Practical guidance for In-Hospital
Preparation on
Operating Room management for
Mass Casualty Incidents

The Olympic and Paralympic Games MCI Committee,
Japanese Society of Anesthesiologists

Contents
Contents

1

Summary2

Preface2

Introduction

3

1. Establish a chain of command and create a plan4

2. In-hospital cooperation and preparation for medical demand surge

5

3. Space7

4. Staﬀ

9

5. Stuﬀ

11

6. Ethical considerations

12

Appendix

14

References

15

1

Summary
To prepare for the Tokyo Olympic and Paralympic Games in the summer of 2020, theJapanese Society of Anesthesiologists (JSA) joined the Academic Consortium on
Emergency Medical Service and Disaster Medical Response Plan during the Tokyo Olympic
and Paralympic Games in 2020, consisted of 27 academic societies, and launched the
Olympic and Paralympic Games MCI Committee to draft this practical guidance forhospitals on preparing for mass casualty incidents. This guidance lists recommendations
from the references published by academic organizations at many countries as well as
proposals from the committee based on the Japanese healthcare environments and social
infrastructure. Key points and checklists are summarized into six sections: 1) Establish achain of command and create a plan, 2) In-hospital cooperation and preparation for
medical demand surge, 3) Space, 4) Staﬀ, 5) Stuﬀ, 6) Ethical considerations, and eachsection includes the suggestion of leaders and persons to be involved by each item. We
created this guidance to help anesthesiologists address mass casualty incidents (MCIs),
focusing on safe and eﬃcient management of operating rooms as well as the entire
hospital.

PrefaceThis is the revised English version of the practical guidance developed by The Olympic andParalympic Games MCI Committee of the Japanese Society of Anesthesiologists.

2

Introduction
Japan has experienced many mass casualty incidents (MCIs) caused by multiple events
including a sarin gas attack on the Tokyo subway system, a train derailment accident on
the JR Fukuchiyama Line, and a mass murder at a facility for the disabled in Sagamihara
and natural disasters occurring at multiple areas. Although the Disaster Medical AssistanceTeam (DMAT), launched in 2005, has achieved some positive results in Japan, our social
infrastructure and medical facilities are not well prepared for MCIs such as acts of terrorism
or riots compared with those in the United States and European countries. To prepare for
the Tokyo Olympic and Paralympic Games originally scheduled in the summer of 2020, theAcademic Consortium on Emergency Medical Service and Disaster Medical Response Plan
during the Tokyo Olympic and Paralympic Games in 2020 (http://2020ac.com/) was
launched in May 2016. The Japanese Society of Anesthesiologists (JSA) joined theconsortium as the 23rd member in October 2018 and organized the Olympic andParalympic Games MCI Committee (the MCI committee). We see the Olympic andParalympic Games as an important opportunity for medical facilities to prepare for MCIs
that may occur as a consequence of any events. Thus, we drafted this guidance to help
anesthesiologists address MCIs, focusing on safe and eﬃcient management of operatingrooms as well as the entire hospital.
This guidance is intended to focus on MCIs, but not intended to address cases where
public utilities or medical facilities are damaged due to large-scale natural disaster. This
guidance lists recommendations referred to the literature and guidelines published byacademic organizations of various countries as well as proposals from the committee
members. The proposals are based on the Japanese healthcare environments and social
infrastructure, which may be somewhat diﬀerent from those in other countries. Eachchapter is composed of “Points to be addressed during MCIs : Recommendations andproposals” and “MCI preparation checklist” so that the guidance can be universally usedeven though the scale, community characteristics, and clinical practices vary by medical
facility. If any position listed in the guidance do not exist in your facility, a person who isequivalent may hold the position and most of the case, anesthesiologists can act as apotential operating room (OR) manager.
Although the Tokyo Olympic and Paralympic Games were postponed until the summer of2021, we believe that this guidance is valuable to prepare MCIs or the infection disastersuch as Coronavirus disease 2019 (COVID-19) pandemics. We hope that this guidance canhelp anesthesiologists contribute to their medical facilities and their local communities.
MCIs are matters not only for major hospitals!

