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									Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                        Section

                COMMAND AND COORDINATION                                                      7
7.1       Context

7.1.1     In order to achieve a combined and coordinated response to a Major             See Section 4-
          Incident, the management of the response is divided at Trust level into        Great Western
          three levels, Operational (Bronze), Tactical (Silver) and Strategic (Gold).    Service
          The requirement to implement one or more of those management levels
          will depend upon the nature of the incident; however an operational level of
          command will always be established and possibly a tactical level if

7.1.2     Operational and Tactical command and co-ordination will be delivered from
          two facilities.

          •   Operational Control Room (Bronze) - Patient Admissions Centre and
              Nurse Bank

          •   Tactical Control Room (Silver) - Directors Offices

7.2       Operational (Bronze) Coordination

7.2.1     Operational (Bronze) coordination will be achieved, firstly by the ‘Site’      See Appendix
          Manager and secondly by a Senior Manager. The latter will undertake            34- First
          regular operational hospital management, will receive regular orientation      Action Card
          and training and will be completely familiar with the Major Incident Plan.
          Each team will have action cards to ensure the Trust response is identical,    See Appendix
          irrespective of the hour or day. The roles are named as:                       35- Operational
                                                                                         Action Card
          •   First Responder (Site Manager)

          •   Operational Coordinator (On-call Manager 1st line contact)

7.3       Operational Control Room (OCR)

7.3.1     The OCR is located on the south corridor and is in close proximity to
          Switchboard, the Staff Volunteers and Rest Centre and a short distance
          from the Relatives Reception Centre. The OCR normally provides
          accommodation for Site Management and through an adjoining door the
          Nurse Bank office. This entire complex will be used for the OCR with the
          Nurse Bank office used as an Operational Planning Room and for
          Ambulance Liaison.

7.3.2    The following staff will work directly from the OCR:

         •    First Responder (Site Manager)

         •    Operational Coordinator (1st line On-call Manager)

         •    Bed Manager (Bed Manager)                                                  See Appendix
                                                                                         36- Bed
                                                                                         Manager Action
Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                   Section

                COMMAND AND COORDINATION                                                 7
         •    Critical Care / Theatres / Clinical Support
                                                                                    See Appendix
                                                                                    37- GP Liaison
         •    Services Coordinator                                                  Action Card

         •    Admin & Clerical support and runners                                  See Appendix
                                                                                    38- Critical
         •    Ambulance Liaison                                                     nical Support
         •    Emergency Planning Lead                                               Coordinator
                                                                                    Action Card

                                                                                    See Appendix
                                                                                    and Clerical
                                                                                    Support Action

7.3.3     The resources for the OCR includes:                                       See Appendix
                                                                                    40- Bleep/Useful
          •   Direct dial telephones

          •   12 telephone extensions + 6 additional available if required

          •   Fax lines

          •   E-mail account majorincident-Bronze@ruh-bath.swest.nhs.uk, mirrored
              in each office

          •   Document boxes for plans and action cards

          •   Wipe board and dry marker pens

7.4       First Responder

7.4.1     Members of the First Responder (FR) team

          •   Site Manager (Patient Access Team)

          •   Night Nurse Practitioners

7.4.2     The First Responder will be:

          •   Available on-site 24/7

          •   Informed by voice bleep ‘Team 25’

          •   Issued the alert message and repeated x 3
Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                          Section

                COMMAND AND COORDINATION                                                        7
7.4.3     The FR will be responsible for completing the actions detailed on the ‘First     See Appendix
          Responder’ action card. Critical actions include:                                41 Alert Record
          •                                                                                See Appendix
          • Completing required documentation                                              42- Response
                                                                                           Check List
          •   Deploying Emergency Department Forward Observer                              See Appendix
                                                                                           43- Emergency
          •   To fax the bed state to the Ambulance Service                                Department
                                                                                           Observer Action
          •   Finding help                                                                 Card

                                                                                           See Appendix
                                                                                           44- Division
                                                                                           Bleep Holders
                                                                                           Action Card

                                                                                           See Appendix
                                                                                           45- Risk

                                                                                           See Appendix
                                                                                           46- Bed State

