By John Carter

The commonly accepted definition of a mass-fatalities incident is "any incident resulting in more deaths than can be managed with locally available resources." Traditionally, the term has been used to describe high-energy events, such as airline crashes, explosions or acts of terrorism. However, the involvement of hospitals in high-energy events has usually been limited to caring for an increased number of patients resulting from the disaster.

In recent years, this response has been defined as "surge capacity." With funding and guidance provided through the Health Resources and Services Administration and Assistant Secretary for Preparedness and Response, as well as tools developed by the Agency for Healthcare Research and Quality, hospitals have worked to develop plans to care for an unprecedented number of victims from terrorist events and natural disasters. With the passage of the Pandemic and All-Hazards Preparedness Act in 2006, the focus has increasingly turned to the care of pandemic influenza victims.

Hospitals have been challenged to increase their bed capacity, improve communications with local response partners, and address such complex issues as supply management and staff shortages. But how will we deal with the anticipated in-hospital deaths that will occur during a pandemic? The Centers for Disease Control and Prevention (CDC) estimates that in addition to 314,000 to 734,000 hospitalizations, a pandemic could cause 89,000 to 207,000 deaths.

The normal processes for dealing with a hospital death can be both time-consuming and labor-intensive. In addition, from the pronouncement of death to the removal of the body to a funeral home, many of the processes rely on elements that are outside of the hospital’s control. How soon will the physician pronounce death? How much time will the family spend with the deceased? How soon will the transportation to the funeral home arrive? Does the death fall under the jurisdiction of the local forensic authority (medical examiner, coroner, justice of the peace) and require their action?

If hospitals hope to manage the projected number of deaths from a flu pandemic or other mass-fatality scenario in a timely and respectful manner, they must develop streamlined protocols and processes.

Phases of mass-fatality response

The phases of response in a mass fatality incident are recovery, identification, notification and disposition. Following a high-energy event, the recovery and identification phases can be extremely challenging. Recovery is a methodical (and sometimes very slow) process during which remains are located and catalogued. In the identification phase, highly technical processes such as DNA analysis, radiographic and dental comparisons, and other scientific methods are used to positively identify human remains.

Following identification, the family is notified of the findings, and preparations are made for final disposition. Usually the disposition phase is handled in the standard manner by a funeral home or coroner’s office.

For hospitals, the recovery and identification phases are less difficult. Generally, patients are positively identified when admitted to the hospital, and the remains of the deceased are intact in a hospital bed.

The notification and disposition phases, however, will pose a different set of issues for hospitals. While most hospitals have a policy for notifying a family of a loved one’s death, the task is often assigned to chaplaincy or social services. After the family has spent some time with the deceased, the body is prepared and usually released to the funeral home of their choice.

This works well in the case of a single death, but processes will need to be changed if multiple deaths occur.

A fatality management team

Hospitals may need to consider streamlining their procedures to deal with large numbers of deaths. One method could be to create a team of specialists who will be tasked with notification of families and disposition of bodies. The goal of this team will be to reduce the amount of time needed to make the hospital bed available to care for a living patient.

This team could consist of just three people: a Notification Specialist, a Documentation Specialist, and a Preparation Specialist.

The Notification Specialist should have training in family notification. This person may be a member of the hospital’s chaplaincy or social work staff, but would have to be fully informed about the decedent in order to answer family questions. Their duty is to notify the family members of the death and assist them in any way possible. If standard funeral home removal is available, the Notification Specialist would contact the funeral home with instructions.

The Documentation Specialist is tasked with ensuring that all paperwork is completed and that the body is properly tagged for identification. This member of the team is also responsible for managing any relevant records, such as medical records or death certificates.

The Preparation Specialist prepares the body for pickup. Depending on the circumstances of death, this could include removing indwelling medical devices (if allowed by hospital policy) and cleaning the body for presentation to the family. The method used should be guided by hospital policy.

In the event that local funeral home pickup is not available, the Documentation Specialist and Preparation Specialist are also responsible for physically moving the deceased to the hospital morgue or temporary storage location.

Disposition of hospital victims

If funeral home services are overwhelmed with a large number of victims to be removed, hospitals may be responsible for providing temporary refrigerated storage. Unfortunately, morgue capacity in most hospitals will not be adequate for this task. Several solutions are available, including refrigerated trailers or buildings, free-span structures, or temporary centralized morgue facilities.

(Even though a pandemic would be considered a disaster, care must be given to assure that remains are treated with the utmost respect. Stacking bodies on top of each other is never an acceptable process.)

Regardless of the type of storage chosen, this must be done as part of a comprehensive community plan, developed in cooperation with local forensic authorities, emergency management and public health agencies. By working together, these agencies can improve processes, reduce costs and better support the families of the deceased.

About the author

John Carter is the chief executive officer for Emergency Preparedness Consulting, LLC. He was previously the medical services officer/hospital preparedness coordinator for the Iowa Department of Public Health. He is a Certified Emergency Nurse and Paramedic Specialist and served as an emergency department nurse in a Level One trauma center and as an EMS training lieutenant at the Nevada Test Site Fire Department. Carter is a peer reviewer for the Emergency Nurses Association’s journal Disaster Management & Response, is a member of the Emergency Management and Preparedness workgroup and is on the faculty of the National Mass Fatalities Institute. He holds an associate’s degree in nursing, a bachelor’s in criminology and sociology, and a master’s in public administration.