31. Establish a chain of command and create a plan
(1) Points to be addressed during an MCI: Recommendations and Proposals
An operating room (OR) manager and anesthesiologists should be involved in thein-hospital emergency headquarter.
Several sets of surgery teams consisting of various professionals should be formed incase of surge in demand.
Medical staﬃng shall be increased according to the guidelines for OR use during MCIs.
Hospital should closely cooperate with other facilities in the community to address an
MCI, including coordinating the transport of patients and blood products.

(2) MCI preparation checklist
No. Activities during MCI

Preparation for MCI

Leader

Persons involved Completion

Each department
works eﬀectively.

Establish institutional
MCI guidelines.
Conﬁrm and simulate achain of command
based on the guidelines.

Hospitaldirector

Chiefs of clinicaldepartment;
Nursing director;
Hospital
administration
head

Operating rooms
function
systematically andeﬀectively.

Establish andperiodically review theoperating manual for
OR during MCI.
Participate in thein-hospital emergency
headquarter.

OROR
manager management
committee

Cooperate withother facilities in thecommunity.

Create a list of partner
facilities in thecommunity.
Hold meetings withpartner facilities
periodically to discuss
methods and areas forcooperation.

Hospitaldirector

1

2

3

4

Nursing director;
Hospital
administrationhead

2. In-hospital cooperation and preparation for medical demand surge(1) Points to be addressed during an MCI: Recommendations and Proposals
Information on the location and characteristics of an MCI shall be shared with relevant
administrative organizations and neighboring medical facilities.
Manpower should be reserved to perform triage for emergency surgeries.
OR manager shall determine whether to postpone scheduled elective surgeries andsecure ORs and staﬀ to deal with MCI related events.
OR manager shall determine whether it is necessary to isolate patients to prevent
exposures or contaminations with unknown substances.
If needed, OR manager should consider transferring patients to neighboring facilities in
the community appropriately based on the patientsʼ and facilityʼs characteristics.

* Surge capacity means the capacity to implement appropriate medical activities withlimited medical resources when there is a surge in the number of patients.

* Although the principle of disaster medical care is to act based on accurate information,
it is unlikely that accurate information could be obtained during the initial stage of anMCI.

5(2) MCI preparation checklist
No. Activities during MCI

1

2

3

4

Preparation for MCI

Leader

Persons involved Completion

Estimate thedemand for ORs andexecute plans in theoperating manual for
OR during MCI.

Conﬁrm the means toshare information with
relevant administrative
organizations andemergency department(ER).
Develop partnerships
with neighboring
facilities.

ORmanagerORmanagement
committee;
Chiefs of clinicaldepartment

Share information on
the situation at the
MCI site and ER.
Organize the teams
for emergency
surgeries.

Specify how to secure
space, staﬀ, and stuﬀ
according to a scale ofthe facility in theoperating manual for
OR during MCI.
Conduct simulations.

ORmanagerORmanagement
committee;
Chiefs of clinicaldepartment

Perform triage for
emergency
surgeries.

Include plans of triage
for emergency surgeries
into the operating
manual for OR during
MCI.

OR
managerORmanagement
committee;
Chiefs of clinicaldepartment

Secure OR staﬀ andshare information
with them.

Specify the way tosecure manpower andto evaluate patientsʼ
characteristics in theoperating manual for
OR during MCI.
Conduct simulations.

ORmanagerORmanagement
committee;
Chiefs of clinicaldepartment

63. Space(1) Points to be addressed during an MCI: Recommendations and Proposals
ORs shall be secured for emergency surgeries.
The patient ﬂow from entry into the hospital, entry into the OR, exit from the OR andentry into the ward should be unidirectional.
Transport and admission rooms shall be secured for patients undergoing surgeries or
staying in the post-anesthesia care unit (PACU).
The number of available ORs should be reported periodically to the emergency
headquarter.
Use of a part of ORs and PACU as beds for intensive care unit (ICU) shall be considered.

7(2) MCI preparation checklist
No. Activities during MCI

Preparation for MCI

Leader

Persons involved CompletionConﬁrm which ORs
and PACU beds areoccupied.

Create action cards foreach role.
Specify thecommunication
pathway.

ORmanagerORmanagement
committee

Establish
unidirectional
patient ﬂow.

Specify the patient ﬂow
and the transport
procedures, including
designated persons fortransport, in theoperating manual forOR.
Conduct simulations.