7.4.4     Initiate in a ‘Declared’ alert the 1st stage of the ‘capacity expansion plan’.

7.5       Operational Coordinator

7.5.1     Members of the Operational Coordinator (OC) team

          •   Assistant Director of Nursing, Medicine

          •   Assistant Director of Nursing, Surgery

          •   Assistant Director of Nursing, Corporate Division

          •   Senior Nurses from the Medical and Surgical Division

          •   Speciality Managers

          •   Assistant Divisional Manager Medical Division

          •   Assistant Divisional Manager Surgical Division

          •   Assistant Divisional Manager Specialties Division

          •   Members from the 1st Line On-call managers

7.5.2     Operational Coordinator

          One Operational Coordinator will be:
Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                    Section

                COMMAND AND COORDINATION                                                  7
          •   Available 24/7

          •   Informed by radiopager/ mobile telephone/ bleep

          •   Issued the alert message

          •   On-site or on-call

          •   Able to arrive at the hospital within 30 minutes of alert

7.5.3     The OC completes the instructions as detailed on the ‘Operational
          Coordinator’ action card.

7.5.4     In a ‘Declared’ alert the OC deploys Forward                               See Appendix
          Coordinators:                                                              47- Discharge
                                                                                     Centre Manger
                                                                                     Action Card
          •   Critical Care, Theatre and Clinical Support Services Observer
                                                                                     See Appendix
          •   Transfer Lounge Manager                                                48- ‘Transfer
                                                                                     Lounge Log
          •   Forward Emergency Department observer                                  Discharged

                                                                                     See Appendix
          •   Casualty Enquiry Bureau + Police Documentation Team Coordinator
                                                                                     48- Transfer
                                                                                     Lounge Log
          •   Relatives Centre Coordinator                                           Patients
          •   Staff Reception / rest Centre Coordinator

          •   Documentation Observer

          •   Loggist

7.5.5     The OC initiates the ‘Expansion Plan’ if required to accommodate:

          •   Priority 1 = 10 patients for Critical Care

          •   Priority 2 = 100 patients requiring a bed within 4 hours

          •   Priority 3 = 100 + minor injuries

          •   Other emergencies and GP admissions

7.5.6     The OC conducts frequent situational briefings with key staff including:

          •   Site Manager / Bed Manager

          •   Divisional Bleep Holders

          •   Forward Observers / Coordinators
Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                         Section

                COMMAND AND COORDINATION                                                       7
          •   Casualty Enquiry Bureau

          •   Communication team – information for the media briefings

          •   Ambulance Liaison

7.5.7     The FR and OC must be completely familiar with the command and co-
          ordination procedures detailed on the action cards.

7.6       Critical Care Services

7.6.1     In a declared alert the critical care forward observer for the critical care,
          theatre, radiology, pathology and pharmacy will be based in the operational
          control room. They will:

          •   Work with and report to the Operational Coordinator

          •   Monitor the involvement and capacity of the critical care services

          •   Problem solve for the critical care services

          •   Support the emotional welfare of staff

7.7       Transfer Lounge

7.7.1     In a declared alert the transfer lounge forward coordinator will be based in
          the Discharge Centre and will report to the operational coordinator. They

          •   Open the Discharge Centre if necessary

          •   Transfer existing patients to the Discharge Centre

          •   Coordinate clinical services and transport to enable discharge home or
              transfer to community hospitals to help generate Trust capacity

7.8       Casualty Enquiry Bureau + Police Documentation Team

7.8.1     In a declared alert the casualty enquiry bureau forward coordinator will be     See Appendix
          based in the 1st floor management offices (complaints and litigation) they      49- Casualty
                                                                                          Enquiry Bureau
          may also use the senior receptionist office in ED to gather accurate data       Coordinator
          about casualties and will report to the operational coordinator. They will:     Action Card

          •   Manage and coordinate all patient and relative documentation and            See Appendix
                                                                                          50- Casualty
              enquiries                                                                   Enquiry Bureau
                                                                                          Contact Log
          •   Receive all Major Incident patient registration documents from
              Emergency Department
Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                        Section

                COMMAND AND COORDINATION                                                      7
          •   Receive all enquires from relatives and friends of patients

          •   Provide for the operational, tactical, communication, receiving ward,
              welfare and Police documentation team information regarding patient
              identity and relative information

