In addition to complying with Section 3 of this guidance, its emergency procedures must clearly be compatible not only with those of the other emergency services but also those used by the wider NHS. To enable this compatibility to be maintained, NHS Boards will recognise that the Scottish Ambulance Service should always be consulted about projected changes to local NHS emergency plans.
D7 Major Incident Notification The notification arrangements are set out as follows:
D7.1 Potential Major Incident On receipt of information indicating a potential Major Incident, the Ambulance operations room will, in addition to mobilising appropriate ambulance resources, alert Designated Receiving Hospitals, Medical Incident Officers, Immediate Care Scheme doctors and such others as planned locally between the Service and NHS Boards. Alerting messages will take the following form:
"This is the ambulance service. We are responding to a "Major Incident Alert". This message is timed at...... The location is...... The nature of the incident is...... ".
D7.2 Cancellation of Alert If an alert is cancelled, the following message will be sent:
"This is the ambulance service. Major incident cancelled. This message is timed at ...... "
D7.3 Major Incident Confirmed When further information confirms a major incident, it will be reported to Designated Receiving Hospitals etc. thus:
"This is the ambulance service. Major Incident Confirmed. This message is timed at...... The location is...... The nature of the incident is...... The approximate number of casualties is...... "
D7.4 Major Incident Stand Down Ambulance operations room will notify those previously alerted when, for them, the incident is cleared and they are resuming normal service activity.
D8 Communications Support When necessary, the Scottish Ambulance Service will deploy a Mobile Ambulance Control Unit (MACU) and associated control staff to the scene of a major incident. In addition to providing support for the Ambulance Incident Officer, it is equipped with radio facilities for the local control of ambulances in the vicinity of the scene, with dismounted ambulance staff, and for maintaining communication with the Ambulance operations room. It will normally be able to provide direct communications links from the scene to Designated Receiving Hospitals and Board Control Centre where these are needed by the Medical Incident Officer.
CONTACT POINTS
D9 The first point of contact for enquiries about the Scottish Ambulance Service and its response to emergencies is the local Divisional Manager:
North & West (Highland and Western Isles) 01463- Raigmore Gardens 235789 INVERNESS IV2 3UL North East (Grampian, Orkney and Shetland) 01224- Ashgrove Road West 812200 ABERDEEN AB16 5EG West Central (Greater Glasgow and Lanarkshire) 0141-353 4 Maitland Street 6001 GLASGOW G4 0HX East Central (Tayside, Fife and Forth Valley) 01382- 76 West School Road 882400 DUNDEE DD3 8PQ South West (Argyll and Clyde, Ayrshire and Arran, Dumfries and Galloway) 01292- Maryfield House 284101 Maryfield Road AYR KA8 9DF South East (Lothian and Borders) 0131-446 111 Oxgangs Road North 2600 EDINBURGH EH14 1ED
D10 Particular questions relating to the air ambulance service should be directed to:
Air Control Officer Ashgrove Road West ABERDEEN AB2 5EG Tel. 0345-123999
D11 National Headquarters of the Scottish Ambulance Service is at:
Tipperlinn Road EDINBURGH EH10 5UU Tel. 0131-446 7000
RESPONDING TO EMERGENCIES: ANNEX E
SCOTTISH NATIONAL BLOOD TRANSFUSION SERVICE
E1 The mission of SNBTS is to provide a comprehensive range of safe and efficacious blood, blood products and services, and other human tissues for patients throughout Scotland. Supply and demand is managed nationally whereby blood is collected from voluntary donors by collection teams based at Transfusion Centres at Inverness, Aberdeen, Dundee, Edinburgh and Glasgow. Whole blood is processed and tested in Edinburgh and Glasgow and is distributed to blood banks under SNBTS control at major hospitals in the cities listed above and onwards to other local blood banks. It is at the same hospitals that clinical Services, including transfusion advice and cross matching, are provided to Trusts. Transfusion Centres will be notified by the Scottish Ambulance Service of any major incident. The SNBTS Clinical Director at each Transfusion Centre will make arrangements for the emergency supply of blood components and blood products, in liaison with NHS Board Control Centres, and supported by the SNBTS Supply Chain.
E2 Blood Transfusion Centres
North of Scotland Tel: 01463-704212 Raigmore Hospital Fax: 01463-237020 INVERNESS IV2 3UJ Aberdeen and NE Scotland Tel: 01224-685685 Foresterhill Road Fax: 01224-695351 Foresterhill ABERDEEN AB25 2ZW East of Scotland Tel: 01382-645166 Ninewells Hospital Fax: 01382-641188 DUNDEE DD1 9SY Edinburgh & South East Scotland Tel: 0131-536 5300 Royal Infirmary of Edinburgh Fax: 0131-536 5356 (Bloodbank) Lauriston Place EDINBURGH EH3 9HB West of Scotland Tel: 0141-357 7700 Gartnavel General Hospital Fax: 0141-357 7701 25 Shelley Road GLASGOW G12 0XB
E3 Head Office In addition to supervising and co-ordinating the activities of Transfusion Centres and the Processing & Testing laboratories, and maintaining links with similar services elsewhere in UK and abroad, Head Office oversees the development, production and supply of plasma products by the Protein Fractionation Centre and diagnostic reagents by Diagnostics Scotland.
Scottish National Blood Transfusion Unit Tel: 0131-536 5700 Head Office Fax: 0131-536 5781 21 Ellen's Glen Road EDINBURGH EH17 7QT
RESPONDING TO EMERGENCIES: ANNEX F
NHSSCOTLAND CENTRALLY MANAGED SERVICES
NHS NATIONAL SERVICES SCOTLAND
F1.1 NHS National Services Scotland provides a range of services to support the operations of the NHS Boards and the front-line NHS throughout Scotland. The headquarters of the Agency and a number of its Divisions are located at:
Gyle Square 1 South Gyle Crescent EDINBURGH EH12 9EB
Tel: 0131-275 6000
F1.2 The Director of each Division is accountable to NHS National Services Scotland General Manager and Board for the work of that Division and that it meets the needs of the NHS in Scotland, including those needs which might arise in an emergency. The roles of two Divisions are described elsewhere:
Scottish National Blood Transfusion Service (Annex E)
Scottish Centre for Infection and Environmental Health (Annex P)
Central Legal Office
F1.3 CLO provides a comprehensive advisory service on all aspects of health service law. It offers specialist services in the areas of litigation, contracts, property and employment law and the extent of its medical legal expertise is unrivalled in Scotland .
Central Legal Office is located at:
Anderson House Breadalbane Street Bonnington Road EDINBURGH EH6 5JR
Tel: 0131 275 7800
Pharmacy Practice Division
F1.4 PPD provides professional information and advice on pharmaceuticals and their use to all sectors of the NHS in Scotland 0131-557 3733.
Diagnostic Scotland
F1.5 With close relationships with universities and others involved in fundamental medical research, Diagnostic Scotland develops and provides diagnostic products and technologies as required by NHS laboratories to support patient care 0131-531 1161.
Scottish Healthcare Supplies
F1.6 SHS offers to the NHS in Scotland a range of contracting and technical services which are most effectively and economically provided on a national scale. Its Contracts Branch (0131-551 8118) arranges procurement from industry of consumable medical equipment, drugs, services for the disabled, energy, food, transport and general supplies needed by the NHS in Scotland. The scale of its purchasing give SHS considerable influence with industry; a potential benefit in obtaining extra goods or services to meet the needs of an emergency. The SHS Equipping and Technical Branches (0131-551 8278) are concerned with the procurement, installation and commissioning of major items of technical medical, dental and scientific equipment and provide advice on the safe use of such equipment. Incidents with any such equipment which might prejudice patient or staff safety are required to be reported to SHS (0131-551 8402) who will investigate. Investigation is also conducted by SHS, on behalf of The Crown Office, on any medical equipment involved in cases subject to fatal accident inquiries.
National Services Division
F1.7 NSD plans and funds a range of specialist clinical and support services which because of their nature are best organised at a national level 0131-551 8136.
Dental Practice Division
F1.8 As monitor, quality controller and paymaster of dentists providing NHS dental services, DPD can provide information on all aspects of dentistry in Scotland 0131-551 8106.
Information and Statistics Division
F1.9 Statistical information covering all activities of the NHS in Scotland is collected, analysed and stored by ISD to support and inform decision-making by the Scottish Executive Health Department and by managers at every level in the NHS in Scotland. ISD reports are widely distributed. If further information or interpretative assistance is required in an emergency, ISD may be able to assist (0131-551 8899). ISD through its Information System Support Group (ISSG), is also the focal point for central information technology and telecommunications services and is available to provide expert assistance in these fields 0131-551 8370.
STATE HOSPITAL
F2.1 The responsibility of a Special Health Board, the State Hospital at Carstairs provides specialist treatment and care for patients whose psychiatric condition requires them to be held in a secure establishment. The General Manager is accountable for the operation of the Hospital, including the development of necessary emergency plans. The Hospital may be able to provide emergency advice and assistance to NHS Boards and Trusts in situations where particular skills are relevant 01555-840293.
NHS HEALTH SCOTLAND
F3 This Special Health Board exists to provide a national focus for health improvement in Scotland. NHS Health Scotland leads and develops national programmes to deliver support for the health improvement challenge. Its expertise, material and communication resources might provide invaluable support and existence when required by NHS Boards in an emergency 0131-536 5500.
SCOTTISH AMBULANCE SERVICE
F4 See Annex D
RESPONDING TO EMERGENCIES: ANNEX G
LOCAL AUTHORITIES
"In exercising their respective functions, Health Boards, local authorities and education authorities shall co-operate with one another to secure and advance the health of the people of Scotland". NHS (Scotland) Act 1978 s13.
G1 Close collaboration between the local authority social work services departments and various points within the NHS is a matter of routine and is essential to best practice in both organisations. Similarly partnership between local authority environmental health officers and NHS Board public health doctors is fundamental to aspects of the routine work of both. These and other examples illustrate the operational interdependencies which exist between the NHS and local authorities on an everyday basis; in an emergency they are likely to increase.
G2 The 32 local authorities in Scotland have maximum flexibility to develop policies and deliver services in the way which best reflects local needs and circumstances. Services may be provided by a local authority at its own hand, by purchase from another council or the private sector, or alternatively, by a number of councils forming a joint board to oversee provision of a particular service for their combined area. Police (see Annex H) and Fire Services are organised on that basis.
G3 The general purpose of local authorities to support the welfare of people in their areas gives them a uniquely comprehensive knowledge of those areas. The broad range of their planning, education, social work, housing, transport and protective services gives them both immediate access to considerable resources and widespread influence locally. These attributes, together with that of their locally elected basis, gives local councils unrivalled potential to provide leadership in an emergency.
G4 Emergency planning is a local authority function. Section 84 of the Local Government (Scotland) Act 1973 gives councils powers to take immediate action where an emergency or disaster either threatens or has occurred; other enactments place a duty on local authorities to develop general emergency plans against specific contingencies. These specific statutory duties, together with the general duty to care for its population, make it important that NHS emergency planning is co-ordinated with that of local authorities.
G5 Councils' Chief Executives, and their Emergency Planning Officers, are encouraged by the Scottish Executive to base their emergency response and management arrangements on the same principles outlined for the NHS in Scotland at paragraphs 1.8 et seq. of this guidance. Following the concepts of Integrated Emergency Management and Combined Response, local authorities will initially provide such corporate support and assistance needed by the emergency services, NHS or individual council services (eg, Social Work, Environmental Health) in responding to an emergency. They will work closely with the police or other authority leading the co-ordination of the initial response and if necessary undertake a support co-ordination role. Following the immediate response phase of an emergency, a local authority is likely to assume from the police or other initial co-ordinator overall leadership of follow-up activity needed to restore normality.
G6 Local authorities in Scotland are listed below by NHS Board area:
NHS Argyll and Clyde Argyll and Bute Council East Renfrewshire Council (with NHS Greater Glasgow) Inverclyde Council Renfrewshire Council West Dunbartonshire Council (with NHS Greater Glasgow) NHS Ayrshire & Arran East Ayrshire Council North Ayrshire Council South Ayrshire Council NHS Borders Scottish Borders Council NHS Dumfries and Dumfries and Galloway Council Galloway NHS Fife Fife Council NHS Forth Valley Clackmannanshire Council Falkirk Council Stirling Council NHS Grampian Aberdeen City Council Aberdeenshire Council Moray Council NHS Greater Glasgow City of Glasgow Council East Dumbartonshire Council East Renfrewshire Council (with NHS Argyll and Clyde) North Lanarkshire Council (with NHS Lanarkshire) South Lanarkshire Council (with NHS Lanarkshire) West Dumbartonshire Council (with NHS Argyll and Clyde) NHS Highland Highland Council NHS Lanarkshire North Lanarkshire Council (with NHS Greater Glasgow) South Lanarkshire Council (with NHS Greater Glasgow) NHS Lothian City of Edinburgh Council East Lothian Council Midlothian Council West Lothian Council NHS Orkney Orkney Islands Council NHS Shetland Shetland Islands Council NHS Tayside Angus Council Dundee City Council Perth and Kinross Council NHS Western Isles Western Isles Council
RESPONDING TO EMERGENCIES: ANNEX H
POLICE
H1 All police forces in Scotland maintain arrangements for immediate response to any incident involving any danger to people or property, or which might lead to disorder or to disruption of the ordinary life of the communities they serve. The powers, organisation, training, equipment and local knowledge necessary for their normal duties give the police an authority and versatility invaluable in any emergency, both in an operational capacity at the scene and in its management at a more strategic level.
H2 Among the tasks likely to be carried out by the police in response to a major incident are:
• Exercising overall co-ordination of all action at the scene of the emergency and in immediate response to it. • Controlling access to the scene of the major incident and of crowds and traffic elsewhere to support the work of all responding services, e.g. ambulance routes, access points to hospitals. • Safeguarding people and property directly or indirectly involved. • Performing such essential tasks as may be necessary before the arrival of specialist services, calling out such specialist and supporting services as may be needed. • Provision of communications. • Establishing the identity of any dead or injured, maintaining suitable records and informing relatives. • Keeping the public informed through the media and by establishing a Police Casualty Bureau. • Arranging mortuary facilities and disposal of the dead. • Reporting fully upon the emergency at its termination, conducting any criminal investigation required and facilitating the work of other statutory investigatory bodies.
H3 Emergency Planning. To enable the police to co-ordinate effectively the operational response of all agencies to an emergency, it is clearly essential that they are kept familiar with NHS emergency arrangements. Since police and NHS have a common objective in securing public safety, the closest possible liaison should be maintained on all aspects of emergency planning between NHS Trusts and local operational police commanders, and, more strategically, between NHS Boards and police force headquarters.
H4 Police Casualty Bureau. When a major incident involves a significant number of casualties the police will establish a Police Casualty Bureau as the single point to which casualty enquiries should be directed. Its telephone number, but not location, will be released via the media to the general public. To facilitate this, it is important that hospitals receiving casualties arising from the incident should provide to the police, as casualties arrive, details of numbers, identities where established and condition, and that this information is regularly updated. Whether the police deploy officers to receiving hospitals to assist in the collection and collation of such information or not, hospital emergency plans should specify arrangements.
H5 Disposal of the Dead. Removal of the dead from the scene of a major incident, and for providing temporary mortuaries, are the responsibility of the police to arrange. Nevertheless the Scottish Ambulance Service and NHS Trusts should assist where this can be done without detriment to their normal tasks. Whether casualties pronounced dead on arrival at hospital are removed to a separate mortuary or to the hospital mortuary should be decided in consultation with the police.
H6 Forensic Responsibilities. Responsibility for determining the cause of accidental death is that of the Procurator Fiscal, and may require post mortem examinations by forensic pathologists. Such examinations, involving forensic odontologists too, may also be necessary to establish identity. This may require additional mortuary facilities, possibly for prolonged periods, and assistance from NHS pathology, radiology and laboratory resources. While NHS Trusts have a duty to provide assistance to the Procurator Fiscal, and the police as his agents, in this should it be requested, that duty is, of course, subordinate to their duty to provide health care for the living.
H7 Police Forces in Scotland. Contact addresses for the Forces are as follows:
Central Scotland Police (covers area served by NHS Forth Valley) Tel: 01786-456000 Randolphfield Fax: 01786-451177 STIRLING FK8 2HD Dumfries and Galloway Constabulary (covers area served by NHS Tel: 01387-252112 Dumfries and Galloway) Fax 01387-260501 Cornwall Mount DUMFRIES DG1 1PZ Fife Constabulary (covers area served by NHS Fife) Tel: 01592-418888 Detroit Road Fax: 01592-418444 GLENROTHES KY6 2RJ Grampian Police (covers area served by NHS Grampian) Tel: 01224-386000 Queen Street Fax: 01224-643366 ABERDEEN AB9 1BA Lothian and Borders Police(covers areas served by NHS Lothian and Tel: 0131-311 3131 NHS Borders) Fax: 0131-311 3038 Fettes Avenue EDINBURGH EH1 4RB Northern Constabulary (covers areas served by NHS Highland, NHS Tel: 01463-715555 Orkney, NHS Shetland and NHS Western Isles) Fax: 01463-230800 Perth Road INVERNESS IV2 3SY Strathclyde Police(covers areas served by NHS Argyll and Clyde, Tel: 0141-532 2000 NHS Ayrshire and Arran, NHS Greater Glasgow and NHS Fax: 0141-532 2475 Lanarkshire) 173 Pitt Street GLASGOW G2 4JS Tayside Police (covers area served by NHS Tayside) Tel: 01382-223200 PO Box 59 Fax: 01382-200449 4 West Bell Street DUNDEE DD1 9JU British Transport Police (Provides police service on the railway Tel: 0141-332 9811 system) Fax: 0141-335 2155 "D" Division 90 Cowcaddens Road GLASGOW G4 0LH
RESPONDING TO EMERGENCIES: ANNEX I
OFFSHORE EMERGENCIES
I1 The health care of people embarked in ships or on off-shore oil/gas installations is the responsibility not of the NHS, but of the ship owner or installation operator. Owners or operators may employ medical officers and or support staff to serve in the ship or installation and are likely to employ or retain a medical officer on-shore who will have details of medical facilities aboard. It is from this "Company Doctor" that first intimation may reach the NHS that its assistance may be required in the event of an off-shore emergency. In other cases the alert will be given by HM Coastguard, either directly or via the police.
I2 HM Coastguard HM Coastguard is the responsible authority for the initiation and co- ordination of civil maritime search and rescue within the UK Search and Rescue Region. This includes the mobilisation, organisation and tasking of adequate resources to respond to people in distress at sea or to people at risk of injury or death on the cliffs or shoreline of the United Kingdom. Its Maritime Rescue Co-ordination Centres (MRCC) and their supporting Maritime Rescue Sub-Centres (MRSC) covering Scottish offshore waters and coastline are located as follows:
Centre Telephone Telex
MRCC Aberdeen 01224-592334 73123
MRCC Clyde 01475-729988 777006
01475-729014
MRSC Forth 01333-450666 72440
MRSC Shetland 01595-692976 75141
MRSC Stornoway 01851-702013 751557
MRSC Belfast 02891-463933 74399
I3 Search and Rescue Resources immediately available to MRCCs and MRSCs are known as Declared Facilities, which are those designated as available according to specific criteria. Declared Facilities include RNLI lifeboats, military and coastguard search and rescue aircraft and HM Coastguard cliff rescue teams. Additional facilities are those such as warships and other vessels at sea and nearby offshore oil/gas installations which may be available and offer assistance. Control of resources at the scene will normally be vested in an on-scene commander. This role may initially be assumed by the vessel/installation with the problem, or be delegated by the MRCC or MRSC to another appropriately equipped ship, aircraft or nearby installation.
I4 "Casualty" In an off-shore emergency use of the word "casualty" can lead to confusion. Under established international maritime usage, the term is applied to a disabled vessel as well as retaining its normal meaning of an injured person.
