Major incidents—a definition:

“An event that owing to the number, severity, type or location of live casualties requires special arrangements by the health services.”1

If casualties in major incidents are to receive the best possible care then quality planning and preparation is essential.1 The prospect of dealing with a major incident that results in large numbers of injured children is daunting. Nevertheless, such incidents do occur both in the UK and abroad (table1). Although major incidents can arise from a variety of causes,2 children may be prominent in many types of major incident (table 1).3-17 Those providing paediatric services may feel that major incident planning is an area in which they have a small role to play. In fact, they can play a vital role in the preparation and response to a major incident involving children.18

Difficulties in the management of children during a major incident have been documented at all stages of the incident response. In the prehospital phase, problems have been identified in determining triage and transport priorities.9 10 In the hospital reception phase, difficulties have arisen in mobilising staff experienced in managing children, and in obtaining adequate amounts of paediatric equipment.11 In the surgical phase of a major incident, concern has been expressed at the standard and choice of surgical procedures performed by non-paediatric surgeons.6 The common theme is not that planning for children failed, but rather that planning for children did not exist.

Major incident planning should follow an “all hazards approach”1 19 that is designed to deal with all types of major incident. Certain types of incident require additional arrangements if optimal patient care is to be achieved.19Incidents resulting in chemical,20 burn,21 or radiation22 casualties require additional arrangements, primarily because the resources to deal with these types of patients are scarce and often located in regional centres, at least in the UK. An incident resulting in only a few such casualties may result in the declaration or even decompensation23 of a major incident.

Few UK hospitals are staffed or equipped to deal with more than a few seriously injured children, with well documented shortages of paediatric surgical24 and intensive care unit beds.25 Specialist services for children are geographically scattered and some are confined to specialist hospitals not always co-located with emergency departments.26 This distribution might make it difficult to provide specialist care during a major incident.

The need for paediatric major incident planning is recognised in many countries,27-29 but few centres in the UK recognise it as a priority.30 Recent analysis of hospital major incident plans has shown that fewer than one third of hospitals plan for the care of children in major incidents,19 and that prehospital teams rarely contain staff trained in paediatrics.31

We conducted a three part Delphi study with the aim of identifying and improving areas of concern in planning for major incidents involving children.

Results

We present our results as a series of consensus statements. These are summaries of the main points of consensus from rounds 2 and 3 of the Delphi study. These summaries are based on the original set of over 200 statements, which are available elsewhere (Carley SD, MPhil Thesis, Manchester University, 1997).

Tables 3-7 show the results for the three phases of major incident response,19 that is: preparation (table 3), management (table 4), and support (tables 5, 6, and7).

Discussion

Conducting research into major incidents is difficult because the events are unpredictable. Clinical experimentation is impossible so, traditionally, practice has been based upon a small number of case reports and expert opinion. The opinions of single authors are highly susceptible to bias. This is particularly so with regard to major incident planning because we believe a multidisciplinary approach is necessary. Committees and expert working groups are also susceptible to bias through confounding by interpersonal relationships.36We used the Delphi method in an attempt to reduce bias.37

The process produced a series of statements on which a panel of experts has achieved consensus. These cover prehospital and hospital phases of planning and response to a major incident involving children. It became clear that the difficulties of managing children should be considered when planning for major incidents, so that both clinical expertise and equipment resources will be available. This may require cooperative planning arrangements between hospitals.2 Such arrangements must be made in advance of a major incident because they are difficult to coordinate successfully when an incident is in progress.

Many of the consensus statements extrapolate on the principles relevant to adult major incident planning19 (for example, the provision of suitable equipment). However, the provision of specialist services proved a particular consideration. Tertiary services (in particular intensive care and surgery) may be at a premium during a major incident. It would be impractical to transfer all children to specialist centres for assessment and treatment because this would merely result in transferring a major incident from one hospital to another. Clearly, a form of triage is required to identify those children most likely to benefit from tertiary services. The use of a paediatric assessment team (PAT) has been proposed as a solution to this problem. This concept is not new, having been proposed for chemical, burns, and radiation incidents.19 These specialist PATs only form during the response to a major incident. However, they are similar to paediatric intensive care retrieval teams, consisting of senior, skilled staff experienced in travelling to and working in other hospitals. It is quite likely that the services of an intensive care retrieval team would be required in a major incident involving children, and we suggest that this role be formalised with the addition of a paediatric surgical opinion. Membership will depend upon local resources but should be made explicit in local and regional major incident plans.

So far as we know, this is the first time that a systematic approach to expert opinion has been taken in this field of research. However, our findings must be interpreted with some caution for the following reasons.

First, the definition of expertise is subjective and relies upon the leading researcher and advisors knowing who are the potential experts in the field. We attempted to seek representation from all specialities with an interest in major incident planning for children, based upon our own knowledge, and recognise this as a source of bias. Second, the Delphi method only explores those areas of concern raised by members of the group, so important areas of planning might have been overlooked. Third, although the group appears to have achieved consensus on many statements this does not necessarily mean agreement. Delphi group members who are tired or bored with the process might shift towards consensus to stop the process.

This Delphi study did not produce a succinct set of guidelines for use by emergency planners. Our accompanying paper illustrates how the principles outlined in this paper can be translated into practice.

Delphi group members

David Larkin (Ambulance Service Association), Alan Parker (Ambulance Service Association), Andrew Marsden (Scottish Ambulance Service), Chris Carney (Staffordshire Ambulance Service), Duncan MacPherson (Department of Health), David Ward (Regional Emergency Planning Advisor, North West region), Gordon Tunley (Regional Emergency Planning Advisor, Oxford), Mike Williams (Accident and emergency (A&E)), Jim Wardrope (A&E), Tom Beattie (Paediatric A&E, Edinburgh), Ian Swann (A&E, Glasgow), Anthony Redmond (Disaster Medicine, Stoke), Roger Snook (Immediate Care, Bath), Tim Hodgetts (Immediate Care/Disaster Medicine, Surrey), Barbara Phillips (Paediatric A&E, Liverpool), Lynn Williams (Paediatric A&E, Nottingham), John Leigh (Anaesthetics, Bristol), Fiona Jewkes (Paediatrics, Cardiff), John Scott (BASICS/Immediate Care, Cambridge), Matthew Cooke (A&E/Immediate Care, Birmingham), Simon Davies (Nursing/Immediate Care, Staffordhire), Tracy Matthews (Nursing/A&E, Manchester).