Policy responses and statements
- Name of organisation:
- Department of Health
- Name of policy document:
- NHS Emergency Planning Guidance 2005 - Critical Care Contingency Planning in the event of an emergency where the numbers of patients substantially exceeds normal critical care capacity - A consultation
- Deadline for response:
- 14 November 2006
Background: This consultation calls for comments on this set of general principles to guide all NHS organisations in developing their ability to respond to an emergency where the number of patients substantially exceeds normal critical care capacity within the context of the NHS Emergency Planning Guidance 2005.
The purpose of this best practice guidance is to describe a general set of principles to National Health Service (NHS) organisations in planning, preparing and responding to all types of emergencies arising from any accident, infectious epidemic, natural disaster, failure of utilities or systems or hostile act resulting in an abnormal casualty situation or posing any threat to the health of the community or in the provision of services that involve significant numbers of patients with requiring critical care. The guidance covers adults and children.
This is an underpinning section of the NHS Emergency Planning Guidance 2005 and must be used in conjunction with this and other relevant underpinning sections.
COMMENTS ON
DEPARTMENT OF HEALTH
NHS EMERGENCY PLANNING GUIDANCE 2005: CRITICAL CARE CONTINGENCY PLANNING IN THE EVENT OF AN EMERGENCY WHERE THE NUMBERS OF PATIENTS SUBSTANTIALLY EXCEEDS NORMAL CRITICAL CARE CAPACITY
The Royal College of Physicians of Edinburgh is pleased to respond to the Department of Health on its consultation on NHS Emergency Planning Guidance 2005 relating to critical care contingency planning.
This consultation paper is sensible and useful but, perhaps by necessity, it is limited in scope. While it highlights a number of potential problems it is very ‘general’ in its approach and does not attempt to come up with any solutions or formal structure for contingency planning other than that a plan is required. There is no doubt that in such situations the existing services would be completely overwhelmed. That is self evident, and most of the content of the consultation paper could be described as common sense and obvious. That is not necessarily a criticism. It is difficult to ensure that Emergency Planning receives the attention it should, given that the vast majority of hospitals may never have to put their plans into action. This paper is therefore useful in ensuring that there is an awareness of the necessity for such planning, and providing a focus and opportunity to reconsider any existing plans.
It is difficult to cover all eventualities in such a short discussion paper and, from that point of view, the general approach is probably unavoidable.
SPECIFIC POINTS
The ‘introduction section’ [paragraphs 1 – 10] are useful and point 4, in particular, ensures that the reader is aware that general principles are the thrust of the document rather than specific action points.
The document points out that the guidance under no circumstances should be used to respond to a problem arising from staff shortages, waiting list pressures, management failures or other local institutional deficiency. This is clearly because this has happened in the past, and perhaps the reasons for this are understandable. These issues may well result in services being overwhelmed in the same way as an emergency incident. It would be worthwhile including a section in the guidance note stating that all organisations should have a separate contingency when the service difficulties arise from these areas rather than an emergency incident.
Definitions for critical care. This is quite clearly a definition of the different levels of critical care and does not attempt to define ‘the incident’ itself. Paragraph 10 has a definition of sorts of potential incidents and the College feels that this could usefully be included under a separate section.
The College is rather doubtful that ways of working and clinical practices which may have to be adapted for critical care contingency planning would have to be sustainable for as long as 3 months. We would have thought that planning would have included a strategy for sharing the clinical load across a wider geographical area to ensure this prolonged period did not occur. It would be unrealistic to suggest that the routine elective activity could be affected for this length of time.
While it would be ‘ideal’ for staff to be seconded to training courses, we are unsure how realistic it is to maintain a high level of preparedness. There is a limit to how much time and effort can be concentrated on an area that most NHS employees, even those working in the relevant areas, will not be exposed to throughout their career. Clearly, this is desirable but not terribly realistic. We agree that there should be planning to provide generic, ‘off the shelf’ training at short notice.
It is quite clear that when services are overwhelmed, triaging decisions that limit access to ‘critical care’ will be taken. The College completely agrees that these decision making processes will need to be agreed in advance, and we feel that this should be highlighted. We would also suggest that when such decisions are activated in the acute situation, they should be made and agreed by two clinicians. In the event of a pandemic there may be major ethical issues in deciding who should be treated and how these decisions should be made. It is clearly useful to have a second opinion. It could be particularly difficult if hospital staff became infected while looking after patients and themselves needed intensive care. We would suggest that the document should mention such problems and the need to consider ethical issues that might arise. There is a very useful report from the University of Toronto’s Joint Centre for Bioethics which discusses the ethical considerations in planning for pandemic flu: ‘Stand on Guard for Thee’.
Communication is not covered in sufficient detail. This has been a significant problem in previous major incidents as well as mock major incidents that Fellows of the College have been involved in. While what is said in Paragraph 52 and 53 is useful, the advice should go further and be expanded to mention video conferencing, telephone conferencing and also use of the internet, television, radio and communicating with staff and with the public. These ‘indirect’ forms of communication would be particularly appropriate and necessary in a pandemic.
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The other areas which the College feels could usefully be covered in this document are the processes for declaring that the presenting incident is likely to overwhelm services. Some of our Fellows’ experiences from major incidents suggests that this is an area which is always felt to be somebody else’s responsibility, and some guidance on assessment of the incident and declaration of the incident would be useful.
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There is clearly a major difficulty in ensuring that all staff are up to speed when such an incident occurs, and what is desirable in many cases is not achievable. The College is unsure how the correct level of preparedness could be achieved, and we do not think the consultation document comes up with any answers.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[6 November 2006] |