I5 Health Care Offshore Survivors recovered from danger in an offshore search and rescue operation may be transferred to a receptor ship or platform prior to being brought ashore. While oil/gas platform operators will normally have contingency arrangements for mobilising reinforcement for medical facilities on their installations to provide care for injured survivors, this is unlikely to be the case with ships. Should a ship's captain request such assistance, there may be a humanitarian need, notwithstanding its normal territorial boundaries, for the NHS to respond. Accordingly coastal NHS Boards, in association with the Scottish Ambulance Service, should consult with HM Coastguard as to whether local arrangements are likely to be required.
I6 Landing Survivors Whether survivors, including those injured, are brought ashore by ship, boat or helicopter, procedures at the landing point and during subsequent transfer and admission to hospital or reception centre should follow those used for a land based incident. Initial co-ordination of onshore activities arising from an offshore emergency will be undertaken, as normal, by the police who will maintain close liaison with HM Coastguard.
I7 Diving Accidents Victims of diving accidents may require specialist treatment. Advice on the management of such a patient should be obtained from an appropriate consultant as soon as possible. Transfer of the patient, under pressure, from the scene of the incident to a suitable hyperbaric chamber may be required. While Aberdeen Royal Hospitals NHS Trust operates the only NHS hyperbaric chamber in Scotland, agreements exist with other operators for use of their chambers in an emergency.
I8 Hyperbaric Chambers Contact details of hyperbaric chamber operators are as follows:
Operator/Address Telephone Bar Comments Aberdeen Royal Hospitals 01224-681818 31 Say "diving emergency" NHS Trust (switchboard) Hyperbaric Medicine Unit Royal Infirmary Foresterhill Aberdeen AB9 2ZD C&R Diving 01806-242755 5 In silent hours: Sella Ness Industrial Estate Shetland Coastguard Graven 01595-692796 Mossbank Shetland HM Naval Base Clyde 01436-810947 7 Indemnity form required for Hyperbaric Medicine Unit/Northern (Unit) civilians Diving Group 01436-674321 Faslane ext 3206 Helensburgh Dunbartonshire G84 8HL Dunstaffnage Marine Research 01631-562244 6 In silent hours: Laboratory Oban Coastguard Oban 01631-63720 Argyll PA34 1AD The Underwater Centre Ltd 01397-703786 2 x In silent hours: Fort William 6 Oban Coastguard Inverness-shire 10 01631-563720 PH33 6LZ University Marine Biological 01475-530581 6 In silent hours: Station Clyde Coastguard Millport 01631-563720 Isle of Cumbrae KA28 0EG
I9 Pollution Incidents HM Coastguard, together with its associated Marine Pollution Control Unit, have import functions in response to oil or other hazardous substance pollution incidents in UK waters, and on the shoreline. Further details are at Annex M.
RESPONDING TO EMERGENCIES: ANNEX J
INCIDENTS INVOLVING IONISING RADIATION
J1 INTRODUCTION
J1.1 The nature and scale of the required NHS response to an emergency involving ionising radiation will vary according to the particular incident, which might range from a major accident at a nuclear reactor to one involving a ruptured or misplaced medical or industrial radioactive source. Whatever the circumstances, and however minor an incident involving nuclear radiation might be, it is likely to generate immediate and widespread public concern and media interest. This Annex contains details of the special arrangements and procedures necessary for NHSScotland to deal with casualties, to protect people against harm from environmental contamination and to otherwise safeguard human health following an incident involving ionising radiation.
NHS Board Responsibilities
J1.2 NHS Boards are responsible for the preparation and maintenance of contingency plans appropriate to their area to provide:
J1.2.1 Treatment and care of casualties, including the identification through monitoring of anyone, injured or not, contaminated with radioactive material and its removal by decontamination.
J1.2.2 Advice to the emergency services, local and other authorities, the public and the media about effects of a radiation incident on human health, and of counter- measures to those effects.
J1.2.3 Control over arrangements for the administration of stable iodine.
J1.2.4 Co-ordination of NHSScotland arrangements with those of operators of nuclear sites, of others whose business involves handling radioactive materials, the emergency services, regulatory and other authorities through participation in local inter-agency emergency management machinery.
J1.2.5 Notification of, and keeping informed, SEHD and other NHS Boards in the event of an incident.
J1.2.6 Initiation of measures to assess longer term health effects including confirmation of calculated assessments of population exposure by sample validation monitoring, and by monitoring individuals who have reason to suppose they have been exposed to higher than average levels of contamination.
J1.2.7 (for minor incidents) Provision of assistance under the NAIR scheme (Appendix 1, paragraph 1J.8).
J1.2.8 Ready access to the appropriate specialist clinical and radiation protection expertise and advice which any of the above might require.
J1.2.9 Participation in regular exercises to test responses to a nuclear incident that might affect people in their NHS Board area.
J1.3 The following NHS Boards should act as “lead Board” in relation to the development, exercising and implementation of emergency plans relating to the major nuclear establishments in their areas. Lead Boards should maintain liaison with the site operator on health aspects of planning, and should consult and keep informed other NHS Boards affected, the Scottish Ambulance Service and SEHD (NHS Emergency Planning Unit).
Lead Board Nuclear Establishment
Argyll and Clyde Clyde Submarine Base and nuclear warship berths as notified.
Ayrshire and Arran Hunterston Power Station and nuclear warship berths as notified.
Dumfries and Galloway BNFL Chapelcross.
Fife Nuclear warship re-fitting facilities, Rosyth.
Highland Dounreay (both AEA and MoD sites) and nuclear warship berths as notified.
Lothian Torness Power Station.
J2 PLANNING BACKGROUND
J2.1 The Government Department which will act as “Lead Department”, and thus co- ordinate Central Government support to the response, will depend on the nature and circumstances of the particular incident. So too will overall responsibility for the co- ordination of action at the scene and in its vicinity. The arrangements that apply in particular scenarios are outlined at Appendix 1 to this Annex.
J2.2 Whatever the scenario, and whichever UK Government Department is the Lead Department, the SEHD retains its overall responsibility for the management of NHSScotland, and for providing advice to other Departments, to Ministers and, when necessary, directly to the public on the health implications of any emergency. In the event of a major nuclear emergency, The Scottish Executive would open the Scottish Executive Emergency Room (SEER) to provide a focal point for co-ordinating the response of all Scottish Executive departments involved and would be assisted as necessary by other Government and non- Government agencies, including the National Radiological Protection Board (NRPB).
National Radiological Protection Board (NRPB)
J2.3 The National Radiological Protection Board (NRPB) provides independent advice to Government, other agencies and the public on radiation protection. In the emergency planning context NRPB advises on the radiological consequences of foreseeable accident scenarios and on the implications for emergency planning. NRPB specifies and advises on Emergency Reference Levels (ERLs) which are primarily intended for use in the development of emergency plans, although they may also be useful following an incident to assist in determining whether or not particular emergency measures are indicated. (See Appendix 3.) In a post-incident situation NRPB assesses and advises on the radiological consequences of the incident and co-ordinates monitoring information outside any site emergency plan area. NRPB may be able to provide support to NHS Boards in their responsibility for radiation monitoring of certain sections of the affected population following an incident.
J2.4 NRPB is also responsible for the administration of the NAIR scheme (see Appendix 1, paragraph 1J.8).
Plans for Specific Contingencies
J2.5 Site operators and users of radioactive materials are responsible for ensuring the safety of workers and the public so far as is reasonably practicable and for preparing contingency plans to deal with incidents. Specific plans are in existence for all major civil and military nuclear sites and for certain other contingencies described at Appendix 1. Site plans should identify a detailed emergency planning zone (DEPZ) closely surrounding each installation within which arrangements to protect the public should be planned in detail. Plans need to be capable of responding to incidents, which although very unlikely, may extend beyond the DEPZ. The exact response must be based on an assessment made at the time and the response may make use of plans made to deal with other major incidents.
J2.6 Formal arrangements exist at major nuclear sites for consultation between site operators and local interests including NHSScotland. Site operators need to be aware of relevant NHSScotland arrangements so that these can be described in their emergency plans. NHS Boards with a nuclear installation within their areas need to be familiar with all aspects of the site emergency plan and ensure that the involvement of the health services is taken into account. The lead NHS Board (see J1.3 above) should be represented on the site Emergency Planning Co-ordination Committee (EPCC) or its equivalent and take an active part in its proceedings.
J2.7 It should be noted that differences of terminology exist in the arrangements for managing civil and military nuclear incidents; the basic arrangements are, however, broadly similar. At a major civil nuclear establishment, initial implementation of the site’s emergency plan will be undertaken at the Site Emergency Control Centre (SECC). The operator is then required to activate an Off Site Facility (OSF), well clear of the plant, for overall incident management. Operation of the OSF is co-ordinated by the police. The lead Government Department would, on the advice of the Chief Nuclear Inspector (or Deputy), arrange for the appointment of a Government Technical Adviser (GTA). The GTA would go to the OSF and provide advice both to the Government and to those involved in responding to the incident locally. The NHS Board within whose boundary the site is located should be represented at an appropriate senior level (usually including the Director of Public Health) in the OSF to:
J2.7.1 Give advice to the police, site operator, local authorities, GTA and others on health implications and possible health measures, drawing upon necessary technical assistance, monitoring data and assessments from the site operator, NRPB, SEPA and other sources;
J2.7.2 Advise on the implementation and progress of NHSScotland emergency arrangements and their co-ordination with those of others;
J2.7.3 Ensure the provision of information about the incident and its management to the NHS Board Control Centre for transmission to hospitals, general practitioners and other NHSScotland staff who need it and to neighbouring NHS Boards;
J2.7.4 Participate in media briefing at the OSF or its associated Media Briefing Facility (MBF);
J2.7.5 Maintain direct contact with SEHD to ensure full consistency, and synchronisation, of health advice given locally with that nationally by Ministers and the Chief Medical Officer.
J2.8 Where a Local Authority Emergency Centre (LAEC) is established separately as a focal point for local co-ordination, the NHS Board may require to be represented there as well as at the OSF.
J2.9 Formal planning arrangements may not exist for other users of radioactive materials. NHS Boards should make themselves aware of users within their areas, and liaise with them as necessary on emergency arrangements. This is best done in co-operation with local authorities who will normally have been notified.
J3 COUNTER-MEASURES
J3.1 In the context of implementing counter-measures, 3 time phases can be identified: pre-release, emergency and longer term. The pre-release phase starts when a substantial risk of imminent release of radioactive material is identified and ends when either a release occurs or the plant is brought back under control. During this period, precautionary counter- measures may be implemented, to ensure that appropriate protection is in place before a release occurs. The emergency phase lasts from the time a release occurs until shortly (i.e., no more than a day or two) after the plant has been made safe and there is no further imminent threat of release. The longer-term phase follows the emergency phase and continues until no further remedial measures are required. This may be a matter of weeks, months or years. Counter-measures which may be implemented during all 3 phases of an incident are as follows, further information is at Appendix 3:
3.1.1 Sheltering - the public would be advised to stay indoors, close doors and windows and follow advice given by local radio and television stations. Sheltering reduces the risk of exposure to direct radiation and the inhalation of radioactive material;
J3.1.2 Taking stable iodine tablets - to minimize the effects of any uptake of radioactive iodine from the passage of the plume. These tablets work by saturating the thyroid gland with non-radioactive iodine to reduce the uptake of radioactive iodine (it should be noted that radioactive iodine is only likely to be present in an accident involving a nuclear reactor);
J3.1.3 Evacuation - from a downwind sector from the site to reduce the risk of exposure to radioactivity in the plume or deposited on the ground;
J3.1.4 Control of contaminated/potentially contaminated food supplies - in accordance with advice from the Food Standards Agency. Control would be established by Order made under the Food and Environment Protection Act 1985;
J3.1.5 Control of contaminated/potentially contaminated water supplies - in accordance with advice from the Scottish Executive Environment and Rural Affairs Department.
J3.2 In the longer term further measures may need to be implemented including:
J3.2.1 Relocation - the longer-term removal of people away from the contaminated area to avoid the accumulation of high long-term radiation doses from the ground deposition of radionuclides. It may be implemented either following evacuation or as a separate action;
J3.2.2 Decontamination of land and property - following assessment of alternative means of decontamination and of any resultant waste disposal, major civil engineering to immobilise material to prevent, for example, its resuspension in air might be required.
J3.3 The key factor in determining whether, when and how to implement or cease any counter-measure is that it should do more good than harm, especially as regards human health. NHS Boards should thus ensure that they are fully involved in the assessment and decision making process.
J4 ARRANGEMENTS FOR CASUALTIES
Radiation Hazards
J4.1 The principal hazard is the release from safe containment of materials emitting ionising radiation. The amount, type and form of the material would depend on its source and the nature of the incident. For example, radioactive material might be released from a nuclear reactor, from a wide variety of substances in transit or from products in storage or use industrially, in research or health care. Radioactive material released in an incident is likely to be carried by the wind, behaving like a plume of smoke, dispersing into the air and depositing activity on the ground. People may thus incur:
J4.1.1 Exposure to direct radiation from a radioactive plume following a substantial airborne release, or from radionuclides deposited on the ground or in buildings;
J4.1.2 Exposure to radiation from radionuclides contaminating the body surface, clothing or possessions;
J4.1.3 Internal exposure to radiation following inhalation or ingestion of radioactive substances as a result of direct atmospheric or environmental contamination or, subsequently, by radioactive material in water or food.
J4.2 Although incidents involving radioactive materials used in industry, medicine, research, teaching or agriculture will be more limited in their environmental impact, they are likely to occur much more frequently than nuclear site incidents and can have serious health consequences. Plans should anticipate the possibility of contamination, and of radiation injury, to both workers and members of the public
Casualties
J4.3 It is anticipated that non-essential personnel would be evacuated from a nuclear site before any significant release of radiation occurs, thereby limiting the number of casualties. Possible casualties can be considered under 3 headings:-
J4.3.1 Conventional Injury Conventional injuries could arise from events leading to the incident, such as fires or steam leaks; or follow incidents and panic.
J4.3.2 External Exposure People bringing the plant under control or attempting to save life, as well as injured individuals immobilised close to the reactor or plant could receive significant doses of external radiation affecting the whole or parts of their bodies.
J4.3.3 Contamination People may become externally contaminated either by exposure to a radioactive cloud or by contact with contaminated surfaces. In addition, particles from the radioactive cloud could be inhaled or ingested with resultant internal contamination.
J4.4 The casualties require different handling depending on the radiation exposure, however it is an important principle that treatment of life threatening injury should take priority over monitoring or decontamination.
J4.4.1 Physically injured and known not to have received a significant dose of radiation and known not to be contaminated with radioactive material - These patients require no special facilities relating to radiation. They present no hazard to attendants, vehicles and treatment facilities. They will require a full assessment and subsequent medical counselling.
J4.4.2 Exposed to a high radiation dose whether physically injured or not - Treatment should be directed to managing the effects of the received dose. Unless they are also contaminated with radioactive material, they present no hazard to attendants and there is no risk of contamination of vehicles or treatment facilities. However, if they also have physical injuries then this can seriously affect their prognosis and medical management. (See Appendix 4.)
J4.4.3 Contaminated or possibly contaminated whether physically injured or not- Contaminated casualties are those who have radioactive material on their skin or clothing or who have inhaled or ingested radioactive material. This material will continue to emit radiation so long as it is active and not removed thus adding to the radiation dose received by the individual if the contamination persists. Transfer of contaminating material to attendants or to the patient’s surroundings can cause a small risk of individuals other than the patient receiving a radiation dose. Precautions will be required to reduce the spread of contamination to attendants, vehicles and treatment facilities. Decontamination is required to prevent or reduce further radiation doses, to remove the risk of inhalation or ingestion of contaminating material, or the transfer of such material to others (see Section J5). Patient clothing, dressings, swabs etc. and excreta should be bagged, labelled and retained for analysis.
Action at the Scene of an Incident
J4.5 Contingency plans for major nuclear installations do not envisage ambulance or other NHSScotland staff having to enter an area where they would be exposed to high levels of radiation or to heavy contamination. Similarly, it is extremely improbable that staff attending a nuclear industry or MoD off site incident would be exposed to levels of radiation that would cause a significant health risk. However, there are precautions which should be taken at an incident site and in the handling of possibly contaminated casualties.
J4.6 Monitoring facilities and/or expert advice may be available at the incident site to permit a rapid assessment of any contamination of the casualty. If monitoring facilities are not available, any casualty must be assumed to be externally contaminated and handled accordingly. (Handling casualties with internal radioactive contamination alone normally requires no special protective clothing above what is already familiar to ambulance staff.) Significant external contamination is unlikely to be found outside a major nuclear establishment that would have its own staff to deal with immediate medical treatment and casualty handling. However, in the extremely unlikely event of staff having to deal with casualties who might be significantly externally contaminated or enter an area that is grossly contaminated the main priority will normally be to minimize the risk of internal contamination due to inhalation of airborne radioactive materials. The use of PPE issued to the ambulance service and NHSScotland for protection against radioactive materials will be part of the associated training programme. , Site operators would be responsible for assessing the risk and for issuing any additional or alternative protective clothing. Where possible, advice from an NHS Radiation Protection Adviser should be sought.
J4.7 Precautions should be taken to reduce the spread of possible contamination. Placing a plastic sheet beneath the patient can reduce contamination of the stretcher or the ambulance. Placing a similar sheet over the patient’s body can further reduce spread of contamination (in the absence of plastic sheets, ordinary sheets and blankets may be used). On arrival at a hospital they should not remove such sheets until the patient has entered the hospital.
J4.8 Potentially contaminated casualties should not be given either food or drink (unless oral medication is urgently required - this may include stable iodine where appropriate - but in all cases must not prejudice management of the casualty’s injuries and must be preceded by local facial decontamination) nor be allowed to smoke until they have been monitored and if necessary decontaminated. Ambulance and other NHSScotland staff who have handled potentially contaminated casualties should take similar precautions.
Transport to Hospital
J4.9 Where the casualty’s condition permits, he should be taken to a hospital designated to receive contaminated casualties (see para J4.11 below). Where this would result in unacceptable delay in obtaining treatment for serious or life-threatening injuries, the casualty should be taken to the nearest Accident & Emergency department. In either event, the hospital must be notified before arrival that a casualty who is or may be contaminated with radioactive substances is to be expected so that appropriate arrangements can be made.
J4.10 After the patient has been delivered to the hospital, the ambulance should be parked in a designated area to await monitoring and decontamination. The ambulance crew should remain at the hospital until they can be monitored and, if necessary, decontaminated. Any used protective clothing should be placed in a plastic bag for subsequent monitoring.
Designated Hospitals
J4.11 Each NHS Board should make arrangements for, and designate in its emergency plan, a hospital or hospitals prepared to accept casualties arising within its area who are contaminated with radioactive material. Minimum requirements for such designation are:
• 24-hour Accident and Emergency cover
• ready availability of medical physics facilities capable of measuring the extent and distribution of the contamination;
• appropriate facilities for decontamination.
J4.12 While contaminated casualties should normally be taken to a designated hospital, the physical condition of the casualty or other circumstances might require treatment to be given in any hospital with Accident & Emergency facilities. Thus, it is important that all such hospitals should have contingency arrangements to deal with contaminated casualties. It will usually be possible to seek further advice from a designated hospital before proceeding beyond the initial treatment stage. Nevertheless, staff should be aware of the basic precautions to allow them to treat contaminated casualties without risk to themselves, and of procedures for obtaining expert advice and assistance. A series of suggested management criteria are presented at Appendix 4.
J4.13 Not all hospitals designated to accept casualties contaminated with radioactive material will be able to treat those affected by a high radiation dose. Also, not all casualties exposed to high external radiation doses (for example in incidents involving irradiation facilities and industrial radiography) will have residual contamination with a radioactive substance. Any necessary decontamination, initial monitoring and first aid treatment might be carried out on the premises where the incident occurred, or in a hospital designated to receive casualties contaminated with radioactive material. Casualties exposed to high doses of radiation should then be transferred to a hospital able to provide the necessary specialist treatment and care.
