"A really bad day at the office: evacuation, contamination and escalation in critical care " - A report from the NWLCC Network emergency ...
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North West London
“A really bad day at the office: evacuation,
contamination and escalation in critical care “
A report from the NWLCC Network emergency preparedness event held on 11th September 2008
Polonium-210
Contents
Page number
1. Introduction 3
2. Aims 3
3. Scope 3
4. Learning from: - a fire evacuation 4
- a radiation incident 7
- an on-site pharmaceutical major incident 9
Appendices: Programme 13
Delegate list 14
NWLCC Network information 16
Acknowledgements
We would like to thank the following people for their thoughtful perspectives and excellent presentations
Dr Craig Carr Consultant ICM, Royal Marsden Hospital Foundation Trust
Dr Jim Down Consultant ICM, UCLH Foundation Trust
Dr Ganesh Suntharalingam Network Medical Lead and Consultant ICM, NWLH Trust
Dr Steve Brett Consultant ICM, Imperial College Healthcare Trust
Heather Lawrence Chair for the event, Chief Executive, Chelsea and Westminster Hospital Foundation Trust
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 2
Introduction
1. This report is a summary of the learning points from the NWL Critical Care Network emergency preparedness event held on 11th September
2008. We hope you find the report useful.
2. The event was designed to capture the experiences of staff and immediate learning arising from several emergency incidents in London all of
which directly affected critical care services. The incidents considered at the Network event were :
The fire at the Royal Marsden Hospital requiring the full evacuation of the Intensive Care Unit and transfer of patients to another hospital;
The management issues for an Intensive Care Unit following a patient’s death being linked to a major dose of Polonium- 210 at UCLH and;
The need to escalate critical care facilities and admit 6 patients simultaneously to an already almost full Intensive Care Unit at NWLH as a
consequence of a drug trial incident locally
3. A session on pandemic flu was also included to emphasise escalation, contamination and business continuity issues that apply.
Aims and proposed outcome for the day
4. The aims and the proposed outcome for the day were to:
• Share the experience gained from these incidents with a wider critical care audience;
• Improve awareness of local learning from these incidents;
• Consider application of any learning locally;
• Develop and share key learning points from the day in the form of a short report.
Scope
5. There has been no attempt to summarise Trust/Agency debriefings for any of the incidents. The event and this report were designed to
capture issues highlighted for critical care services and staff by critical care responders and to facilitate thinking and discussion regarding
critical care business continuity.
6. There were some common themes from the event which included
Planning and preparation
Role of staff including diversion from normal working
Staff communication needs
The challenges of Media management particularly in a single site incident
Business continuity
7. Learning points from each of the incidents reported have been set out in detail in pages 4-11. Useful website links have been set out at the
end of each incident section.
8. A Flu pandemic guidance framework for critical care has been developed for London and is available from the NWLCC network or any trust
emergency planning/flu lead.
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 3
Learning from a fire evacuation
A fire at the Royal Marsden Hospital in January 2008 triggered evacuation of the hospital. This included the full
evacuation of the Intensive Care Unit (ITU) as well as patients from theatre/recovery areas. Patients were transferred to
another hospital – the Royal Brompton Hospital.
ICU operational design – you can design out many problems with planning and training
1. Fire planning
• think multiple escape routes – horizontal and vertical and the need for multiple options
• think much faster spread than anticipated
• think loss of efficacy of smoke doors
• think local shut-down of ventilation systems – do you know how/where to turn this off for your area
to delay spread of smoke via ventilation system?
• think bariatric patients and space restrictions -can you get big patients out via emergency routes?
• know your fire lifts and how they operate – some lifts are designed to work in a fire – do you know
which and how they work?
2. People and skills
• think staffing ratios
• think how would you evacuate at night?
• think who will take charge and with what levels of responsibility?
• think rehearsals and drills – have you practiced using evac chairs or evac fire sheets?
• think case notes and drug charts – don’t leave them behind when you go
3. Policy and
training • Have you read the ICS 1998 “Guidelines for Fire Safety in the Intensive Care Unit”?
• Have you read about disaster management and planning – and your local major incident policy?
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 4• Have you read local fire policies and offered constructive criticism if you disagree with the
relevance/content regarding its application to your areas?
• How do you learn from the experience of others?
• How useful do you find fire training? If you find it unhelpful then get the trust to change its delivery
and make it relevant to your area of work and the challenges you might have?