          •   Provide a help desk function for the concerned

7.9       Relatives Reception Centre

7.9.1     In a declared alert the Relatives’ Reception Centre Manager will be based      See Appendix
          in the Postgraduate Medical Centre (PGMC) dining room and will report to       51- Relatives
                                                                                         Manager Action
          the operational coordinator. They will:                                        Card

          •   Receive all relatives and friends who arrive at the hospital               See Appendix
                                                                                         52- Relatives
          •   Transfer relative information to the casualty enquiry bureau               Information

          •   Keep relatives informed and comfortable

          •   Repatriate relatives and patients

          •   Manage identification of the dead patient with the mortuary and police

          NB: The atrium reception staff will be required to receive and direct all
          people making enquires. The Friends volunteers will be required to escort
          all relatives to the PGMC

7.10      Staff Reception Centre

7.10.1 In a declared alert the staff reception centre will be based in the Lansdown      See Appendix
       Restaurant and report to the operational coordinator. They will:                  53- Staffing
                                                                                         Centre Manager
                                                                                         Action Card
          •   Work with the Divisional Bleep Holders to allocate volunteer staff to
              clinical areas as required                                                 See Appendix
                                                                                         54- Staff and
                                                                                         Volunteer Log
          •   Receive volunteer staff

          •   Establish the skills of each volunteer and allocate staff to tasks as
              requests are received from the Operational Control Room

          •   Provide rest and recuperation for staff, which will include catering and
              rest areas

          •   Document all actions and details of volunteer staff

          •   Support the emotional welfare of staff

7.10.2 For staff alerted by bleep or pager or call-in, go direct to the area as          See Appendix
       requested. Any member of staff not on duty who wishes to help is                  53- Staffing
Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                          Section

                COMMAND AND COORDINATION                                                        7
          requested to go the Lansdown Restaurant where they will be received,             Centre Manager
          their details recorded including the contribution they could best provide. All   Action Card
          staff must observe the following:                                                See Appendix
                                                                                           54- Staff and
          •   Do not contact the hospital Switchboard unless critically urgent             Volunteer Log

          •   Bring your security identification as all entrances will be patrolled by

          •   Enter the site via Evelyn Road or Penn-lea entrances only. Both
              barriers will be opened and patrolled by security. Do not enter via the
              Main or Emergency Department entrances

          •   For volunteers arriving at the reception centre state your name, role,
              and if you speak a foreign language

7.11      Documentation Observer

7.11.1 In a declared alert the documentation forward observer will be available by
       bleep and report to the operational coordinator. They will:

          •   Check all areas are completely familiar with the documentation to be
              used in the Major Incident

          •   Ensure all completed documentation is direct to the required area
          •   Check for completeness and legibility

          •   Coordinate the security of all management documentation and
              switchboard computer logs in relation to the Major Incident from all
              areas involved

7.12      Ambulance Liaison

7.12.1 Will be dispatched to undertake the role of Ambulance Liaison officer. They
       will be located in the Nurse Bank office with an adjoining door to the
       Control Room. The room is provided with a fax and two direct dial
       telephones not routed through switchboard. In addition a Raynet terminal is
       available routed to a roof aerial.

7.13      Tactical Coordinator (TC)

7.13.1 When more than one agency is operating at the tactical level there must be
       consultation between the various agency Tactical Coordinators (TC). The
       TC must not become involved with activities of the Operational
       Coordinator, but concentrate on the overall general management. In order
       to effect co-ordination, the TC will liaise with other Silver control areas in
       other Trusts and allied agencies. Establishment of inter-service
       communication links will support the effective running of the incident. The
       OC together with 2nd line on-call manager Duty Director (DD) will
       determine the need for a Tactical Control Room (TCR) to be established.
Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                         Section

                COMMAND AND COORDINATION                                                       7
7.13.2 The tactical (Silver) level of command exists to:

          •   Liaise with the OC regularly for situational briefings

          •   Complete the corporate risk assessment

          •   Evaluate the implications for the Trust for the specific incident faced

          •   Authorise as required the Operational Coordinator to cancel elective
              surgery and outpatient clinics

          •   Authorise any required re-allocation of resources to meet the incident

          •   Develop a plan to return the Trust to ‘normal’ operation as soon as

          •   With the support of the press officer provide media briefings with
              information provided by the OC, Casualty Enquiry Bureau

