Communication

Communication is an indispensable component of a coordinated MCI response. Effective communication during an MCI requires using modern communication devices with adequate backup, or redundant systems (eg, radio, satellites, geographic positioning systems), or other innovative technology to enable real-time situational awareness and information sharing. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Adelaine, Shoaf and Harvey20–Reference Zafar, Jawad and Shamim62} The evolving role of social media such as live Twitter feeds, Facebook updates, text messages, and chat rooms has been explored for their ability to contribute to situational awareness, communication with the victims and their loved ones, and information sharing among the media, key stakeholders, and frontline providers. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Adelaine, Shoaf and Harvey20,Reference Aten, Leavell and Gonzalez24,Reference Biddinger, Cadigan and Auerbach28,Reference Biddinger, Reisman and Seger29,Reference Bradt31,Reference Brands, Hernandez and Stenberg32,Reference Callaway, Peabody and Hoffman35,Reference Cha, Kim and Kim36,Reference El Sayed, Chami and Hitti39–Reference Giacobe and Soule42,Reference Hick, Koenig and Barbisch46,Reference Juffermans and Bierens50,Reference Kearns, Skarote and Peterson51,Reference Moser, Connelly and Baker55,Reference Stander, Wallis and Smith59–Reference Wurmb, Schorscher and Justice61,Reference Farmer, Stoerger and Vyavahare63–Reference Wachira, Abdalla and Wallis66} Pre-determined contacts for designated personnel, collaborating entities and other agencies, improves efficiency and the flow of information. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Adelaine, Shoaf and Harvey20,Reference Adini, Bodas and Nilsson21,Reference Homier, Hamad and Larocque48,Reference Hsu, Jenckes and Catlett49,Reference Stander, Wallis and Smith59,Reference Avidan, Hersch and Spira67–Reference Lynn, Gurr and Memon74} Standard and ad-hoc channels of communication help provide situational awareness, clarify misinformation, address concerns, and facilitate response activities. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Adelaine, Shoaf and Harvey20–Reference Almogy and Rivkind23,Reference Balasegaram, Kar-Purkayastha and Bussell25,Reference Bernardo and Veenema26,Reference Broeze, Falder and Rea33,Reference El Sayed, Chami and Hitti39,Reference Gotham, Sottolano and Hennessy44–Reference Hick, Koenig and Barbisch46,Reference Moser, Connelly and Baker55,Reference Wild, Maher and Frazee60,Reference Avidan, Hersch and Spira67,Reference Lynn, Gurr and Memon74–Reference Currie and Heslop77}

Safety and Security

Safety and security must always be prioritized with any MCI, recognizing that some incidents, such as terror attacks or chemical hazards, require containment and pose a greater security threat than others. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Brands, Hernandez and Stenberg32,Reference Bukowski34,Reference Crawford, Mackway-Jones and Russell37,Reference El Sayed, Chami and Hitti39,Reference Holgersson47,Reference Little, Cooper and Gope54,Reference Stander, Wallis and Smith59,Reference Zafar, Jawad and Shamim62,Reference Albanese, Burich and Smith75,Reference Currie and Heslop77–Reference Weyand, Junck and Kang92} Moreover, security officials maintain the law and order at the scene and at the hospitals receiving injured patients, controlling access points, and restricting it to only authorized personnel, monitoring for suspicious activities, and preventing crowds from interfering with emergency operations. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Brands, Hernandez and Stenberg32,Reference Bukowski34,Reference El Sayed, Chami and Hitti39,Reference Gabbe, Veitch and Curtis40,Reference Holgersson47,Reference Hsu, Jenckes and Catlett49,Reference Stander, Wallis and Smith59,Reference Zafar, Jawad and Shamim62,Reference Jenckes, Catlett and Hsu73,Reference Autrey, Hick and Bramer81,Reference Golabek-Goldman87,Reference Brooke Lerner, O’Connor and Schwartz91–Reference Seaton, Maier and Sachdeva94} Deploying a safety officer to identify potential threats and implement appropriate safety procedures is essential in virtually all MCIs. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Cha, Kim and Kim36,Reference El Sayed, Chami and Hitti39,Reference Holgersson47,Reference O’Neill56,Reference Albanese, Burich and Smith75,Reference Autrey, Hick and Bramer81,Reference Liebergall, Braverman and Shapira93} In response to the safety and security challenges adopted in some settings is the introduction of Tactical medicine, in which out-of-hospital care is provided by specially trained practitioners, many with military and/or law enforcement training, who operate in hostile environments. ^{Reference Broeze, Falder and Rea33,Reference Autrey, Hick and Bramer81,Reference Golabek-Goldman87,Reference Jacobs95–Reference Madzimbamuto97}