• With a decision to evacuate the ITU - who makes it? Where does the decision rest?
4 Exits
• Are the fire exits secure?
• Are there any covers over the external exits to prevent falling debris from above injuring those
escaping? Most fire exits don’t have any cover. What about yours?
• How do you know which exits are safe?
• Can you get patients out easily?
• How do you evacuate?
• Are the doors sensible for getting patients on mattresses through – even very large patients?
5 Equipment
• Do you have Fire Slide sheets for every bed space?
• Do you know how to use them and have you practiced using them?
• Do you know how to use evac chairs and have you tried using them?
• Also see ICS guidance regarding equipment
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 56 Transfer to
another hospital – • In this incident the critical care patients were transferred to the Royal Brompton Hospital (RBHT).
the Royal This hospital had activated their major incident response plan and diverted staff from normal
Brompton working to support the staff at the Royal Marsden and effect safe transfer of patients in
Hospital conjunction with the London Ambulance Service and Royal Marsden teams.
• RMH teams retained responsibility for their patients
• Remember to consider:
Patient documentation
Patient registration on another hospital system
Staff access to computer systems
Prescribing
Treatment continuity
Useful websites
/guidance
ICS guidelines Fire -
icu.pdf
ICS Fire guidance http://tinyurl.com/ics-fire-safety or, attached:
Fire sheets: http://www.hospitalaids.co.uk/product_03.php
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 6Polonium-210 Learning from a radiation incident
In November 2006, the death of a patient in ITU from polonium -210 poisoning resulted in staff in the Intensive Care Unit at
UCLH facing a radiation incident.
What is Polonium – 210 Features
• Silvery grey dust
• Background 30 mBeq (cigarettes) • T1/2 138 days, body extraction T1/2 37days
• Manufacture ~ 1mg per year from bismuth • 10% absorbed
• Spark plugs • To liver (30-40%) kidneys (10%) Skeleton 5%
• Manhatten project • Damage done by alpha particles.
• Neutron trigger with Beryllium • Alpha particles non-penetrative but polonium gets everywhere
• Satellites
• Picogram amounts for anti-
static
• α emitter 21084 Po → 206 82Pb + 4 2He
Very Efficient 1mg Po = 5 G radium
1 Radiation sickness Acute radiation sickness
• Destroy cell walls and thus cells • Common pathway of pathology
• Cells experience DNA damage and are • GIT. Nausea, vomiting, diarrhoea gastritis
unable to repair the damage. • Bleeding
• Cells experience a non-lethal DNA mutation • Alopecia
that is passed on to subsequent cell • Latent phase “walking ghost”
divisions. This mutation may contribute to • Marrow aplasia
the formation of a cancer • Delirium coma
• Cells experience DNA damage and are able Gut and bone marrow
to detect and repair the damage.
Radiation sickness follows a common pathway of pathology
depending on the level of exposure
Treatment is largely supportive unless very early or there is a cold
isotope or very occasionally BMT is possible.
2 Helpful agencies The Health Protection Agency (HPA) was the key link (contact local
office). They are an “independent body that protects the health and
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 7well-being of the population”. They cover:
• Infectious diseases
• Chemicals
• Poisons
• Radiation
They are also clinical and can then link with the Atomic Weapons
Establishment (AWE) and forensics science service, the Police and
the Government if necessary.
3 Testing
• Geiger counter – internal gamma unlikely Testing is moderately difficult and complicated. A Geiger counter is
• Alpha counter helpful in that if negative, it implies staff will be safe with universal
• Polonium precautions.
– Secondary gamma activity
– Too little to detect mass spectrometry
4 Staff safety Universal precautions were enough in this case and probably all
cases except gamma and beta emitters (geiger positive).
5 Information dissemination • Sensitive information needs handling well
• International relations in this particular case
• Staff safety - reassurance needed for staff
• Staff morale – speed of information provision supports this
• Shift patterns – make sure you cover everyone
• Incomplete knowledge
• Disinformation – challenge this
• Need a very well organised system of information
dissemination and you need to catch all staff ASAP.
The combination of media circus, radiation, leaks and spooks led to
very high levels of staff anxiety – regular & comprehensive
information dissemination to staff is crucial.
6 Media • Regular press statements
• Say nothing else
Intense media interest • But… Leaks, Circus, Experts, Friends!
Give/ hold regular press conferences and avoid other contact.