Preparation of Casualty Reception and Treatment Areas
J4.14 The selection of a suitable area for the reception and treatment of suspected contaminated casualties may present considerable difficulty. Ideally, an area which is physically separate from the main area of the Accident & Emergency department and has its own outside entrance or a room(s) within the department which can be closed off should be selected, in order to minimize disruption to normal working during the treatment of the contaminated patient and during any necessary subsequent monitoring and decontamination procedures. Any monitoring and decontamination equipment and other material specifically required for the handling of contaminated casualties should be stored as near to the designated area as is practicable. If no accommodation can be provided with adequate separation from the main Accident & Emergency department, consideration may have to be given to closing or restricting the normal use of the department during the handling of the incident, and diverting routine work elsewhere.
J4.15 The selected area should be equipped to allow resuscitation and emergency treatment, as well as decontamination to be carried out. The need for these facilities might preclude the setting aside of accommodation specifically to cover such a rare event. Other factors which should be considered include:
J4.15.1 Ventilation: the ventilation arrangements should be such as to minimize the risk of contamination from the designated area being transmitted to other parts of the hospital by this means.
J4.15.2 An adequate water supply is essential for decontamination purposes and the drainage system should be such as to allow discharge only of amounts of radioactive materials within the permissible limits for this method of disposal, under the supervision of the Radiation Protection Adviser.
J4.15.3 Adequate means of communication should be available to minimize the necessity for staff to move to and from the potentially contaminated areas.
J4.15.4 Mobile X-ray equipment should be considered to obviate the need to take a possibly contaminated casualty into the main X-ray department.
Measures to Prevent the Spread of Contamination
J4.16 Possible spread of contamination can be minimized by relatively simple measures and this will greatly simplify subsequent monitoring and decontamination procedures. Where time permits, detailed advice from the Radiation Protection Adviser should be obtained.
J4.17 Work surfaces etc. in the designated area can be protected by plastic sheeting, heavy- duty paper, blankets or sheets. Plastic sheeting on floors is not recommended. Similar means can be used to minimize contamination of ambulances, stretchers and trolleys. A plentiful supply of paper towels and tissues should be available.
J4.18 Entry to, and departure from the designated area should be strictly controlled. There should be facilities to allow such staff to change their footwear on leaving the designated area. However, ideally, nothing and no one should leave the area until monitoring and decontamination has been carried out to an acceptable level.
J4.19 Decontamination of the patient (see Appendix 4) should be carried out in the controlled area where this is compatible with the patient’s need for treatment. However, the urgent treatment of injuries takes precedence over decontamination. If the patient needs to be transferred to the operating theatre or intensive care unit before decontamination can be completed, the main consideration should be the possibility of removal of clothing, where most of the radioactive contaminant is likely to reside. If transfer for treatment prior to full decontamination becomes necessary, the possible spread of contamination may be reduced by covering appropriate areas with plastic sheeting or other impervious material. If the patient does have to be transferred, this must be done by staff other than those who have been working in the controlled area.
J4.20 All material which might have become contaminated such as patients’ clothing, dressings, items of equipment, staff protective clothing and fluid used for washing, if beyond safe discharge levels (see J4.15.2), should be retained within the area in suitable containers. Such containers, appropriately labelled, must not be disposed of except under the instructions of the Radiation Protection Adviser. Urgent laboratory specimens may be sent to the laboratory but the outside of containers should be swabbed to remove any contamination and the specimens labelled to indicate to laboratory staff the need for caution in handling and disposal.
J4.21 Any area in which a contaminated person has been handled must be monitored and, if necessary, decontaminated before it can be used for any other purpose.
Disposal of Bodies
J4.22 Conventional cleansing of the body, with suitable precautions to prevent contamination of the attendant or the surroundings will usually reduce external contamination to an acceptable level. However, bodies contaminated by radioactive material must not be released for burial or cremation until radiation protection advice has been obtained on the proposed method of disposal. Until such a decision is reached, the spread of contamination can be prevented by enclosing the body in a heavy-duty plastic body-bag. In the case of certain radionuclides it may also be necessary to store the body in an area away from places to which members of staff and the public have access.
Protection of Staff
J4.23 Suitable protective clothing should be made available for all staff engaged in the handling and treatment of contaminated patients. Overalls, rubber gloves and boots (e.g., operating theatre clothing) are likely to be adequate to deal with the majority of situations. However, in handling patients whose skin, hair or clothes might be with significantly contaminated by radioactive materials, the need for respiratory protection should be considered. Waterproof aprons should be worn by those staff who are expected to wash skin or wash out wounds etc.
J4.24 Careful handling procedures will minimize contamination of staff, the area and equipment. Any staff members who have handled contaminated patients or materials should be monitored and, if necessary, decontaminated before leaving the designated area. Staff must be warned not to eat, drink or smoke until monitoring and decontamination has been carried out.
Training
J4.25 All Accident & Emergency staff should have sufficient knowledge of radiation protection to reduce, as far as practicable, hazards to the patient, to colleagues and themselves and to limit contamination of premises and equipment. Practical skills, including contamination monitoring and decontamination should be maintained through regular exercises of procedures.
J5 MONITORING AND DECONTAMINATION
J5.1 Monitoring and any necessary decontamination of workers, casualties and others, including members of the rescue services, at a major nuclear site would normally be carried out by the operator's staff, the SAS and the fire brigades. Further monitoring, and where necessary decontamination, of casualties taken to hospital should be undertaken there as described in Appendix 4.
J5.2 There will also be a need to monitor all other people who may be contaminated, or who think they may be contaminated, as a result of the incident. NHS Boards should take the lead in co-ordinating off-site monitoring of people.
Planning a Monitoring Strategy
J5.3 The very wide range of potential incidents involving the release of radioactive material is reflected in the correspondingly wide range of responses required. As a general principle, plans should give detailed guidance on how to carry out monitoring following the largest incident that can reasonably be foreseen; they should, however, also allow the response to be flexible, and should enable the response to be extended to deal with much larger (but much less probable) incidents, or demand from large numbers of members of the public for monitoring.
J5.4 In developing plans for personal monitoring, the underlying principles should be to enable measures that would significantly reduce doses to individuals to be carried out promptly, to ensure that scarce staff, equipment and other resources (e.g., showering facilities at a reception centre) are used effectively, and to keep members of the public who have been monitored fully informed. The administrative tasks of running a monitoring programme should not be underestimated.
J5.5 Priority should normally be given to monitoring for external contamination (i.e., activity deposited on the skin, hair or clothing). This involves the use of hand-held equipment and might indicate a need for decontamination measures such as washing exposed skin which can result in significant dose reductions. Monitoring for internal contamination (normally resulting from inhalation or ingestion of contaminated material) requires more specialist equipment and is for dose assessment rather than decontamination.
J5.6 In order of importance, the objectives of a radiation monitoring programme for members of the public following a major radiation incident are:
J5.6.1 To identify those who are externally contaminated at a level which requires urgent decontamination to avoid illness.
J5.6.2 To reassure those who are not so contaminated.
J5.6.3 To identify those who are externally contaminated at lower levels but for whom decontamination is still justified.
J5.6.4 Where radioactive iodine is involved, to inform assessments of thyroid uptake and radiation dose.
J5.6.5 To prioritise subjects for assessment of uptake of other radionuclides and resulting radiation dose.
J5.6.6 To provide information to individuals on their internal radiation dose, with the aim of providing reassurance where appropriate.
J5.6.7 To supply information on radiation doses received by members of the public for incident assessment purposes.
J5.7 Monitoring of people affected by emergency counter-measures (evacuation, sheltering, distribution of stable iodine) should be given a higher priority than monitoring other groups within the general population.
J5.8 The public’s perception of risk from radiation, and their reaction to a radiation incident, will play a considerable part in determining the demand for personal monitoring.
J5.9 Within the term monitoring it is useful to distinguish screening, where an action level is set to decide between alternative courses of action; and measurement, where numerical values are recorded for the purpose of dose assessment. Several distinct phases of a monitoring programme can be identified:
J5.9.1 Early screening of possibly large numbers of people for external contamination;
J5.9.2 Subsequent screening of essentially the same group of people for internal contamination;
J5.9.3 At a later stage, more accurate measurement of radio-iodine thyroid uptake and/or assessment of uptake of other radionuclides using whole body monitor facilities with the aim of assessing internal radiation dose;
J5.9.4 Long-term follow-up studies to assess doses received by the general population in the affected area.
J5.10 If persons being monitored are externally contaminated, then avoidance of contamination of the monitoring area is essential. Measures should be put in place to monitor and control the spread of contamination as far as possible.
J5.11 All staff should be given training, or should have sufficient experience to be able to take on their allocated role.
J5.12 To illustrate the issues that need to be considered when planning a monitoring programme, guidance is given at Appendix 5 for 2 incident scenarios that would be among the largest that could reasonably be foreseen. The first scenario is a nuclear power reactor accident resulting in release of fission products, which requires monitoring for several hundred people. The second is a nuclear weapons accident (non-nuclear explosion or fire) resulting in localised dispersal of airborne plutonium oxide, also requiring monitoring for several hundred people. The first scenario is discussed in detail, the second only briefly.
J5.13 The guidance given for these scenarios is addressed primarily to NHS Boards within whose area the incident occurs. NHS Boards more distant from the site of an incident, whether within or outside the UK, may also need to implement a monitoring programme. Away from the immediate vicinity of the incident significant levels of external or internal contamination of people are unlikely to occur, and so simplified plans based on the guidance given in Appendix 5 could be developed. Nevertheless, there may well be demands for monitoring from very large numbers of people.
The Radiation Monitoring Unit (RMU)
J5.14 NHS Boards may need to establish a temporary RMU to carry out the first two phases of monitoring listed in paragraph J5.9. This Unit would primarily be intended for monitoring evacuees. The later phases of monitoring are likely to be conducted at hospitals with medical physics departments (although other facilities are likely to be available, and their use should be considered). The establishment and operation of a RMU are discussed at Appendix 5.
Decontamination at the scene of an incident.
J 5.15 Arrangements for decontamination of casualties contaminated with chemical, biological or radiological materials at the scene of an incident are defined in a joint emergency services' guidance document "Guidance for the emergency services on decontamination of people exposed to hazardous chemical, biological or radioactive substances". APPENDIX 1 TO ANNEX J
ARRANGEMENTS FOR PARTICULAR CONTINGENCIES
1J.1 OVERSEAS REACTOR INCIDENT
An incident involving a nuclear reactor overseas can lead to contamination of the environment within the UK (e.g. Chernobyl 1986). People and goods close to the scene may subsequently enter the UK.
LEAD UK GOVERNMENT Department for Environment, Food & Rural Affairs DEPARTMENT
SCOTTISH LEAD DEPARTMENT Environment and Rural Affairs Department
NHSScotland RESPONSE ROLES Monitoring of people, including returning travellers, who may have been exposed. Advice and information to the public on health effects.
Participation in validation monitoring to assess long term health effects.
EXISTING PLANS/REFERENCES National Response Plan RIMNET (Radioactive Incident Monitoring Network) is a system of 92 monitoring sites across the UK incorporating alerting mechanisms, a central database for post incident radiological measurements, and associated communications to distribute information summaries and data.
1J.2 UK CIVIL NUCLEAR REACTOR SITES
Civil Reactors are operated in Scotland at Hunterston B, Torness (British Energy) and Chapelcross (BNFL). Hunterston A (BNFL) and AEA Technology’s reactors at Dounreay are being decommissioned. The most Northerly of reactors in England are at Sellafield in Cumbria and Hartlepool.
SITE INCIDENT CONTROL Site operator, control of off-site activities established at Off Site Facility initially co-ordinated by police.
LEAD UK GOVERNMENT Department of Trade and Industry (DTI) (The Office DEPARTMENT for Civil Nuclear Security (OCNS) has been part of DTI since October 2000.)
SCOTTISH LEAD DEPARTMENT Enterprise and Lifelong Learning Department
NHSScotland RESPONSE ROLES Treatment and care of casualties.
Advice on health effects to authorities, the media and public.
Advice on implementation of countermeasures to site operator, police and other authorities.
Monitoring of people in the vicinity who may have been contaminated with radioactive material.
Provision of health care services to people evacuated from the vicinity.
Reassurance and validation monitoring as required.
Participation in regular multi-agency exercises to test emergency response.
EXISTING PLANS/REFERENCES HSE Guidance
Site specific plan required to be produced by each operator in conjunction with local authorities and others, including NHS Boards, out to 40km from the site.
1J.3 MILITARY NUCLEAR REACTOR INCIDENT
Nuclear powered warships are based at the Clyde Submarine Base (including HMS Neptune, Faslane, and the RN Armament Depot Coulport). A number of berths elsewhere in Scottish waters are designated for their use and dockyard facilities at Rosyth are used to refit nuclear submarines and to berth decommissioned vessels. The MOD’s VULCAN test reactor is operated at Dounreay.
SITE INCIDENT CONTROL Under Military Co-ordination Authority, control of off-site activities co-ordinated by civil police at off- site facility.
LEAD UK GOVERNMENT Ministry of Defence (MOD) DEPARTMENT
SCOTTISH LEAD DEPARTMENT Justice Department
NHS RESPONSE ROLES As for civil nuclear site (para 1J.2 above)
EXISTING PLANS/REFERENCES Joint site specific plan (e.g. CLYDEPUBSAFE, ROSPUBSAFE) produced by local authority in
conjunction with site operator and others including NHS Board.
1J.4 NUCLEAR FUEL/WASTE IN TRANSIT (CIVIL OR MILITARY)
Nuclear fuel and associated radioactive waste is transported in secure protective containers between reactor sites and reprocessing/storage facilities by road, rail, sea or air.
INCIDENT SITE CONTROL Police with fire service and consignment owner support.
LEAD UK GOVERNMENT (Civil) DTI's Office for Civil Nuclear DEPARTMENT Security (OCNS), (Military) MOD SCOTTISH LEAD DEPARTMENT (Civil) Enterprise and Lifelong Learning Department (Military) Justice Department
NHS RESPONSE ROLES As for civil nuclear site (para 1J.2 above).
EXISTING PLANS/REFERENCES RADSAFE brings together individual nuclear operators’ plans. It provides expert assistance to the emergency services and others via a single focal point (0800 834 153)
1J.5 NUCLEAR WEAPON TRANSPORT INCIDENT
The dominant radioactive hazard involved in an incident in which both a nuclear weapon casing and its transport container were breached is alpha radiation from plutonium. All nuclear weapons movements, by road, air or sea, are conducted by specially trained personnel.
INCIDENT SITE CONTROL Police, initially advised by convoy commander until arrival of Military Co-ordinating Authority.
LEAD UK GOVERNMENT MOD DEPARTMENT
SCOTTISH LEAD DEPARTMENT Justice Department
NHS RESPONSE ROLES As for civil nuclear site (para 1J.2 above).
Specialist doctors, health physicists, monitoring and experts will be made available quickly from the MOD’s Nuclear Accident Response Organisation (NARO) to provide any advice/assistance required.
EXISTING PLANS/REFERENCES Local Authority and Emergency Service Information on Nuclear Weapons Transport Contingency Plans (LAESI) issued by the MOD.
1J.6 SATELLITE WITH NUCLEAR POWER OR MATERIAL RETURNING TO EARTH
Should a satellite containing nuclear material, through malfunction or other cause, leave its orbit it might re-enter the earth’s atmosphere. While most will burn up and pose no hazard; some will reach the surface substantially intact, while others will break up scattering pieces widely. Such incidents are almost always predictable in terms of timing and broad geographical area of impact, but less so as to the damage they might bring.
SITE CONTROL Police
LEAD UK GOVERNMENT Home Office DEPARTMENT
SCOTTISH LEAD DEPARTMENT Justice Department
NHS RESPONSE ROLES As required
1J.7 INCIDENT ARISING FROM INDUSTRIAL/AGRICULTURAL/SCIENTIFIC/ EDUCATIONAL/MEDICAL USE OF RADIOACTIVE MATERIAL
Under Health and Safety at Work legislation employers have a responsibility for protecting their employees and other people from any harmful effects of their work activities. In particular, Regulation 7(1) of the Ionising Radiation Regulations 1999 requires employers to assess the potential hazard of their use of radioactive material.
SITE CONTROL Employer or Police.
LEAD UK GOVERNMENT Depends on incident DEPARTMENT
SCOTTISH LEAD DEPARTMENT Depends on incident (Note - SEHD for any incident involving NHSScotland use of material).
NHS RESPONSE ROLE As required. Note - NHS Trusts using radioactive material should ensure their emergency plans cover incident management, liaison with the local authority and emergency services, the notification of HSE and SEPA where appropriate, and provide for the immediate notification of both the NHS Board and SEHD should any significant incident occur.
EXISTING PLANS/REFERENCES HSE Guidance
1J.8 NATIONAL ARRANGEMENTS FOR INCIDENTS INVOLVING RADIOACTIVITY (NAIR)
1J.8.1 The NAIR scheme is co-ordinated by NRPB to provide specialist advice where plans do not exist for specific events. Details of the scheme are available on the NRPB website at (http://www.nrpb.org/radiation_incidents/nair.htm) and from the NAIR Handbook (http://www.nrpb.org/radiation_incidents/nair_2000.pdf). Its function is to make available, to the police and other emergency services, advice on safety measures required at incidents involving, or thought to involve, radioactive substances. The scheme provides for assistance in 2 stages. The first stage enables an experienced person to advise the police whether a potential hazard from radioactivity exists, and if it does, on the action necessary to minimize and contain any danger. The second stage provides for more sophisticated resources should they be necessary. Each police force has been allocated first and second stage assistance centres. These are contacted by calling 0800 834 153 which connects the caller to the Atomic Energy Agency constabulary who will then co-ordinate communication with the appropriate assistance centres and will inform SEPA. Several first stage assistance centres are NHS medical physics departments; second stage centres are invariably major nuclear establishments.
1J8.2 The arrangements are intended to cover incidents in public places (e.g., damage to containers, discovery of suspected radioactive substances) and incidents involving the public in premises where radioactive materials are not normally handled. NAIR is not intended to cover incidents in premises where radioactive substances are normally handled because in these cases staff should be available who are competent to deal with the problem. Nor are NAIR arrangements intended to cover on or off site incidents at civil nuclear installations, MoD establishments, or transport accidents involving nuclear fuel or weapon components as described at paragraphs 1J.2-1J.5 above. (For offsite transport, the RADSAFE provisions referred to in 1J.4 apply but the contact number is the same as that for NAIR). However, should the police consider that a danger to the public exists and if planned expert assistance is not immediately available, they may seek assistance via the NAIR arrangements. The NAIR arrangements are quite separate from NHS contingency plans. Specifically, the designation of hospitals prepared to accept contaminated or irradiated casualties is a matter for NHS Boards. Lists of such hospitals are held by NRPB for the purposes of NAIR response. NAIR does not cover arrangements for dealing with casualties or with arrangements for monitoring casualties or the public following an accident.
1J8.3 Since NAIR is founded upon the use of individual specialists drawn from their normal duties as required, NHSScotland medical physics staff, and in particular Radiation Protection Advisers, may be participants in NAIR. Staff called out under the NAIR arrangements are working on normal NHSScotland duties, and thus subject to the provisions of the NHSScotland Superannuation and Injury Benefits Schemes as well as the Industrial Injuries Scheme.
APPENDIX 2 TO ANNEX J
EMERGENCY REFERENCE LEVELS/INTERVENTION LEVELS
2J.1 The NRPB’s published principles for intervention after a nuclear accident require the implementation of counter-measures which aim to do more good than harm, taking account of all likely consequences. The quantitative criteria recommended by NRPB for the introduction of counter-measures to protect the public are known as Emergency Reference Levels (ERLs).
2J.2 ERLs are expressed in terms of radiation dose to an individual that could be averted if the counter-measure is taken. For each counter-measure a lower and upper ERL is set. The lower ERL is the smallest reduction in dose likely to offset the disadvantages introduced by the counter-measure: it should be regarded as the threshold for considering implementation of the counter-measure. The upper ERL is the reduction in dose for which the counter- measure would be justified in nearly all situations, and above which strenuous efforts should be made to implement it.
