Mass-Fatality Management Planning - A Hospital Perspective

Most hospital emergency-preparedness efforts within the United States focus on doing “the greatest good for the greatest number” (of live patients). However, U.S. disaster literature reveals relatively few instances in which a hospital has confronted and been forced to deal with a large number of dead and/or dying citizens. Nonetheless, today’s risk of mass-casualty transit accidents, fires, explosions, and outbreaks of pandemic flu or other lethal diseases provide valid reasons why the nation’s hospitals should give much more thought to how they would cope with large numbers of fatalities rather than simply provide care for those still living. For that reason, a well prepared hospital will have a Mass Fatality Plan included as an annex to the hospital’s overall Emergency Operations Plan (EOP).

Writing a well constructed plan should and usually does begin by convening authorities (including writers) already familiar not only with the topic – and a working knowledge of their own facility – but also with the community’s capabilities for caring for the dead. The hospital participants should include clinically trained staff, administrative personnel, legal counsel, and, if available, medical ethicists. External participation should be sought from the medical examiner’s office – and/or the coroner’s office – and local funeral homes as well as state and local fire/EMS, law-enforcement, and public-health agencies.

The planning meetings should address the individual and collective situations of all of those who have died (regardless of their individual ages) as well as those expected to pass away – but still have some signs of life present (e.g., a pulse, blood pressure, etc.). The plan, once drafted, should be reviewed by the hospital’s Emergency Preparedness Committee, and then forwarded to decision-making officials for final approval and adoption. After the plan is approved it should be made available, in both written and electronic formats, for use by morgue personnel and members of the hospital’s own “Command Post” to use as and when needed during and in the aftermath of a mass-casualty incident (MCI).

Terminology and Other Relevant Considerations

A comprehensive mass-fatality plan will address a number of factors, including but not necessarily limited to the following:

• The terminology used (which should be consistent throughout);

• The possibility that the event or incident for which the plan is being written may be either natural or manmade (e.g., the result of a terrorist attack);

• A list, preferably short, of the decision makers who are authorized to activate After the plan is approved it should be made available for use as and when needed during and in the aftermath of a mass-casualty incident the plan – as well as some suggested decision criteria that should be considered prior to implementation;

• The management of persons who die inside the hospital (or other medical facility) as well as those who die either at the scene of the incident or while en route to the hospital or other medical facility; 

• The criteria required for notification and/or close consultation with local and/or state medical examiners or coroners, as well as funeral-home director(s) to decide on handling procedures, safety precautions, and documentation requirements;

• The decontamination of decedents who might have been contaminated during or because of the incident;

• The possible expansion of the storage space available for bodies – e.g., through the use of internal refrigeration areas, refrigerator trucks, rooms, and/or tents equipped with commercially available cooling devices and/or similar systems;  

• The respectful handling of the dead – an umbrella term that includes but is not necessarily limited to the proper identification of those deceased, the “stacking” or other mingling of the bodies (if and when necessary), relevant religious and cultural concerns that should be observed, and the prompt disposition of the bodies (by transferring them to a medical examiner’s office, for example, or to a funeral home);

• The collection, management, and security of valuables;

• Family notification procedures (which whenever possible should be carried out in collaboration with local officials – e.g., at a family assistance center);

• The behavioral health support that might be available (not only for a decedent’s family but also for hospital personnel);

• The laws, rules, and regulations governing evidence collection and preservation;

• Law-enforcement investigation expectations; and 
• Documentation procedures.

After the plan has been completed, a creative training program should be developed and provided to those persons expected to implement the plan. Such training could be carried out through traditional room-based presentations or through on-line education, or both.  Tabletop drills and/or functional exercises can be scheduled to rehearse actual use of the plan as part of a broader MCI response effort focused on a mass-fatality management theme.  

Coordination, Cooperation, and Training

In conducting a “live” drill, knowing how to emulate the dead is a particularly important aspect of the training that must be addressed. The use of volunteer “victims” playing the dead, and/or of CPR “dolls,” and/or the use of paper-cutout victims are among the various options that are worth considering.

For a rigorous evaluation of the plan, any exercises scheduled should be conducted in company with the external partners who assisted in writing and/or reviewing the plan. Among those partners (individuals as well as organizations) should be the medical examiner/coroner, law-enforcement and fire/EMS personnel, and the directors or managers of funeral homes. Any changes made to the plan should be based on the lessons learned from the training and exercises.

To summarize: Almost all of the nation’s hospitals routinely plan, train, and exercise to maximize their ability to save lives, but deaths will sometimes occur nonetheless, and must be dealt with. Deaths that occur simultaneously in large numbers present a variety of problems not only for the hospital involved but also for the community that the hospital serves.  For that reason alone, it is important that a community’s Mass Fatality Annex be written by a multidisciplinary group of personnel from the hospital – but with significant assistance provided by other “stakeholders” in the community. The final version of the plan should be comprehensive yet succinct, easily readable, and available for ready access – whether for training or for a real-world emergency.