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U.S. Department of Health and Human Services

1.1 Mass Casualty and Mass Effect Incidents: Implications for Healthcare Organizations

The first step in developing a healthcare emergency response system is to fully understand the range of potential hazards and their impact, the complexities of healthcare emergency response, and the difficulties of delivering healthcare services during a disaster.

1.1.1 The Range of Hazard Impacts on Healthcare
Organizations

In emergency management, “hazard” refers to the underlying etiology for any type of emergency. A wide range of actual or potential hazards is relevant to healthcare organizations in any locale. Using a Hazard Vulnerability Analysis (HVA – see Chapter 5), healthcare organizations may identify and characterize hazards according to the following attributes:

  • The general probability of hazard occurrence in the community and in the specific location of the healthcare organization that is performing the HVA.
  • The general impact of the hazard, should it occur, on both the community and the healthcare organization. “Risk” can then be calculated, since it is a function of the probability (likelihood) of a hazard occurrence and the impact (consequences) of a hazard on the target.[1]
  • The specific vulnerabilities of the healthcare organization to the hazard impact. This is a primary concern since the safety of staff, patients, and visitors, and the maintenance of critical healthcare services to patients currently being treated, are paramount.
  • The specific vulnerabilities of the community to the hazard. This can be used to project the potential service demands that may be placed on healthcare organizations during emergencies. Service demands may extend beyond traditional medical services to include treating first responders, providing preventive medical information to the public, or establishing large-volume medical screening capabilities.

In a detailed HVA, vulnerability is examined and characterized for the healthcare organization in a manner that provides information for all four phases of Comprehensive Emergency Management – mitigation, preparedness, response, and recovery.[2] Vulnerability is multifaceted and involves the following:

  • Disruption from the hazard impact directly on the healthcareorganization (e.g., flooding of a hospital), thereby affecting its normal healthcare service delivery
  • Disruption of the healthcare organization’s function indirectly from a hazard impact on infrastructure and support services, including utilities and re-supply (e.g., power outage after a storm)
  • Impact on the healthcare organization’s operations from unusual service demands (e.g., treating even a few patients with Severe Acute Respiratory Syndrome (SARS) or multiple burn patients in a nonburn facility).

For these reasons, healthcare organizations may characterize hazards as primarily “mass casualty,”[3] and/or “mass effect” (Exhibit 1-1).

Exhibit 1-1. Mass Casualty and Mass Effect Incidents

Mass Casualty Incident: An incident that generates a sufficiently large number of casualties whereby the available healthcare resources, or their management systems, are severely challenged or unable to meet the healthcare needs of the affected population.

Mass Effect Incident: An incident that primarily affects the ability of an organization to continue its normal operations. For healthcare organizations, this can disrupt the delivery of routine healthcare services and hinder their ability to provide needed surge capacity. For example, a hospital’s ability to provide medical care to the victims of an earthquake is compromised if it must focus on relocating current patients because a section of the facility was destroyed.

Adapted from Barbera JA, Macintyre, AG, Shaw G, et al, Emergency Management Principles and Practices for Healthcare Systems (2006) Available at: www1.va.gov/emshg/page.cfm?pg=122.

1.1.2 Characteristics of Incidents Confronting Healthcare Organizations

Incident characteristics vary across hazards and even within a specific hazard type.[4] These characteristics should be considered when assessing the value of a Healthcare Coalition to participating healthcare organizations and the local jurisdiction. The following is a partial list of incident characteristics that are relevant to Coalition operations.

Sudden versus slow onset: Mass casualty and mass effect incidents may occur suddenly with extraordinary medical resource needs, or they may evolve slowly and with warning, allowing for more extensive evaluation before instituting response measures. In a slow onset incident (e.g., heat wave), a Healthcare Coalition may facilitate inter-facility action planning and enable healthcare organizations to anticipate mutual aid and other resource needs. In sudden onset incidents, rapid notification to all local and regional healthcare organizations through the Healthcare Coalition may be critical so organizations can respond effectively, support each other, and interact with local jurisdictional authorities.

During sudden onset incidents, many victims reach hospitals (or other healthcare providers) on their own or through the assistance of bystanders, and not by way of Emergency Medical Services (EMS). Therefore, victims may arrive with little or no prior notification and without being matched with the most appropriate facility. The ability of healthcare organizations to rapidly obtain additional resources, provide input to EMS for appropriate patient distribution, and assist each other in matching resources to patient needs may best be addressed through a Healthcare Coalition.

