Emergency nursing during major incident plans

Hospitals expect a major incident plan to be implemented every three years, but following recent events in London and Manchester, such plans have been activated five times in three months.

When the extent of the Grenfell Tower fire became clear, nearby St Mary’s Hospital activated a major incident plan – for the third time in three months.

Picture: Alamy

As the major trauma centre for north west London, the hospital also cared for casualties from the two terrorist attacks in the capital – in Westminster and Borough Market.

Recent months have seen an intense period of major incidents for a number of emergency departments (EDs), both in the capital and in Manchester, where 22 people died and more than 100 were injured in a suicide bomb attack.

James Bird, lead nurse for emergency medicine at St Mary’s, which is part of Imperial College Healthcare NHS Trust, says that normally a major incident would be expected once every three years. On all three recent occasions, staff at the hospital provided rapid, exceptional care for a sudden influx of patients, with often severe trauma injuries.


Number of terrorism-related deaths in the UK since 1970


‘We are seasoned,’ Mr Bird says. ‘We know that the plan is fully understood by everyone in the department.’

TV documentary

The activity prompted by a major incident was captured by a BBC documentary team for the series Hospital, when a crew happened to be filming during the Westminster attack. The programme showed how the perpetrator was the first casualty to arrive, with armed police on hand, and followed the stories of a number of victims.

When the warning of a major incident is received at St Mary’s, all except one entrance to the ED is locked, and the doctors focus on reviewing every patient, either rapidly admitting them or sending them home. ‘Over the last three incidents we have always started with a full department and we can generally empty it over 20 minutes,’ Mr Bird says.

Cages filled with extra equipment for trauma injuries, such as chest drains and tourniquets, which are always ready for a major incident, are brought out into the correct areas. Paediatric equipment is taken to all the resuscitation bays. Staff take up their positions, including a senior doctor and senior nurse who triage every patient on arrival. Trauma teams are set up and waiting in bays, and staff move from the usual IT system to paperwork, as it is quicker.

Extra staff

For major incidents, especially the Borough Market attack and Grenfell Tower fire which took place at night, extra staff are often needed. ‘The nurse in charge will start calling in staff not on the next shift,’ Mr Bird says. ‘Everyone wants to come in and is keen to help. Part way through we had to say we had sufficient staff, because we needed them for the next shift. It is encouraging that even after three incidents in three months, people still want to help and there is no fatigue.’

When the first casualties start to arrive, everyone is clear of their role, Mr Bird says. ‘It is calm, we know exactly what we are going to be doing,’ he says. ‘But it is emotive, because you are seeing the aftermath to a terrorist attack or the Grenfell fire. We had children who had been in a fire in their home. Everyone just wants to do their best at 3am for the patients.’

Other people still need help with the usual serious health problems, such as heart attacks and strokes, Mr Bird says. They are treated the same as casualties from the major incident, being triaged and then cared for within the same system.

The plan is reviewed after each major incident, and small adjustments made each time to improve the emergency response, he says.


fire-related fatalities in England in 2015-16


Hospitals in Manchester found themselves at the centre of a major incident in May when a terrorist blew himself up outside an arena as crowds flooded away from a concert. A total of 22 people died, plus the bomber, and 119 were injured, 23 critically. Many of those caught up in the horrific attack were children.

Wythenshawe Hospital’s ED was among those that helped the dozens who sustained injuries. Senior sister Rachel Flatley says: ‘It had been one of our busiest days on record and then we got that phone call. Everyone just responded amazingly, they kept calm. Initially we didn’t have much information.’

Lessons to be learned

The staff implemented the major incident plan and doctors starting clearing the ED. Extra staff were called, and many more who had seen the breaking news on social media just turned up. The hospital received 11 casualties, seven of whom were critical.

 ‘We have done lots of training and planning, and everyone did exactly what they needed to do,’ Ms Flatley says. ‘I had an experienced team of ED nurses. The teams responded with expertise. They assessed patients, scanned them and they went straight up to theatre – if that was needed. So the plan worked. It was unbelievably smooth and that is what helped a lot of people get their heads around it – realising that there is a plan there, it worked and, awful as it was, people were well looked after.’

RCN professional lead for acute, emergency and critical care Anna Crossley says of the spate of recent incidents that EDs have had to cope with: ‘Every time there are always lessons to be learned and ways to do things differently next time. In each incident there are things that work well and things that don’t go as well to be built on for next time.’

Despite the unusual volume of casualties that a major incident can bring, and the extra staff on hand, Mr Bird says it is work that all ED nurses are familiar with.

‘The key thing to remember is that this is what we normally do,’ he says. ‘If you think about the types of injuries from Westminster and Borough Market, they were stabbings and road traffic collisions. It is what we do every day. In these incidents, we see a lot of them and provide care to a very high standard very quickly.’

Recent major incidents for EDs

22 March – an attacker drove a car into pedestrians on Westminster Bridge, killing four people and injuring more than 50. He fatally stabbed police officer Keith Palmer outside the Houses of Parliament before he was shot dead by police.

22 May – a terrorist blew himself up outside Manchester Arena as people poured out at the end of an Ariana Grande concert. The star had many young fans at the event. A total of 22 adults and children died, as well as the bomber, and 119 were injured, 23 critically.

3 June – three terrorists drove into pedestrians on London Bridge before stabbing people in the busy Borough Market area. Eight people were killed and 48 were injured before the police shot the assailants dead.

14 June – a fire spread rapidly through the 24-storey Grenfell Tower in Kensington, trapping residents; 80 people have either died, or are missing presumed dead. Many more were injured.

19 June – a van was driven into worshippers outside a mosque in north London.  One man who had fallen ill before the incident died and nine others were injured.


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Mental health and staff well-being in the emergency department – RCNi articles

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