Useful Health Protection Agency www.hpa.org.uk/ Atomic Weapons Establishment www.awe.co.uk/
websites
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 8Learning from an on-site, pharmaceutical, major
incident
On March 13th 2006 a clinical trial of TGN1412 ( Recombinant humanized anti-CD28 superagonist antibody at an
independent commercial drug testing facility located on a DGH site – Northwick Park Hospital ) resulted in the rapid and
simultaneous admission of 6 patients into a nearly full Intensive Care Unit.
The unusual aspects of this incident were that it was a ‘Chemical’ incident, an Internal incident, a novel agent previously
unknown in humans, empirical Rx, a single-site story for the media and there were immediate global consequences for trial
conduct. There were however, no contamination issues, no staff health issues and there was clear identification of the agent
(though not the effects).
1 • 1 pt admitted to ITU, 5 to Recovery, all within short space of time and commencing
Capacity expansion level 2/3 care immediately on arrival. Clinical decision to admit and treat all patients
as a single cohort. No staggered admission via A&E/theatres as with other
incidents, so no ITU preparation time.
• 5 additional bed spaces created in adjacent Recovery using ITU escalation plan. 5
trolleys converted into functioning ITU bed spaces within 1 hr of decision.
• ICU and Recovery staff normally work closely and many are cross-skilled. ICU
nursing ratio flexed to liberate staff to work in Recovery. Staff assigned by role not
patient to form ‘production line’ – e.g. one i/c documentation, one for drugs, one
anaesthetist + nurse to form ‘central line team’ as patients arrive. One admission
per 5-10 minutes at peak activity, all patients receiving drug treatment, CPAP or
ventilation, central venous cannulation, some on inotropes, and all going onto
haemofiltration as equipment arrived.
• Phasing: used two-phase approach: expand into Recovery, concentrate on active
treatment, and stabilise situation overnight at 166% over-capacity; identify and
agree beds in other units overnight for stable ITU patients, but wait for daytime
teams to arrive to form multiple transfer teams at 08.00. Started all theatre lists
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 9normally next day, since Recovery not essential to begin list. In the event no
elective patients cancelled.
• Deliberate decision to limit clinical staff call-in overnight to minimise confusion and
ensure that sustainable numbers “for the day after” were maintained. This was the
correct clinical decision but (slightly earlier) management-only major incident
activation would have been useful for logistical support, early activation of Press
office, etc.
• Network contacts were used to borrow haemofiltration equipment from other
Network support intensive care units and agree decant beds – those in Network much easier to
contact/agree than others due to familiarity.
• Trust-contracted taxi service unable to help move equipment (‘no drivers free’) so
used Police – need to ensure mechanisms are in place to over-ride contract and
use other providers in emergency.
Things to do differently: Overnight activation of Trust major incident ‘spine’
(management, Press office, etc.) even if not a full clinical callout, would have helped
minimise staff distraction by press, handling of relatives in large numbers. This took place
within 12 hours and was very effective once in place. Suggest such a “Trust management
activation” mechanism is considered for major incidents, so that there is a mechanism to
do so without automatically cascading and calling in clinical staff – this was the deterrent in
this case.
Deviations from normal practice included: task-based nursing, stable patients
transferred, triumvirate on-call, expert panel set up to manage information flow and
cohorted decisions (see below).
2 Management of uncertainty
• Ethical issues:
• Unpredictable effects • Admit as a cohort? (meant moving other pts out, contrary to usual practice)
• Unpredictable severity • Treat as a cohort? (spectrum of severity in a completely unknown disease – is it
• Unknown kinetics in right to risk novel therapy and high-dose steroids for the least sick as well as most
humans sick? Do you ‘risk’ all patients with empirical treatment, or treat one patient to test
response - or is this itself an unethical internal? We took latter view and treated all)
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 10• Ethics of sampling (pts now off-study and unconsented – so cannot take multiple
samples for investigation alone, but failure to do so may impact on patients later
since cytokine levels etc. are highly time-sensitive).
3 information management -Massive amount of information flow – trial documentation, drug development
and decision-making input, regulatory bodies, plus multiple internal and external clinical opinion, some
invited, some not. Also responsibility for updating MHRA and other investigating
bodies – very involved discussions, happening in real-time alongside clinical Rx.
- 3 intensivists shared on-call in first 72 hrs and then continued input on
‘triumvirate’ basis so that all decisions were by consensus.