2J.3 ERLs recommended by NRPB are:
Counter-Measure Dose Equivalent (mSv)
Lower ERL Upper ERL
Sheltering - Whole Body 3 30 - Thyroid/lung/skin 30 300
Evacuation - Whole Body 30 300 - Thyroid/lung/skin 300 3,000
Stable Iodine - Thyroid 30 300
2J.4 ERLs cannot of course be compared directly with measurements in the field, or with the results of measuring samples of materials from the environment. It is necessary therefore for “trigger” or site specific intervention levels, expressed in the same quantities as measurements are expressed, to be calculated for each site and for each possible counter- measure. Trigger levels should be explicitly included in local plans and be compatible with ERLs.
APPENDIX 3 TO ANNEX J
COUNTER-MEASURES
Sheltering
3J.1 In this context sheltering refers to staying indoors, with doors and windows closed and ventilation systems turned off. It provides protection from external irradiation from radioactive material in the air and that deposited on the ground, and from inhalation of radioactive material. Typical dose reductions for solidly built and reasonably airtight UK housing are a factor of 10 for external exposure and a factor of 3 for inhalation of particulates. However, the dose reduction for inhalation of vapours (e.g., elemental radioiodine) is negligible, and the protection against external irradiation afforded by light constructions, such as caravans, is very small. The level of protection afforded will not, in general, be significantly affected by occasional opening and closing of outside doors, or short trips out of doors for essential activities.
3J.2 If a release to atmosphere occurs, there are 4 main situations for which sheltering is likely to be the optimum counter-measure:
• a release consisting mainly of radioisotopes of noble gases (to reduce the external dose);
• a release which would result in relatively low doses;
• a release which would result in very large short-term doses, for which evacuation could not be carried out in advance of the release;
• circumstances in which evacuation either is not possible or would entail considerable risk to the evacuees.
3J.3 Where radioiodine is known to form a significant part of the release, the administration of stable iodine (to reduce the dose to the thyroid from inhalation of radioiodine) in conjunction with sheltering (to reduce the amount of radioactive materials inhaled and the external irradiation dose) can form a very effective counter-measures strategy. However, it is important not to overlook the inhalation dose likely to be received from other radionuclides. It must also be remembered that the benefit of sheltering is strongly dependent on the type of buildings available to accommodate people and the available means of communicating the advice to shelter and cease sheltering. It is therefore important to take these factors into account when formulating emergency plans for specific sites.
Evacuation
3J.4 In this context, evacuation is defined as the removal of people from an area in order to avoid (or potentially to avoid) relatively high short-term exposures. The primary purpose of evacuation is to protect the population against the inhalation of radionuclides and external exposure from radionuclides in the air and deposited on the ground. It is distinct from relocation, which is the removal of people from the contaminated area for periods of weeks,
months or years to avoid chronic, long-term exposures, although relocation may be carried out as an extension to evacuation.
3J.5 Evacuation is the only counter-measure which has the potential to prevent virtually all exposure to a release. However, this is only achieved if the evacuation is carried out before the release occurs. In other situations partial dose savings will usually be achieved, although it is possible that evacuation may result in higher doses than alternative counter-measures or than no counter-measures, if it is incorrectly implemented. While people are in transit, their protection against external irradiation and inhalation of radionuclides is likely to be very much less than the protection they would receive from remaining inside solidly constructed buildings. It is therefore not advisable to evacuate people through areas where radionuclide concentrations in air are relatively high, unless it is judged that the dose which they would receive if any other counter-measures strategy were implemented (including taking no counter-measures) would be higher than the dose received during the evacuation.
3J.6 Evacuation can be effective for reducing doses following many different types of accidental release. It can be effective in situations involving an accidental release to atmosphere, or localised contamination of the environment following, for example, the breakage of a radiography source or the crash of a nuclear-powered satellite. Five main situations can be identified in which evacuation is likely to be the optimum early counter- measure:
• precautionary evacuation, in response to the threat of a probable release;
• in response to a large release of predictable duration or size, particularly one for which there is sufficient advance warning for people to be moved before it begins;
• in response to an accident for which the release to atmosphere may be prolonged, and the size of a release is very uncertain and potentially large;
• after the cessation of a release to atmosphere, to avoid doses from short-lived radionuclides deposited on the ground;
• after the cessation of any release, to avoid external exposure while localised, short- term decontamination is carried out.
3J.7 As with sheltering, where radioiodine is known to form a significant part of the release, the administration of stable iodine in conjunction with evacuation can form a very effective counter-measures strategy. However, it should be noted that it is not necessary to administer stable iodine if precautionary evacuation has been carried out, or the evacuation was achieved very quickly after the start of the release.
Administration of Stable Iodine Tablets
3J.8 Where material escaping after an incident at a nuclear installation contains radioactive iodine this may be inhaled, or ingested via contaminated food or water. This will give a radiation dose, in particular to the thyroid which concentrates and stores any form of iodine. A radiation dose from ingestion can be averted or minimized by restrictions in the supply of food - most likely milk and milk products. Uptake of inhaled radioactive iodine to the thyroid can be blocked by the administration of stable (i.e., non-radioactive) iodine. Whilst
most effective if given shortly before or immediately after exposure, stable iodine will still block uptake of radioactive iodine to a useful extent up to some hours after exposure.
3J.9 Planning Requirement Emergency plans drawn up to deal with incidents at major nuclear sites should include detailed arrangements for the supply, storage, authorisation to issue and rapid distribution of stable iodine tablets to staff on the site, to responding emergency services personnel and to members of the public in the DEPZ. Plans should also address, in outline, how those detailed arrangements might be extended beyond the DEPZ in the unlikely event that distribution might be required there. While it is also unlikely that incidents other than those involving a major nuclear reactor site will require this counter- measure, outline arrangements to secure tablet supplies and effect distribution should be developed by all NHS Boards.
3J.10 Planning Responsibility Responsibility for taking the lead on planning the distribution of stable iodine tablets to the public rests with lead HNS Boards, as defined at paragraph J1.3. Development and maintenance of effective plans will require Boards to secure the active co-operation of the site operator, local authority, emergency services and other agencies which might be able to make people available to assist in the task.
3J.11 Authority to Issue Tablets should only be issued to the public on the authority of the Director of Public Health. To ensure that tablets can be issued without delay when required, Directors of Public Health should give prior authorisation for the commencement of issue in the event of specific, pre-determined conditions. Precise parameters should be set for this including “trigger” measurements derived from application of NRPB’s Emergency Reference Levels to site specific modelling, predicting the nature, extent, direction and mobility of any release.
3J.12 Stocks of Tablets Bulk stocks of tablets are required to be provided and maintained by site operators. To facilitate rapid distribution when required, some of this stock might be pre-positioned in reception centres, schools, health centres, emergency services’ stations or other premises with appropriate and secure storage facilities. In such cases the quantity of tablets held in each place should be detailed, together with responsibilities for their custody, periodic inspection and issue.
3J.13 Distribution Planning Detailed plans should be drawn up for the rapid distribution of stable iodine tablets to all people within the DEPZ. The effectiveness of the tablets for thyroid blocking depends on administration shortly before, or as soon as possible following, exposure to radioiodine. 60-70% blocking can be obtained at 3 hours, but 50% of radioactive iodine uptake will still occur at 5½ hours. As indicated in paragraph 3J.3 above, the combination of sheltering with the administration of stable iodine is important. Immediate sheltering followed by stable iodine at 3 hours can avert up to 95% of the dose to the thyroid, even after 6 hours sheltering the taking of stable iodine can avert up to 90%.
3J.14 Pre-Distribution Pre-distribution of stable iodine tablets to less accessible households or communities may have to be considered if detailed local feasibility appraisal concludes that no means can be found to effect distribution to them at the time sheltering was implemented. Before approval to pre-distribution is given, Scottish Executive Health Department should be consulted. [DN. Do we want to retain this?] A report should be submitted stating in clear terms the nature of the problem, attempts made and with whom to
overcome it, and details of arrangements for the safe storage and keeping in date of pre- distributed tablets.
3J.15 Issue Those who may be available to assist in the issue of stable iodine tablets include people employed by the site operator, emergency services and local authority, as well as NHSScotland staff. Sufficient manpower should be earmarked not only to issue tablets at reception centres, but also in circumstances where evacuation is not implemented and the population is advised to shelter. Those issuing tablets to the public and acting under the authority of the Director of Public Health will be indemnified by Scottish Ministers against legal liability arising from the issue of tablets.
3J.16 Advice to the Public When tablets are issued they must be accompanied by clear instructions on their use, on contra-indications and on any necessary follow-up. To facilitate this, leaflets have been printed and are stored with bulk stocks of the tablets. In the event of an incident in which there was no requirement for the issue of stable iodine, arrangements should be made for the public to be told that the risk from exposure to radioactive iodine had been assessed as being low and therefore tablets will not be issued.
Food Counter-measures
3J.17 The ingestion of contaminated food following an accident can be reduced by a wide range of controls and remedial actions, including measures introduced at the farm, the use of food processing and preparation, and controls or restrictions on the sale or distribution of foods. Controls may also be placed on the use of contaminated animal feeds. The most extreme, but often the simplest measure, particularly where food supplies are plentiful, is the banning of all food contaminated above a specified level. In any consideration of such measures NHS Boards should collaborate with representatives of the Scottish Executive Environment and Rural Affairs Department and the Food Standards Agency
3J.18 Regulations have been issued by the Council of the European Union specifying intervention levels (here termed CFILs) for radioactive contamination in marketed foods and animal feeds. The levels specified for foods are consistent with the latest advice from the International Commission on Radiological Protection (ICRP). If restrictions were imposed on food at the levels of the CFILs, then the doses received by most individuals in the UK would be very small. Estimates of the upper levels of dose that would be received are, at most, similar to those from natural radiation exposure. The Council Regulations do not provide intervention levels for drinking water supplies. NRPB recommends UK Action Levels for drinking water that are equal to the CFILs specified for liquid foods. The CFILs and NRPB’s Action Levels for drinking water supplies are listed in the tables below:
Council Food Intervention Levels in Major Foods (Bq/Kg)*
Radionuclide Baby Food Milk & Cream Other Foods Liquid Foods (not minor foods)
Isotopes of strontium 75 125 750 125
Isotopes of iodine 150 500 2000 500
Alpha-emitting isotopes of 1 20 80 20 plutonium and transplutonium elements
Others 400 1000 1250 1000 (t½ > 10 days)
* These levels are associated with specific exclusions and restrictions, as detailed in the Council Regulations.
UK Action Levels for Drinking Water Supplies
Radionuclide Action Level (Bq/1)
Isotopes of strontium 125
Isotopes of iodine 500
Alpha-emitting isotopes of plutonium and 20 transplutonium elements
Others (t½ > 10 days) (excluding tritium, carbon-14 1000 and potassium-40)
APPENDIX 4 TO ANNEX J
CASUALTY RECEPTION AND TREATMENT
4J.1 All persons involved in a radiation accident should be carefully interviewed; a full, detailed description of the radiation situation should be made as soon as possible. For purposes of dose assessment it is often useful, by means of a diagram, to show the position of each person present at the accident site.
4J.2 The first priority is the treatment of life-threatening injuries (shock, bleeding, thermal burns, fractures etc.) by whichever type of specialist is appropriate for the condition.
4J.3 The second priority is the assessment of the extent and magnitude of contamination, and decontamination as necessary. Any person with external contamination should be specially and separately treated. The most effective decontamination procedure is washing, subject to control by monitoring. (See Appendix 5).
4J.4 The third priority is that if there is suspected internal contamination, a quick assessment of its nature and degree should be made so that appropriate measures to reduce internal contamination may be started as soon as possible.
4J.5 Suggested Management Criteria
Type of Exposure Possible Consequences Treatment I. EXTERNAL Localised erythema with Clinical observation and EXPOSURE possible development of treatment. Localised Exposure blisters, ulceration and more often to hands necrosis Specialist advice may be sought. Total or partial body No clinical manifestation for Clinical observation and exposure 3 hours or more following symptomatic treatment. with minimal and delayed exposure. Not life Sequential haematological clinical signs threatening. Minimal investigations. haematological changes Total or partial body Acute Radiation Syndrome of Start treatment as above exposure mild or severe degree with early prodromal signs dependent on dose Specialist advice should be sought Patient requires specialised treatment. Full blood count and HLA typing are essential before transfer to a designated hospital if feasible. Total or partial body Possible severe combined Treat life-threatening exposure injuries, life threatening conditions. with thermal, chemical or radiation burns and/or Recommended that early trauma transfer to a specialist hospital should take place.
Meanwhile carry out actions as above.
II. EXTERNAL Low level contamination Decontaminate skin and CONTAMINATION intact skin which can be monitor. Unlikely. Possible mild cleaned promptly radiation burns. Possible radiation burns. Low level contamination Specialist advice may be Possible percutaneous intake intact skin where cleaning is sought. of radionuclides delayed Possible internal Low level contamination Specialist advice should be contamination with thermal, chemical or sought. radiation burns and/or trauma Likely internal contamination Extensive contamination Specialist advice should be with associated wounds sought. Possible severe combined Extensive contamination First aid, plus treatment of injuries and internal with thermal, chemical or life threatening injuries. contamination radiation burns and/or trauma. Early transfer to a specialist hospital is recommended. III. INTERNAL Inhalation and ingestion of + CONTAMINATION radionuclides insignificant Specialist advice should be No immediate consequences. quantity (activity) sought No immediate consequences Inhalation and ingestion of Nasopharyngeal lavage radionuclides important. Early transfer to a significant quantity (activity) specialist hospital is essential to enhance excretion of radionuclides.
No immediate consequences. Absorption through + damaged skin Specialist advice should be (see II above) sought. Severe combined radiation Major incorporation + injury. with or without external Treat life threatening total, or partial body or conditions and transfer to a localised irradiation, serious specialist hospital. wounds and/or burns
+ Stable iodine should be administered to casualties who have potentially been exposed to radioactive iodine; if the casualty’s condition precludes administration specialist advice should be sought.
4J.6 Laboratory Samples The following samples should be collected from patients who may have incurred internal radiation. All biological samples should be retained for subsequent analysis.
A. Blood, approximately 20-30ml for the following analyses:
1. Full blood count 2. Cytogenetic analysis (24 hrs after exposure is optimum time) 3. Biochemical analysis (serum amylase) 4. Analysis for radionuclide content
B. High Nasal (bilateral) and throat swabs - dry swabs stored in labelled holders without transport medium. Should be taken as early as possible and the time recorded. Will need to be sent to laboratory specialising in the measurement of radionuclides.
C. Urine:
1. Routine analysis 2. Biochemical (creatinuria) 3. Analysis for radionuclide content
D. Stools (for estimation of radionuclide contents).
4J.7 The following initial decontamination procedures should be followed:
• Experience has shown that washing with water will effectively remove contaminated material from the skin in most cases. Initial treatment and any necessary washing to remove as much of the suspected contamination as practicable should be done in the controlled area.
• Open wounds should be irrigated and the irrigate saved and labelled. Special care needs to be taken to prevent the spread of possible contamination to other parts of the body and in the cleaning of areas near the eyes and mouth.
• It is inadvisable to excise wounds unless contamination is obvious, or unless surgically indicated, before monitoring assistance is available.
APPENDIX 5 TO ANNEX J
RADIATION MONITORING FOR MEMBERS OF THE PUBLIC
ESTABLISHING A RADIATION MONITORING UNIT
5J.1 The RMU should, where possible, be located at, or adjacent to, a reception centre established by the local authority and specified in the site Emergency Plan. However, suitable NHS or other premises nearby may need to be utilised. Police and the local authority should be consulted when selecting a site. Premises with the following facilities will be required:
• A segregated area where potentially contaminated people can await monitoring. Direct access from outside is desirable; control is needed to prevent their mixing with people known to be free of external contamination.
• An area adjacent to it for external contamination monitoring.
• An area immediately adjacent to that which can be used for decontamination of people. It should have running hot and cold water for washing and, if possible, showering facilities.
• A separate area adjacent to the external monitoring area where internal contamination monitoring can take place.
• Storage for spare outdoor clothing and shoes.
• Storage, well separated from other areas, for contaminated clothing and other contaminated material which may include valuables such as personal jewellery.
• A reporting/recording area with telephone and fax.
• An area, well separated from the monitoring areas, reserved for counselling concerned individuals.
• Separate exit.
It is advisable to develop layout plans for the RMU in advance.
Those attending the RMU should be given a leaflet describing what will happen to them and why. The leaflet should instruct people to minimize movement within the waiting area; this will reduce the possibility of cross-contamination.
Suggested Operational Protocol for the RMU
5J.2 The responsibility for operation of the RMU will lie with the most senior Medical Physicist present. Staffing
5J.3 Typical staffing might be:
• Medical Physicist in charge • Medical Physicist/Technicians (or similar grade staff from other organisations) • Nurses • Clerks
Arrangements exist in some areas for the nuclear site operator to provide additional staff capable of carrying out monitoring measurements. NRPB may also be able to provide staff to assist with monitoring.
Equipment
5J.4 The following monitoring equipment is suggested:
• contamination monitors e.g., Mini Instruments EP15, Nuclear Enterprises BP4, Berthold LB1210B;
• iodine-in-thyroid monitors e.g., Mini 44A or 44B with ratemeter;
• check sources.
In addition, spare instruments of each type in use should be available. A suggested list of other specialised equipment is at the end of this Appendix.
Preparation of the Unit
5J.5 It is suggested that the following steps should be taken to prepare the area:
• Clear all unnecessary furniture if time allows.
• Identify the areas to be used for the purposes specified in 5J.1 taking due account of the needs of individual dignity/modesty. If necessary, use partition screens and tape barriers to create separate areas.
• Arrange the waiting area in a way that discourages unnecessary movement, perhaps by setting up a queue using tape barriers. Chairs may be provided but must be covered with polythene sheet, to be removed when the person leaves the waiting area.
• Place “tacky mats” (disposable mats with an adhesive surface that removes contamination from the soles of shoes) at all entrances and exists to the area.
• Cover heavily used areas of the floor throughout the RMU (e.g., doorways) with e.g., heavy-duty paper. The floor area between the monitoring area and the decontamination area must be covered. Tape all joins. • Fix signs at the entry and exit to the RMU prohibiting entry to unauthorised persons.
• Provide protective clothing for the staff.
• Each staff member should ensure that they have been provided with the necessary equipment and supplies to carry out the task to which they are allocated.
Operational Protocol for a Nuclear Power Reactor Incident
5J.6 The operational protocol suggested for a nuclear power reactor incident resulting in release of fission products is summarised in the following flow diagram. It illustrates the decisions to be made and the sequence of events for each person entering the RMU. A discussion of 'action levels' and the various stages in the process follows.
COMMENTS SCREENING ACTIONS
Monitor on entry to STAGE 1 RMU Rapid screening for 1. Remove clothing external contamination 2. Decontaminate
È 3. Measure remaining contamination Carry out actions promptly Above Action Level A? Æ Yes 4. Send to hospital È No
Monitor head, hands, elbows STAGE 2 feet, buttocks Screening for external contamination Å 1. Wash or shower at RMU Repeat screening and È 2. Change clothing washing once if Above Action Level B? Æ necessary, then proceed Yes È No A------B
All individuals to be screened STAGE 3 Screening for internal contamination (e.g. thyroid) •Thyroid measurement È •Whole body measurement Measurements made Å •Refer for long-term follow-up to assess internal Prioritise measurements dose ------Æ •Advise to return home, shower È and change Report monitoring results to individual and STAGE 4 RIMNET CDF Reporting and Counselling Action Levels
5J.7 Appropriate action levels would be recommended at the time of the accident by NRPB, taking account of the specific circumstances of the accident, and in particular the radionuclide composition of the release. Illustrative values for action levels are given below for planning purposes only.
5J.8 Action Level A should be set so as to identify levels of contamination that could cause deterministic effects on skin (radiation burns), or that could result in committed effective doses of the order of 10 mSv if the activity is ingested. In most cases, the latter criterion is more restrictive than the former, and satisfying it therefore leaves a margin of safety for the avoidance of deterministic effects. Ingestion dose coefficients are generally higher for children than for adults, and so the former must be used when setting the Action Level. If it is assumed that activity distributed over an area of skin of 10cm2 might be ingested before the contamination is removed by normal processes, then the intake criterion corresponds to an activity concentration of the order of 104 Bq cm-2 for a typical β-emitter such as 131I. The localised skin dose rate from contamination of 104 Bq cm-2 over an area of 10cm2 would be of the order of 10 mSv h-1. The corresponding reading on an EP15 contamination monitor would be about 100 counts per second at a distance of 30cm from the contaminated area. (Note: full scale on the EP15 is 600 counts per second).
