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EM TopicsDisaster preparedness and hospital incident command

EM · Disaster preparedness and hospital incident command

Disaster preparedness — hospital incident command, surge capacity, MCI triage, decontamination and the PICE classification

Also known as Hospital Incident Command System · HICS · Mass casualty incident preparedness · Surge capacity · SALT triage · START triage · PICE nomenclature · CBRNE preparedness · Crisis standards of care

Disaster preparedness in the emergency department — the systems and planning layer the consultant is accountable for, distinct from the bedside MCI response: the PICE nomenclature that classifies the event, the Hospital Incident Command System (HICS) that commands the response, the surge continuum from conventional to contingency to crisis and the crisis standards of care it invokes, the SALT and START mass-casualty triage tools and the shift to a population standard of care, the decontamination procedure and PPE for the CBRNE event, the specific antidotes with their doses, and the planning of mutual aid, redundant communication and staged evacuation. ACEM-primary, globally tagged.

medium17 referencesUpdated 25 Aug 202620 min readVerification in progress

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ACEMFRCEMABEMFRCPCCCFPEMEBEEM

Red flags

  • The mass casualty incident shifts the standard of care from the individual to the population — the greatest good for the greatest number
  • The incident commander coordinates the response and never treats patients — the commander who treats loses the overview
  • SALT is the proposed national mass-casualty triage guideline (Lerner 2008); START is the older adult-only tool — know both and their difference
  • The contaminated casualty who self-presents through the front door can shut an ED down — lockdown and decontamination precede treatment
  • The first casualties to arrive are usually the least injured walking wounded — the seriously injured arrive later by ambulance
  • Crisis standards of care are invoked only at the crisis end of the surge continuum — the decision is explicit, documented and reversible
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Related topics

  • Team-based care and crisis resource management in the emergency department
  • The Australasian Triage Scale — categories, validity, reliability and the under-triaged patient
  • Patient disposition and safety-netting in the emergency department
  • Medical error and patient safety in the emergency department
  • Breaking bad news and communication in the emergency department — the SPIKES framework
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Your progress

Saved on this device.

Practise this topic10 MCQs with explanations

Target exams

ACEMFRCEMABEMFRCPCCCFPEMEBEEM

Red flags

  • The mass casualty incident shifts the standard of care from the individual to the population — the greatest good for the greatest number
  • The incident commander coordinates the response and never treats patients — the commander who treats loses the overview
  • SALT is the proposed national mass-casualty triage guideline (Lerner 2008); START is the older adult-only tool — know both and their difference
  • The contaminated casualty who self-presents through the front door can shut an ED down — lockdown and decontamination precede treatment
  • The first casualties to arrive are usually the least injured walking wounded — the seriously injured arrive later by ambulance
  • Crisis standards of care are invoked only at the crisis end of the surge continuum — the decision is explicit, documented and reversible
The one-line answer

Disaster preparedness is the systems layer the consultant is accountable for — the PICE nomenclature that classifies the event (not the casualties), the Hospital Incident Command System that commands the response (the commander coordinates and never treats), the surge continuum from conventional to contingency to crisis with the crisis standards of care it invokes, and the SALT triage tool that sorts casualties under a population standard of care — the greatest good for the greatest number. The three examiner traps are the commander who treats, the contaminated self-presenter who walks through the front door, and the assumption that the first casualties to arrive are the most seriously injured.[1][4]

Meet the patient — or rather, meet the scenario

It is 08:00 on a Tuesday. Ambulance control notifies you that a coach has rolled twelve kilometres away, with an estimated thirty casualties including children. Your ED has twelve treatment bays, is at 80 per cent occupancy, and both resuscitation bays are occupied. You are the consultant in charge. No casualties have arrived yet.[4]

The two questions that decide the next hour are the two that decide every disaster response: is the system ready before the first casualty arrives? (command, surge, triage, lockdown) and who makes the population-standard decisions? (the Incident Commander, not the bedside clinician). Everything below hangs on those two questions.[1]

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References17ShowHide
  1. [1]Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature--a functional impact approach: the PICE system Acad Emerg Med, 1996.PMID 8816190
  2. [2]Lerner EB, Schwartz RB, Coule PL, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline Disaster Med Public Health Prep, 2008.PMID 18769263
  3. [3]Cone DC, Serra J, Burns K, et al. Pilot test of the SALT mass casualty triage system Prehosp Emerg Care, 2009.PMID 19731169
  4. [4]Christian MD, Devereaux AV, Dichter JR, et al. Introduction and executive summary: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement Chest, 2014.PMID 25144202
  5. [5]Hick JL, Hanfling D, Cantrill SV Allocating scarce resources in disasters: emergency department principles Ann Emerg Med, 2012.PMID 21855170
  6. [6]Dichter JR, Devereaux AV, Sprung CL, et al. Mass Critical Care Surge Response During COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings From the Task Force for Mass Critical Care Chest, 2022.PMID 34499878
  7. [7]Dichter JR, Brown D, Zamorano C, et al. The Minnesota Critical Care Working Group 1: Monitoring and Coordinating Statewide Critical Care Surge Response in the COVID-19 Pandemic, March 2020 Through July 1, 2021 Chest, 2025.PMID 39622470
  8. [8]Jovan JD, Foggle J Implementation of the Hospital Incident Command System in response to the COVID-19 pandemic in the United States: A systematic review J Emerg Manag, 2024.PMID 39545433
  9. [9]Alshaikh E, et al. Pediatric Decontamination Considerations in CBRN Events: A Scoping Review Disaster Med Public Health Prep, 2025.PMID 41321230
  10. [10]Schaffer DH, Hayoun MA Nerve Agents StatPearls [Internet], 2025.PMID 29630210
  11. [11]Streckbein S, Kohlmann T, Luxen J, et al. [Triage protocols for mass casualty incidents : An overview 30 years after START]. Unfallchirurg, 2016.PMID 25648872
  12. [12]Malek A, et al. Effectiveness of Chemical, Biological, Radiological, Nuclear, Explosive (CBRNE) Event-Response Training in a Hospital Setting: A Scoping Review Disaster Med Public Health Prep, 2025.PMID 41431954
  13. [13]Shaltout AE, et al. Accuracy and Timeliness of Prehospital Global Triage System Protocols in Mass Disasters: A Systematic Review of Systematic Reviews Cureus, 2025.PMID 41127758
  14. [14]Rotenberg JS, Newmark J. Nerve agent attacks on children: diagnosis and management Pediatrics, 2003.PMID 12949297
  15. [15]O'Brien DJ, Walsh DW, Terriff CM, et al. Empiric management of cyanide toxicity associated with smoke inhalation Prehosp Disaster Med, 2011.PMID 22336184
  16. [16]Lawson-Smith P, Jansen EC, Hyldegaard O. Cyanide intoxication as part of smoke inhalation--a review on diagnosis and treatment from the emergency perspective Scand J Trauma Resusc Emerg Med, 2011.PMID 21371322
  17. [17]Thiermann H, Worek F, Kehe K. Limitations and challenges in treatment of acute chemical warfare agent poisoning Chem Biol Interact, 2013.PMID 24091052

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Related topics

  • Team-based care and crisis resource management in the emergency department
  • The Australasian Triage Scale — categories, validity, reliability and the under-triaged patient
  • Patient disposition and safety-netting in the emergency department
  • Medical error and patient safety in the emergency department
  • Breaking bad news and communication in the emergency department — the SPIKES framework