- Advisory expert panel set up on day one, to manage external opinion and direct
management so as not to distract from hour-to-hour running of Unit. Defined
meeting times (12/24/48 hrly) to avoid bedside scrum. Intensivist-chaired. Key
invited members were academic haematologist, microbiology, and external
intensivist to provide diversity of input, plus drug development experts as required.
* Keep intensivist control – unit must function as normal even in complex
circumstances.
- Documentation – of all decisions, copied into all six notes – organisational and
clinical and remember to record any impact on other patients, esp. outward
transfers (audited via Network – no attributable harm to third parties from transfer).
Note that 2 families of transferred (non drug trial) pts came later with requests for
explanation and assurance that no risks taken.
4 Communications Response to the media
• Operational disruption • Set up a press room – well away from the Unit
• Therapeutic rapport • Active regular accurate briefing – well away from the unit. Journalists mainly
– Patient and family want to know is that their rivals are not getting information before them, so will co-
• Confidentiality operate with scheduled group briefings if trust established.
– Breaches of privacy • Ensure “Credible source” provided, suggest pooled interviews with the press
– Patients identifiable • Control the message and keep confidentiality. Bland content, issued frequently,
in media with clinical credibility, works better and is less risky than silence or inevitable leaks.
• Legitimate public interest • Watch out for “fake” staff/ vicars/ relatives trying to get onto ITU – be vigilant with
– Accurate information access
vs. rumour • Had to make clear separation between NHS team and drug company in same
• Implications for trial building from the outset, to establish trust and rapport – lack of confidence in clinical
regulation team from patients and families would otherwise have made treatment impossible.
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 11• As well as ‘the public’, there was legitimate, external specialist interest (academic,
regulatory, governmental, and commercial). Duty to inform regulatory bodies,
collaborate with adverse event reporting, plus in this case extensive consequences
for global trial conduct as events unfolded. Many bodies with a legitimate ‘right to
know’ balanced against individual patient confidentiality.
• Confidentiality complicated by pts becoming identified by selves and family –
so briefing on e.g. condition of “the 2 sickest patients” etc. no longer anonymous.
Also impacted on publication since patients in data tables can be identified by
severity.
5 Challenge : disclosure, • ‘Duty to inform’ – intense speculation feeding into regulatory and biological
reporting discussions worldwide at early stage. E.g. comment by family member to press re.
swollen heads, leading to incorrect speculation in science press re. angioedema.
Only way to share key information is consented publication. Express publication via
NEJM with full consent and peer review but huge issues of:
• privacy (pts identified in Press and identifiable by severity)
• trial data ownership (patients, drug and trial companies, NHS)
• Regulatory consequences
• Data ownership
• Intellectual property
• Defamation risk
Useful Clinical case report: http://content.nejm.org/cgi/reprint/355/10/1018.pdf
websites
For sites where high-risk phase one trials may be undertaken:
DH Expert Scientific Group report into phase one trials (for ITU facilities see pp 92-93)
http://tinyurl.com/phase-one-trials
BIA/ABPI Joint Task Force on Early Stage Trials:
http://www.abpi.org.uk/information/pdfs/BIAABPI_taskforce2.pdf (ITU facilities pp 6, 10, 26)
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 12Appendix A - Programme
Network Event: Emergency Preparedness
“A really bad day at the office -contamination, evacuation and escalation in critical care”
11 September 2008: 1.30pm – 5.00pm
Programme
1.30 Registration, coffee/tea and networking
2.0 Welcome: Heather Lawrence, Chair of the Network
2.05 Introduction to “a really bad day at the office”- aims for the afternoon
2.10 Fire: Evacuation of an ITU –getting patients out of the hospital and into a place of safety – the Royal Marsden Hospital experience
Craig Carr, Consultant ICM, Royal Marsden NHS Foundation Trust
2.40 Pandemic Influenza – clinical epidemiology
Steve Brett, Consultant ICM, Imperial College Healthcare Trust
3.20 Tea and coffee break
