By Abdolghader Pakniyat, Reviewed by DR. Sabrina Berdouk

The Scenario: The “City Center Collapse”

Hypothetical training scenario.

14:00: You are the attending physician on duty. Dispatch reports a partial collapse of a stadium during a high-profile event. Expected casualties: 150+. Your hospital is 4 kilometers from the scene.

An MCI creates care demands that require additional response resources. Activate the hospital emergency plan and incident-command support according to acuity, staffing, and capacity. For this scenario, assume the ED is 20% above licensed bed capacity; that is an illustrative assumption, not a universal MCI threshold or automatic authorization to change standards of care. (ASPR TRACIE planning guidance)

Phase 1: Activation and The “15 ’til 50”

The “15 ’til 50” framework is a preparedness goal for receiving 50 or more patients within 15 minutes of notification, not a guaranteed warning period. Patients may arrive before formal activation. (Guide overview)

• Activation: Use the activation code, authority, and interim clinical leadership specified in your hospital emergency operations plan. Role titles and assignments vary by facility.
• Anticipating the Surge: Arrival timing, transport mode, and severity vary; do not assume two fixed waves.
  • Self-presenters: Patients may arrive rapidly by taxi, private car, or on foot, including people with serious injuries. Walking alone does not establish a Green category; each patient still needs individual assessment.
  • EMS arrivals: Timing and injury severity depend on the incident, extrication, transport access, and destination decisions; critical patients may arrive early or late.
• Update estimates: Use dispatch, EMS, and actual presentations. A first-hour count multiplied by two is not a reliable universal prediction.
• Leadership: Share current capacity and specialty needs with EMS; coordinate destination decisions through the regional response plan. Do not assume one bypass pattern.

Phase 2: The 10-Step Immediate Action Checklist

Use your approved emergency plan and immediate-action checklist. The following ten prompts should be adapted to your facility; several actions will run in parallel.

1. Assign Roles: Use Job Action Sheets. (See Phase 3 for example roles).
2. ED Huddle: Brief the team. Distribute vests, walkie-talkies, and triage tags.
3. Reverse Triage: Reassess current ED patients for safe discharge or transfer to designated surge care areas with appropriate staff, monitoring, and handoff.
4. Clear the Floor: Move suitable admitted patients to planned surge areas only when the receiving team can safely provide their required care and monitoring.
5. Adapt Triage: Activate the hospital disaster triage pathway while maintaining assessment and essential care for existing patients and new emergencies unrelated to the incident. Explain expected delays and the planned alternative care arrangements. Clear the parking lot for ambulances. See ASPR TRACIE MCI planning guidance.
6. Deploy Triage: Use the location designated in the emergency plan, adjusted for contamination, security, weather, and patient access; an outdoor site is not always appropriate.
7. Access control: Use the hospital security plan while keeping required emergency exits and evacuation routes usable. Coordinate entry screening and ambulance/ambulatory flows with security and facilities teams.
8. Downtime Tracking: Activate paper backup when electronic registration or documentation cannot keep pace or is unavailable. Maintain patient identifiers and category counts under the local tracking plan.
9. Staff Recall: Use the approved recall system; tell staff where to report and who will assign them.
10. Logistics Call: Request supplies for the anticipated case mix and staffed spaces. Escalate oxygen, blood-product and equipment shortfalls through incident command.

Phase 3: Personnel and Role Assignments

These are example assignments. Use your approved role titles, competencies and Job Action Sheets, with vests or other clear identifiers so everyone knows who is responsible.

• MCI Triage MD: Prioritizes rapid sorting and individual assessment, while delivering the brief lifesaving interventions permitted by the adopted triage system when trained, equipped, and safe to do so. Avoid prolonged treatment that prevents assessment of other casualties.
• Charge RN: Coordinates beds and communicates with the Command Center.
• Disposition RN: Coordinates the designated discharge area after clinician reassessment, with a documented onward care plan and handoff where needed.
• Flow RN: Coordinate movement to the designated resuscitation area and onward destination agreed by treating and receiving teams. A Red tag sets urgency; it does not automatically select the OR or ICU.

Phase 4: Logistics, Equipment, and Meds

Keep immediately needed supplies accessible near care areas and test replenishment routes; do not assume an off-site store can meet the first surge.

• Hardware: Stock cots, tourniquets, and hemostatic dressings for the facility’s hazards, expected casualties, and response capacity. Figures such as 20–40 cots or 100 tourniquets are examples, not universal minimums; use a local inventory plan.
• Pharmacy Carts: Standardized packs including RSI medications, analgesics, antibiotics, and anticonvulsants. Pharmacy must rotate these regularly to prevent expiration.

For bleeding patients, mobilize the blood bank early and agree how urgent blood products will reach each treatment area. Coordinate resupply and use the local transfusion pathway; a stockpile alone does not ensure delivery. See ASPR TRACIE planning guidance.

Include pediatric readiness: child-sized airway and monitoring equipment, weight-based medication aids, staff with pediatric skills and a regional escalation route. Adult stock lists alone are insufficient.