Human Resources

MCI response depends upon adequate and appropriate personnel capacity. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Adelaine, Shoaf and Harvey20,Reference Almogy and Rivkind23,Reference Bernardo and Veenema26,Reference Biddinger, Cadigan and Auerbach28,Reference Bradt31,Reference Gabbe, Veitch and Curtis40,Reference Hick, Koenig and Barbisch46,Reference Holgersson47,Reference Little, Cooper and Gope54,Reference Moser, Connelly and Baker55,Reference Avidan, Hersch and Spira67–Reference Berger, Körner and Bernstein69,Reference Lynn, Gurr and Memon74,Reference Autrey, Hick and Bramer81,Reference Baker82,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Brandenburg and Arneson98–Reference Smith, Paturas and Tomassoni104} Human resources are not limited to paramedics, nurses and doctors, but include all who care for patients during an MCI, such as uninjured or mildly injured survivors, bystanders and community volunteers. ^{Reference Almogy and Rivkind23,Reference Broeze, Falder and Rea33,Reference El Sayed, Chami and Hitti39,Reference Zafar, Jawad and Shamim62,Reference Baldwin and Wilson68,Reference Baker82,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Halpern, Tsai and Arnold102,Reference Aliyu105,Reference Ching and Preparation106} Depending upon the extent, location and duration of an MCI, fire, rescue and security services, incident management teams, ambulance and transport crew, hospital ancillary staff, translators, information technology (IT) specialists and engineers, as well as social services—who can assist with emotional trauma and maintain a family information center—should remain engaged and involved in providing acute care. ^{Reference Almogy and Rivkind23,Reference Biddinger, Baggish and Harrington27,Reference Einav, Schecter and Matot38,Reference Ghanchi41,Reference Little, Cooper and Gope54,Reference Baldwin and Wilson68,Reference Lynn, Gurr and Memon74,Reference Autrey, Hick and Bramer81,Reference Baker82,Reference Brandenburg and Arneson98,Reference Ablah, Tinius and Konda107–Reference Deelen, Costermans and Moss113} Some experts outlined core competencies for frontline responders participating in an MCI response. ^{Reference Bloch, Schwartz and Pinkert30,Reference Broeze, Falder and Rea33,Reference Bukowski34,Reference Crawford, Mackway-Jones and Russell37,Reference Savoia, Biddinger and Burstein58,Reference Bulson, Bulson and Vande Guchte84,Reference Higgins, Wainright and Lu89,Reference Brandenburg and Arneson98–Reference Chim, Yew and Song100,Reference Ablah, Tinius and Konda107,Reference Ablah, Molgaard and Fredrickson114–Reference Veenema and Toke125} Enabling factors that enhance core competencies include specific training on the incident command system framework, as well as collaborative exercises and drills to better organize a multidisciplinary and multi-agency response. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Alexander22,Reference Almogy and Rivkind23,Reference Bernardo and Veenema26–Reference Biddinger, Reisman and Seger29,Reference Bukowski34,Reference Cha, Kim and Kim36,Reference Crawford, Mackway-Jones and Russell37,Reference Gabbe, Veitch and Curtis40,Reference Gotham, Sottolano and Hennessy44,Reference Hardy, Fattah and Wisborg45,Reference Hsu, Jenckes and Catlett49,Reference Leahy, Yurt and Lazar53,Reference Little, Cooper and Gope54,Reference O’Neill56,Reference Savoia, Biddinger and Burstein58,Reference Wild, Maher and Frazee60,Reference Jenckes, Catlett and Hsu73,Reference Lynn, Gurr and Memon74,Reference Friedman, Rose and Koskan76,Reference Allen, Parrillo and Will80,Reference