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Nonmedical Concerns for Hospitals in a Mass-Casualty Incident

While there are obvious and significant medical concerns associated with mass-casualty incidents (MCIs), there are also nonmedical concerns that can adversely impact a hospital during an MCI. Failure to plan for these issues, including consequence management, could result in life-safety concerns for responders, hospital staff, patients, the public, and others at the hospital. These planning elements are the responsibilities of professional emergency management for strategic and operational design, and the tactical missions for the hospital’s incident command center (ICC). While critical medical issues are normally managed through the ICC, which usually has a medical operations branch or group, there are also nonmedical issues for a hospital that can be associated with an MCI, including security and safety concerns, processing unaccompanied minors, and increased governmental relations. Unaccompanied minors could be a mix of children who have been transported to the hospital without their parents or guardians or, through the triage and treatment process, become separated from parents or guardians, including school or daycare officials.

Security and Safety Concerns

Maintaining the security and safety of all involved in an MCI response—as well as other aspects of the hospital’s ongoing operations—is paramount and pertinent to any incident. The MCI may be categorized by law enforcement officials as a criminal incident, requiring the investigation of patients brought into the emergency department and the preservation of evidence. In fact, suspect(s) may be brought in at the same time as victims for triage and treatment. Hospitals need to plan for a worst-case set of scenarios. The lack of a comprehensive security plan, established perimeter controls, vetted and credentialed assigned responders, and a view that the MCI may be part of a larger complex, coordinated attack can all present life-safety issues for MCI victims, first/emergency responders, and even the general public.

Heightened security should be at the scene of the MCI, as well as implemented at supplemental sites, such as morgue facilities and critical infrastructure for the hospital. Even responding ambulances (unless pre-cleared) should be staged away from the triage and treatment areas (as should other “spontaneous” responders who appear at the hospital, without being requested through the ICC), vetted, screened, and systematically released to transport patients, to reduce the possibility of a secondary attack on first responders. Perimeter control, including designated hot, warm, and cold zones (along with decontamination capability, as needed), should be established and maintained. Self-deploying responders, spontaneous volunteers, and others who attempt to help from outside the cold perimeter should be redirected. If the incident is large enough and response is sustained over multiple days (such as a wildfire, tornado, or earthquake response), these unassigned responders might be needed. Otherwise, they could potentially be a threat or hazard. Lacking accountability checks and supervision, unassigned responders do not have the oversight for potential misconduct and could place themselves in harm’s way. In large-scale incidents, the possibility of impostors posing as first responders can also generate threats and hazards.

Complex, coordinated terrorist attacks (CCTAs) present a unique challenge to prehospital medical responders. When overwhelming numbers of patients present almost simultaneously, factors such as multiple sites and modes of attack, varying mechanisms of injury, and secondary threats combine to create a confusing and complex operating environment for all responders. CCTAs are intentional, mass-violence incidents that involve coordinated tactics, various weapon types, and potentially multiple sites of attack. Responding to an incident such as this creates an uncertain environment with a high index of suspicion for secondary attacks. In the confusing and dangerous response to CCTAs, triage of victims is more difficult than in other disasters or MCIs.

Unaccompanied Minors

The presence of unaccompanied minors further exacerbates the complexity of MCIs. Two challenges that this vulnerable population faces are the general lack of identification documents, which can make reunification difficult, and the need to establish a safe, dedicated area for unaccompanied minors post-treatment. Minors should be considered at the beginning of the hospital’s planning process, as it should always be assumed that minors will arrive as patients during an MCI. Planning should include a multidisciplinary team from the hospital as well as law enforcement and social service agencies.

Patient tracking and registration is critical to ensure timely and safe reunification. Hospitals in larger regions may benefit from pre-hospital data systems that can be incorporated into hospital electronic medical systems or have their own systems to capture data for identifying demographics. If systems are capable, photographs of the minors should be added to patient records along with any disabilities, disaster association, and distinguishing marks. Proper identification helps prevent harm, such as releasing the child to the wrong caregiver. For any child that cannot be identified, hospitals should coordinate with law enforcement and social service agencies via communication methods that were established during the planning process.