Insidious versus obvious onset: Incident onset may be obvious or insidious, requiring adequate surveillance systems for recognition and determination of the incident size and scope. In the case of the latter, the ability to rapidly gather and synthesize data from healthcare organizations may be important to determining that a dangerous incident is evolving.

Short duration versus prolonged incidents: Preparedness planning and exercises often focus on short duration, high intensity incidents. However, healthcare emergencies can be prolonged with ongoing service needs and continuity of operations issues. It is important for healthcare planners to recognize that a prolonged incient (days to weeks) will almost always have a major impact on the healthcare organization. Increased personnel commitment during a prolonged response can be difficult to sustain given the manpower constraints faced by many healthcare organizations. The financial impact of a prolonged response on a healthcare organization, due to disruption of normal healthcare service delivery, must also be addressed. The Healthcare Coalition can promote access to resources that may be critical to sustaining continuity of operations in addition to addressing surge needs.

Terrorism and other fear-generating hazards: Some mass casualty or mass effect incidents, particularly acts of terrorism such as the anthrax mailings in 2001, result in a large population of concerned, potentially exposed persons. Substantial medical and public health resources must be devoted to evaluate these patients. Victims may require specialized medical and public health capabilities, ranging from population-based mental health interventions to treatment for such issues as chemical burns, inhalational respiratory failure, or radiation syndromes. The ability to share expert advice and establish uniform diagnostic and treatment protocols during response may be as important as acquiring adequate equipment and supplies.

Exhibit 1-2. Example of how expert medical advice can be shared during an emergency

During the 2001 anthrax attacks in the Washington, D.C. metropolitan region, members of the medical community initiated a series of teleconferences to coordinate the clinical management of patients with suspected anthrax across the affected jurisdictions (Washington, D.C., suburban Maryland, and northern Virginia). The calls provided a forum to exchange information on diagnosis and treatment, such as the usefulness
of chest CTs in detecting early signs of inhalational anthrax, the lack of value of nasal swabs in making a diagnosis, and the effectiveness of certain antibiotic treatments. The calls also helped to dispel rumors circulating in the media.

Gursky E, Inglesby TV, and O’Toole T. Anthrax 2001: Observations on the Medical and Public Health Response. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, Volume 1, (2003).

1.1.3 Critical Issues in Healthcare Organization Emergency Response

Healthcare organizations’ actions during an emergency or disaster can be complicated by a range of response issues. While the primary responsibility for emergency response lies with the executive leadership of each healthcare organization, the support activities performed by an effective Healthcare Coalition may be very helpful. The following issues should be considered when examining the Healthcare Coalition’s potential roles during incident response.

The need for continuity of healthcare operations despite a hazard impact: Because of the critical services they provide, healthcare organizations can rarely halt operations before or after a hazard impact. They must continue to provide a safe environment for current patients, staff, and visitors.

The need to maintain adequate healthcare service delivery while addressing all aspects of medical surge: Any hazard that directly impacts a healthcare organization will likely produce a range of response issues. Medical care must be provided to hazard victims while maintaining operations for the usual patient population. The organization may also be required to perform other activities, such as participating in risk reduction for potential victims (through advice, prophylaxis, and other health interventions), assisting with mass fatality response, and addressing the psychological needs of patients, staff, and visitors.

The fragility of healthcare organizations’ physical facilities: The following physical attributes of healthcare organizations make them somewhat “fragile” compared to other emergency resources:

  • The structural layout and supporting infrastructure is often complex and of varying age and reliability.
  • Building occupancy remains relatively high 24/7, with the associated maintenance requirements.
  • Environment of care, healthcare operations, and patient/staff safety depend heavily on facility infrastructure (e.g., electricity, water, HVAC, communications). The loss of water, electricity, and HVAC created life-threatening conditions in hospitals after Hurricane Katrina, even in patient care locations that otherwise were undamaged.
  • Multiple hazards may exist within the facility (e.g., chemicals used in medical diagnostics, radiation emitters used in cancer therapy, cleaning and sterilizing materials).