Baker82–Reference Bulson, Bulson and Vande Guchte84,Reference Jacobs and Burns96,Reference Burke, Iverson and Goodhue99,Reference Chim, Yew and Song100,Reference Ablah, Tinius and Konda107,Reference Abraham108,Reference Cocco and Thomas-Boaz110,Reference Collignon111,Reference Deelen, Costermans and Moss113,Reference Catlett, Jenkins and Millin118,Reference Gebbie, Peterson and Subbarao121,Reference Seifman, Ek and Menezes124,Reference Janati, Sadeghi-Bazargani and Hasanpoor126,Reference Jenkins, McCarthy and Sauer127} Cultural competency must be kept in mind when responding to any MCI, but especially those predominantly affecting minority populations, children, elderly, low-income, and alternatively abled persons. ^{Reference Bernardo and Veenema26,Reference Gomez, Haas and Ahmed43,Reference Holgersson47,Reference Friedman, Rose and Koskan76,Reference Allen, Parrillo and Will80,Reference Bulson, Bulson and Vande Guchte84,Reference Brandenburg and Arneson98,Reference Burke, Iverson and Goodhue99,Reference Abraham108,Reference Andrulis, Siddiqui and Gantner109} Advance contingency agreements between different organizations, institutions, and jurisdictions for resource and personnel sharing can help in recruiting individuals to deal with a large influx of victims over a short period of time. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Adelaine, Shoaf and Harvey20,Reference Bernardo and Veenema26,Reference Biddinger, Baggish and Harrington27,Reference Broeze, Falder and Rea33,Reference Gomez, Haas and Ahmed43,Reference Gotham, Sottolano and Hennessy44,Reference Hick, Koenig and Barbisch46,Reference Holgersson47,Reference Kearns, Skarote and Peterson51,Reference Little, Cooper and Gope54,Reference Lynn, Gurr and Memon74,Reference Golabek-Goldman87,Reference Jacobs and Burns96,Reference Corcoran, Niven and Reese101,Reference Smith, Paturas and Tomassoni104,Reference Cocco and Thomas-Boaz110,Reference Catlett, Jenkins and Millin118,Reference Avitzour, Libergal and Assaf128–Reference Shartar, Moore and Wood130} Keeping an active roster of available volunteers and required staff is often useful in rapidly building surge capacity by ensuring that personnel are both prepared and willing to participate in MCI response activities. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Adelaine, Shoaf and Harvey20,Reference Adini, Bodas and Nilsson21,Reference Biddinger, Reisman and Seger29,Reference Broeze, Falder and Rea33,Reference Gabbe, Veitch and Curtis40,Reference Ghanchi41,Reference Hick, Koenig and Barbisch46,Reference Homier, Hamad and Larocque48,Reference Hsu, Jenckes and Catlett49,Reference Baldwin and Wilson68–Reference Lynn, Gurr and Memon74,Reference Corcoran, Niven and Reese101,Reference Smith, Paturas and Tomassoni104,Reference Adams and Melius115,Reference Catlett, Jenkins and Millin118,Reference Devereaux, Christian and Dichter120} Addressing the emotional trauma of the volunteers and staff in the aftermath of an MCI should be considered during an emergency medical response. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Adini, Bodas and Nilsson21,Reference Gabbe, Veitch and Curtis40,Reference Ghanchi41,Reference Holgersson47,Reference Baldwin and Wilson68,Reference Albanese, Burich and Smith75,Reference Baker82,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Liebergall, Braverman and Shapira93,Reference Aliyu105,Reference Cocco and Thomas-Boaz110,Reference Catlett, Jenkins and Millin118,Reference Chang, Vacanti and Michaud119,Reference Gebbie, Peterson and Subbarao121,Reference Veenema and Toke125,Reference Biddison, Berkowitz and Courtney131}

