This paper provides a practical approach to the difficult problem of planning for a major incident involving children. It offers guidance on how general principles resulting from an expert Delphi study can be implemented regionally and locally. All phases of the response are covered including preparation, management of the incident, delivery of medical support during the incident, and recovery and support. A check list for regional planners is provided. Supplementary equipment is discussed and action cards for key roles in the paediatric hospital response are shown. Particular emphasis is placed on management of the secondary–tertiary interface including the special roles of paediatric assessment teams and paediatric transfer teams. A paediatric primary triage algorithm is provided. The important role of local interpretation of guidance is emphasised.
- major incident
- Delphi study
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Four to five major incidents occur in the United Kingdom each year1 and many involve children. However, a recent survey showed that only 31% of hospitals make specific plans for the care of children involved in major incidents.2 The number of children involved in recent incidents has ranged from 6–67 (10–100% of all victims).
We have reported the results of an expert Delphi study examining the care of children in major incidents.3 This paper offers practical advice on how general guidance that resulted from the Delphi study can be implemented at regional and local hospital and prehospital level. We have not dealt with the care of children who are indirect victims of an incident (for example when main carers are injured or killed) as this is not primarily a health service responsibility.
Our guidance is intended to undergo local interpretation and to be incorporated as part of an overall major incident plan. In particular it seeks to use the expertise of tertiary and secondary paediatric services to support all phases of the major incident response when children are involved.
Practical advice is given for the preparation phase, for the management of the incident, the delivery of medical support during the incident itself, and for the recovery and support phases following the incident.
We have considered three aspects of preparation: planning, equipment, and training.
Regional planners should ensure that plans are in place for children at every receiving hospital, and that a realistic assessment and statement of the paediatric resources available has been made at each hospital. Units should also make realistic estimates of the number of seriously ill or injured children they are capable of receiving in one hour. Table 1 provides a checklist for hospitals that might receive children from a major incident.
Planning should assume that at least 10−15% of major incident patients require paediatric equipment. Prehospital paediatric equipment should be available as a supplement to general equipment, either in the form of snatch bags or boxes. Paediatric equipment must be made available in each area receiving patients. Table 2 shows the minimum supplementary equipment for every 10 children expected.
All clinicians involved in the paediatric clinical response should be trained at least to the level of advanced paediatric life support (APLS) provider.4 In addition, those involved in managing the response and all who might be involved in the prehospital response should be trained in major incident management to the level of major incident medical management and support (MIMMS) provider5 or equivalent.
Medical management includes command and control of the response, safety aspects, communications, and assessment. Only the command of the response will differ when children are involved.
Children will be dispatched to hospital by the ambulance and medical incident officers at the scene, and transported to hospital by the ambulance service. All hospitals that might receive children should appoint a paediatric coordinator to assist the hospital coordination team in managing them and overseeing their care. Table 3 shows an action card for the paediatric coordinator.
Some specialist paediatric resources and services are limited so decisions must be made about which patients need them most. These scarce resources are most likely to be found at children’s hospitals, which must therefore be central to the decisions about how patients are allocated. Where there is no specialist children’s hospital, those housing the specialist services must nominate a lead hospital. Deciding on resource allocation will be much more difficult if children are dispersed around many receiving hospitals. To inform the decision making process, lead paediatric units must be able to provide paediatric assessment teams (PATs) that can go to the receiving hospital to assess which children warrant transfer to specialist services. It is likely that PATs will be based on existing paediatric retrieval services. Table 4 shows an action card for a PAT.
Medical support for children involved in major incidents includes triage, treatment, and subsequent transport.
If only a few children are involved then standard triage sieve–triage sort methodology5 can be used, despite the fact that it is known to over triage children. If there are more than five children aged 3 years or younger then the Eichelberger modification6 should be applied to both sieve and sort methods. Figure 1 shows a modified primary triage scheme (sieve).
It is most unlikely that individual receiving hospitals will be able to provide enough specialist paediatric staff to oversee the treatment of every child admitted during a major incident. Nor indeed will this be necessary as many emergency department staff will be well versed in caring for injured children. However, paediatric expertise should be available for seriously ill and injured children wherever they are. This can be achieved by forming paediatric treatment teams; an action card for such a team is provided in table5.
If many children are involved, it is likely that only those identified by the PAT as requiring tertiary paediatric care will be transported from the primary receiving hospital. If few are involved then the decision to move may be made following normal referral mechanisms. However this decision is made, sick or injured children must be stabilised and transported by clinicians skilled in their transfer. Such personnel may be available from within the receiving hospital or may be made available by the tertiary paediatric centre. To facilitate these transfers, a paediatric transfer team should be formed; an action card for a paediatric transfer team is provided in table 6.
Recovery and support
Emotional support and counselling should be offered to children, families, and staff. Adequate provision must be made for this and maintained until no longer needed.
Audits should be done following a major incident to determine whether the care of children was optimal. Children’s hospitals should coordinate collation of a casualty incident profile (CIP)1 7 of the child victims of the incident. As a minimum, the CIP should include the following:
mechanism of injury (if any)
injury description (AIS)/illness description (ICD)
Once this has been done, a postincident meeting involving all hospitals concerned should discuss how the children were cared for.
We have provided a practical approach to the difficult problem of planning for the rare but potentially devastating occurrence of a major incident involving children. The principles we expound can be applied generally. Local decisions must be made on how to modify our approach to work in practice. Children’s emergency and inpatient provision changes, so local decisions to designate lead and receiving hospitals are essential. For this reason strategic (regional) planning teams must include a specialist with expertise in paediatric matters.
Simon Carley was Hillsborough Research Fellow of the Royal College of Surgeons of England while this research was carried out, and was supported by a grant from the Hillsborough Trust.