Phase 5: Triage Mastery—SALT vs. START

Triage should be rapid. SALT is an endorsed all-hazards framework; this does not establish universal superiority over every other system. Use the triage system adopted by the regional response plan and train consistently with partner agencies. (SALT framework)

• SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport):
  • Step 1 (Global Sort): Direct patients who can walk to a safe area. Global sorting sets assessment order: assess those who are still or have an obvious life threat first, those who wave or make purposeful movements second, and walking patients third. It does not assign a final color.
  • Step 2 (Individual Assessment): Every patient, including those who walked, needs assessment of breathing, perfusion, mental status, injuries, and immediate life threats.
  • Step 3 (LSIs): During assessment, provide the brief lifesaving interventions permitted by SALT when trained, equipped, and safe: control major hemorrhage, open the airway (with consideration of two rescue breaths for a child), decompress the chest when indicated, and administer indicated antidotes. Avoid prolonged treatment that delays assessment of other casualties.
  • Step 4 (Assign Category): Use the complete SALT individual-assessment algorithm to assign Red (Immediate), Yellow (Delayed), Green (Minimal), Black (Dead), or Grey (Expectant). The Immediate/Expectant decision includes likelihood of survival with current resources. Provide comfort care and pain relief for expectant patients as resources permit, and reassess categories as clinical status and resources change.

START and JumpSTART are different pathways: adult respiratory/perfusion thresholds must not be copied into pediatric triage. JumpSTART uses pediatric physiology and its own apnea assessment. Use the complete adopted chart and age rules; do not combine it with SALT’s child rescue-breath step.

For facility triage, WHO’s MC-IITT is another framework. Its colours differ from SALT: Grey means deceased, while Blue includes patients needing palliative care or curative treatment beyond current capacity. Confirm the system and category meaning during handover; a colour alone can mislead.

Phase 6: Zone Management and Tracking

Move patients to the designated care areas with staff, equipment and monitoring appropriate to their needs. Reassess on arrival and during waiting; a coloured zone is not itself a care plan.

• Reassessment: Conditions change. A Yellow patient with occult internal bleeding may deteriorate. Repeat assessment and update the category promptly when findings change.
• Diagnostics: Use the planned electronic or downtime order process. If paper orders and runners are needed, preserve patient identification and reliable result communication.
• Reunification: Link hospital and EMS identifiers. Use the designated family-support service and protect confidentiality. Keep unaccompanied children supervised and verify the authorized caregiver before release under the local safeguarding plan.

Phase 7: Special Considerations—CBRNE and Tactical

If chemical exposure is suspected, direct potentially contaminated arrivals to the designated decontamination pathway before entry into clean care areas. Use PPE matched to the hazard and task and trained staff. An explosion alone does not establish chemical contamination.

• Contamination zones: Follow the local hazardous-material plan for contaminated, decontamination, and clean treatment areas. Use trained teams and appropriate PPE; these zones are not interchangeable with tactical threat zones.
• Decontamination: Prompt disrobing can substantially reduce contamination, but is not the whole dry-decontamination process. Use exposure-specific dry or wet methods under hazardous-material guidance rather than an automatic shower sequence. Protect privacy and prevent hypothermia. (CHEMM guidance)
• Tactical: Follow incident-command and law-enforcement direction on access and threat zones. Under TECC guidance, indirect-threat care occurs in an area of relative safety; a warm zone is not necessarily fully secured. Interventions depend on the evolving threat, available resources, and responder training.

Phase 8: Resource Scarcity and Ethics

As resources dwindle, care shifts on a spectrum:

• Contingency Care: Adapt spaces, staffing, or resources while aiming for functionally equivalent care. Staffing must match acuity, competencies, monitoring, and required tasks; no single nurse-to-patient ratio guarantees safe contingency care. (ASPR TRACIE care-spectrum guidance)
• Crisis Care: When shortages threaten patient outcomes despite efforts to obtain or adapt resources, use the institution’s crisis-care process and appropriate clinical, ethics, and incident-command support. Allocation requires individualized assessment of likely treatment benefit under applicable guidance and law, not categorical exclusion by age or disability. See U.S. ASPR TRACIE guidance and U.S. HHS nondiscrimination principles.

Document the shortage, attempts to obtain resources and the reason for allocation decisions. Reassess as capacity changes and explain decisions to patients and families. A resource-limited decision is not the same as concluding that treatment cannot benefit the patient.

Phase 9: System-Wide Integration

The ED cannot survive alone.

• Inpatient Support: Activate agreed admission and transfer pathways with receiving teams. Match each patient’s ongoing needs to available staff, monitoring and space.
• HICS: Where HICS is used, clarify the ED/Casualty Care Unit’s reporting line in the local organization chart; role names and structures can vary.
• Maintenance: Exercise and review the local emergency plan using the requirements that apply to your facility. For U.S. hospitals under the Joint Commission’s 2026 hospital standards, EM.16.01.01 specifies two exercises per year, including an operations-based exercise, with defined options and exemptions. Do not assume the same accreditation rules apply in every jurisdiction.

Strategic Mentorship: Identifying Blind Spots

When planning for your facility, consider these operational risks:

1. The Communication Blackout: Rehearse the downtime plan: patient identifiers, accessible paper records, result communication and a reliable patient-location record. Whiteboards and runners are options; protect confidential information.
2. The “Fixation” Trap: Triage physicians can become occupied with one patient while others await assessment. Provide the brief lifesaving interventions allowed by the adopted triage algorithm, then assign a category and continue sorting. Avoid prolonged procedures; SALT does not specify a universal 15-second treatment cutoff.
3. Reverse Triage Pushback: Agree transfer criteria and escalation routes before an incident. Leadership authorization does not replace reassessment, receiving capacity or a named handoff. Use the WHO hospital checklist to support local planning.

The Mass Casualty Incident” (Roberts & Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, Chapter 75)