Planning, Policy, and Procedures

Local planning, policies, and procedures, or a collective MCI plan, provides the framework to activate and deactivate MCI response and guide response activities. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Alexander22,Reference Biddinger, Baggish and Harrington27,Reference Brands, Hernandez and Stenberg32,Reference Broeze, Falder and Rea33,Reference El Sayed, Chami and Hitti39,Reference Gabbe, Veitch and Curtis40,Reference Leahy, Yurt and Lazar53,Reference Moser, Connelly and Baker55,Reference Savoia, Biddinger and Burstein58,Reference Stander, Wallis and Smith59,Reference Berger, Körner and Bernstein69,Reference Farmer and Carlton71,Reference Lynn, Gurr and Memon74,Reference Baker82,Reference Higgins, Wainright and Lu89,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Liebergall, Braverman and Shapira93,Reference Liebergall, Braverman and Shapira93,Reference Seaton, Maier and Sachdeva94,Reference Brandenburg and Arneson98,Reference Cocco and Thomas-Boaz110,Reference Collignon111,Reference Carley, Mackway-Jones and Randic117,Reference Catlett, Jenkins and Millin118,Reference Devereaux, Christian and Dichter120,Reference Al-Shamsi, Moitinho de Almeida and Nyanchoka132–Reference Zoraster, Chidester and Koenig134} Following local standard operating procedures (SOP) and predetermined policies and protocols, next steps include clear role identification, delegation of responsibilities, record-keeping, patient triage, clinical care delivery, resource allocation, maintaining stockpiles of essential equipment and supplies, information flow, victim identification, and routine communication with staff, media and families. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Biddinger, Baggish and Harrington27,Reference Broeze, Falder and Rea33,Reference Bukowski34,Reference El Sayed, Chami and Hitti39,Reference Gabbe, Veitch and Curtis40,Reference Hick, Koenig and Barbisch46,Reference Leahy, Yurt and Lazar53,Reference Savoia, Biddinger and Burstein58,Reference Avidan, Hersch and Spira67,Reference Berger, Körner and Bernstein69,Reference Farmer and Carlton71,Reference Lynn, Gurr and Memon74,Reference Baker82,Reference Higgins, Wainright and Lu89,Reference Liebergall, Braverman and Shapira93,Reference Seaton, Maier and Sachdeva94,Reference Brandenburg and Arneson98,Reference Cocco and Thomas-Boaz110,Reference Collignon111,Reference Carley, Mackway-Jones and Randic117,Reference Catlett, Jenkins and Millin118,Reference Devereaux, Christian and Dichter120,Reference Biddison, Berkowitz and Courtney131–Reference Zoraster, Chidester and Koenig134} When additional health-care personnel are needed, emergency credentialing could be used to facilitate the process, and providing hazard pay and benefits for first responders should be taken into consideration, including provisions providing legal indemnification to providers, support staff, institutions, and other responding agencies. ^{Reference Broeze, Falder and Rea33,Reference El Sayed, Chami and Hitti39,Reference Gabbe, Veitch and Curtis40,Reference Hick, Koenig and Barbisch46,Reference Leahy, Yurt and Lazar53,Reference Baldwin and Wilson68,Reference Jenckes, Catlett and Hsu73,Reference Lynn, Gurr and Memon74,Reference Higgins, Wainright and Lu89,Reference Smith, Paturas and Tomassoni104,Reference Ablah, Tinius and Konda107,Reference Catlett, Jenkins and Millin118,Reference Devereaux, Christian and Dichter120,Reference Gebbie, Peterson and Subbarao121,Reference Veenema and Toke125,Reference Janati, Sadeghi-Bazargani and Hasanpoor126,Reference Shartar, Moore and Wood130,Reference Biddison, Berkowitz and Courtney131,Reference Zhong, Clark and Hou133,135–Reference Tami, Bruria and Fabiana137} Vendor agreements and inventory management policies may shorten the time to deploy essential materials and equipment to ensure their availability. ^{Reference Bernardo and Veenema26,Reference Biddinger, Cadigan and Auerbach28,Reference Gabbe, Veitch and Curtis40,Reference Gomez, Haas and Ahmed43,Reference Hick, Koenig and Barbisch46,Reference Kearns, Skarote and Peterson51,Reference Moser, Connelly and Baker55,Reference Lynn, Gurr and Memon74,Reference Albanese, Burich and Smith75,Reference Baker82,Reference Brandenburg and Arneson98–Reference Chim, Yew and Song100,Reference Hick, Hanfling and Cantrill103,Reference Collignon111,Reference Catlett, Jenkins and Millin118,Reference Devereaux, Christian and Dichter120,Reference Shahrestanaki, Khankeh and Masoumi129,Reference Rebmann, McPhee and Osborne136,Reference Adini, Aharonson-Daniel and Israeli138–Reference Rubinson, Hick and Hanfling140} A post-MCI debriefing should be conducted during which participating organizations report their data and respond to questions fostering a culture of transparency, accountability, and community practice. ^{Reference El Sayed, Chami and Hitti39–Reference Ghanchi41,Reference Berger, Körner and Bernstein69,Reference Baker82,Reference Madzimbamuto97,Reference Cocco and Thomas-Boaz110,Reference Deelen, Costermans and Moss113,Reference Carley, Mackway-Jones and Randic117,Reference Tami, Bruria and Fabiana137,Reference Brunner, Rocha and Chudgar141–Reference Hendrickx, D’Hoker and Michiels143} Periodic assessments of MCI response capabilities and the evaluation of training and preparedness of the responders should be incorporated into the process of ensuring readiness to respond to future MCIs. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Alexander22,Reference Almogy and Rivkind23,Reference Biddinger, Baggish and Harrington27–Reference Biddinger, Reisman and Seger29,Reference Crawford, Mackway-Jones and Russell37,Reference Hardy, Fattah and Wisborg45,Reference O’Neill56,Reference Rimstad and Braut57,Reference Zafar, Jawad and Shamim62,Reference Farmer, Stoerger and Vyavahare63,Reference Berger, Körner and Bernstein69,Reference Faccincani, Della Corte and Sesana70,Reference Lynn, Gurr and Memon74,Reference Currie and Heslop77,Reference Allen, Parrillo and Will80–Reference Baker82,Reference Brandenburg and Arneson98,Reference Burke, Iverson and Goodhue99,Reference Aliyu105,Reference Cocco and Thomas-Boaz110,Reference Collignon111,Reference Seifman, Ek and Menezes124,Reference Janati, Sadeghi-Bazargani and Hasanpoor126,Reference Shahrestanaki, Khankeh and Masoumi129,Reference Esbitt139,Reference Hendrickx, D’Hoker and Michiels143–Reference Thomas, Hsu and Kim149}