ORmanagerORmanagement
committee

Find ward or ICU
beds for patients
undergoing
surgeries or staying
in PACU.

Conﬁrm the availabilityof ward beds.
Designate responsible
persons for patienttransport during MCI in
the operating manualfor OR. Conductsimulations.

ORmanagerORmanagement
committee:
Nursing
department

Conﬁrm the numberof available ORs.

Develop protocol of
periodic report to theemergency headquarter
about the information
on available ORs.

OR
managerORmanagement
committee

5Determine whether
to postpone
scheduled elective
surgeries.

Develop anddisseminate the criteria
to postpone elective
surgeries during MCI.

OR
managerORmanagement
committee

Develop the operatingOR
manual for ORs andmanager
PACU beds to convert to
ICU beds.
Conduct simulations.

ICU physicians;
Nursing
department

6

Conﬁrm ORs and
PACU beds to beconverted to ICU
beds.
Check the availabilityof equipment for theconversion.

1

2

3

4

8

4. Staﬀ(1) Points to be addressed during an MCI: Recommendations and Proposals
The hospital director shall declare an MCI emergency.
Trauma and emergency surgery response teams should be formed.
Each profession or department should establish the means to assemble staﬀ in an
emergency.
ER, ICU, and OR should closely cooperate with each other.
Assign staﬀ to take care of patients who need assistance.
If overstaﬀed, the leaders should send oﬀ some of the members and make them oncall.
Staﬀ should work in shifts to prevent overwork and attention should be paid to enablestaﬀ to rest.
A system should be established to record and share medical records during MCI.

9

(2) MCI preparation checklist
No. Activities during MCI

1

4

7

Persons involved Completion

Develop theinstitutional MCI
guidelines.

Hospitaldirector

Safetycommittee;
Hospital staﬀ

Prepare the means
to assemble staﬀ.

Develop contact lists foreach profession or
department.
Conduct simulations.

Hospitaldirector

Chiefs of clinicaldepartment;
Nursing director;
Hospital
administration
head

Form trauma andemergency surgery
response teams.

Conduct training on
damage control
surgery*.
Create action cards foreach role.

OR
manager

Chiefs of clinicaldepartment;
Nursing
department;
Hospital
administration

Eﬃciently conduct
activities with fullcooperation of the
OR staﬀ.

Specify the chain ofcommand andcommunication
pathway in theoperating manual for
OR during MCIs.

OR
manager

Chiefs of clinicaldepartment;
Nursing
department;
Hospital
administration

Ensure cooperation
with ER and ICU.

Create action cards foreach role.
Specify allocation of
staﬀ in the operating
manual.
Conduct simulations.
Visualize the availabilityof equipment.

ORmanager

Chiefs of clinicaldepartment;
Nursing
department

Assign staﬀ to takecare of patients whoneed assistance.

Develop theinstitutional MCI
guidelines.
Conduct simulations.

Hospitaldirector

Chiefs of clinicaldepartment;
Nursing
department

Clean ORs after
surgeries withmassive bleeding.

Allocate cleaning
personnel.
Simulate cleaning
operations.

Nursing
director

Infection control
department

5

6

LeaderHospital director
declares an MCI
emergency.

23Preparation for MCI* Damage control surgery is one of the treatment strategies of trauma to save lives. It is
performed to achieve primary hemostasis and stabilize hemodynamics before thetrauma triad of death (i.e. metabolic acidosis, coagulopathy, and hypothermia)
develops.
10

5. Stuﬀ(1) Points to be addressed during an MCI: Recommendations and Proposals
Information on type and scale of MCI shall be shared with the emergency headquarter.
The number of available ORs should be conﬁrmed. A suﬃcient number of ORs for
emergency surgeries should be secured.
The number of patients acceptable for the hospital should be estimated based on
available resources including medical supplies, devices, drugs, and blood products
required for damage control surgeries.
When medical supplies, devices, drugs and blood products are not suﬃciently
available, procurement requests shall be made to the emergency headquarter.

(2) MCI preparation checklist
No. Activities during MCI

1

2

3

4

Preparation for MCI

Conﬁrm the numberof available ORs.
Check the availabilityof medical supplies
and devices required
for surgery andanesthesia.

