What steps should be taken in the emergency department during a mass casualty incident?

Mass Casualty Incident Management in the Emergency Department

Immediately activate your Hospital Incident Command System and implement a phased surge capacity response that prioritizes rapid triage, infrastructure expansion, and resource allocation to save the greatest number of lives. 1, 2

Immediate Activation Steps

1. Activate Incident Command Structure

• Establish the Hospital Emergency Executive Control Group immediately to set overall incident priorities, provide management decisions, and prioritize use of hospital staff and facilities 1
• Implement the five functional areas: command, operations, planning, logistics, and finance/administration 2
• Designate a critical care lead physician to provide planning expertise and technical assistance to the incident manager, including information on resources needed and patient status 1

2. Implement Triage System

Use a three-tiered triage approach: primary (pre-hospital), secondary (ED arrival), and tertiary (critical care allocation) 2

• Secondary triage at ED entrance should be performed by emergency physicians immediately upon patient arrival to prioritize patients to treatment areas 2
• Apply the START (Simple Triage and Rapid Treatment) protocol, which demonstrates 100% sensitivity for identifying emergent patients requiring immediate intervention 3
• Designate a triage officer (intensivist or surgeon with critical care experience) to apply inclusion/exclusion criteria and allocate scarce critical care resources 2

3. Secure and Control the Facility

• Implement rapid lockdown of the facility for security purposes through external infrastructure controls 4
• Establish screening and triage of all persons on entrance to the facility 1
• Position triage location strategically at the ambulance bay to permit efficient vehicle flow and casualty discharge 4

Surge Capacity Expansion (Phased Approach)

Conventional Capacity (First Response)

• Maximize existing ICU bed occupancy and staffing through call-backs 1
• Move stable ICU patients to step-down units using pre-existing "bump lists" 1
• Implement "surge discharge" protocols to prioritize floor patients for early discharge or movement to holding areas 1

Contingency Capacity (3-43 Patients)

Expand into adapted areas of the facility while maintaining functionally equivalent care 1

• Utilize post-anesthesia care units (6 beds), pre-induction areas (6 beds), and special procedures/outpatient surgery units (12-24 beds) 1
• Move stable critical care patients with less resource demand to medicine floors 1
• Request additional staffing for overflow areas 1

Crisis Capacity (>43 Patients or Resource Exhaustion)

Implement significant changes to standard practices when resources are overwhelmed 1, 2

• Add cots or stretchers to existing units and hallways 1
• Use oxygen-saturation monitors with high/low rate alarms instead of usual cardiac monitors 1
• Implement tiered staffing where one nurse/physician with critical care expertise supervises several staff with lesser training 1
• Prepare for at least 300% increase in ICU capacity beyond baseline 1

Critical Infrastructure Considerations

Essential Systems to Maintain

• Ensure lighting, communications, information technology, fire suppression, HVAC, nutrition services, laboratory, and radiology remain operational 1
• Identify units with separate ventilation and negative airflow for isolation of infectious patients 1
• Understand interface with mass fatality plans and prepare temporary accommodation for excess decedents using refrigerated trailers or augmented spaces 1

Imaging Strategy

Restrict CT imaging to potentially severe head injuries during mass casualty response 5

• Prioritize plain films in the ED over CT for initial assessment 5
• The radiologist should cancel all non-head CTs in the ED until no additional MCI patients are expected 5
• Triple radiology staff through mobilization protocols 5

Resource Allocation and Triage Criteria

Inclusion Criteria for Critical Care

Focus primarily on respiratory failure requiring ventilatory support 2

Exclusion Criteria for Critical Care

Exclude patients with: 2

• Poor prognosis despite ICU care
• Resource requirements that cannot be provided
• Underlying illness with poor prognosis and high likelihood of death
• Minimal illness who are "too well" for ICU resources

Objective Scoring

• Use Sequential Organ Failure Assessment (SOFA) scores to determine extent of organ dysfunction across respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems 2
• Apply Minimum Qualifications for Survival (MQS) as a ceiling on resources expended per patient 2

Staffing and Personnel Management

Critical Care Nursing

• Nursing supervisor maintains overall patient lists, transfer lists, manages nursing staff and shifts, and facilitates bed changes/movements/transfers 1
• Develop phased staffing plans that provide sufficient patient care supervision during contingency and crisis situations 1

Personal Protective Equipment (PPE)

• Change PPE between patient contacts during conventional care 1
• Minimize number of caregivers and assure staff/patient/visitor PPE compliance 1
• Initiate staff exposure tracking immediately 1

Key Operational Principles

Timeline Expectations

• Plan to provide emergency mass critical care for 10 days without sufficient external assistance 6
• Expect greatest surge of ICU patients approximately 4-6 weeks after first confirmed admission in pandemic scenarios 2
• Anticipate substantial extra workload lasting several weeks 2

Coordination Requirements

• Coordinate response activities with neighboring/regional facilities 2
• Establish regional situational awareness through a Central Triage Committee that monitors supply and demand across geographic areas 2
• Implement patient tracking techniques from point of entry 4

Common Pitfalls to Avoid

• Do not initiate crisis triage protocols until all efforts to extend available resources or obtain additional resources have been instituted 2
• Avoid over-triage (allocating critical care to patients who don't require it) and under-triage (failing to recognize severity) 2
• Do not allow trainees to provide patient care during initial conventional response phase 1
• Ensure triage criteria are objective, ethical, transparent, applied equitably, and publicly disclosed 2

Medication Stockpiling

Develop a 48-hour stockpile of drugs likely required for most patients based on proven efficacy, cost, ease of administration, and ability to rotate into formulary prior to expiration 6