3.35 Polonium- 210 contamination in an ITU (From Russia with love)
Jim Down, Consultant ICM, UCLH NHS Foundation Trust
4.05 Escalation, information, and the management of uncertainty: An on-site, pharmaceutical major incident
Ganesh Suntharalingam, Network Medical lead & Clinical Director at NWLH Trust
4.25 Discussion – actions for improving local plans
4.55 Round up and close
A meeting of the NWL CC Network Medical Forum will take place at 5pm
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 13Appendix B – delegate list
Delegate list 11.9.08
Emergency Preparedness "A really bad day at the office - contamination, evacuation and escalation in critical care"
Trust or Organisation Name Role
Jane Tippett Assistant Director of Nursing
Chelsea and Westminster
Foundation Trust Rona McKay Clinical Nurse Lead
Matthew Rigg Charge Nurse A&E
Cath Englebretsen clinical specialist Physiotherapist
Elaine Manderson CNS ICU
Hazel Boyle Nurse Band 7
Caroline Younger Nurse Band 7
Emma Long Nurse Band 7
Jo Steen Nurse Band 7
Gordon Turpie Nurse Band 7
Ann Sorie Nurse Band 7
Amanda Dixon Nurse Band 7
Hwee Leng Lim Senior Staff Nurse
Charlene Brown Nurse Band 7
Jiii Bien Nurse
Rebecca Hill CNS ICU
Danielle Pinnock Nurse Band 7
Department of Health Dr Matthew Fogarty Cross Government Programmes Manager, Emergency Preparedness Division
Ealing Hospital Trust Angeline Chew Senior Sister/ Acting Matron
Felicia Kwaku Head of nursing
Hillingdon Hospital Trust Anne Knight George Consultant ICM
Sohan Bissoonauth ITU Manager
Imperial Healthcare Trust Deirdre O’Sullivan Senior Sister ITU
Doris Doberenz Consultant ICM
Sarah Rodenhurst Emergency Planning Manager
John Clark Associate Director of Nursing
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 14Roseanne Meacher Consultant ICM
Melanie Denison Acting Clinical Nurse Manager
Paul Southern Senior Duty Manager – Senior Nurse
Steve Brett Consultant ICM
Siew Teow Lim Staff Nurse
Simon Ashworth Consultant ICM
North West London CC Network Heather Lawrence Network Chair & CE of C&W Trust
Angela Walsh Network Director
Carol McLoughlin Commissioning Project Manager
Dr Ganesh Suntharalingam Medical Lead
NW London Hospitals NHS Trust Johann Grundlingh Specialist Registrar
Colin McDonnell Clinical Site Practitioner
Julie Donoghue Modern Matron A&E
Deborah Taylor Senior Sister A&E
Christine Shanahan Sister
Kathryn Judge Sister
Yasmin Kabani Senior Nurse
Jacek Borkowski Consultant Anaesthetist
Dr David Adeboyeku Critical Care Consultant
Royal Brompton & Harefield Hospitals Charles Gillbe Consultant Anaesthetist, & Network Medical Forum Chair
NHS Trust Surjeet Kaur Service Manager – Critical Care
Joy Anderson Senior Nurse/Matron AICU
Ben Creagh-Brown AICU Research registrar
Craig Brown Clinical Specialist Physiotherapist
Annette Brice Senior Physiotherapist
Royal Marsden Hospital Dr Craig Carr Consultant ICM
University College Hospital Foundation Jim Down Consultant ICM
Trust
West Middlesex Hospital Stephanie Stevenson-Shand Matron/Head of Service
NHS Trust Barbara Thomas Senior Sister
Janice Scott Sister
Tim Peters ICU Consultant
Whittington Hospital NHS Trust Martin Kuper Consultant Anaesthetist
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 15North West London
Appendix C - Network Information
The North West London Critical Care Network represents commissioners and healthcare providers and has strategic and operational roles.
The Network’s operational activities are focused on clinical needs and “problems that need fixing”, providing good clinical engagement.
The Network Steering Group has representatives of each hospital group and each profession, who can link and feedback to colleagues.
The Network includes cross-hospital professional forums ( medical, nursing and therapists) which link directly to the relevant staff groups
Core activities include
Provider development
o Service improvement
o Clinical pathways across organisations
o Training and inter-organisational governance
o Standards and quality
o Events and task group sessions
Commissioning ‘Resource’
o Clinical reference/input/ collective expert advice
o Quality standards for commissioning critical care
o Service configuration
o PbR/CCMDS
‘one stop shop’; data, information on critical care
Address
North West London Critical Care Network
C/O Ealing PCT
1 Armstrong Way
Southall
UB2 4SA Tel: 020 331 39309 Contact: critcarenetworknwl@nhs.net
NWLCC Network: Emergency preparedness event 11.9.08 Editors: Angela Walsh, Network Director, Ganesh Suntharalingam, Medical Lead, November 2008 16You can also read