Command, Control, and Coordination

A central body or lead agency maintains hierarchy, inter-agency response coordination, and mobilizes resources. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Adini, Bodas and Nilsson21,Reference Alexander22,Reference Biddinger, Cadigan and Auerbach28,Reference Bradt31,Reference Cha, Kim and Kim36,Reference Hardy, Fattah and Wisborg45,Reference Holgersson47,Reference Juffermans and Bierens50,Reference Moser, Connelly and Baker55–Reference Savoia, Biddinger and Burstein58,Reference Wurmb, Schorscher and Justice61,Reference Zafar, Jawad and Shamim62,Reference Ganz, Schafer and Yang64–Reference Wachira, Abdalla and Wallis66,Reference Jenckes, Catlett and Hsu73,Reference Baker82,Reference Gryth, Rådestad and Nilsson88,Reference Higgins, Wainright and Lu89,Reference Burke, Iverson and Goodhue99,Reference Chim, Yew and Song100,Reference Cocco and Thomas-Boaz110,Reference Collignon111,Reference Catlett, Jenkins and Millin118,Reference Chang, Vacanti and Michaud119,Reference Shahrestanaki, Khankeh and Masoumi129,135,Reference Adini, Aharonson-Daniel and Israeli138,Reference Cone142,Reference Bacis145,Reference Thomas, Hsu and Kim149–Reference Xu and Li155} At the local level, a physical emergency operations center (EOC) with well-defined jurisdictional responsibility is mandated for MCI management. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Adini, Bodas and Nilsson21,Reference Alexander22,Reference Biddinger, Cadigan and Auerbach28,Reference Bradt31,Reference Bukowski34,Reference Cha, Kim and Kim36,Reference Holgersson47,Reference Juffermans and Bierens50,Reference Moser, Connelly and Baker55–Reference Stander, Wallis and Smith59,Reference Wurmb, Schorscher and Justice61,Reference Zafar, Jawad and Shamim62,Reference Ganz, Schafer and Yang64–Reference Wachira, Abdalla and Wallis66,Reference Jenckes, Catlett and Hsu73,Reference Baker82,Reference Gryth, Rådestad and Nilsson88,Reference Higgins, Wainright and Lu89,Reference Burke, Iverson and Goodhue99,Reference Cocco and Thomas-Boaz110,Reference Collignon111,Reference Catlett, Jenkins and Millin118,Reference Chang, Vacanti and Michaud119,Reference Shahrestanaki, Khankeh and Masoumi129,135,Reference Cone142,Reference Bacis145,Reference Thomas, Hsu and Kim149,Reference Born, Briggs and Ciraulo151–Reference Shah, Rehman and Sayyed158} EOCs play an important role by coordinating amongst organizations that need medical resources with those that can provide medical resources and delegating various emergent tasks among different entities. ^{Reference El Sayed, Chami and Hitti39,Reference Juffermans and Bierens50,Reference Little, Cooper and Gope54,Reference Catlett, Jenkins and Millin118,Reference Born, Briggs and Ciraulo151,Reference Comfort, Dunn and Johnson152,Reference Xu and Li155,Reference Fletcher, Knight and Pockrus157,Reference Abbasi and Kapucu159,Reference Christian, Sprung and King160} EOCs follow the framework of a centralized and hierarchical incident command system (ICS) in directing all response activities. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Adini, Bodas and Nilsson21,Reference Alexander22,Reference Biddinger, Cadigan and Auerbach28,Reference Cha, Kim and Kim36,Reference Holgersson47,Reference Juffermans and Bierens50,Reference O’Neill56–Reference Stander, Wallis and Smith59,Reference Wurmb, Schorscher and Justice61,Reference Zafar, Jawad and Shamim62,Reference Ganz, Schafer and Yang64–Reference Wachira, Abdalla and Wallis66,Reference Jenckes, Catlett and Hsu73,Reference Baker82,Reference Gryth, Rådestad and Nilsson88,Reference Higgins, Wainright and Lu89,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Burke, Iverson and Goodhue99,Reference Cocco and Thomas-Boaz110,Reference Catlett, Jenkins and Millin118,Reference Chang, Vacanti and Michaud119,Reference Shahrestanaki, Khankeh and Masoumi129,135,Reference Cone142,Reference Thomas, Hsu and Kim149,Reference Born, Briggs and Ciraulo151–Reference Xu and Li155,Reference Fletcher, Knight and Pockrus157,Reference Shah, Rehman and Sayyed158,Reference Hoffner, Keck and Hemphill161–Reference Zane and Prestipino163} Based on the extent and duration of the MCI, the ICS system can be lean or more expansive, requiring additional command and support roles to facilitate the operations of care delivery for at least 10 days without external assistance. ^{Reference Adini, Bodas and Nilsson21,Reference Biddinger, Reisman and Seger29,Reference Bukowski34,Reference Gabbe, Veitch and Curtis40,Reference Gomez, Haas and Ahmed43,Reference Juffermans and Bierens50,Reference Berger, Körner and Bernstein69,Reference Albanese, Burich and Smith75,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Catlett, Jenkins and Millin118,Reference Devereaux, Christian and Dichter120,Reference Rubinson, Hick and Hanfling140,Reference Cone142,Reference Bacis145,Reference Born, Briggs and Ciraulo151–Reference Filmer and Ranse153,Reference Zane and Prestipino163,Reference Kearns, Marcozzi and Barry164} Incident command should be established at the scene of the MCI, within each responding agency, as well as at each health facility that receives victims, and should include clinical and nonclinical representatives to ensure a multidisciplinary approach to disaster management. ^{Reference Biddinger, Reisman and Seger29,Reference Bradt31,Reference Bukowski34,Reference Holgersson47,Reference Rimstad and Braut57,Reference Avidan, Hersch and Spira67,Reference Lynn, Gurr and Memon74,Reference Albanese, Burich and Smith75,Reference Halpern, Tsai and Arnold102,Reference Avitzour, Libergal and Assaf128–Reference Shartar, Moore and Wood130,Reference Hendrickx, D’Hoker and Michiels143,Reference Assa, Landau and Barenboim150,Reference Comfort, Dunn and Johnson152,Reference Filmer and Ranse153,Reference Fletcher, Knight and Pockrus157,Reference Shah, Rehman and Sayyed158,Reference Hoffner, Keck and Hemphill161–Reference Zane and Prestipino163,Reference Born, Briggs and Ciraulo165}

Care Delivery

Care delivery is an umbrella term that covers a variety of operational and logistical activities. Approximately two-thirds of the articles, or 67%, covered clinical medical response for MCIs in the pre-hospital and hospital setting, discussing rational use of resources, triage, decontamination, surge capacity, stockpiles of medical supplies and equipment, bottlenecks in providing critical services, care of pediatric patients and other special populations, specialized management of burn injuries, and the unique considerations of chemical, biological, radiological and nuclear (CBRN)-related MCIs.