Once a child has received treatment, they need a safe place to wait until they are reunified with appropriate caregivers. Having a pediatric-designated area in the hospital should be determined pre-incident and included in the MCI plan. These areas should be monitored by staff, including extra security, and be separate from Hospital Reunification Centers and the Emergency Department. Having qualified staff available who can help calm, assure, and distract children can mitigate long-term mental health effects. Other resources to consider are age-appropriate meals, sleeping arrangements, and hygiene supplies. And this same set of protocols and processes will benefit adult patients who lack competency, such as those involved in an MCI at an adult daycare center, group home, memory care unit of an assisted living facility, or other custodial care sites.

Governmental Relations

Researchers from the Harvard School of Public Health and the New York State Department of Health have proposed the concept of a meta-leader for emergency management. Overcoming traditional silo thinking is critical during large-scale MCIs, especially when those incidents could be cascading to or from other hazards or threats or are part of a complex, coordinated attack. The silos (even a silo of excellence) within government, as well as between government and private or nonprofit sectors, need to be overcome. A broader (“meta”) view of the incident is always better than a myopic one.

On any large-incident response, the best primary jurisdictional leaders conducting government relations are those who understand the strengths and capabilities of other groups outside of their own, how to influence and integrate those capabilities for collaboration, and how to engender “cross-organizational confidence.” Hospital executives do not report to mayors or police chiefs, and vice versa, yet they may be candidates for roles in a unified command of an MCI. Governmental relations experts can coordinate with others up from the municipality, down from the federal government, sideways across departments within that level of government, and across to nonprofit and nongovernmental groups through public-private partnerships. Potential investigation aspects impacting the hospital’s operations may need to be deconflicted with the life-safety prioritization. For example, preserving evidence that is contaminated with chemical, biological, or radiological hazardous material needs to be performed safely, and prioritizing patient safety is paramount.

Be Prepared for an MCI

Before the next MCI, some critical steps can be taken to help manage the incident and mitigate the consequences:

  • Security concerns such as perimeter control and the credentialing of responders can be accomplished via standing protocols from the U.S. National Preparedness Goal’s protection and prevention missions.
  • Healthcare leaders can establish multidisciplinary teams in collaboration with external agencies to develop plans for safely managing unaccompanied minors and adults lacking competency.
  • Governmental relations can be nurtured with ongoing and continuous connections made between levels and organizations within government to partners inside and outside their organizations through meta-leadership.
  • Finally, any finance or administration issues between governmental and nongovernmental organizations can be resolved—with planning, organization, equipment, training, and exercising practiced by public-private partnerships—coordinating well in advance with the local government and the hospital.

MCIs need to be managed as complex incidents. Some of the nonmedical concerns involved, such as security issues, challenges with unaccompanied minors, and governmental relations, can all be overcome with proper collaborative and coordinated planning, organization, equipment, training, and exercising beforehand.

Joanmarie Verrico Wallster

Joanmarie Verrico Wallster has over 18 years of experience in healthcare, with a primary focus on emergency management and security. She serves as an instructor in physical and verbal interventions and hospital emergency response training. Joanmarie holds an associate degree in criminal justice and a B.S. in health services administration. Her commitment to helping others extends to her volunteer work with the American Red Cross, where she contributes to information and planning. Joanmarie’s extensive background and dedication to her field underscore her expertise and passion for ensuring safety and preparedness within healthcare settings.

Michael Prasad
Michael Prasad

Michael Prasad is a Certified Emergency Manager®, a senior research analyst at Barton Dunant – Emergency Management Training and Consulting, and the executive director of the Center for Emergency Management Intelligence Research. He researches and writes professionally on emergency management policies and procedures from a pracademic perspective. His first book Emergency Management Threats and Hazards: Water was published by CRC Press in September 2024, and his second book Rusty the Emergency Management Cat is now available on Amazon to assist emergency managers in communicating with families to help them alleviate disaster adverse impacts on children. He holds a B.B.A. from Ohio University and an M.A. in emergency and disaster management from American Public University. Views expressed may not necessarily represent the official position of any of these organizations.

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