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«Developed in collaboration between the following Los Angeles County partners: Department of Coroner Department of Health Department of Public Health, ...»

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Mass Fatality Incident Management:

Guidance for Hospitals and Other Healthcare


August 2008

Developed in collaboration between the following Los Angeles County partners:

Department of Coroner Department of Health Department of Public Health,

Services, Emergency Medical Office of Health Assessment &

Services Agency Epidemiology, Data Collection

& Analysis Unit

Los Angeles County Mass Fatality Incident Management: Guidance for Hospitals and Other Healthcare Entities




County-Wide Coordination

Key Contacts


Planning Overview

10 Questions to Get Started

Sample Table of Contents

Checklist: MFI Planning


Hospital Mass Fatality Incident (MFI) Management Unit

Job Action Sheet: MFI Unit Leader

Checklist: MFI Management Unit Equipment and Supplies

Card: Decedent Information and Tracking

Form: Fatality Tracking


Decedent Processing: Potential Bottlenecks

Flow Chart: Death at A Hospital

Flow Chart: Pandemic Influenza Death at A Hospital


Fact Sheet: About Death Certificates and Facts About Signing the Death Certificate

Flow Chart: Death Certificate Process

Sample: Form VS-11E Certificate of Death

Fact Sheet: California Electronic Death Registration System (CA-EDRS)

Fact Sheet: Information on the LAC Public Administrator


Fact Sheet: Health Risk from Dead Bodies and Basic Infection Control for Staff Handling Dead Bodies 28 Fact Sheet: Human Remains Storage Myths and Truths

Fact Sheet: Decomposition

Fact Sheet: Recommended Methods of Storage for Hospitals

Checklist: Surge Morgue Equipment and Supplies


Mass Fatality Pandemic Influenza Exercise Sample Pre and Post Test Questions

Web Resources

August 2008 Los Angeles County Mass Fatality Incident Management: Guidance for Hospitals and Other Healthcare Entities


A mass or multi-fatality incident (MFI) results in a surge of deaths above what is normally managed by normal medicolegal systems. In the event of a major disaster within Los Angeles County, it may be several days before the Department of Coroner, County Morgue, or private mortuaries can respond, process and recover decedents. The following guidelines have been developed to aid hospitals and other healthcare entities in their response to an MFI.

While this guidance is intended for use during a county-wide MFI, the principles can be applied anytime a hospital is experiencing a surge of deaths above what is normally managed by the hospital. These principles can also be used by any healthcare entity of any size to manage an MFI. The forms and checklists are designed to be personalized by your facility as needed.

This guidance includes information on preserving and safeguarding decedents, property, and evidence. It will also discuss the processes and issues for decedent identification, next of kin notification, death certificate processing, tracking, storage, and final disposition.

The goal of these guidelines is to enhance the ability of Los Angeles County and its healthcare partners to respond to and manage a surge in the number of decedents as a result of any disaster, including an influenza pandemic. While the importance of religious, cultural and mental health considerations is recognized, it is not addressed here. These guidelines focus on decedent processing for medical and legal reasons.

This guidance was developed in collaboration between the Los Angeles County Department of Coroner, Department of Health Services, Emergency Medical Services Agency (EMS), and Department of Public Health, Office of Health Assessment & Epidemiology, Data Collection & Analysis Unit. This document is available for download at the EMS Web site: http://ems.dhs.lacounty.gov/.

August 2008 Los Angeles County Mass Fatality Incident Management: Guidance for Hospitals and Other Healthcare Entities


The Los Angeles County Department of Public Health registers approximately 57,000 deaths/year.

It is the duty of the Department of Coroner to determine the circumstances, manner and cause of all violent, sudden, or unusual deaths.

A mass or multi fatality incident (MFI) results in a surge of deaths above which is normally managed by a community’s usual medicolegal system.

The Los Angeles County Department of Coroner is the lead agency to manage an MFI, however it is not solely responsible for all aspects of response to an MFI.

Medicolegal systems may continue to experience a “normal” case load as well as the case load from the MFI with the possibility of an increase in accidental deaths (due to therapeutic complications and/or those resulting from the increased use and operation of motor vehicles/heavy equipment), homicidal (due to civil unrest), and/or suicide cases.

The Department of Coroner, Department of Health Services, Department of Public Health, hospitals and other healthcare entities have limited fatality surge space or equipment.

Federal or military assistance in fatality management may not be available to local jurisdictions in widespread incidents such as a pandemic.

Disposition of human remains requires a death certificate.

In all US jurisdictions, a treating or primary care physician is authorized to sign a death certificate provided the patient dies from natural causes and has knowledge of the causes of death.

Human remains do not pose additional health risks to the community.

Those who physically handle remains may be at risk of blood borne or body fluid exposure requiring universal precautions and proper training for handling the dead.

It is more important to ensure accurate and complete death investigations and identification of the dead than it is to quickly end the response.

The time to complete fatality management of a mass fatality event may exceed six months to a year.

Mental health professionals, social service organizations and religious leaders will have to be educated in the mass fatality management process at all levels to ensure the process is understood and can be properly communicated to the general population in their response activities.

August 2008 Los Angeles County Mass Fatality Incident Management: Guidance for Hospitals and Other Healthcare Entities


Mass fatalities may occur as the result of a variety of events, including natural disasters or disease outbreaks, large accidental incidents, or as the result of the intentional use of a chemical, biological, radiological, or explosive agent. Since an MFI is likely to result from a major incident, the Los Angeles County (LAC) Sheriff’s Department has overall responsibility for managing the incident response, and the LAC Office of Emergency Management has overall responsibility for managing recovery.

