Royal Marsden's cool heads and smart systems

When the fire alarm sounded at the Royal Marsden Hospital in west London on 2 January, staff quickly realised this was no false alarm.

Two weeks later, the crisis is over, the patients are back and it is almost business as usual. But as the specialist cancer hospital clear-up finishes, an analysis of how the incident was handled will begin, not only to inform the Marsden's emergency plans but the NHS's as a whole.

"The biggest lesson learnt for the NHS that day is that fire training for staff is unbelievably important, because the way that nurses and the rest of the staff initially handled the patients and others in the building was absolutely exemplary," says Professor Martin Gore, medical director of the Royal Marsden.

"Everything was prepared so that when we gave the instruction to leave the ward and evacuate the building it could just happen like clockwork and we weren't evacuating rows of patients lying in beds."

Emergency plan

Non-ambulant patients were sitting in chairs or strapped to mattresses and everyone had blankets. Patients were led or carried down the stairs by doctors and nurses and portering, estates and works staff. Many went first to a nearby church but local shops and businesses also opened their doors.

"The church became the main assembly centre except for those patients that we moved immediately to the Brompton," Professor Gore explains. "We had a connection with the local church through our chaplaincy. We sent a whole load of nurses and doctors with blankets to look after the patients and to start to triage them."

As soon as the seriousness of the fire had been realised, the Marsden rang nearby Royal Brompton Hospital to warn it to activate its emergency plan because it would be receiving patients, including some requiring intensive care.

Most patients were assessed and booked in within an hour and all within three. Some were able to walk the short distance to the Brompton and the rest were brought in ambulances. Two patients undergoing surgery were closed up and brought to the Brompton still intubated, as if they were just going to recovery. Their procedures were completed the next day.

The Brompton set up two triage teams, one for patients requiring critical care and the other for those who did not.

Royal Brompton medical director and deputy chief executive Timothy Evans says: "We had an administrator, a very senior clinician and nursing support for each. We got through something like 60 patients in an hour or so. Some of those walked in but a lot were brought in ambulances. The ambulances got five or six patients round really pretty quick, I think if they hadn't it would have been a real problem.

No one was lost, he adds. "I know that sounds odd, but they could have walked off or been taken off to other places by relatives."

Invaluable training

A mini-Marsden was set up within the Brompton. Professor Evans explains: "The Marsden people were given access badges labelled Royal Marsden within the first few hours, so they could access all restricted areas. They could prescribe, they had their pharmacist join our pharmacist and it all worked remarkably."

"Where I think both organisations did brilliantly was [not only] getting patients out of the fire, but actually making certain that they were immediately moved to another hospital so their treatment didn't hiccup," he adds.

A crisis team met every six hours at first and then every 12 hours to ensure patients needing treatment got it.

Staff at both hospitals found their emergency incident training invaluable. Professor Evans says: "We are constantly reviewing our processes and we are always doing these exercises, which everyone thinks are a bit naff, but actually the training and being absolutely familiar with the people that you work with and how they will react in these sorts of circumstances is very important."

Professor Gore agrees, adding that the importance of fire doors was also very evident. "There is one office that was badly burnt out, other than that there are a couple of areas on the wards where you can see the smoke has been, but remarkably very little structural damage to look at."

The operating theatres in the basement are undamaged, although they are out of action because of damage to plant facilities on the roof.

The overwhelming view is that both the Marsden and the Brompton handled the incident incredibly well but two factors undoubtedly helped - their close proximity and the timing of the incident, just after the holidays and in the middle of the day.

Fortuitously the Brompton had closed two wards for Christmas, which were due to reopen that day, and the Marsden had not been full to capacity. Only 79 inpatients needed transferring, although many were pretty sick.

As it was the middle of the day and the middle of the week, the chief executive and many senior people were in the hospital and this certainly helped, Professor Gore says.

Marc Beveridge, the Health Protection Agency's deputy regional health emergency planning adviser for the East of England, says it is important for the Marsden and the Brompton to conduct a formal review of how the incident was handled, "looking at what went well and any issues that weren't covered in the emergency plan or didn't work so well and coming up with a process to implement any recommendations".

"There is also a huge element now about looking at audit trials and accountability and the legal aspects of decisions that have been made - making sure that thought process rationale has all been documented and so on," Mr Beveridge adds.

Trusts should also be aware that they must still comply with the EU working-time directive, even in an emergency situation.

Recommendations from a formal review should then be shared locally and any issues of national significance brought to the attention of the strategic health authority representative on the national emergency planning group that sits every few weeks.

As incidents are rare, the UK closely collaborates with international partners and the military so that experience of real life events and simulations are shared.

All hospitals have evacuation plans for fire, but these are usually designed to move patients around a building to a place of safety. A full evacuation is extremely rare.

Maximum survival

Dr Penny Bevan, director of the emergency preparedness division at the Department of Health, says the biggest lessons about how to do this came from Hurricane Katrina, when New Orleans' hospitals had to be fully evacuated.

"One of the key things was prioritising those patients that needed evacuation to ensure you got maximum survival. With the Marsden fire they managed to evacuate people who were highly dependent either from critical care or from theatres without any loss of life and there are obviously skills involved in doing that."

The 7/7 London bombings in 2005 highlighted several issues that needed addressing, the largest being the need for a resilient communication system. While the Marsden found the mobile phone network a useful tool, during a major incident disruption to power suppliers could bring down phone masts or public calls could swamp networks, as happened that July.

The civil contingency secretariat at the Cabinet Office is in charge of a cross-government drive to make communications more resilient. A tetra-encrypted digital radio network - which is supposed to be secure - is being rolled out to ambulance services, the Health Protection Agency and the police.

The frailty of the mobile phone network was also highlighted by last summer's floods. Although in Carlisle the hospital escaped the flood waters, loss of the power supply meant the mobile phone mast went down.

The London bombings also raised issues about ensuring medical supplies during severe traffic disruption and how best to manage blast injuries.

Most difficulties occur when vital services such as communications, power, water and other supplies are lost. As a result, Dr Bevan reveals a major focus of emergency preparedness now revolves around business continuity management.

She says: "You wouldn't have thought that the 2004 tsunami had a potential knock-on to hospital supplies in the UK, but there were actually two large shiploads of supplies destined for the UK in Colombo, Sri Lanka, when the tsunami hit.

"Had those ships not been able to set sail to the UK within a couple of days, the knock-on would have been shortages within a couple of weeks, so we are working hard to understand the interconnections of the globalised supply chain."

Dr Bevan says the Marsden fire was handled so well because its chief executive "is very engaged", had well thought-out plans embedded in the system and good mutual aid arrangements with the Brompton.

"Someone has to be in charge and that person needs to get in quickly," she says.

"Initially if it is a Sunday afternoon it is going to be the senior nurse in, but you need to be able to escalate that fairly rapidly to a director level. That person needs to be able to run whatever it is, so if it is a hospital they need to be a senior and experienced manager."

A study published in the BMJ in 2006 showed that many staff were not prepared for a major incident; 47 per cent of registrars had not read their hospital's major incident plan and only 54 per cent were confident that they knew what their role would be during a major incident.

Martin Shalley, immediate past president of the British Association of Emergency Medicine, doubts that things have improved significantly since then.

"The problem is that the emergency plan is huge and it covers everything. Certainly all doctors when they start are encouraged to look at the emergency plan and look at the bit that is relevant to them," he says.

"It is difficult to be 100 per cent sure that they all do, but certainly as long as the main players are aware and people know where to report to, they can be told what to do relatively quickly."