          •   Liaise with Silver Controls for other acute Trusts (mutual aid) the
              Strategic Health Authority, PCT’s, local authorities and ambulance

          •   Authorise and arrange to meet and conduct the reception of VIP’s
              which is managed by the press officer

          •   To keep staff informed regularly regarding the incident status and
              information. The communication team has available to it radio pagers
              pager and voice bleeps, the intranet front page, E-mail and bulletins for
              long term incidents

7.13.3 If it becomes apparent that resources or expertise beyond                          See Appendix
       the level of the tactical commander are required, or should there be the           55- Tactical
       need to coordinate more than one incident / scene (where tactical                  Action Card
       command has been established), it may be necessary to implement a
       strategic (Gold) level of management.                                              See Appendix
                                                                                          56- Risk

7.14      Tactical Control Room (TCR)

7.14.1 The TCR is located in the Directors’ Offices on the first floor immediately
       above and a short distance from the OCR. The facility contains a number
       of offices a meeting room, which will accommodate 12 people with an
       adjacent open office area accommodating four personal assistants. The
       meetings room and adjacent open office area will be used for the Tactical
       command and co-ordination. This will be established as required.
Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                        Section

                COMMAND AND COORDINATION                                                       7
7.14.2 The following staff will work directly from the TCR:                              See Appendix
                                                                                         57- Medical
                                                                                         Director Action
          •   Duty Director (2nd line on-call manager)                                   Card

          •   Medical Director                                                           See Appendix
                                                                                         58- Director of
                                                                                         Nursing Action
          •   Facilities Manager (Director / Senior Manager)                             Card

          •   Administration & Clerical support and runners (Chief Executive PA)         See Appendix
                                                                                         59- Facilities
                                                                                         Manager Action
          •   Director of Nursing                                                        Card

                                                                                         See Appendix
                                                                                         60- Director of
                                                                                         Facilities Action

                                                                                         See    Appendix
                                                                                         61-     Facilities

7.14.3 The resources for the TCR includes:

          •   1 direct dial telephone

          •   12 telephone extensions

          •   2 Fax lines

          •   E-mail account majorincident-Silver@ruh-bath.swest.nhs.uk

          •   Flip Chart

7.15      Strategic (Gold)

7.15.1 This is the Senior tier of management and will be based in the Local
       Emergency Centre at the Headquarters of the Avon & Somerset
       Constabulary at Portishead or at Wiltshire Police Headquarters at Devizes,
       which has extensive communication facilities. ‘Gold Control’ would only be
       used in a large-scale incident to make strategic decisions about
       deployment of resources, managing populations, providing information and
       the restoration of normality. A member of the Strategic Health Authority
       would represent the Health Service.

7.16      Working with the Police

7.16.1 In the event that the Police request the preservation of forensic evidence,
       Trust staff must take all reasonable steps to collaborate with this. Staff
       must ensure the patient is not adversely affected as a result of the efforts to
       preserve forensic evidence. Property should be handled as minimally as
Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                       Section

                COMMAND AND COORDINATION                                                     7
          possible wearing gloves and placed in a sealed bag. The bag will be
          supplied in Emergency Department and labelled. Once sealed the bag
          must not be opened unless authorised by the Police. Patient Affairs staff
          will liaise with the Police regarding relevant patient property issues.

7.16.2 The Police Documentation team will be based with the Casualty Enquiry
       Bureau staff on the first floor management offices to the rear of Emergency
       Department. The Police will need access to the basic patient information,
       name, address and D.O.B for any Major Incident patient. The information
       will be recorded and forwarded to the Police Casualty Bureau.

7.16.3 In exceptional circumstances the Police may be able to assist with the
       contacting and transportation of critical staff to the Trust. The circumstance
       of an incident cutting off or blocking a key staff member may be a scenario
       the police or military could assist with.

7.17      Volunteers

7.17.1 Any member of the public wishing to volunteer to help should be asked to
       wait in the Atrium. The main entrance receptionists will record their details
       and thank them for the offer of help. It is standard practice to decline the
       offer of assistance.

7.18      Friends of the RUH

7.18.1 The Friends of the RUH lead will be contacted by the Control Room team           See Appendix
       and briefed regarding support required. The Friends principle role is to         62- Volunteers
       guide relatives to the Post Graduate Centre as they arrive at the main           Action Card
       entrance. In addition they will provide support in the established clinical
       areas with refreshment for patients and staff.