The Department of Coroner is the lead agency on fatality management during a disaster, and has an established Emergency Response Plan. Included is an MFI Plan that outlines the actions to be taken by the Coroner and its relationships (via the Standardized Emergency Management System and Incident Command System) with the Operational Area (Los Angeles County), local, state and federal law enforcement, fire, hazmat, LAC Department of Public Health Data Collection and Analysis Unit, on such topics as team deployment, equipment, scene assessment, decedent transport, examining and processing, and body storage options. (Note: Federal or military assistance in fatality management may not be available to local jurisdictions in widespread incidents such as a pandemic.) Each disaster scenario presents specific considerations, however all sudden and unexpected deaths as well as traumatic deaths fall under Coroner jurisdiction. A community-wide MFI, especially one due to a disease outbreak or other public health emergency may also fall under the jurisdiction of the Public Health Officer. Hospitals should stay alert for supplemental guidance on identifying the underlying cause of death or other significant conditions contributing to death. This information may be issued from the Department of Coroner or the Department of Public Health.

Hospitals will continue to interact and receive incident updates with Los Angeles County through the LAC Department of Health Services Emergency Medical Services Agency via established systems including the Medical Alert Center, ReddiNet, Hospital Emergency Administrative Radio (HEAR), and with the Department of Public Health through usual channels such as the Acute Communicable Disease Control Hospital Outreach Unit or the Health Alert Network (HAN).

August 2008 Los Angeles County Mass Fatality Incident Management: Guidance for Hospitals and Other Healthcare Entities


Los Angeles County Department of Coroner 24/7: 323-343-0714 Renee GrandPre, Disaster Coordinator, RGrandPre@coroner.lacounty.gov

–  –  –

Los Angeles County Department of Public Health Acute Communicable Disease Control For biological incident reporting, including suspect pandemic influenza Business Hours (Mon-Fri, 8:00am-5:00pm): 213-240-7941 After Hours: 213-974-1234 Data Collection and Analysis Unit 213-240-7785; http://www.lapublichealth.org/dca Vital Records Office: 213-240-7816 (deaths) Los Angeles County Morgue / Decedent Affairs 323-226-7161 Los Angeles County Public Administrator’s Office General: 213-974-0404 Investigation Unit: 213-974-0460 http://ttc.lacounty.gov/Proptax/PA_openning.htm California Electronic Death Registration System (EDRS) Helpdesk 916-552-8123 https://ca.edrs.us (CA-EDRS login page) August 2008 Los Angeles County Mass Fatality Incident Management: Guidance for Hospitals and Other Healthcare Entities


Joint Commission While conducting hospital MFI planning is prudent and should be a part of all emergency management plans and emergency operations plans, it is also a new element in the 2008 Joint Commission Environment of Care Emergency Management Standards, EC.4.18: The organization establishes strategies for managing clinical and support activities during emergencies, specifically EC.4.18.5: The organization plans to manage the following during emergencies: mortuary services.

In 2009, MFI planning will be incorporated in the Emergency Management Chapter and included in Standard EM.02.02.11 which states that as part of its Emergency Operations Plans, the organization prepares for how it will manage patients during emergencies. Specifically in EM., the performance measure states that the Emergency Operations Plan describes the following: How the hospital will manage mortuary services.

Hospital Preparedness Program According to US Department of Health and Human Services Hospital Preparedness Program guidance (Target Measure H4.1), all HPP-funded hospitals will have a finalized written plan for mass fatality management by August 08, 2009. A finalized written plan is one that has received senior management approval. This plan should include at minimum, current information on (a) trained and available personnel; (b) equipment, supplies, facilities, and other material resources; and (c) operational structure and standard operating procedures for disposition of the deceased.

Review Existing Hospital Resources and Plans/Policies/Practices As part of the planning process, identify existing resources and procedures in place for the management of deaths at your facility. This may include your Decedent Affairs or Medical Records departments. Staff may already be familiar with and regularly use common forms such as the LAC Department of Coroner Form 18: Hospital and Nursing Home Facility Report and Form VS-11: Certificate of Death. They may already be trained on using the Electronic Death Registration System (EDRS). Also identify any formal or informal mass fatality or fatality surge plans that you may have. These may include memoranda of understanding (MOUs) with local mortuaries or refrigeration container companies. Many facilities have informal plans on managing a surge of fatalities, and these should be converted to written plans.

Develop a Written Plan The included Hospital MFI Plan checklist (see page 9) can be used to evaluate a current MFI plan or provide guidance in developing an MFI plan. And as always, be sure to train to and exercise the plan.

The fact sheets and flow charts included in this guidance may be helpful when developing the plan and in conducting trainings.

August 2008 Los Angeles County Mass Fatality Incident Management: Guidance for Hospitals and Other Healthcare Entities


“Death does not end human suffering, especially when death is sudden, as the result of a disaster. The death of a loved one leaves an indelible mark on the survivors, and unfortunately, because of the lack of information, the families of the deceased suffer additional harm because of the inadequate way that the bodies of the dead are handled. These secondary injuries are unacceptable, particularly if they are the consequence of direct authorization or action on the part of the authorities or those responsible for humanitarian assistance.” Mirta Roses Periago, Director, Pan American Health Organization

1. What are the decedent management priorities of your organization? What key assumptions are these priorities based upon?

2. Does your organization have a written mass fatality plan in place? If so, who has the authority to activate these plans and/or procedures, and have you trained to the plan?

3. Do you have staff and resources identified that will be dedicated to mass fatality incident management?

4. What are the possible bottlenecks in the decedent processing procedures? Have any solutions been developed and/or implemented to mitigate these issues?

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