5J.9 Action Level B should be set so as to identify those who are externally contaminated at lower levels, but for whom immediate decontamination at the Unit is still justified. The action level should be based on prioritising the use of the available decontamination facilities to benefit those in most need, and on the general ALARA principle of taking simple steps to minimize doses. It is not a boundary between high and low risk. In setting it, account would need to be taken of the available resources and numbers requiring monitoring. For example, an action level of 300 counts per second at a distance of 1cm from the contaminated area measured using an EP15 monitor would correspond to an activity of about 1000 Bq distributed over an area of 10cm2. This could give rise to an ingestion dose to a child of the order of 0.1 mSv for a typical β-emitter such as 131I, or a localised dose rate to the skin of the order of 0.1 mSv/hour.
Stage 1
5J.10 People arriving at the facility should be rapidly screened to identify those in need of urgent decontamination. (If the person is identified as someone who has earlier been asked to evacuate or shelter or who has been offered stable iodine, then that person should be given priority for the rapid screening measurement and for subsequent monitoring measurements.) This is the first priority of the facility because the actions to be taken will reduce the risk of injury, even though it is extremely unlikely that such levels of contamination would occur. It is important to identify and treat such people as quickly as possible so as to maximise the dose reduction (they should not be kept waiting while others are monitored), and also to reduce the potential for them to contaminate other people and the facility. If Action Level A is exceeded, the person should be sent immediately for decontamination. A measurement should then be made of the amount and location of any surface contamination remaining. All persons who exceed Action Level A on the first measurement must be sent directly to a hospital designated to receive contaminated casualties.
5J.11 Persons found to be below Action Level A should proceed to the second stage of external contamination screening (waiting in a segregated part of the reception area if necessary).
5J.12 The tasks of Stage 1 could be carried out by one medical physicist, one nurse and 2 clerks. A throughput of about 100 per hour should be possible (although additional clerks would be needed to achieve this). If levels of contamination above Action Level A are
encountered, then additional nursing staff would be required to carry out decontamination procedures.
Stage 2
5J.13 Here, more detailed contamination monitoring would be carried out. Persons found to be above Action Level B should proceed to the decontamination area. Measurements above this action level should be recorded, those below it only if time permits. Following decontamination, the person should return for a second screening measurement. One further pass through the decontamination procedures may be advised, but the person should then pass on to Stage 3. Persons below Action Level B could be advised to shower and change as soon as convenient on their return home if this is considered necessary.
5J.14 Persons remaining between Action Levels A and B after decontamination could have a wide range of levels of external contamination. Action Level B would be set on the assumption that activity on the skin would be removed within a few days by normal processes. Consideration should therefore be given to carrying out follow-up measurements after a few days have elapsed.
5J.15 The tasks of Stage 2 could be carried out by teams consisting of one medical physicist, one clerk to record measurements, and one nurse working in the decontamination area. A team would have a throughput of about 20 per hour (assuming most do not need decontamination). To deal with 300 people, at least 3 such teams would therefore be advisable.
Stage 3
5J.16 It is possible that internal contamination may be found in circumstances where no external contamination is present (e.g., the person may already have washed and changed clothes; intake may have been by ingestion, etc.). If the accident resulted in release of radioiodine then measurements of iodine-in-thyroid using hand-held detectors would be the most useful screening method. For other accidents involving fission products, similar measurements of, for example, the chest or abdomen may be feasible, depending on the circumstances of the release.
5J.17 Monitoring results should be used to prioritise people for more accurate uptake measurements, probably comprising iodine-in-thyroid measurements and whole body measurements of other fission products. This prioritisation could include the use of an exemption level below which no further measurements are required. All screening measurements should be recorded, as it may be feasible to use them to provide dose estimates. 5J.18 Body monitoring facilities for uptake assessments could be provided by some medical physics departments. NRPB may be able to provide additional facilities, including a mobile body monitoring system. Some nuclear industry site operators may also be able to provide assistance.
5J.19 The tasks of stage 3 could be carried out by teams consisting of one medical physicist and one clerk to record measurements. A team would have a throughput of about 50 per hour.
5J.20 Internal contamination monitoring has a lower priority than external contamination monitoring. Resources may need to be fully utilised in order to complete the latter within a reasonable time, and in such circumstances it would be acceptable to delay internal monitoring. For instance, individuals who have passed through the external contamination resources for internal contamination monitoring become available.
Stage 4
5J.21 Arrangements should be made for recording the monitoring results of each person passing through the Unit. Monitoring will fall into 2 categories:
a. internal contamination;
b. external contamination.
Examples of report forms are at the end of this Appendix.
5J.22 NHSScotland Medical Physics Departments that wish to submit internal monitoring data to the RIMNET Central Database Facility (CDF) need to be Approved RIMNET Data Suppliers. This status can be achieved via a number of routes. One of these is through the Department of Health which will accredit hospitals that meet specific criteria already demonstrated under the Medicines (Administration of Radioactive Substances) Regulations 1995. This route, unlike others, will not incur cost. Hospitals participating in this scheme will send data to NRPB, in its capacity as co-ordinator of monitoring information.
5J.23 The same departments will be invited to submit summaries of external monitoring data to NRPB. These will not be entered onto the RIMNET CDF, but will give valuable information in the context of population exposure. Details of this scheme, including the accreditation process and precise data formats, will be given under a separate notification.
5J.24 Results of monitoring should also be reported to the individuals monitored. Any doses assessed should be reported, but information given will need to be put into the context of implications for health. This could be achieved by providing a report form, prepared in advance, for the various categories defined in the screening process. An example of such a report form is attached. Trained staff should be available for counselling concerned individuals.
Control of Contamination in the Radiation Monitoring Unit
5J.25 If external contamination is found on persons being monitored, then a member of staff should be allocated to the task of monitoring and controlling contamination of the RMU. Heavily used areas should be regularly monitored, with particular attention paid to tacky mats, floors and seating. Tacky mats and polythene covers should be replaced regularly. Thyroid monitoring probes should be sealed in polythene bags when in use. Checks on background count rates for all of the monitoring instruments in use should be made frequently. Monitoring and decontamination staff should use protective, disposable clothing, and should avoid direct contact with persons being monitored. The Physicist in Charge should be kept informed.
5J.26 Conversely, if external contamination is not found, then contamination control measures should be relaxed as soon as possible in order to minimize unnecessary alarm in members of the public.
Staff Duties
5J.27 Reception/Waiting Area Team
(a) Medical Physicist
• Carry out rapid screening for external contamination on people as soon as possible after they arrive at the Unit, as discussed in paragraphs 5J.10-15. The screening measurement could be made on people queuing in the waiting area, or at the entrance to the Unit provided this does not cause queues to build up outside the Unit. Using an EP15 or similar instrument, rapidly scan (in about 20 seconds) the body at a distance of about 30cm, concentrating on head, hands, elbows, feet, buttocks. If Action Level A is exceeded, then send the person immediately to the decontamination area, first removing and bagging shoes if they are contaminated; overshoes should be provided.
(b) Clerks
• Give appropriate directions to people at the entrance to the Unit. Fill in parts 1 to 9 of the Report form for each person. If the person is identified from the answer to part 2 as someone who has earlier been asked to evacuate or shelter, or who has been offered stable iodine, then that person should be sent immediately for the rapid screening measurement. Otherwise, send people one at a time for rapid screening as requested by the medical physicist. Pass on the Report form. Do not step onto uncovered floor areas.
All staff members should remain in the waiting area until the last person has been sent through. Then pass through the monitoring areas to be checked for contamination before leaving the unit.
5J.28 External Contamination Monitoring Area Team
Medical Physicist and Clerk
• Carry out the second stage screening for external contamination, as discussed in paragraphs 5J.13-15. Using an EP15 or similar instrument, scan the body slowly at a distance of about 1cm, concentrating on those areas of the body most likely to have been contaminated (head, hands, elbows, feet, buttocks). The full scan should take at least 3 minutes.
• Identify contaminated areas on the Report form and indicate the measured count rates, and the instrument type. If the person is being re-monitored, indicate that this is the case.
• Where contamination exceeds Action Level B, ask the person to proceed to the decontamination area, first removing and bagging shoes if they are contaminated;
overshoes should be provided. Pass the report form to the nurse. On return from the decontamination area, the person should be monitored immediately.
• Where contamination is found to be below Action Level B, ask the person to proceed to the internal contamination monitoring area. Pass the report form to the staff member there.
• Ask for the next person from the waiting area but do not step on to the covered floor area. After all people from the waiting area have been checked and passed through to the internal contamination monitoring area, monitor each other and then proceed into that area to be checked before leaving the unit.
5J.29 Decontamination Area Staff
• Carry out decontamination procedures discussed in paragraphs 5J.10-15. These are similar for Stage 1 and Stage 2, but would clearly be more urgent for Stage 1.
• Ask the person to remove contaminated clothing. This, together with shoes, should then be bagged, given an identifying tag, and stored. A receipt for contaminated clothing, jewellery etc. must be given.
• Encourage and assist the person to remove contamination from the identified area(s) using soap and water. Light scrubbing may be used but care must be taken to avoid damaging the skin, or spreading the contamination to other parts of the body or into cuts and grazes. The person may shower, but it is important to avoid washing radioactive material into the nose or mouth. Ordinary towels should be used for drying; they should then be bagged and stored.
• Provide any necessary alternative clothing.
• Ask the person to go to the external contamination monitoring area. Pass the Report form to the staff member there. • Do not enter the external contamination monitoring area until all persons have been checked. Then proceed to the external contamination monitoring area to be monitored.
5J.30 Internal Contamination Monitoring Team
• Carry out the internal contamination monitoring as described in paragraphs 5J.16- 20. Using Mini Instruments Type 44A or similar instrument, position the end of the probe at the front of the neck, as close as possible without making contact. The measurement should take approximately one minute.
• Record the measured count rate and ask the person to proceed to the Physicist in Charge. Pass on the Report form.
5J.31 Physicist in Charge
• Supervise the layout of the RMU before admission of the first person. People may be allowed to proceed to the reception and waiting areas once they are ready and staffed. Subsequent preparation of the RMU will then be carried out from the internal contamination monitoring end.
• Once people have entered the external contamination monitoring area, there must be no movement of staff against the direction of flow (with the exception of any staff member assigned to contamination control).
• Depending on the level of contamination found, decide what further external or internal contamination measurements are necessary and give each person an information sheet (see Report form). Arrange for attendance at an Uptake Measurement Unit if appropriate. Record the details in sections 10 and 11 of the form.
• Discuss with the Radiation Protection Adviser the arrangements for dealing with contaminated clothing and valuables. Consider decontamination of any clothing and provision of alternative outdoor clothing.
5J.32 Decommissioning of the Radiation Monitoring Unit
• The Physicist in Charge will be responsible for planning and carrying out decommissioning of the unit.
• When all people have passed through the RMU, a full survey of all areas including the entrance should be made to identify contaminated surfaces. All contaminated objects should be placed in polythene bags. Contaminated sheeting should be folded and also placed in polythene bags.
• All bags containing contaminated waste should be sealed, labelled with the maximum count rate measured at the surface of the bag, and removed for storage. Request advice from the Radiation Protection Adviser on disposal.
• A final radiation survey should be arranged before the area is put back into general use.
Operational Protocol for a Nuclear Weapons Accident
5J.33 Similar arrangements for external contamination monitoring as for a nuclear reactor accident could be put in place. The relevant stages in the screening process are those shown in the preceding flow diagram above the line A---B (see para 5J. 6).
5J.34 Contamination would be by alpha-emitting radionuclides, and so action levels would need to be set on the basis of inhalation or ingestion of material deposited on the skin, rather than on the basis of deterministic effects to the skin. If it is assumed that activity distributed over an area of skin of 10cm2 might be inhaled before the contamination is removed by normal processes, then a committed effective dose of the order of 10 mSv could result from an activity concentration of the order of 30 Bq cm-2 of 239Pu oxide. A value for Action Level A set so as to identify this level of contamination would correspond to a reading on an EP15 contamination monitor of 15 counts per second at a distance of 1 cm. (Note that
although not intended for alpha measurements, this type of instrument is sensitive to alpha radiation.) A value for Action Level B would be determined from a consideration of available resources, as discussed in previous sections.
5J.35 External contamination screening measurements could be used to prioritise people for subsequent internal contamination measurements. These would include radiochemical analysis of urine and faecal samples, and lung monitoring using specialised detectors. Facilities for carrying out such measurements are available primarily within the nuclear industry. The NRPB would advise on available resources. Assistance would be provided by MoD personnel at the site of the accident.
SUGGESTED LIST OF SPECIALISED EQUIPMENT FOR RADIATION MONITORING UNIT
Equipment for controlling movement Warning signs Barrier tape Barriers
Protective clothing Paper Coveralls (e.g., Tyvek) Latex gloves (large, medium, small) Plastic overshoes
Material for prevention of contamination Tacky mats Small polythene bags Polythene sheeting and Kraft paper Vinyl sealing tape
Personal decontamination equipment Mild soap Lanoline Dilute Cetrimide Plastic sponges Soft nail brushes Towels Polythene bags (to hold clothing etc.) Adhesive labels with trefoil symbol Disposable trousers, tops, slippers
Building decontamination equipment Polythene buckets Decon Soap powder Plastic sponges Scrubbing brushes
Stationery and communications Record forms, Information sheets Notebooks Wax pencils FAX machine
Monitoring instruments See paragraph 5J.4
DO NOT UNDER-ESTIMATE THE AMOUNTS REQUIRED
EXAMPLE OF A SUBJECT REPORT FORM
QUESTIONNAIRE FOR USE AT RADIATION MONITORING UNIT
A. To be completed on arrival
1. Name (Title, Forename, other initials, Surname):
2. Have you been asked:
a. to evacuate; or YES/NO b. to shelter; or YES/NO c. have you been offered stable iodine? YES/NO
3. Date of Birth (Day/Month/Year):
4. Sex:
5. Address:
Telephone No: (Home) (Work)
6. Date and time of arrival at Radiation Monitoring Unit:
7. Details of movement during the emergency:
8. Have you seen or been treated by your GP or any hospital within the past month? If so, please give details:
9. Name and Address of GP:
B. To be completed after monitoring, form to be retained by Physicist in Charge
10. Report Form issued:
Follow-up action necessary: 11 12 13 14 15 (circle one)
EXAMPLE OF A MONITORING/CONTAMINATION REPORT FORM
EXTERNAL CONTAMINATION REPORT FORM
To be retained by the Physicist in Charge
Area of Body Count rate (s-1) Instrument
Before After Decontamination Decontamination
Head
Left/Right Hand
Left/Right Elbow
Feet
Buttocks
Other
INTERNAL CONTAMINATION REPORT FORM
To be retained by the Physicist in Charge
Radionuclide Count rate (s-1) Activity (Bq) Effective Dose (if estimated) (mSv)
THYROID
WHOLE BODY
OTHER
REPORT FORM (Delete paragraphs not applicable)
To be retained by the person monitored
YOU ATTENDED THE RADIATION MONITORING UNIT AT ...... ON ......
11 Monitoring has been carried out, and no radioactive contamination has been detected. No further action is required.
12 Monitoring has been carried out. A small amount of radioactive contamination has been detected on your skin. You are advised to return home, take a shower or bath as soon as convenient, put on clean clothes and wash those you were wearing; no further action beyond this is required.
13 Monitoring has been carried out. A small amount of radioactive contamination has been detected on your skin. You should have already been offered facilities to wash, and to change your clothing, in order to remove this material. No further action is required.
14 Monitoring has been carried out. A small amount of radioactive contamination has been detected on your skin. You should have already been offered facilities to wash, and to change your clothing, in order to remove this material. You should attend the Uptake Measurement Unit at ...... hospital for follow-up measurements. The hospital Medical Physics Department will contact you within a few days with appointment details. Further information and advice will be given.
15 Monitoring has shown that you may have swallowed or inhaled small amounts of radioactive material. You should attend the Uptake Measurement Unit at ...... hospital for follow-up measurements. The hospital Medical Physics Department will contact you within a few days with appointment details. Further information and advice will be given.
Other Information:
If you have any concerns or wish to discuss this matter further, please contact your GP.
Signed ...... Physicist in Charge ......
RESPONDING TO EMERGENCIES: ANNEX K
RECEPTION AND TREATMENT OF CASUALTIES FROM ABROAD
K1 While the NHS in Scotland is established to meet the health care needs of people resident in or visiting Scotland, it may at short notice be required also to provide treatment and care for UK armed forces casualties evacuated here from any military operations or training being conducted overseas. This Annex outlines arrangements developed for that contingency, but these should also provide a basis for planning for the reception and treatment of other categories of casualty which might be brought to this country.
MILITARY OPERATIONS
K.2 There is a wide range of scenarios in which the UK armed forces might become operationally engaged and incur casualties. Medical resources deployed to an operational theatre will usually be organised in 3 tiers:
K.2.1 Pre hospital resources moving with combat units able to provide immediate care, stabilisation and resuscitation.
K.2.2 Forward hospital resources keeping close enough to combat units to enable seriously injured casualties to receive life saving resuscitation surgery within 2 hours of injury and life sustaining primary surgery within 4 hours.
K.2.3 Main hospital resources which may be up to 500 miles from the forward facilities and with specialist teams able to undertake the balance of necessary primary surgery. The need to retain capacity to treat incoming casualties will determine what further treatment is provided in the operational theatre beyond that necessary to prepare casualties for their evacuation to UK.
K.3 Evacuation of casualties to UK will normally be by air using aircraft adapted to the role and with accompanying medical/nursing staff. Plans exist to rapidly augment RAF aeromedical evacuation capacity with civil airliners when necessary. The UK destination airfield will be as close as possible to the hospitals(s) at which the casualties are to be treated.
K.4 Casualties evacuated from "low intensity" military operations, such as the support of peace-keeping in Bosnia, or those who become ill or are injured in peacetime garrisons or military training overseas will most often be sent to UK hospitals with Defence Medical Services' staff, either the Royal Hospital, Haslar, or an NHS hospital containing a Ministry of Defence Hospital Unit. However as soon as "higher intensity" military operations are expected, those Defence Medical Services personnel will be used to bring overseas theatre and evacuation resources described at paras K.2 and K.3 above to full strength. Then, or at any time should an unexpectedly high number of "low intensity" operational or training casualties occur, military casualties evacuated to the UK will be passed directly to the NHS for treatment and care.
IMPACT ON NHS
K.5 Such is the range of possible scenarios and circumstances that any estimate of casualty numbers must be very tentative. However military planning assumptions include that a future engagement might include a period of up to 4 days continuous "high intensity" conflict. It is estimated that this which could lead to the evacuation to UK of up to 6000 battle casualties, some 10% of whom might come to Scotland. For planning purposes the NHS in Scotland should thus be prepared to receive a peak flow of some 600 battle casualties for treatment and care within a few days starting some 48 hours after the commencement of "high intensity" conflict. In addition to UK military casualties, assistance might be required to support the care of US or other allied nations' casualties.
CASUALTY DISTRIBUTION
K.6 The overall allocation of casualties to the NHS in Scotland will be determined by Scottish Executive Health Department in consultation with the other UK Health Departments and the military authorities, taking account of up-to-date information on casualty numbers and treatment needs and the availability of NHS capacity. NHS Boards should be prepared to provide collated information when required on the availability of treatment resources within their areas in order to inform decisions.
K.7 Each incoming casualty evacuation aircraft is likely to contain patients whose needs range from immediate specialist hospital treatment, through less urgent hospital in-patient care, hospital out-patient care to care in the community. To ease handling problems, the number of casualties on each flight will where possible be limited; 50 is a planning figure.