7.19      Blood Donors

7.19.1 Any member of the public wishing to volunteer to provide blood will have
       their details recorded thanked for the offer and re-assured the information
       will be passed to the blood transfusion service who will contact them if
       additional stocks are required.

7.20      Foreign Languages

7.20.1 The communications team will maintain a list of translators in the hospital.

7.21.     NHS Direct

7.21.1 If required and appropriate NHS Direct offers a resource for assisting in the
       provision of health advice / reassurance for the public. This will be around
       public health type scenarios resulting from a Major Incident. NHS direct
       national on call team can be contacted on the NHS Direct number
       0845 46 47.
Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                     Section

                COMMAND AND COORDINATION                                                  7
7.22      Supplies

7.22.1 The supply chain is critical to the effective management of an incident.
       NHS supplies would be alerted and the normal process for delivery would

          The supplies team will be available to process orders quickly with the chain
          or authority and authorisation assumed by the Operational Coordinator. For
          items over £1,000 the authority would be through Silver control.

          The contracts to manage breakdown for critical equipment must include the
          companies’ response time and method of contact.

          The supplies department will be able to support contact information for
          equipment and supplies used on site.

          Managers must consider opportunities for emergency or mobile
          replacement for high-risk single items of equipment. For example a mobile
          CT scanner can be available within 12 hrs and forms part of the Radiology

          The Strategic Health authority Silver control team will coordinate any large
          scale or special supplies required for the health community and engage
          NHS supplies to manage the process.

7.23      Military Assistance

7.23.1 If military assistance was required the RUH Silver control would contact the
       Strategic Health Authority Silver control team. They will access the required
       support on their behalf of the Trust and coordinate any required response
       across the Health Community. Military assistance is most likely required in
       an environmental and mass casualty incident.

7.23.2 Repatriation of military personnel will be coordinated through the strategic
       health authority. The Trust will supply a mobile medical team to the air-
       head and make available the required number of beds.

7.24      Stand Down Procedure

7.24.1 The Ambulance Service will declare stand down by contacting the
       Emergency Department Shift Coordinator.

          The Operational Coordinator will be informed a Stand down message has
          been received. A decision will be made when to issue this to the hospital
          through Switchboard contacting all staff previously alerted. The timing of
          this will be with consideration for:

          •   Have all the casualties arrived at the hospital

          •   Is the full extent of the incident known
Royal United Hospital Bath NHS Trust
Royal United Hospital Bath NHS Trust                                                     Section

                COMMAND AND COORDINATION                                                  7
          •   Are all systems in place throughout the hospital to deal with the
              ongoing situation

7.24.2 The team will then consider the impact and advise on the need for:
       • Further patient movements around or out of the hospital

          •   Information and arrangements for relatives and staff

          •   Information for the media

          •   Staffing needs throughout wards and departments

          •   Arrangements for debriefing and support

          Once senior staff have been informed by switchboard they must inform
          their team as well as those who have been put on standby at home.

          It is essential that all staff who were notified of the alert are informed
          of the ‘Stand down’

          •   Phone people at home

          •   Prepare defusing gatherings immediately before staff go off duty only
              for them to talk if they wish about what happened that was positive.
              Ensure there is a list of names of all the staff who were involved to
              check all are considered and cared for after the incident

          •   Involve staff who were not on duty and ‘missed it’

          •   Access professional managed debriefing meetings, which will be
              arranged by the welfare team

          All Major Incident documentation no matter how small including scraps of
          paper must be taken to the control room and handed to the Operational
          Coordinator. These are vital as evidence of the Trusts effective response.

7.25      Key Points
          • Operational Bronze Command and Co-ordination will be established

          •   A First Responder (FR) will brief alerted staff from the Operational Co-
              ordination Centre OCC and may initiate the 1st expansion and
              reception of patients

          •   The Operational Coordinator (OC) (Bronze) will be specially trained and
              be responsible for the operational command and co-ordination of the
              incident following the ‘Escalation plan as detailed
          •   The Tactical Coordinator (TC) (Silver) will support the OC and establish
              a Tactical Coordination Centre if required in the Directors Office

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