The operational components of pre-hospital MCI care delivery include evacuation, triage, and safe transport of the victims. ^{Reference Rimstad and Braut57,Reference Zafar, Jawad and Shamim62,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Zoraster, Chidester and Koenig134,Reference Lowe154} Several different triage methodologies have been used and tested in disasters, such as the START, JumpSTART, SALT, or SORT algorithms, among others, which quickly prioritize victims and assist in casualty distribution and setting up treatment areas where patients can be separated into cohorts based on triage categories. ^{Reference Biddinger, Baggish and Harrington27,Reference Bloch, Schwartz and Pinkert30,Reference Bradt31,Reference Crawford, Mackway-Jones and Russell37,Reference El Sayed, Chami and Hitti39,Reference Gabbe, Veitch and Curtis40,Reference Hardy, Fattah and Wisborg45–Reference Holgersson47,Reference Knotts, Etengoff and Barber52,Reference Leahy, Yurt and Lazar53,Reference Moser, Connelly and Baker55,Reference Wild, Maher and Frazee60,Reference Zafar, Jawad and Shamim62,Reference Berger, Körner and Bernstein69,Reference Albanese, Burich and Smith75,Reference Baker82,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Burke, Iverson and Goodhue99,Reference Corcoran, Niven and Reese101–Reference Hick, Hanfling and Cantrill103,Reference Aliyu105,Reference Ablah, Tinius and Konda107,Reference Abraham108,Reference Cocco and Thomas-Boaz110,Reference Catlett, Jenkins and Millin118,Reference Devereaux, Christian and Dichter120,Reference Veenema and Toke125,Reference Jenkins, McCarthy and Sauer127,Reference Zoraster, Chidester and Koenig134,Reference Bacis145,Reference Roccaforte and Cushman148,Reference Born, Briggs and Ciraulo151,Reference Lowe154,Reference Christian, Sprung and King160,Reference Adini, Cohen and Glassberg166–Reference Silvestri, Field and Mangalat184} However, triage is a dynamic process, and patients may need to be reevaluated and reassigned to a different category. ^{Reference Almogy and Rivkind23,Reference Biddinger, Baggish and Harrington27,Reference Broeze, Falder and Rea33,Reference Cha, Kim and Kim36,Reference El Sayed, Chami and Hitti39,Reference Gabbe, Veitch and Curtis40,Reference Hick, Koenig and Barbisch46,Reference Holgersson47,Reference Hsu, Jenckes and Catlett49,Reference Juffermans and Bierens50,Reference Leahy, Yurt and Lazar53,Reference Wild, Maher and Frazee60–Reference Zafar, Jawad and Shamim62,Reference Ganz, Schafer and Yang64,Reference Wachira, Abdalla and Wallis66,Reference Avidan, Hersch and Spira67,Reference Baker82,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Jacobs95,Reference Jacobs and Burns96,Reference Corcoran, Niven and Reese101–Reference Hick, Hanfling and Cantrill103,Reference Aliyu105,Reference Jenkins, McCarthy and Sauer127,Reference Avitzour, Libergal and Assaf128,Reference Zhong, Clark and Hou133,Reference Zoraster, Chidester and Koenig134,Reference Ashkenazi, Olsha and Schecter144,Reference Bond, Subbarao and Kimmel146,Reference Roccaforte and Cushman148,Reference Assa, Landau and Barenboim150,Reference Born, Briggs and Ciraulo151,Reference Lowe154,Reference Christian, Sprung and King160,Reference Adini, Cohen and Glassberg166,Reference Challen and Walter168–Reference Field and Norton174,Reference Gebhart and Pence176–Reference Hirshberg, Frykberg and Mattox189} In such instances, emphasis is placed upon directing scarce resources to those who have the best chance of survival. ^{Reference Almogy and Rivkind23,Reference Albanese, Burich and Smith75,Reference Baker82,Reference Chim, Yew and Song100,Reference Corcoran, Niven and Reese101,Reference Hick, Hanfling and Cantrill103,Reference Aliyu105,Reference Abraham108,Reference Cordner and Ellingham112,Reference Devereaux, Christian and Dichter120,Reference Veenema and Toke125,Reference Biddison, Berkowitz and Courtney131,Reference Born, Briggs and Ciraulo151,Reference Christian, Sprung and King160,Reference Field and Norton174,Reference Hirshberg, Holcomb and Mattox180,Reference Hogan and Brown181,Reference Castle187} When determining appropriate and timely patient distribution, the distance to the nearest facility, type of injuries sustained, special patient needs (eg, pediatrics, burns), and the capabilities of the receiving hospital should be considered, as well as an emphasis of managing families as best as possible. ^{Reference Adini, Bodas and Nilsson21,Reference Almogy and Rivkind23,Reference Biddinger, Baggish and Harrington27,Reference Biddinger, Reisman and Seger29,Reference Bloch, Schwartz and Pinkert30,Reference Broeze, Falder and Rea33,Reference Cha, Kim and Kim36,Reference Crawford, Mackway-Jones and Russell37,Reference El Sayed, Chami and Hitti39,Reference Holgersson47,Reference Leahy, Yurt and Lazar53–Reference Moser, Connelly and Baker55,Reference Wild, Maher and Frazee60,Reference Avidan, Hersch and Spira67,Reference Jenckes, Catlett and Hsu73,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Jacobs95,Reference Brandenburg and Arneson98,Reference Chim, Yew and Song100,Reference Halpern, Tsai and Arnold102,Reference Hick, Hanfling and Cantrill103,Reference Collignon111,Reference Carley, Mackway-Jones and Randic117,Reference Devereaux, Christian and Dichter120,Reference Joho, Lozano and Pagella123,Reference Seifman, Ek and Menezes124,Reference Avitzour, Libergal and Assaf128,Reference Al-Shamsi, Moitinho de Almeida and Nyanchoka132,Reference Zoraster, Chidester and Koenig134,Reference Adini, Aharonson-Daniel and Israeli138,Reference Hendrickx, D’Hoker and Michiels143–Reference Bacis145,Reference Branas, Sing and Perron147,Reference Assa, Landau and Barenboim150,Reference Lowe154,Reference Kearns, Marcozzi and Barry164,Reference Adini, Cohen and Glassberg166,Reference Cryer, Hiatt and Eckstein173,Reference Castle187,Reference Conlon and Martin188,Reference Kanter190} When indicated, mass decontamination procedures are initiated at the scene of injury and repeated or continued at a health facility. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Crawford, Mackway-Jones and Russell37,Reference Albanese, Burich and Smith75,Reference Currie and Heslop77–Reference Allen, Parrillo and Will80,Reference Baker82–Reference Chilcott, Larner and Durrant86,Reference Higgins, Wainright and Lu89,Reference Hood, Fernandes-Flack and Larrañaga90,Reference Abraham108,Reference Collignon111,Reference Ashkenazi, Olsha and Schecter144,Reference Bacis145,Reference Lowe154,Reference Born, Briggs and Ciraulo165,Reference Burgess, Kovalchick and Harter191}