K.8 Civil and military airfields throughout the UK have been surveyed for suitability and handling facilities to receive the range of aircraft types which might be used for casualty evacuation flights, and a number have been selected for use as casualty reception airheads.
K.9 The distribution of casualties to appropriate treatment facilities will be for local determination. Named NHS Boards are to assume responsibility for this in respect of the following Scottish Airheads:
K.9.1 Glasgow Airport Greater Glasgow (assisted as necessary by Argyll and Clyde) K.9.2 Edinburgh Airport Lothian K.9.3 Prestwick Airport Greater Glasgow (assisted as necessary by Ayrshire and Arran) K.9.4 RAF Leuchars (not all aircraft Tayside (assisted as necessary by Fife) types can be handled) K.9.5 Aberdeen Airport (not all aircraft Grampian types can be operated) K.9.6 RAF Kinloss Grampian K.9.7 Inverness Airport (limited aircraft Highland types only)
NHS RECEPTION ARRANGEMENTS
K.10 Planning. The period of tension which will generally precede an outbreak of hostilities should allow time for the preparation of detailed plans. However Greater Glasgow and Lothian NHS Boards should maintain outline plans able to be activated at 48 hours notice in respect of Glasgow and Edinburgh airports.
K.11 Preparation. As soon as the arrival in Scotland of a casualty evacuation aircraft is contemplated, Scottish Executive Health Department will alert the appropriate NHS Board and arrange for details of casualties to be forwarded directly to it by the military authorities (likely to be the Medical Evacuation Cell (MEC) at HQ Land Command) as they become available. This will allow the Board, in consultation with NHS Trusts and the Scottish Ambulance Service, to make a provisional allocation of casualties to hospitals or other facilities.
K.12 Reception. Arrangements at the Airhead should be based on those for the site of a major incident as described in Section 3 of this Guidance. Details should be determined in consultation with airport management, the ambulance service, police and military representatives. The NHS Reception Team should be led by a doctor (Medical Incident Officer) who on receipt of up-to-date information from the flight medical team will be able to confirm or modify the provisional distribution plan and direct the ambulance service (Ambulance Incident Officer) accordingly. While advance information should assist in determining the composition and equipment of any site medical team, it should have sufficient capacity to care for casualties whose condition may have deteriorated in flight. Clinical responsibility for patients transfers to the NHS on their disembarkation including patients whose condition does not require their admission to hospital.
K.13 Security. Information about preparations for the receipt of military casualties, and any details about those casualties will normally be highly sensitive. Both preparations and arrival of military casualties are also likely to generate considerable media interest. All staff involved should be briefed accordingly and police advice and assistance should be sought to maintain the security of reception arrangements and, where necessary, receiving hospitals.
FURTHER GUIDANCE
K.14 More detailed guidance will be issued in advance of any planned military operation in which the evacuation of casualties to the NHS is anticipated.
RESPONDING TO EMERGENCIES: ANNEX L
COMMUNICATIONS
L1 The rapid, accurate and assured passage of timely information from, to and between everyone involved is fundamental to the effective management, support and delivery of every NHS service. Any major emergency will inevitably and immediately create demands for significantly more and wider exchange of information than under routine conditions.
NORMAL NHS COMMUNICATIONS
L2 While physical means of transferring information (messengers, couriers, mail) continue to play an important part in NHS communications, the NHS has become increasingly dependent on telecommunications (telephone, radio, fax, e-mail, other computer linkages, video, paging) to the extent that any significant loss or constriction of service would itself constitute a major emergency. It is important that local co-ordination of NHS requirements for telecommunications services and of how they are met (MEL(1996)80) takes due account of this and that NHS Boards and Trusts regularly assess and test the readiness, resilience, suitability, flexibility and capacity of their communications systems and procedures so that the right information will always reach the right people, in the right form and at the right time.
L3 No telecommunications system can be relied upon absolutely. No system can be made totally immune to component failure, damage or interference whether man-made or natural. Every telecommunications system has a finite capacity and if overloaded will cease to fulfil its purpose. Chief Executives and General Managers will wish to satisfy themselves that their telecommunications managers/service providers have taken such factors into account and that communication links of a "mission-critical" nature have been properly identified, afforded appropriate protection (e.g. priority network access, separation of incoming/outgoing traffic, more than one power source, connection to more than one switch or exchange, priority fault repair) and where necessary, alternative stand-by links on separate systems (electronic and/or physical) are kept immediately available. Clearly staff who may have to use alternative systems need to be practised in their use.
L4 Emergency Communications Requirements The routine processes of planning and preparing for response to emergencies of every kind must include assessment of all possible needs for communication to achieve the mobilisation of that response and for its management, co-ordination and support. Such emergency communication requirements should be considered as part of the total "normal" NHS communication requirement and be provided for and managed accordingly. Wherever possible, systems tried, tested and familiar through everyday use should be those used to support emergency response. By definition, communications equipment and links necessary to NHS emergency response must be regarded as "mission-critical" as described in paragraph L3 above and given appropriate protection and/or back-up.
PUBLIC TELECOMMUNICATIONS NETWORKS
L5 Overloading of the public telecommunications networks is a likely consequence of a major emergency. To enable their networks to continue to operate, operating companies will
institute measures to manage access to them. On certain networks priority access schemes are available. Essential NHS lines may qualify under the following schemes:
L5.1 Government Telephone Preference Scheme (GTPS)
• Operated by BT in conjunction with some other operators on behalf of the Government, GTPS provides for a small proportion of lines connected to a public telephone exchange to retain outgoing service when others are barred. It would come into operation only if an intolerable burden was placed upon the public switched telephone network. • Preference Category I is for lines vital to the prosecution of war and to national survival after an attack on UK and is limited to 2% of lines connected to an exchange. Lines serving the following may be considered for designation as Category I:
¾ Area Health Boards ¾ NHS and private hospitals ¾ Common Services Agency including SNBTS and Supplies Division ¾ Scottish Ambulance Service ¾ Manufacturers, distributors and wholesalers of pharmaceuticals and other essential medical equipment and supplies
• Preference Category II is for additional lines necessary to maintain the life of the community during a civil emergency. Categories I and II combined cannot exceed 10% of lines connected to an exchange. In addition to further lines serving those qualified for Category I, the following may be considered for designation as Category II:
¾ NHS Clinics/Dentists/Doctors: Business lines only. Residential lines will continue to be able to receive calls. ¾ Community Nurses/Midwives ¾ Pharmacies ¾ Home dialysis and certain other patients whose treatment demands it.
• Bids for preference should be restricted to the absolute minimum and have regard to alternative means of communication eg, private networks (such as NHS Net), private wires, radio. Where a requirement exists for preference treatment to be provided through a private branch exchange (PBX), this may require equipment modification. Where the telecommunications service is provided by an operator other than BT or Cable and Wireless, it may nevertheless involve connections via their local exchanges and GTPS might be available on those lines. • Local arrangements for the co-ordination of telecommunications (see paragraph L2 above) should include periodic review and update of designated GTPS numbers and for the establishment and maintenance of liaison with designated BT/Cable and Wireless contact points.
L5.2 Access Overload Control (ACCOLC) for Cellular Radio Systems
ACCOLC is a control programme which the cellular radio network providers (e.g., Vodafone, Orange) each implement to ensure that in an emergency, essential users of mobile phones are afforded priority access to calls on their network which would otherwise become congested by non-essential users. When implemented, only mobile phones registered and modified under the scheme are able to initiate calls in the area of the network cells to which it is
applied; ACCOLC does not affect unmodified mobile phones' ability to receive calls. For ACCOLC to be effective, it is essential that the number of modified phones be kept to the absolute minimum.
• In the event of an emergency, ACCOLC will normally be invoked by network operators only when requested individually to do so by the police, and then only in radio cells covering the scene of the emergency. The police will usually only request ACCOLC activation when normal emergency services communications systems prove insufficient. • Bids for the registration of NHS mobile phones whose use to initiate calls at the scene of a major emergency is judged essential should be submitted in the first instance to Scottish Executive Health Department (Emergency Planning Unit).
L6 Any emergency in which an NHS organisation is involved is likely to result in a significantly increased number of incoming calls from the public networks. These may include enquiries from casualties' relatives, from other members of the public, offers of assistance and the news media seeking information. The handling of each different type of call may require the rapid reinforcement of switchboard operators with separate groups of appropriately prepared staff. The ready availability of sufficient lines and terminal equipment should be ensured as described in para L3 above.
EMERGENCY COMMUNICATIONS ASSISTANCE
L7 Should, in an emergency, established communications systems fail to meet demand, suffer damage or unforeseen requirements arise which are essential to management of the emergency, assistance may be sought from the appropriate NHS Net provider, BT or Cable and Wireless Communications. These operators have agreed to pool resources in such circumstances.
Emergency Contact Numbers:
BT 0345-555999 CWC 0500-050748
L8 A number of organisations operate their own, private, communications networks and may be able to assist the NHS in an emergency. These include:
Local Authorities Police/Fire Services Utilities Motoring Organisations Radio Amateurs Emergency Network (RAYNET) The Armed Forces
L9 Emergency Communications Network An emergency communications network is maintained by The Scottish Executive linking it to police force headquarters, local authority emergency centres and certain NHS and other points.
COMMUNICATION WITH THE PUBLIC
L10 Different sorts of emergencies will generate different levels of public interest or anxiety. In some circumstances general information will meet all enquirers' needs, while in others information supplied will require to be tailored to the individual circumstances of the enquirer. Methods used to communicate with the public need to be selected with care and in the light of the particular circumstances. The needs of people whose first language is not English or who are blind, deaf or otherwise impaired should be considered.
L11 Response to Individual Enquiries/Questions.
L11.1 The initiative rests with the questioner to choose who, how and where to seek information. Pharmacies, health centres, GPs, community staff, A & E Departments may be visited or telephoned, use may be made of established telephone helplines or other NHS telephone numbers. Where arrangements are routinely in place to focus enquiries to particular points or telephone numbers, and even when emergency helplines are established, some enquiries will continue to be made of staff who routinely interface with the public. All who receive questions must either be briefed sufficiently to answer, or know where to refer enquirers.
L11.2 Telephone Helplines Establishment of a telephone helpline is a useful means of focusing enquiries to a single point. It can free the resources of others for priority tasks and allows greater consistency of information to be achieved. All operators must be trained in advance, have the appropriate communication skills and be able to interpret written briefing notes to form answers to questions posed. The written briefing must address all foreseeable questions, but be as short and simple as possible. It is likely that a high proportion of calls will simply seek factual information and can be handled in that way. However, in some circumstances some callers may require counselling, more detailed information, or professional advice to be given and appropriately qualified staff may need to be available to take over such calls from the initial operator. Where the nature of the emergency is such that there is a possibility that operator access to named patient data will be required (e.g. anomalies in an NHS screening programme), any emergency helpline should be operated exclusively by NHS staff. For other circumstances the services of a commercial call centre operator (such as Network Scotland which operates the permanent NHS helpline) might be retained as an alternative to maintaining the necessary staff training and equipment.
L12 Publishing Information Providing information to the public will in certain emergencies be an essential part of protecting them against threats to their health, relieving anxiety and/or enabling them to adjust their use of what may be overstretched NHS services. Methods available include the following:
L12.1 Broadcast Media Since an emergency will be news, TV and radio broadcasters will normally co-operate in passing on information to the public (see also Annex O). When information is broadcast within news programmes, editorial control rests with the broadcaster. NHS Boards and Trusts may also initiate standing arrangements with radio and TV studios serving their areas for the broadcasting of emergency announcements by them on local, regional or national stations. These arrangements should include procedures for authorisation of such messages and their verification by the broadcaster prior to transmission. The text of emergency announcements can also be transmitted on Teletext.
L12.2 Newspapers As with the broadcast media, the press will normally co-operate in passing on information, but retain editorial control of what is printed in their news columns. Consideration should thus be given to the publication of important announcements as paid advertisements.
L12.3 Leaflets The Royal Mail's postcode and delivery systems enable the speedy and targeted distribution of leaflets, either by the next mail delivery or in certain circumstances by special delivery. Other organisations may in certain areas offer comparable services.
L12.4 Internet While public access to the Internet is increasing, use of the Internet should be regarded as an auxiliary rather than main means of communication.
RESPONDING TO EMERGENCIES: ANNEX M
INCIDENTS INVOLVING CHEMICALS
Introduction
M1 Worldwide, there are more than 11 million known chemical substances, of which some 60,000-70,000 are in regular use. A significant number of these are hazardous to health when inhaled, ingested or absorbed through the skin. Such exposures might be chronic, for example in a workplace situation, or acute, for example as a result of an accidental exposure.
M2 This guidance is concerned primarily with acute chemical exposures, for incidents that might occur at an industrial site, during transportation of chemicals, during disposal of chemical waste, or through acts of chemical terrorism. The general aim is to ensure a well- planned NHSScotland response within the concept of 'Integrated Emergency Management' (IEM) adopted by central and local government. This document therefore provides guidance on how the NHS Boards can fulfil their responsibilities for the protection of health and the provision of health care in co-ordination with other agencies including the ambulance, police and fire services and central and local government.
M3 The nature of many chemical incidents is that they present continuing threats to the health and safety of responding emergency service personnel. Such threats might include fire, explosion and illness or injury due to exposure to hazardous chemicals. The Health and Safety at Work Act 1974 and subsequent regulations, place specific duties on employers (including the NHSScotland and the Scottish Ambulance Service) to make appropriate provisions to safeguard the health and safety of their employees. This same legislation also places specific duties on employees to take reasonable steps to safeguard their own health and safety and that of others. This Annex also provides guidance, therefore, on appropriate health and safety provisions for healthcare staff when responding to chemical incidents.
Roles and Responsibilities
M4 Many chemical incidents demand a multi-agency response, proper co-ordination of which requires clarity over their individual roles and responsibilities. The general roles and responsibilities of various agencies including the police, fire brigade etc are described throughout the main body of this document and in Annexes A through H. In this section, we consider the particular roles and responsibilities for agencies responding to incidents at one or more sites where a release of chemicals has occurred. It is acknowledged, however that in some circumstances, such as chemical pollution from incidents occurring overseas, no specific site of release might be identifiable.
The Police
M5 Arrangements for overall command and control at the site of a major chemical incident will normally depend on the magnitude of the required response.
M6 For the least serious of incidents such as a small domestic fire resulting in minor smoke inhalation, each of the emergency services has its own operational responsibilities and deploys its resources under the command of its own incident officers. Close liaison is,
however essential, for example to ensure that all casualties have been located and, where appropriate, the police will normally act as the co-ordinator of the overall response at the scene.
M7 For incidents of greater severity, for example where a number of members of the public have been exposed to an ongoing release of chemicals due to a factory incident, each of the emergency services will have its own Incident Commander and co-ordination of the activities under the control of each of these commanders will usually fall to the police.
M8 An example of a very large incident, would be a major explosion at an industrial site regulated under the provisions of the Control of Major Accident Hazards (COMAH) Regulations 1999, involving a large number of casualties and a continuing threat. Such incidents require strategic decisions about deployment of resources, managing populations, etc and a more formal command structure, perhaps involving an off-site emergency room, would normally be established by the police.
M9 An incident involving chemical terrorism or the need for sheltering or evacuation of the local population would normally be managed by the police. Special provisions for incidents involving deliberate release of chemicals are described in separate SE Guidance.
The Fire Service
M10 In some cases, fire service personnel will be the only responders who have the necessary equipment and training to allow them to work safely near to the source of a chemical incident. Therefore, at the immediate scene of a chemical incident that presents an ongoing threat to the public or to emergency personnel, the fire brigade will take appropriate steps to identify the chemicals concerned and set-up appropriate cordons around the contaminated area. Depending on the severity of the threat, these might include an "inner cordon" with access normally restricted to fire brigade officers who will rescue casualties from within it. Treatment and triage of these and other casualties would normally be carried out by ambulance and medical staff working within an "outer cordon" identified by the fire service as combining the necessary requirements for operational safety and efficiency. Defined (but less stringent) access restrictions also apply for the outer cordon.
M11 Casualties of a chemical incident might require decontamination ahead of medical treatment or release from the scene. Separate guidance for the emergency services on decontamination is provided elsewhere and this defines the roles and responsibilities on the fire service particularly in the provision of "mass decontamination" (for example using cold water sprays).
M12 The fire service will normally take principal responsibility for identifying the chemical(s) in question and for obtaining basic information on their toxicity in terms, for example, of their labelling under the Chemicals (Hazard Information and Packaging for Supply) Regulations 2002 (CHIP). (These require and "indication of danger" in terms of with internationally recognised pictograms and "risk phrases" (e.g. R23 means Toxic by inhalation).) The brigades also have access to appropriate chemical information databases such as that of the National Chemical Emergency Centre (NCEC) and to appropriate sources of expert advice and technical support. They will also be able to obtain predictions from the Meteorological Office of the likely behaviour of any airborne pollutant. Co-ordination of the collection of any environmental samples required for subsequent chemical identification
would also fall to the fire service or, in their absence or where forensic evidence is needed, the police.
The Scottish Ambulance Service
M13 The Scottish Ambulance Service (Annex D) is responsible for triage, decontamination and medical treatment of casualties at the scene of a chemical incident and for getting those deemed to be in need of secondary care to hospital. In fulfilling these responsibilities at the site of a chemical incident, ambulance personnel will work closely with the Medical Incident Officer (Section 3.9 of the main body of this document) and the Site Medical Team (Section 3.11).
M14 The Ambulance Service as employers are bound by the requirements of the Health and Safety at Work Act 1974 and subsequent regulations to fulfil these operational responsibilities with due regard to the safety of their employees and others who might be affected by their activities. This latter group would include, for example, members of the public who might be injured by ambulances travelling to and from the scene.
M15 Health and safety provisions for ambulance service personnel will include reasonable precautions to ensure that they will not be unduly exposed to hazardous chemicals or other dangers at the scene of a chemical incident. These provisions should not rely on the issue of personal protective equipment alone but should consider alternative measures to minimize the threats. These measures might include ensuring that any activities at the site of the incident are carried out in a well ventilated area upwind of the chemical release, that suitable provisions are made for escape in the face of any acute increase in the level of threat (such as a change in the wind direction), provision of real time instruments to measure ambient chemical concentrations etc.. The Scottish Ambulance Service should also arrange for regular training and practice in the implementation of all such health and safety provisions.
M16 These measures should be augmented by provisions for the issue and maintenance of adequate and suitable PPE and for training in its use, in accordance with the requirements of the Personal Protective Equipment at Work Regulations 1992.
M17 Separate guidance for the emergency services identifies the Scottish Ambulance Service as having principal responsibility for decontamination of contaminated casualties at the scene of an incident. Ideally this will involve the use of mobile decontamination units, though in certain circumstances improvised decontamination methods might be applicable. The need for decontamination of ambulance staff working in potentially contaminated areas or with contaminated casualties should also be considered.
The Health and Safety Executive
M18 Health and safety at work is a matter reserved for the UK Government. The Health and Safety Executive (HSE) has responsibility for ensuring the health and safety of people at work and of any members of the public who may be affected as a consequence of work. These responsibilities include ensuring that major industrial sites have emergency plans in place in accordance with the requirements of the Control of Major Accident Hazards (COMAH) Regulations 1999.
M19 The HSE enforces the requirements of the Health and Safety at Work Act 1974 and subsequent regulations (such as the Personal Protective Equipment at Work Regulations 1992), which include provisions for the health and safety of emergency service personnel responding to chemical incidents.
M20 The HSE is also responsible for investigating the cause of any chemical incident notifiable under the Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) Regulations 1995 at any industrial operation. Any such investigation will only begin when the acute phase of the emergency response is over and the area in question has been deemed safe to enter by the fire brigade or police.
Site operators
M21 The primary responsibility for controlling and minimizing risks to health and safety at an industrial site rests with the site operator. Under the Notification of Installations Handling Hazardous Substances (Amendment) Regulations 2002 (NIHHS), site operators must notify the HSE of every site at which specified quantities of hazardous substances are present. Sites at which the industrial process or the nature and quantity of stored substances present a major accident hazard might also be subject to the Control of Major Accident Hazard (COMAH) Regulations 1999.