Specify a procedure for
procuring medical
supplies, includingsterilization, in theoperating manual for
OR during MCI.
Conduct simulations.
Pack surgicalequipment for damage
control surgery in kits.

Leader

Persons involved Completion

ORmanagerORmanagement
committeeORmanager

Medical supply
department

Check the availability Conﬁrm the system of Transfusion Transfusionof blood products for blood ordering and the department department;each blood type.
cooperation withmanager
Clinicalneighboring facilities.
laboratory
Conduct simulations.
Prepare ORs for theconversion to ICU
beds.

Simulate allocation ofOR
resources including
manager
medical equipment andpersonnel.

11

ICU physicians6. Ethical considerations(1) Points to be addressed during an MCI: Recommendations and Proposals
If the consent cannot be obtained from the patient and family members, two or more
healthcare professionals shall admit that the treatment is critical to sustain the patientʼs
life.
Hospital staﬀ shall understand the concept of “the greatest good for the greatest
number” in disaster medical care under limited medical resources and pay attention topeople directly aﬀected by the disaster.
Medical records shall be completed without delay after emergency medical care.
In communication of information, ethical aspects including the protection of personal
information shall be considered suﬃciently.
Palliative care for agonal patients as well as mental support for families of victims andagonal patients should be considered.
Attention should be paid to the mental condition of medical staﬀ.

12

(2) MCI preparation checklist
No. Activities during MCI

Preparation for MCI

Leader

Persons involved Completion

Allocate medical
resources
appropriately.

Develop priority criteria OR
for resource allocation
managercomplying with relevantlaws and regulations.

ORmanagement
committee;
External expert

2

Perform triage andpatient isolation
based on clearlyspeciﬁed criteria.

Develop triage criteria
for emergency surgeries
and isolation criteria forpatients.

OR
managerORmanagement
committee;
External expert

3

Consider ethics incommunication of
information.

Specify content, timing,and method for
information release.

Hospitaldirector

Public relations
department

Develop the manual for
obtaining informed
consent.
Conduct simulations.

ORmanager

Safetycommittee

4Obtain informed
consent for surgery,anesthesia, bloodtransfusion, andinvasive procedures.

5

Consider palliative
care for agonal
patients and mental
support for familiesof victims andagonal patients.

Develop the manual for Nursing
palliative care to critical director
patients and mental
support to their families.

Palliative care
team;
Psychiatrist

Provide mental
support to medical
staﬀ.

Develop the standard ofworking conditions
during emergencies.
Establish mental
support system for staﬀ.

Human
resources
manager1

6

13

HospitaldirectorAppendix
Table 1. Key points of related knowledge about MCIs
1

Change thought process into “the greatest happiness of the greatest number”

2Consider the imbalance between the number of people to be treated and thecapacity of medical resources

3

Surging victims to the institution near MCI, “immediately” and “massively”

4

Many surgery-required traumas in extremities, brain, and abdomen

5

Many transfusion-required cases (Tourniquet removal should be conducted in OR)

6

Various kind of disasters (trauma, burn, poisoning, blast and gunshot)

Table 2. 4S to be secured by each institution
1

Stuﬀ (Physical resources)2

Staﬀ (Human Resources)

3

Space

4

SystemTable 3. What anesthesiologists show do to prepare for MCIs
1

Close in-hospital communication

2

Prioritization of surgeries and close cooperation with other departments

3Participation in medical care outside of OR

4

Simulation training beforehand

14

References
1

Guidance for Intensive Care Units (ICUs) to Prepare for and Respond to Disasters, First
Edition (2018). Crisis Management Committee of the Japanese Society of Intensive
Care Medicine (in Japanese)
Available at: http://2020ac.com/documents/ac/04/5/4/2020AC̲
JSICM̲ICU̲20181105.pdf
Accessed: April 29,2020

2

Farmer JC, Wax R, and Baldisseri MR. Preparing your ICU for disaster response. Societyof Critical Care Med. 2012
Available at: https://store.sccm.org/detail.aspx?id=EPREPARE
Accessed: April 29,2020

3

Hick JL, Christian MD, Sprung CL. Chapter 2. Surge capacity and infrastructure
considerations for mass critical care. Intensive Care Med. 2010;36(Suppl1):S11-S20.