Hospital response must integrate vertical and horizontal response capabilities, tiered surge capacity (conventional, contingency, crisis), maintenance of supply chain, personal protective equipment (PPE) requirements, secondary patient transfers, and the handling of dead bodies. ^{Reference Almogy and Rivkind23,Reference Biddinger, Baggish and Harrington27,Reference Biddinger, Cadigan and Auerbach28,Reference Broeze, Falder and Rea33,Reference Crawford, Mackway-Jones and Russell37,Reference El Sayed, Chami and Hitti39,Reference Gabbe, Veitch and Curtis40,Reference Holgersson47,Reference Little, Cooper and Gope54,Reference Moser, Connelly and Baker55,Reference Albanese, Burich and Smith75,Reference Baker82,Reference Brown, Beatty and O’keefe83,Reference Higgins, Wainright and Lu89,Reference Jacobs and Burns96,Reference Corcoran, Niven and Reese101–Reference Hick, Hanfling and Cantrill103,Reference Aliyu105,Reference Cocco and Thomas-Boaz110–Reference Deelen, Costermans and Moss113,Reference Carley, Mackway-Jones and Randic117,Reference Devereaux, Christian and Dichter120,Reference Zhong, Clark and Hou133,Reference Rebmann, McPhee and Osborne136,Reference Esbitt139–Reference Brunner, Rocha and Chudgar141,Reference Roccaforte and Cushman148,Reference Kearns, Marcozzi and Barry164,Reference Born, Briggs and Ciraulo165,Reference Garner175,Reference Bayram, Zuabi and Subbarao186,Reference Castle187,Reference Caramello, Camerini and Ricceri192–Reference Davis, Poste and Hicks194} In-hospital clinical care can be facilitated by unidirectional patient flow, keeping triage cohorts together, implementing a disaster patient tracking system, pre-positioning pre-stocked medicines and supplies with adjacent quick-reference or action cards, directing skilled staff to pre-allocated areas to provide care, delegating unskilled volunteers to perform menial tasks (transportation of patients, blood, equipment), enacting an early discharge pathway for non-critically ill patients present within the ED and/or hospital, and using a mobile health-based data entry system. ^{Reference Nekoie-Moghadam, Kurland and Moosazadeh13,Reference Almogy and Rivkind23,Reference Einav, Schecter and Matot38,Reference El Sayed, Chami and Hitti39,Reference Hick, Koenig and Barbisch46,Reference Hsu, Jenckes and Catlett49,Reference Juffermans and Bierens50,Reference Knotts, Etengoff and Barber52–Reference O’Neill56,Reference Zafar, Jawad and Shamim62,Reference Wachira, Abdalla and Wallis66,Reference Avidan, Hersch and Spira67,Reference Jenckes, Catlett and Hsu73,Reference Lynn, Gurr and Memon74,Reference Baker82,Reference Liebergall, Braverman and Shapira93,Reference Seaton, Maier and Sachdeva94,Reference Jacobs and Burns96,Reference Halpern, Tsai and Arnold102,Reference Hick, Hanfling and Cantrill103,Reference Abraham108,Reference Cocco and Thomas-Boaz110,Reference Cordner and Ellingham112,Reference Carley, Mackway-Jones and Randic117,Reference Veenema and Toke125,Reference Al-Shamsi, Moitinho de Almeida and Nyanchoka132,Reference Brunner, Rocha and Chudgar141,Reference Born, Briggs and Ciraulo151,Reference Feizolahzadeh, Vaezi and Taheriniya156,Reference Born, Briggs and Ciraulo165,Reference Garner175,Reference Ashkenazi, Kessel and Olsha185,Reference Bayram, Zuabi and Subbarao186,Reference Caramello, Camerini and Ricceri192,Reference Dann, Bonstein and Arbov193,Reference Haverkort, Bouman and Wind195–Reference Soffer, Klausner and Bar-Zohar197} Radiology services, primarily x-ray, and CT scans, are relevant diagnostic modalities in traumatic injuries and guide management decisions, particularly with the assumption that 50% of injured patients will require operative management. ^{Reference Almogy and Rivkind23,Reference Avidan, Hersch and Spira67,Reference Berger, Körner and Bernstein69,Reference Lynn, Gurr and Memon74,Reference Avitzour, Libergal and Assaf128,Reference Ashkenazi, Kessel and Olsha185,Reference Bookman and Zane198} However, radiology has been recognized as a bottleneck for patient care. ^{Reference Bloch, Schwartz and Pinkert30,Reference Kearns, Skarote and Peterson51,Reference Berger, Körner and Bernstein69,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Halpern, Tsai and Arnold102,Reference Veenema and Toke125,Reference Brunner, Rocha and Chudgar141,Reference Bookman and Zane198} Lean strategies are recommended, such as limiting radiologic capabilities to only high priority patients, using bedside ultrasound to facilitate rapid identification of operative pathology, stationing a radiologist with the radiology tech in the patient care area to aid in prompt diagnosis, and facilitating paper-charting or use of a simplified computerized electronic order entry to order a diagnostic study. ^{Reference Almogy and Rivkind23,Reference Bernardo and Veenema26,Reference Bloch, Schwartz and Pinkert30,Reference Brands, Hernandez and Stenberg32,Reference El Sayed, Chami and Hitti39,Reference Hick, Koenig and Barbisch46,Reference Kearns, Skarote and Peterson51,Reference Avidan, Hersch and Spira67,Reference Berger, Körner and Bernstein69,Reference Baker82,Reference Brooke Lerner, O’Connor and Schwartz91,Reference Halpern, Tsai and Arnold102,Reference Hick, Hanfling and Cantrill103,Reference Veenema and Toke125,Reference Biddison, Berkowitz and Courtney131,Reference Brunner, Rocha and Chudgar141,Reference Bookman and Zane198}

