MCI: Not a matter of if, but when

July 30, 2022

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When trauma centers consider mass casualty incident (MCI) preparation, they may imagine the classic scenario: a school bus crash. However, depending on the facility, an MCI could be a two-car crash, says Jay M. Johnson, Ed.D., C.E.M., manager of Emergency Management at Mayo Clinic in Rochester, Minnesota.

Regardless of scenario, planning is crucial to optimize operations in case an MCI occurs nearby.

Johnson indicates that the first step in MCI preparation is acceptance that an MCI can happen in your area and overwhelm your facility.

He says the following are crucial MCI preparation elements, especially for smaller centers with fewer resources.

Know what your facility can handle

Johnson underscores that even MCI's meaning can be nebulous, as it's so dependent on a facility's size and resources.

"It's all about the right patient receiving the right treatment in the right location," says Johnson, who has served on the Southern Minnesota Regional Trauma Advisory Committee education committee. "An MCI is any time the number of patients your facility receives exceeds capability to manage them. As soon as you have one more patient than you can handle, it's a mass casualty."

For critical access hospitals, MCI's definition may mean two patients, or for a large facility, 10 patients.

Another aspect of your facility's capability assessment involves status of patients involved: minor, moderate or severe injuries. For smaller facilities, 10 minor injuries or five moderate and two critical injuries could exceed capacity. Other centers may be able to manage only green injuries with minimal treatment needs per the sort, assess, lifesaving interventions, treatment/transport (SALT) MCI triage.

Johnson encourages the provider team to determine what patient volume and injury complexity surpasses the facility's capacity. He also suggests that MCI planning include calling on your coalition or health system and advising them you are stressed, may need load-shifting and cannot accept transfers.

Johnson feels understanding one's capabilities is crucial to optimal MCI management.

Establish communication pathways internally and to collaborating facilities

As mentioned, Johnson strongly believes in avoiding a Lone Ranger approach in an MCI plan — that collaborating with other area facilities is key. Correspondingly, he advocates putting aside interfacility competition for an MCI, which is all about the patients and getting them needed care.

Johnson says hospitals should expect cellphone problems in an MCI, due to high numbers of individuals communicating about the incident. He suggests exploring multiple potential communication pathways.

"It's easy to overflow a cell system," he says. "Texting is more dependable than voice over cellular networks. It's also hard to beat proximity — face-to-face — communication."

He recommends that staff members who are involved in an MCI have radios and practice changing channels. Landlines provide another communication option.

"If all these don't work, call in the ham radio folks," he suggests.

Johnson also recommends requesting help from nearby facilities to communicate about the MCI.

Determine space, triage and staffing

An MCI prompts the question of where to house patients and their loved ones. No prescribed answer exists, however. Johnson explains it depends on whether available space in your facility can accommodate the people involved. He suggests overflow space planning — including an alternate treatment venue — along with your county emergency management and EMS provider. This may include spaces such as your hospital's cafeteria or a local high school.

At Mayo Clinic, emergency management staff plan for 10 visitors per patient, though distance from home may limit that number.

EMS will initiate triage for patients arriving in its vehicles. Johnson cautions that patients also arrive in privately owned vehicles, requiring triage plans for their arrival. The plan must include patient flow: how to move patients through the facility and to definitive care.

In MCI preparation, a corresponding question to space is staffing, with additional patients requiring care.

Trauma centers often call in ICU staff for help in an MCI, but Johnson cautions this could strain ICUs, a burden MCI planners need to consider.

"You want to leverage resources at your disposal, but not put your other operations in jeopardy," says Johnson.

Johnson suggests an MCI drill can help determine best spaces, triage and staffing, allowing participants the opportunity to work through issues.

Establish behavioral support plans

As MCIs can be a stressful time for patients, families and providers, Johnson recommends behavioral support in the MCI plan, such as professionals available for affected patients and family, and staff respite.

"We need to look out for staff, ensuring they have support in an MCI," he says. "Breaks are crucial. They also need opportunities to discuss what they've experienced in any traumatic event."

He cautions that in smaller communities, relationships between staff and local residents typically are tighter and staff members are more likely to know MCI-affected patients. While this relationship can be a support system, it can also add stress for staff.

Form a plan and drill

Johnson considers taking time for MCI plan formulation crucial. He suggests developing scenarios for a couple of years, especially simple scenarios likely to happen locally, and planning multiple drills.

"No matter the resources in your facility, drills are necessary," he says. "The smaller the facility, the more crucial the practice. If you think you don't have time for it, it's even more necessary. If you haven't drilled it, you don't have a plan."

He explains that drilling your MCI plan — which he suggests not overcomplicating — allows you to know where your strengths and weaknesses lie, noting every facility has opportunities. Johnson also comments that the greatest strength for a small facility is adaptability, a crucial MCI navigation skill.

The Joint Commission requires all hospitals to hold two institutional exercises yearly, with one having a patient surge component and one including community response partners, per the Comprehensive Accreditation Manual for Hospitals. Johnson suggests one tabletop or functional exercise and one full-scale exercise.

After drilling your MCI plan and fixing weaknesses discovered, Johnson recommends plan revision and testing new elements in another drill.

For more information

SALT Mass Casualty Triage On-Line Training Program. National Disaster Life Support Foundation.

The Joint Commission. Comprehensive Accreditation Manual for Hospitals. The Joint Commission; 2021.

Refer a patient to Mayo Clinic.