The Handling of Mass Fatalities During Medical Surges

Emergency managers focus much of their planning efforts on the needs of their communities in times of crisis. These efforts are designed both to ensure continuity of services and to secure the resources necessary for healing their communities from the devastation incurred both during and after the event. Although death is always a difficult subject to address, emergency managers must nonetheless plan for the particularly complicated impact on community resources caused by mass-fatality incidents.

In addition to the medical needs of those seeking health care, hospitals and other acute care providers have the added responsibility of addressing the hospital-based management of mass-fatality situations. However, to effectively address medical surge needs during a mass-casualty scenario, community, public health, and healthcare emergency planners must fully discuss, in advance, fatality management in general and, in particular, the decedent flow process. How the remains of the deceased are handled is not only a major crisis-management issue but also, particularly if mishandled, a substantial social and cultural concern.

The emergency-planning process for mass-fatality incidents must address not only the handling and processing of deceased victims, but also the special needs and personal feelings of the bereaved families. Public information that needs to be disseminated should include such topics as the handling of fatalities, the mandate of dignity for decedents, and protection of the overall health of the community. The lack of an efficient public-information process may very quickly lead to public distrust – along with a perception that government may be interfering with the legal and/or civil rights of the bereaved.

Mass-fatality incidents can often change the normal flow of decedent management and mortuary services – which in some communities, and/or in certain situations, may be rather limited. There also may be difficulty in securing death certificates, which are almost always required prior to releasing the remains of the deceased. To stem the spread of disease during a pandemic or other major public-health emergency, there also may be a need for social distancing, including the imposition of limits on social gatherings – specifically including funerals.

Relevant Questions, Legal Requirements, and Business Continuity Developing the strategies needed to address catastrophic events and lessen the impact of medical surge on healthcare systems is perhaps the most essential aspect of that process. One of the first steps in planning for mass-fatality management is for healthcare facilities toentify their own roles in the process. It is particularly important to understand the planning currently in place to address emergency operations, both within hospital facilities and within the community at large.

There are a number of relevant questions, including the following, that should and must be asked to help healthcare professionals and emergency planners develop an effectively integrated mass-fatality management strategy:

1. Have the hospitals within the regional healthcare system formed the mass-fatality management teams likely to be needed?

2. Does the community emergency operations planentify the mass-fatality management strategies likely to be employed?

3. How will and should hospitals and other healthcare facilities interact with local public health and medical examiner/coroner (ME) systems?

4. What are the relevant laws, rules, and regulations addressing decedent management within the jurisdiction?

Healthcare systems managers and planners must also be aware not only of the legal requirements mandated by state and local governments but also the standards published by such other entities as the U.S. Centers for Disease Control and Prevention, the Joint Commission on Accreditation of Hospital Organizations, the Occupational Safety and Health Administration, and the Health Resources and Services Administration.

In general, mass-fatality incidents fall into one of two categories: (a) an acute localized incident; or (b) a prolonged regional event such as a pandemic. Activation of a healthcare facility’s mass-fatality management strategy may be necessary when there is a medical surge caused by either of these two categories.

In many ways, the management of mass fatalities is also a business-continuity issue for healthcare facilities. Under normal circumstances, most of the nation’s healthcare systems can perform the mass-fatality management functions needed with little or no interruption of normal everyday operations. However, during a large-scale disease outbreak or mass-casualty incident, fatalities can and often do exceed a hospital’s normal operational capabilities, thus putting excessive demand not only on the medical staff but also on the physical resources needed to adequately manage decedent flow.

The Typical Process – And Many Exceptions to the Norm Healthcare systems tend to focus most of their attention, and resources, on the sick and injured – an understandable order of priorities that can often leave healthcare facilities with very limited personnel or resources assigned to morgue services. However, during large-scale mass-fatality events, in addition to providing medical care for the living, hospitals are also responsible forentifying, storing on-site, and properly – and very respectfully – disposing of decedent remains.

It is reasonable to assume that in such events a large number of fatalities will remain at the point of the incident and will not be transferred to a hospital. In fact, as many as 50 to 75 percent of the decedents from a mass-casualty event, depending on the scenario, will probably not be directly, or quickly, transported to hospitals or other healthcare facilities. The majority of these fatalities will be taken from the incident scene directly to the ME’s office for forensic triage and investigation.

However, in a prolonged regional event such as a pandemic, hospitals are more likely to experience both a surge and subsequent in-hospital fatalities for a period ranging from a few weeks to several months. Moreover, because a large geographic jurisdiction will usually be affected by a pandemic, MEs will require additional time to process the incoming remains. MEs working with public health officials will also be required to create a case definition, which is a critical component to the management of decedent flow. After a case definition has been established, MEs will be able to advise healthcare facilities as to which cases require transfer to the ME and which can be released directly to mortuary services.

Additional Complications, Circumstances, and Considerations Another complication to keep in mind is that, when most of the deaths caused by a specific incident occur outside a medical treatment facility, the ME’s resources can become overloaded very quickly. When that happens, hospitals can expect to hold decedent remains for up to several days as MEs and public health officials work together to determine the case definition and investigatory requirements. It also is likely that, during a prolonged event: (a) the number of fatalities needing storage will quickly exceed existing regional capabilities; and (b) limited refrigerated storage may create a need for nontraditional methods of temporary storage.

Mass-fatality management involves a substantial number of technical, legal, and cultural issues in managing morgue services and decedent flow. Community emergency managers and healthcare systems must therefore work together, in advance, to address, at a minimum, several critical planning considerations: (a) integrating public information systems; (b)entifying potential locations for community-based portable and/or temporary morgues; (c) packaging and storing the personal effects of a large number of decedents; (d) processing and issuing death certificates; (e) notifying the next of kin; and (f) managing family relations by providing accurate and detailed information (as quickly as possible, often under very difficult circumstances) as well as referrals to community-based family service systems.

It is clear that planning for a mass-fatality incident involves a number of highly regulated and technical processes. A hospital’s primary function is, and will always be, to care for the sick and injured. However, healthcare-based mass-fatality management should supplement community-based emergency planning for mass-fatality incidents. All emergency-operations efforts involving mass fatalities therefore should be based on the reasonable assumption that the disposition of remains must be carried out in an expeditious but always respectful manner. In addition, healthcare and other relevant policies and plans must be reviewed, updated if and when needed, or created anew to ensure that the needs of the bereaved, and of the community as a whole, are properly considered. Planning should not occur in a vacuum.