4Aylwin CJ, König TC, Brennan NW et al. Reduction in critical mortality in urban masscasualty incidents: analysis of triage, surge, and resource use after the London
bombings on July 7, 2005. Lancet. 2006;368:2219-2225.

5Alﬁci R, Ashkenazi I, and Kessel B. Management of victims in a mass casualty incident
caused by a terrorist bombing: Treatment algorithms for stable, unstable, and in
extremis victims. Military Medicine 2006;171(12):1155-1162.

6

The Centers for Disease Control and Prevention. Blast Injuries: Fact Sheets forProfessionals.
Available at: https://stacks.cdc.gov/view/cdc/21571
Accessed: April 29,2020

7

American College of Emergency Physicians. Bombings: Injury Patterns and Care. Blast
Injuries: Fact Sheets for Professionals by Centers for Disease Control & Prevention.
Available at: https://www.acep.org/blastinjury/#sm00001hlkgl9nydrytc81v5u8a2qz2
Accessed: April 29,2020

8

Special Research Project Supported by the Ministry of Health, Labour andWelfare ‒ Study for Developing Emergency and Disaster Medical Care Systems in
Preparation for the 2020 Tokyo Olympic and Paralympic Games. Clinical PracticeGuidance for Gunshot and Blast Injuries.
Available at: http://2020ac.com/documents/ac/04/2/1/2020AC̲JAST̲gun01̲20180920.pdf
Accessed: April 29,202015

9American Society of Anesthesiologists Committee on Trauma and Emergency
Preparedness (ASA COTEP): OR Mass Casualty Checklist.
Available at: https://www.asahq.org/about-asa/governance-and-committees/
asa-committees/-/media/87b5b2a86ed74e3b8567afe5bb125c7e.ashx
Accessed: April 29,2020

10 Mangunta VR, Patel D. The era of mass casualty events: Perspectives on careparadigms from a critical care anesthesiologist. Missouri Medicine 2019;116(1):49-52.
11 Davidson SL, Dutton RP. Lessons Learned From a Mass Casualty Incident. ASA

Monitor 2018,Vol.82,8-11.
12 Morimura N. In-hospital Medical Response to Mass Casualty Incidents: Lessons

Learned from Guidelines and Experiences Overseas. The Journal of Japan Society for
Clinical Anesthesia, Vol. 39 No.3, 2019. (in Japanese)
13 American Society of Anesthesiologists Committee on Trauma and Emergency

Preparedness operation room procedures for mass casualty.
Available at: https://www.asahq.org/in-the-spotlight/
trauma-and-emergency-preparedness
Accessed: April 29,2020
14 Holcomb JB, del Junco DJ, Fox EE, et al. The prospective, observational, multicenter,major trauma transfusion (PROMMTT) study: comparative eﬀectiveness of atime-varying treatment with competing risks. JAMA Surg 2013;148:127-136.
15 Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red

blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the
PROPPR randomized clinical trial. JAMA 2015; 313:471-482.
16 Giesecke NM. Our role in mass casualty incidents, and an apology. ASA

Monitor2018;82(9),4-5.
17 Kuza C and McIsaac J. Roles of the anesthesiologist during mass casualty event. ASA

Monitor.2017;81(4):14-17.
18 World Medical Association Medical Ethics Manual Third Edition. - Japanese Version(Translated by N. Higuchi et al.). Japan Medical Association, 2016.(in Japanese)
Available at: http://dl.med.or.jp/dl-med/wma/mem/wma̲mem̲all.pdf
Accessed: April 29,2020

16

19 Major Incident Medical Management and Support: The Practical Approach in the

Hospital. Advanced Life Support Group. - Japanese Version. (in Japanese) MIMMSJapan (ed.). Nagai Shoten Co., Ltd. 2009.
20 Murray MJ. Emergency preparedness for and disaster management of casualties fromnatural disasters and chemical, biologic, radiologic, nuclear, and high-yield explosive(CBRNE) events. In: Barash PG, ed. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2013:1535-1549.
21 Gregory J, de Lepinau J, de Buyer A, et al. The impact of the Paris terrorist attacks on

the mental health of resident physicians. BMC Psychiatry 2019;19:79.
22 Mikhail J. The trauma triad of death: hypothermia, acidosis, and coagulopathy. AACN

Clin Issues. 1999 Feb;10(1):85-94.

17