M22 The NIHHS and COMAH Regulations do not apply to every site at which hazardous chemicals may be present in sufficient quantity to pose a significant threat to the health of people in the vicinity. Nevertheless, operators of these sites are bound by the general requirements of the Health and Safety at Work Act 1974 to take all reasonable precaution to minimize the threat that their operations pose to the health and safety of their workers and the local population.
Carriers of hazardous materials
M23 Surface transport of hazardous materials is governed by the "Carriage of Dangerous Goods (Amendment) Regulations 1999" and a range of related regulations on specific issues such as labelling, and on specific classes of materials such as radioactive substances. The HSE has published a number of related guidance documents and their free advice leaflet Are you involved in the carriage of dangerous goods by road or rail?, August 1999 (available at http://www.hse.gov.uk/pubns/indg234.pdf) provides an overview.
M24 The most common transport-related incidents involve actual or threatened accidental spills for which the first priority of the NHS or SAS staff will be to ascertain the chemicals involved and their related risk to health and safety. This information can normally be obtained via the labelling on the packaging or tanker and labelling requirements are defined in the "The Carriage of Dangerous Goods (Classification, Packaging and Labelling) and Use of Transportable Pressure Receptacles Regulations 1996" (and other related regulations including CHIP (see paragraph 12 above)). For example, the packaging of ammonium polysulphide solution should carry the appropriate "Danger sign" pictogram to identify its classification a 'corrosive substance' (Class 8) and also a "Subsidiary hazard sign" which classifies it as 'toxic' (Class 6.1). The packaging should also carry the unique 'UN' number for this material (UN 2818).
M25 SAS staff and NHS staff who might require to attend chemical incidents should be familiar with the general requirements of these labelling systems and with the related mechanisms for obtaining appropriate detailed information on risks and on treatment of casualties. The Local Authorities
M26 Annex G identifies Local Authorities and NHS Boards as having joint statutory obligations for protecting the health of their local populations and this extends to management of public health incidents. In addition, the Control of Major Accident Hazard (COMAH) Regulations 1999, which cover most major chemical and petrochemical plants, require that local authorities make and maintain, comprehensive emergency plans to deal with off-site effects of any major accident at the site.
M27 A major role for the Local Authorities in chemical incident response is likely to come after the immediate response phase of an emergency. The local authority might then assume, from the police or other initial co-ordinator, overall leadership for restoration of- contaminated land and water (in close liaison with the Scottish Environment Protection Agency) and any other local activities needed to restore normality.
The Scottish Executive Health Department (SEHD)
M28 Within the general responsibilities of the SEHD for emergency planning in NHSScotland, as described in Chapter 2 of the main text and in Annex A, the SEHD's Emergency Planning Officer is responsible for regular auditing of the NHS Boards' individual emergency plans, including those for chemical incidents (Section M3) and for ensuring that the provision of these plans are exercised regularly.
M29 For incidents involving more than one NHS Board area, operational co-ordination of the overall NHSScotland response will normally be the responsibility of the NHS Board in whose area is the incident is principally sited. The SEHD will confirm or nominate the lead NHS Board as necessary.
Acute Hospital Trusts
M30 Acute hospital trusts must ensure that satisfactory arrangements are in place for the provision of health care to any casualties of a chemical incident. These casualty management arrangements should be documented in local emergency plans.
M31 The casualty management provisions of these plans should require that the acute hospital trust will;
(i) co-ordinate the operational NHS response, on the receipt of casualties from the scene of a chemical incident;
(ii) ensure that staff are prepared for their roles, through the provision of appropriate training programmes; and that they have access to the advice and expertise needed to provide medical care to casualties of a chemical incident;
(iii) on the basis of a preparatory risk assessment, provide the facilities and equipment necessary for staff to fulfil their roles in a safe working environment: these include
decontamination facilities at casualty receiving hospitals safe working facilities with adequate ventilation etc and personal protective equipment.
NHS Boards
M32 Within the general healthcare and emergency planning responsibilities of each of the NHS Boards (as described in Chapters 1 to 3 of this document) the local Director of Public Health (DPH) is responsible for ensuring that local emergency plans contain appropriate provisions for chemical incident response. This should cover all aspects of the NHSScotland procedures involved from triage, decontamination and treatment of patients at the incident site through to admission to hospital. It should also provide for those in need of other forms of medical assistance such as trauma counselling and for provision of information to the public. A general overview of the scope required for these plans is given in Section M3.
M33 In each of the NHS Board areas, there will be a number of sites where a variety of hazardous chemicals are stored or used. The DPH should take reasonable steps, in liaison with the emergency services, to familiarise him/herself with the range of sites and the principal chemical hazards that they present.
M34 No comprehensive information will be available on the full range of chemicals transported through each of the NHS Board areas. However, the DPH should seek information from consignors and consignees on any regular bulk movements of dangerous chemicals within or through their areas or of any single movements that might present a particular threat. Liaison with the police, fire brigade and local authorities is recommended. M35 During a chemical incident, employees of the NHS Boards, who might include the Medical Incident Officer and the Site Medical Team, will work closely with employees of the Scottish Ambulance Service. The NHS Boards are subject to the same employers responsibilities outlined in Paragraph 14 above and provisions for the health and safety of medical staff should accord with those outlined in Paragraphs 15 through 17.
Scottish Poisons Information Bureau
M36 The Scottish Poisons Information Bureau is part of the National Poisons Information Service. The Bureau provides a 24-hour information service (Tel: 0870-600 6266) including clinical advice, and should be regarded as the primary source of advice for the NHS in Scotland on the diagnosis, investigation and management of people exposed to chemical substances. It also maintains TOXBASE, an online database of information, which is available to registered users at http://www.spib.axl.co.uk/toxbaseindex.htm. TOXBASE carries information on the hazardous nature of chemical substances, their ingredients, the symptoms that might arise by various routes of exposure and their appropriate treatment.
Scottish Centre for Infection and Environmental Health (SCIEH)
M37 SCIEH is available to reinforce, advise or otherwise support NHS Boards’ public health medicine expertise. It has particular skills in epidemiology, in surveillance and control of infection and has in-house veterinary and environmental health specialists. SCIEH maintains liaison with "The National Focus for Chemical Incidents" (a Government funded source of further specialist advice and assistance) and can call on its support and that of other specialist help as may be required. SCIEH thus provides to NHS Boards a one-stop-shop source of
technical public health advice and assistance. Their website is at http://www.show.scot.nhs.uk/scieh/ and their 24 hour contact number is 0141-300 1100.
General emergency planning requirements for a chemical incident response
M38 Each Director of Public Health is responsible for ensuring that their NHS Board's emergency plans include adequate and suitable provision for chemical incident response. In common with the other elements of these emergency plans, the provisions for chemical incidents will be subject to regular review by the NHSScotland Emergency Planning Unit.
M39 Plans should include the following elements.
(i) A defined system, jointly agreed with the other emergency services involved and including acute hospital trusts, for prompt notification of incidents to their respective control centres. This should include an outline protocol for establishing appropriate incident control teams.
(ii) A defined protocol for communication with the Scottish Centre for Infection and Environmental Health (SCIEH). SCIEH will provide advice on the appropriate response on the basis of their own expertise and through their links with the National Focus for Chemical Incidents.
(iii) A defined protocol for communicating with the National Poisons Information Service and for access to their TOXBASE Information Service. (Directors of Public Health should ensure that all appropriate organisations including hospitals and GPs within their particular area are registered users of the TOXBASE Information System.)
(iv) Appropriate protocols for liaison with frontline staff. (A general instruction should be issued that all frontline staff who might need to response to a chemical incident and who carry a mobile phone should have the 24 hour telephone numbers for (at least) the following organisations logged into its electronic phone book. The Scottish Centre for Infection and Environmental Health (0141 211 3600), The Scottish Poisons Information Bureau (070 600 6266), the NRPB (01235 834 590), and the Food Standards Agency (01224 285 107).)
(v) Provisions for the health and safety of staff attending the site of a chemical incident or receiving casualties. These provisions should include the issue and maintenance of adequate and suitable Personal Protective Equipment and training in its use, in accordance with the requirements of the Personal Protective Equipment at Work Regulations 1992.
(vi) Protocols for casualty management. These should include arrangements for providing chemical decontamination equipment both at the scene of a chemical incident and at hospitals and provisions for training in its use.
(vii) Provisions for the collection of samples of blood, urine etc for the purposes of chemical identification and forensic evidence.
(viii) Arrangements for storage, access and distribution of appropriate pharmaceutical supplies including antidotes.
(ix) Arrangements for provision of information to the public.
(x) Arrangements for providing psychological support, particularly for those seeking treatment who have not actually been exposed.
(xi) Reference to the NHS Board's general provisions for accommodating a major short-term increase in hospital admissions. This should include co-operative working with other NHS Boards for chemical emergencies that span more than one NHS Board area.
(xii) Arrangements for post-incident reporting.
M40 Plans should also provide that any proposed substantial changes will be discussed and agreed with the Scottish Executive's NHSScotland Emergency Planning Unit and with the local authority, the local fire and ambulance services and the police.
M41 Chemical incident response plans should be exercised on a regular basis.
RESPONDING TO EMERGENCIES: ANNEX N
RESPONDING TO EMERGENCIES: ANNEX O
ARRANGEMENTS FOR LIAISON WITH THE MEDIA
O.1 A major incident is news. Representatives of the media must be expected to arrive at the scene, at any casualty receiving hospitals and at response control points very quickly, and in large numbers. News desks will make repeated requests for information by telephone too, especially in the early stages of an incident. Similar media pressure will accompany other types of major emergency. How the media is handled will affect how they report the emergency and response to it. How the emergency response is reported can enhance the effectiveness of that response, both immediately and in the longer term. To this end, NHS managers responsible for emergency response must become familiar with media needs, methods and time schedules, and should prepare and train appropriate staff for media liaison duties.
O.2 Should the scale or circumstances of a major incident require it, initially the police will co-ordinate both the release of information to the media and the response to media enquiries. It is thus most important that police advice and assistance is sought by NHS managers when reviewing their arrangements for media liaison. Similarly, within the NHS, each Board must take the lead and establish a single focus for NHS liaison with the media, should more than one NHS organisation become involved in responding to an emergency in its area. The nature and scale of the emergency, and the nature of media interest, will determine the degree to which NHS Boards should act in concert with the police, local or other authorities. Plans for mutual support between Boards should be considered, and while assistance of the Scottish Executive Media and Communications Group may help a co- ordinating NHS Board in providing international, national and regional media with NHS information, Boards should not underestimate the demands on them which co-ordinating media liaison is likely to bring.
PREPARATION
O.3 While this Annex uses a scenario in which casualties are the primary focus of media interest, the principles and arrangements outlined should be adapted as necessary to other major emergencies.
These might include:
• An outbreak of disease in the community, among hospital patients or NHS staff • Coping with the effects of bad weather or industrial action • A quality control, equipment malfunction or other problem with a particular clinical procedure, screening process or pharmaceutical product
O.4 At every level, managers should ensure that arrangements for liaison with the media are integral to their major emergency plans. When these plans are tested or practised, the media arrangements should also be tested in as practical a way as possible eg, by using trained journalists in exercises.
O.5 As part of a hospital emergency plan, a large room should be identified as a Media Centre. It should be sufficiently close to the Hospital Control Centre to facilitate authoritative briefings by members of the Hospital Control Team. If journalists there are provided with
access to adequate communications, are supplied with refreshments, are regularly briefed and have questions answered, they will be less likely to wander elsewhere in the hospital. Ease of access to parked outside broadcast vehicles should be borne in mind.
O.6 A member of staff should be selected as Press Officer who can be dedicated to that role throughout an emergency. He or she should be of sufficient standing and personality to command respect and support within the hospital, particularly among nursing and medical staff. Additional staff should be earmarked to provide on a continuous basis the necessary administrative support which the preparing, typing and copying of news releases and statements will require. The advantages of designating a Press Officer include:
• Journalists and photographers will have a single point of contact for information and will tend to leave other staff free to work without interruption. • The Press Officer will quickly build a working relationship with the Press to the mutual benefit of hospital and media. • Information communicated to the media can be more readily controlled.
O.7 Similar considerations apply to NHS Boards. While a Central Co-ordinating Media Office to provide the single NHS focus for media liaison described above needs to be as close as possible to the Board Control Centre, collaboration between NHS Trusts and Boards may enable a suitably convenient hospital media centre to be utilised. Alternatively Boards may wish to consider joint arrangements with the police and/or local authorities.
ONSET OF EMERGENCY
O.8 Emergency plan implementation should invariably include alerting of hospital press officers and notification of the NHS Board Public Relations Officer. However, a telephoned media enquiry may well be the first intimation of emergency, and others may be received before a press officer is available. It is thus important that duty managers and/or on-call staff are permanently available and prepared to handle such calls.
O.9 The Press Officer's immediate action should be to ensure the Media Centre is functioning and that its communication facilities are operational. Hospital staff should be briefed that when the media arrive they should be escorted to the Media Centre. Film crews and photographers, after taking pictures of ambulances arriving with the injured, will want to take further pictures of the injured in hospital. All hospital staff should thus be on the look- out for strangers with cameras (apparent or concealed) and know of arrangements made to escort them back to the Media Centre.
O.10 Should the major emergency be caused, or suspected to be caused by an act of terrorism or crime, then the police may impose a degree of security around casualties and hospitals treating them. Depending on the circumstances, the police may prevent anyone other than essential health personnel from entering the hospital grounds, including the media. Where this is necessary, it is likely that the police will co-ordinate media briefings and the preparation and release of information. However, an increase in telephone calls from the media to the hospital seeking information is to be expected. Thus it will be essential for the hospital press officer to make himself/herself known to the senior police officer present at the hospital, so that arrangements can be made to secure the co-operation of the media and which satisfy their needs, together with those of the police and the hospital.
O.11 If the emergency is such that more than one hospital receives casualties, has major public health implications or is otherwise likely to attract significant media scrutiny, then its Central Co-ordinating Media Office should be set up by the NHS Board as soon as possible. All hospitals and other NHS organisations involved should keep that office fully up to date with information, including any proposed news releases etc., prior to issue. The staff of the Central Co-ordinating Media Office will require to liaise closely with police information staff, with those of other authorities or agencies involved in the emergency, and with the Scottish Executive Media and Communications Group. The earlier such co-ordination of media liaison is established, the less likely will it be that reporters and their enquiries will get in the way of those engaged in responding to the needs of the emergency itself.
FIRST MEDIA BRIEFING
O.12 Whatever the nature of a major emergency, a media briefing should be held as soon as possible. Press Officers must be aware of the need to maintain medical confidentiality and that any decision to release details of any individual patient must have prior medical and patient consent. At a hospital receiving casualties the Press Officer should, in preparation of briefing, seek to collate the following factual information:
• The time the hospital was told to expect casualties. • The time the first casualties arrived. • The number of injured received. • General information about the casualties as to whether male or female, children under 16, the general nature of injuries, the general type of treatment being given, the numbers admitted or discharged after treatment. • Information about any patients transferred to other hospitals, either for specialist treatment e.g., burns/neurosurgery or to spread the load. • A brief outline of the hospital's emergency plan, when it was activated and the effects on routine hospital work, normal visiting hours etc. • Details of numbers of staff on duty, of specific specialist teams on stand-by or deployed, of routine operations cancelled and any other background information.
O.13 Based on such information, the hospital press officer should prepare a statement. Prior to issue, and after any scrutiny required by the Chief Executive, it should be agreed with the NHS Board's Central Co-ordinating Media Office and with the police, who may require to consult the Procurator Fiscal before agreement to release can be given. The text of the agreed statement must be furnished to the Scottish Executive Media and Communications Group in advance with details of time and place it is to be issued. The Chief Executive, ideally supported by a clinical director/senior consultant (in white coat) and senior nurse, will be expected to:
• Read the statement to the media, answering questions arising from it. • Be prepared to repeat the statement to radio interviewers/television reporters if required. • Announce arrangements for further briefings on a regular and frequent basis.
O.14 The statement to the first media briefing should provide the basis for staff answering many subsequent telephoned media enquiries. Calls should be expected from local daily or evening newspapers or news agencies seeking information about the involvement in the emergency of people from within their circulation areas. The Press Officer should have
sufficient support to allow such calls to be dealt with on a 24 hours a day basis, with all calls being logged. Where confirmation of information not previously released is sought, arrangements should be in place to check with senior staff that confirmation may be given or further, new, information released.
SUBSEQUENT MEDIA BRIEFING
O.15 In preparing the second and subsequent media statements, the Press Officer will need to clear the release of information as before. The following might be given:
• Details of patients, giving names, addresses and ages where medical confidentiality allows and patient consent has been given. Patients should understand the possible impact release of their details might have on next of kin and that a media presence at their address might result. • Further details of the extent of injuries and of treatment. • Details on the numbers of deaths, emergency operations, patients in intensive care; patients discharged home. Note that the police will not allow names of the dead to be confirmed until positive identification has been made and next of kin informed.
O.16 The number and frequency of media briefings will clearly depend on the development of the response to the emergency. Where there is nothing new to be said, then the Press Officer should make a statement to that effect, but promise further briefing when further information becomes available.
MEDIA INTERVIEWS
O.17 As soon as patients arrive at a hospital the media will seek to interview, photograph or film both patients and staff treating them. The Press Officer should check with the police (who may in turn wish to consult the Procurator Fiscal) whether or not any individual patient might thereby be put at risk by such publicity in the context of criminal investigations. Media access to any patient should only be arranged with the consent of the consultant looking after the patient who can confirm that he or she is well enough. No interview or photographs should be taken without the consent of the patient concerned.
O.18 Press Officers should seek to identify a small number of doctors, nurses, ambulance and other staff directly involved in caring for patients who could be made available to give interviews to the media. The media will normally welcome such an opportunity. First-hand accounts of the health response to an emergency reduce the risk of wrong information being circulated and provide an opportunity to publicise what the hospital and the NHS have to face. However, any member of staff being interviewed should be carefully briefed beforehand.
MEDIA FACILITY
O.19 One method by which media access to patients and staff can be arranged is to organise a "short facility" with the media being admitted to a group of patients and/or staff under firm control.
O.20 Care must be taken to ensure that patients' wishes concerning interviews and photographs are made clear, that media activities do not take place without the patients'
consent, nor in a manner which might cause them distress. The programme and time schedule for the facility should be agreed with the media beforehand along the following lines:
O.20.1 The first group of media to be allowed access should be television crews. Only one crew at a time (reporter, cameraman, lights man, sound man) should be admitted and allowed no more than 10minutes. If patients and staff become uncomfortable, tired or distressed during the later stages of the facility, then access by TV crews can be limited. For example, if access is first given to BBC news and ITN, other domestic and international TV stations will be able to obtain film from BBC and ITN.
O.20.2 Press photographers should be the next to meet patients and staff. They should be admitted in groups of no more than 5, each group needing about 5minutes to take their photographs before being escorted back to the Media Centre or out of the hospital. Polite firmness will be needed in turning down requests for extra time.
O.20.3 Radio reporters should be next followed by newspaper reporters. Each group will require some 10-15 minutes.
O.21 Media deadlines (i.e., transmission/broadcast times or the times at which newspaper editions have to be finalised) may mean that the running order of groups above may need to be altered. Where there are space or time restrictions, pooling arrangements should be considered under which one reporter, one colour photographer, one black and white, one radio reporter and one TV crew are admitted and subsequently share their reports/films with all.
VIP VISITS
O.22 Members of the Royal Family and Government Ministers or other dignitaries will often visit the site of a major emergency and hospitals involved in response to it. The Scottish Executive Media and Communications Group, in consultation with other press offices as appropriate, will be responsible for providing advice on media coverage of such visits.
RESPONDING TO EMERGENCIES: ANNEX P
INCIDENTS INVOLVING INFECTION/INFECTIOUS DISEASE
P1 Infection is the entry and development or multiplication of an infectious agent in the body of man or animals. Infection can be caused by micro-organisms such as bacteria, viruses, parasites and fungi. Infection can be spread by a variety of means including: person to person direct spread; droplet spread by inhalation; organisms may enter the body through breaks in the skin, wounds and abrasions; inoculation by means of infected needles or bites from insects carrying organisms infectious to humans e.g. mosquitoes carrying malaria.