Health Finance

Seven of the included articles directly addressed the financing of MCI response. Financial resources, largely determined by the fiscal budget of the city government, determine the extent at which MCI response activities can be operationalized in an effective and timely manner. ^{Reference Adelaine, Shoaf and Harvey20,Reference Biddinger, Baggish and Harrington27,Reference Biddinger, Reisman and Seger29,Reference Gotham, Sottolano and Hennessy44,Reference Golabek-Goldman87,Reference Higgins, Wainright and Lu89,Reference Jacobs and Burns96,Reference Smith, Paturas and Tomassoni104,Reference Seifman, Ek and Menezes124,Reference Janati, Sadeghi-Bazargani and Hasanpoor126,Reference Shartar, Moore and Wood130,Reference Al-Shamsi, Moitinho de Almeida and Nyanchoka132,Reference Born, Briggs and Ciraulo151} Recognizing that there are many competing priorities for municipal funds, local government officials should perform annual hazard analyses to allocate resources corresponding to level of risk. ^{Reference Adelaine, Shoaf and Harvey20,Reference Biddinger, Baggish and Harrington27,Reference Brands, Hernandez and Stenberg32,Reference Gotham, Sottolano and Hennessy44,Reference Moser, Connelly and Baker55,Reference Chim, Yew and Song100,Reference Smith, Paturas and Tomassoni104,Reference Cocco and Thomas-Boaz110,Reference Seifman, Ek and Menezes124,Reference Janati, Sadeghi-Bazargani and Hasanpoor126,Reference Shartar, Moore and Wood130,Reference Al-Shamsi, Moitinho de Almeida and Nyanchoka132,Reference Hendrickx, D’Hoker and Michiels143,Reference Branas, Sing and Perron147,Reference Born, Briggs and Ciraulo165}