The business environment in which healthcare organizations operate day-to-day poses challenges after a hazard impact. Some characteristics of this environment include the following:

  • Healthcare organizations rely heavily on specific equipment and supplies (e.g., pharmacy, sterile supplies) where just-in-time inventory is common and surge resources are limited. Few alternative suppliers or substitute resources may be readily available.
  • Seeking efficiencies, the U.S. healthcare industry generally relies on “just-enough” staffing and space for everyday operations. This business practice adds to the difficulties in achieving adequate surge capacity and capability. Current professional staffing shortages (e.g., nurses) may further exacerbate resource constraints.
  • Required patient care documentation and other regulatory compliance requirements are very labor intensive.
  • Many healthcare organizations regularly experience deficits in operating income. Future income for services is relatively fixed even while expenses increase, and there is a near complete dependency on third party payers to maintain the income stream. Any additional uncompensated emergency care can pose a significant financial risk.
  • The business viability of a healthcare organization is tied in part to its reputation in the community, which can be affected by how the healthcare organization performs in an emergency or disaster.
  • Unlike many businesses, only a limited amount of the work performed by healthcare organizations can be done from an off-site location. This limits the value of “work from home” strategies that are common in business continuity planning.

The “public-private sector divide” during response: Most healthcare organizations in the U.S. are privately owned. While the overall management of healthcare emergencies is typically a public sector responsibility, the delivery of emergency healthcare services is usually performed by private healthcare organizations. This distinction can complicate the response if not adequately addressed through response planning between the public and private sectors.

The following issues should be considered:

  • Privately owned healthcare organizations usually maintain their respective decision-making sovereignty during emergencies, except in extreme or unusual circumstances (e.g., enactment of isolation or quarantine orders by public health authorities). This emphasizes the need for voluntary coordination of decision-making among individual healthcare organizations.
  • For the reasons stated earlier, healthcare organizations need to consider financial solvency and other business continuity issues when determining emergency response actions. These issues will need to be addressed with public agencies during incident response, as well as during preparedness planning. This is one of the most critical reasons for establishing a separate Tier 2 capability, even if it is within an existing multi-tiered organization established by a local or State jurisdiction.
  • Public sector entities also operate under budget constraints that may affect preparedness initiatives (e.g., their ability to stockpile resources). This may also affect their capacity to respond to the needs of private entities, such as healthcare organizations.
  • Regulatory and legal issues may impede public funding to for-profit healthcare organizations that provide disaster services. Historically, it has been difficult for healthcare organizations to recoup their expenditures under the Robert T. Stafford Act or other disaster declarations. This reality should be recognized and addressed fairly for all Coalition member organizations.
  • Private healthcare organizations have not always included public sector agencies in their preparedness planning. Likewise, jurisdictional authorities (Tier 3) have not always demonstrated that they consider healthcare organizations to be essential partners in emergency response. This can adversely affect response if healthcare organizations are not represented in decision-making, resource coordination, and information sharing activities.

The need for a visibly competent healthcare emergency response: In order to maintain the public’s confidence and promote cooperation during extreme emergencies, the public must be assured that healthcare services are being provided in an equitable and ethically sound manner. The importance of maintaining the public’s confidence has several implications for healthcare systems:

  • Ideally, the response strategies, tactics, and public messages developed by healthcare organizations should be consistent with the public sector emergency response.
  • Healthcare providers should be briefed on potentially controversial messages prior to their public release so their questions or concerns can be addressed before they interact with patients or the public.
  • Healthcare providers must manage the fear component of a public health crisis by demystifying any unusual hazard (e.g., anthrax) through a clear explanation of medical tactics to the public, and by promoting consistency in strategy and tactics across all healthcare organizations in the area.

The aforementioned issues should be considered by healthcare emergency planners and public authorities during preparedness planning. None of the issues will likely be obvious to or accepted by the public as legitimate obstacles to effective emergency response.


  1. Adapted from Ansell J, and Wharton F. Risk: Analysis, Assessment, and Management. John Wiley & Sons, Chichester, 1992.
  2. Drabek TE, Hoetmer GJ (Eds). Emergency Management: Principles and Practice for Local Government. International City Management Association, Washington, D.C.; (1991).
  3. Within this text, casualty refers to any human accessing public health or medical services, including mental health services and medical forensics/mortuary care (for fatalities), as a result of a hazard impact.
  4. Within this text, incident refers to any unexpected situation that requires an organization to activate its Emergency Operations Plan and commence emergency response operations. NIMS designates a planned non-emergency situation (e.g., a mass gathering) that activates emergency operations as an “event.”

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  • This page last reviewed: February 14, 2012