P2 The NHS deals with a considerable burden of ill health resulting from infection as part of its normal daily routine. Mostly, infection is dealt with by Primary Care services. Hospitals may deal with more severe infections caused by organisms which may be more virulent and less common than in the community. Circumstances may develop both in the community and in hospital where organisms can cause infection which: affects more than one person; may cause disease not previously recognised in the area; and cases of which may be associated in time, place and person. In those circumstances an outbreak, epidemic or even pandemic of infectious disease may result requiring special arrangements to investigate and control. (An example of such special arrangements is at Appendix 1 which gives guidance relevant to an influenza pandemic.)
P3 An outbreak of infection is normally defined as two or more cases of infection associated in time and place, but in practice may include single cases of infection in excess of what would normally be expected. Under the Public Health (Notification of Infectious Diseases) (Scotland) Regulations 1988, medical practitioners are required to notify the Chief Administrative Medical Officer (CAMO) of the local NHS Board of any patient they believe to be suffering from any of the notifiable infectious diseases as listed in Appendix 2. In addition to advising NHS Boards of isolates of organisms which may be foodborne, all NHS microbiology laboratories participate in a voluntary system of reporting to the Scottish Centre for Infection and Environmental Health (SCIEH), isolates of an agreed list of organisms from any clinical samples analysed that week.
P4 An outbreak may be limited in terms of size and clinical significance depending on the organism, and on the size, location, age and type of the population affected. It may range from the limited family outbreak of food poisoning, to larger outbreaks of influenza affecting a school through to outbreaks of infection which affect a large number of vulnerable sections of the population for example an influenza pandemic. The appropriate response to an outbreak will depend on the particular circumstances. Some outbreaks, for example those limited to one family may need no incident control team. Others may need a locally based incident control team to be established, whereas others may be so large or significant as to need a co-ordinated national response involving local and national major emergency procedures to be activated.
P5 Outbreaks may also occur as part of a wider emergency, for example, a transport accident involving a vehicle carrying infectious material, an outbreak caused by deliberate contamination of public water supplies or a terrorist or criminal act involving the deliberate release of infectious organisms. It is most important that arrangements for the management, investigation and control of outbreaks remain consistent with those described in Part 3 of this
guidance. Arrangements need to be flexible enough to cope with the actual and potential hazards from the most simple outbreak through to more complex and widespread problems which cross NHS Board boundaries and require multiple agencies to investigate and control them.
P6 Surveillance This is the collection, collation, analysis and dissemination of information so as to be able to recognise any change in the characteristics or distribution of a disease which may affect its incidence. It is carried out at local, national and international level. Three important sources of surveillance data include: disease notifications; laboratory reporting; and information on outbreak investigations. At a local level, effective surveillance requires NHS Boards to encourage prompt reporting of relevant information by local health care providers and other local agencies. NHS Boards are required to report notifiable disease information centrally to the Common Services Agency. Notification data is among information passed to SCIEH, the body responsible for national surveillance (see Appendix 3.)
OUTBREAK CONTROL
P7 NHS Boards in Scotland have public health responsibilities to make arrangements for the surveillance, prevention, treatment and control of communicable disease. NHS Boards have a duty to ensure adequate standards of infection control are met by all service providers. These responsibilities are also shared by local authorities. NHS Boards and Local Authorities have a statutory duty to co-operate with one another. In line with national guidelines, co- ordinated incident control plans should be drawn up by NHS Boards in consultation with local NHS Trusts, local authorities and any other public service organisations who may be required to participate in an outbreak response. Such plans should be regularly reviewed and jointly exercised. Plans should detail measures: to prevent its further spread or recurrence; to ensure that effective care and treatment is available to all those affected by the outbreak; to put in place any necessary control measures including the dissemination of information to the public and appropriate external agencies; to document the outbreak including its major epidemiological characteristics and causes; to report on the outbreak.
P8 CAMOs normally delegate responsibility for receiving, analysing and processing notifications to the Consultants in Public Health Medicine (Communicable Diseases/Environmental Health) CPHM (CD&EH). A CPHM (CD&EH) will normally act on behalf of the CAMO to lead and co-ordinate the investigation of outbreaks and advise on control measures.
P9 Incident Control Team An incident control team (ICT) should be established in the light of agreed and co-ordinated local outbreak control plans. Membership of the ICT will depend on the circumstances of each incident. The core of the team for any outbreak in the community will normally include:
• the CPHM (CD&EH) • a local authority Environmental Health Officer • a Consultant Microbiologist • appropriate secretarial support
For outbreaks of infection in hospital, outbreak management will follow locally agreed Hospital Outbreak Control Plans but would be expected to include the same core team of officers.
P10 Health Board Role In a major outbreak, or in cases where the outbreak is part of a larger emergency situation it can be expected that the OCT will be fully involved in the local investigation and control of the outbreak. In such circumstances the Health Board should consider activating its Emergency Plan as described in Part 3 of the guidance above (Paras 3.36-3.39).
FURTHER ADVICE:
P11 Guidelines on the Control of Outbreaks of Food and Waterborne Disease, Scottish Office, January 1996
P12 Arrangements for Actual or Suspected Cases of Viral Haemorrhagic Fever, MEL (1997) 70
P13 Scottish Infection Manual - Advisory Group on Infection. Scottish Office, 1998
P14 The Control of Tuberculosis in Scotland, Scottish Office, 1998
P15 SCIEH (See Appendix 3)
APPENDIX 1 TO ANNEX P
INFLUENZA PANDEMIC
THE THREAT
1P.1 Influenza is a viral infection caused by 3 types of virus: A, B and C. Influenza C is regarded as of relatively little importance. Influenza B assumes prominence periodically, usually affecting the young and the elderly. Epidemic influenza is usually caused by type A.
1P.2 The genetic make-up of influenza A is not constant. Previous exposure to, or vaccination against, one strain may give a person some degree of immunity against a new variant of that strain, but there is no cross-immunity between major strains. Emergence of a significantly different new strain occurs periodically and universal lack of immunity to it gives it the potential to cause a world-wide epidemic (pandemic). The greatly increased international movement of people in modern times now means that pandemic influenza may appear in Scotland with no or very little warning and at a time of the year not necessarily confined to the "normal" UK influenza season of November-March.
Basis for planning
1P.3 World Health Organisation advice is that plans should anticipate illness in at least 25% of the population. While most influenza activity can be expected to last 6-8 weeks, lower levels may continue for twice as long. The incubation period is likely to be 2-3 days, with adults being infectious for 4-5 days and children a bit longer. While a different pattern may emerge in a pandemic, in a lesser outbreak a higher proportion of children is likely to be infected than other age groups, though serious illness and death is more likely among older people with underlying chronic disease. Secondary bacterial infection, particularly of the lungs, is the main complication of influenza, staphylococcal pneumonia being the most serious.
NHS OBJECTIVE
1P.4 To minimise the impact on the population of an influenza pandemic by reducing morbidity and mortality.
PLANNING RESPONSIBILITIES
Co-ordinated, Phased Response
1P.5 The nature of the threat is such that surveillance of influenza and action to counter a pandemic must be undertaken on a co-ordinated basis and world-wide. The UK Health Departments maintain an outline contingency planning framework, The Influenza Pandemic Plan, which identifies the following phases:
Phase 0 The Interpandemic period i.e., normal times. Phase 1 The emergence of a new strain of virus outside the UK. Phase 2 Outbreaks of influenza caused by the new strain outside the UK. Phase 3 New influenza strain isolated in UK.
Phase 4 Pandemic influenza in the UK. Phase 5 Return to background influenza activity.
1P.6 To achieve the objective, action is required in each Phase, including Phase 0. The interval between Phases 1 and 4 is impossible to predict. Successful emergency action during Phases 1 and 2 may reduce the severity of Phase 4, but if the new virus strain first appears in the UK, Phases 1 and 2 will be bypassed.
UK Health Departments
1P.7 Their Pandemic Influenza Plan details UK Health Departments' arrangements for international liaison and surveillance; for the mobilisation and direction of research, development, licensing, production and distribution of vaccines and anti-viral drugs; and for the formulation of clinical guidance and advice to the Government and the public. Copies of the UK Health Departments' Pandemic Influenza Plan have been supplied to each Director of Public Health and to the Director, Scottish Centre for Infection and Environment Health (SCIEH).
1P.8 The Scottish Executive Health Department, as in any other situation of actual or impending emergency, retains its responsibilities for the overall management of the NHS in Scotland.
NHS in Scotland
1P.9 NHS Board emergency plans should include contingency arrangements for the local NHS response to an influenza pandemic. Boards should take the lead in establishing arrangements for co-ordination NHS activity with that of local authorities, the police, voluntary and other organisations with a part to play in achieving the objective. NHS Board plans should include details of:
1P.9.2 Activation and operation of mechanisms for co-ordination with the local authority etc.
1P.9.3 How vaccine needs are to be established (see paragraphP1-16 below).
1P.9.4 Arrangements for the local distribution and administration of vaccine.
1P.9.5 Arrangements for issuing protocols for antibacterial and anti-viral therapy.
1P.9.6 Contingency arrangements for co-ordinating use of resources in shortage e.g.:
• staff • hospital beds • supplies of drugs and equipment
1P.9.7 Mortuary arrangements.
1P.9.8. Provision of information to enable maximum public self-help, understanding of and assistance with NHS plans to secure the objective.
1P.10 SCIEH retains its responsibilities for influenza surveillance and its co-ordination. It should prepare and maintain an Influenza Pandemic Plan to enable the initiation and operation of increased surveillance of influenza activity in Scotland when required (see paragraph P1-13 below).
SURVEILLANCE
1P.11 The key to preparedness is constant surveillance. SCIEH's responsibilities for the collection, collation and analysis of information of influenza activity include morbidity data from influenza spotter general practices, mortality data from the General Records Office and relevant laboratory data. SCIEH maintains close collaboration with the Public Health Laboratory Service (PHLS) in England and has access to world-wide data through the WHO. SCIEH is responsible for providing timely information about influenza to The Scottish Executive, NHS Boards, NHS microbiologists and clinicians. This is done routinely through the SCIEH Weekly Report, augmented as necessary by use of EPINET.
1P.12 While selected General Practices contribute to this routine, Phase 0, surveillance as part of the spotter scheme, it is important that all General Practices report any unusual incidence of 'flu-like illness. Similarly, NHS laboratories investigating such illness should routinely report the isolation of virus strains to SCIEH and submit viral isolates to PHLS Enteric and Respiratory Virus Laboratory, Colindale, for characterisation. Laboratories should also identify, and assess the antimicrobial sensitivities of, bacteria causing complications of influenza.
1P.13 At Phase 1, and with the approval of The Scottish Executive Health Department, SCIEH is to implement its Influenza Pandemic Plan for increased surveillance in Scotland, its co-ordination, and that of associated NHS laboratory activity. SCIEH should ensure the compatibility of its plan with that of PHLS. SCIEH's plan should detail:
1P.13.1 The increased monitoring and laboratory investigation of 'flu-like illness that will be required from Phase 2.
1P.13.2 Collection arrangements for information on antibiotic sensitivity and of resistance patterns of bacteria complicating influenza that will be required during Phases 3 and 4.
1P.13.3 Arrangements for disseminating regular information via the SCIEH Weekly Report, EPINET and other means, as well as for the immediate reporting to the Scottish Executive, NHS Boards and laboratories of important new data as it becomes available.
PREVENTATIVE MEASURES
1P.14 Prevention of influenza by immunisation and/or the use of anti-viral agents is likely to be possible only to a limited extent. Consideration will also need to be given to ways in which transmission might be reduced.
Influenza Vaccine
1P.15 Development of appropriately formulated vaccine cannot commence until Phase 2. Thus given high world-wide demand and the time necessary to produce vaccine, it is likely to be in short supply. In such circumstances, and to ensure equitability, central control of distribution will be established and the Scottish Executive Health Department will issue guidance on who should receive it. The need to keep health and other essential services running will mean that people involved in providing those services may need to take precedence for vaccine over the risk groups will form the basis for determining guidance on vaccine administration. The order of priority may be changed in the light of emerging information about the epidemiology of the pandemic:
Group 1 Healthcare staff with patient contact (including ambulance crews) and staff in residential homes for the elderly. Group 2 Those providing essential public services which would be disrupted by excess absenteeism during an outbreak eg, police, fire, security, communications, certain local authority services, undertakers, utilities, armed forces. Group 3 Those with chronic respiratory or heart disease, renal failure, diabetes mellitus or immuno-suppression due to disease or treatment (a) those over 65 (b) those under 65 Group 4 Women in the last trimester of pregnancy. Group 5 Residents of nursing homes, residential homes and other long-stay facilities. Group 6 All over 75. Group 7 All over 65. Group 8 Household contacts of individuals at risk (Group 3). Group 9 Age groups likely to be particularly susceptible on evidence of population screening tests for antibodies or morbidity/mortality data including that from countries already affected. Group 10 Other selected industries. Group 11 Those aged 20-65. Group 12 Those aged 6 months-19 years.
1P.16 By Phase 3, NHS Boards should be prepared to provide estimated numbers of people by priority group. Vaccine distribution will be organised centrally to ensure geographical equity, NHS Boards should arrange for its administration to priority groups as advised by the Scottish Executive Health Department.
Anti-Viral Drugs
1P.17 The anti-viral agent amantadine may be used prophylactically to control an outbreak or prevent nosocomial spread of influenza A. Doctors will be advised of national policy for the use of such drugs as knowledge of the pandemic and the sensitivity of the pandemic virus to the drug becomes available. Limited stockpiling of amantadine (shelf life 5 years) is under consideration. Worldwide demand from Phase 1 onwards is likely to outstrip manufacturers ability to supply.
Pneumococcal Vaccine
1P.18 Pneumococcal immunisation can reduce the incidence of pneumococcal pneumonia following influenza. Immunisation policy is contained in the Health Departments' memorandum "Immunisation against Infectious Disease". It is unlikely that manufacturers
would be able to satisfy a sudden increase in demand at the time of a pandemic, so risk groups should be immunised during Phase 0.
Other Measures
1P.19 Some slowing of the spread of influenza might be achieved by reducing unnecessary, especially long distance, travel and by encouraging people suffering from the disease to stay at home. Consideration might be given to postponing sporting, entertainment or other public events likely to attract large crowds. Closing schools, particularly where staff sickness levels would otherwise require combination of classes, might also need to be considered.
1P.20 The risk of nosocomial spread may be reduced by isolation of cases. Cancellation of non-emergency hospital admissions and reduction of out-patient attendances, particularly of patients with high risk medical conditions, will need to be considered. As far as possible, patients with influenza should only be admitted to hospital if they have medical complications. Rigorous application of infection control measures will be needed both within hospitals and other healthcare premises.
TREATMENT AND CARE
1P.21 There is no evidence that antibiotics have a place in the management of uncomplicated influenza, but protocols for the treatment of complications such as pneumonia should help ensure the provision of optimal care. SCIEH will issue guidance on prevalent organisms and their antimicrobial sensitivity patterns; local antimicrobial sensitivity patterns need to be taken into account.
Primary and Community Care Services
1P.22 General Practitioners and NHS Trusts which operate primary and community health services are responsible for ensuring the ability of those services to meet peak demand notwithstanding staff sickness. However, the need to reserve hospital capacity for the most critically ill, sickness among those who would normally provide care for people at home (relatives, neighbours, home helps etc) and intense competition for available locum health care staff, must be expected to overstretch these services.
1P.23 At Phase 0 NHS Boards should take the lead in encouraging the development of collaborative contingency arrangements by practitioners (medical, dental, pharmaceutical) and NHS Trusts. Such arrangements might, for example, involve a pooling of health visitors, community and practice nurses, and their undertaking some home visiting which would usually be carried out by a general practitioner. Close liaison with Local Authorities (particularly Social Work and Environmental Health Departments), the Scottish Ambulance Service, community leaders and the voluntary sector is regarded as essential. At Phase 2 Boards should review and update such contingency arrangements; they should be activated at Phase 3.
1P.24 Community pharmacists will need to anticipate increased demand for home treatments such as simple linctus and antipyretics, and for a wider range of prescriptions, including antibiotics and oxygen. Reminders of the association of salicylates and influenza with Reye's syndrome in children under 12 should be considered.
Secondary Care Services
1P.25 Hospital emergency plans should be reviewed at Phase 2 in anticipation of large numbers of patients suffering from complications of influenza. Supplies of relevant drugs (e.g., antibiotics) and equipment (e.g., ventilators) will need to be secured and account taken of likely pressure on intensive therapy, laboratory and mortuary services.
MANAGING THE RESPONSE
1P.26 To maintain strategic control of the NHS response to the pandemic in their areas, NHS Boards will require to assess priorities for, and co-ordinate the use of, scarce resources. Similarly, the Scottish Executive Health Department will monitor the situation across Scotland and act as necessary to ensure that resources are deployed to maximum effect.
PUBLIC INFORMATION
1P.27 Accurate, timely, authoritative and up-to-date information will be needed by the public at all stages. Boards should consult the Scottish Executive Media and Communications Group (Health Desk 0131-244 2951) before releasing information to the media.
APPENDIX 2 TO ANNEX P
NOTIFIABLE INFECTIOUS DISEASES
Anthrax Measles Scarlet Fever Bacilliary Dysentery Membranous Croup Smallpox Chickenpox Meningococcal Infection Tetanus Cholera Mumps Toxoplasmosis Diptheria Paratyphoid Fever Tuberculosis Erysipelas Plague Typhoid Fever Food Poisoning* Poliomyelitis Typhus Fever Legionellosis Puerperal Fever Viral Haemorrhagic Fever Leptospirosis Rabies (including Yellow Fever) Viral Hepatitis Lyme Disease Relapsing Fever Whooping Cough Malaria Rubella
* Food Poisoning includes infections which, while primarily food or waterborne, may also be acquired secondarily by person to person. The reportable infections are:
Botulism E-Coli 0157 Rotovirus Brucelosis Giardiasis Salmonellosis Campylobacter Listeriosis Yersiniosis Cryptosporidiosis Q Fever
APPENDIX 3 TO ANNEX P
SCOTTISH CENTRE FOR INFECTION AND ENVIRONMENTAL HEALTH (SCIEH)
3P.1 SCIEH is a division of the Common Services Agency. Its tasks include:
3P.1.1 The collection, collation, analysis and timely dissemination of information about infectious disease to meet the needs of the NHS in Scotland and the Scottish Executive.
3P.1.2 To carry out these duties SCIEH has close links with diagnostic NHS laboratories, medical, veterinary and reference laboratories, CsPHM (CD&EH) at the NHS Boards, EHOs in local authorities, and the Scottish Executive as well as similar national institutions in other countries.
3P.1.3 To assist with the co-ordination of the investigation and control of outbreaks of infection which cross NHS Board and national boundaries. SCIEH may also provide expertise to assist at Health Board level but always at the invitation of NHS Boards with whom final responsibility lies.
3P.1.4 To provide expert advice or access to expert advice on the control and prevention of illness in all matters relating to infection and environmental health.
SURVEILLANCE
3P.2 NHS Boards and Local Authorities may inform SCIEH of general outbreaks in their areas. Any such information should be timely. SCIEH may by way of their national surveillance function become aware of cases which may be perceived as sporadic at local level but may indicate the presence of a national outbreak.
3P.3 EPINET is a means of transferring surveillance information electronically. It links all NHS Boards in Scotland to a UK wide communications system and includes SCIEH, SEHD, Public Health Laboratory Services (PHLS) other Health Authority users in England and Wales, and limited numbers of local authorities in Scotland. A parallel system of communications is in place between SEERAD and all local authority departments of environmental health in Scotland. It is a closed network called EH-net, particularly useful for speedy transmission of Food Hazard Warning notices.
3P.4 CONTACT DETAILS
SCIEH Clifton House Clifton Place GLASGOW G3 7YY
Tel: 0141-300 1100