On October 1, 2017, during the Route 91 Harvest Music Festival on the Las Vegas Strip, a gunman opened fired from the 32nd floor of a nearby hotel on the crowd of concertgoers. He fired more than 1,100 rounds leaving 59 dead and 527 injured.

Recently, ASPR staff spoke with responding agencies from the Las Vegas shooting to help identify lessons learned that can help other communities, specifically members of the nation’s 476 health care coalitions , prepare for, respond to, and recover from these traumatic, no-notice incidents. Here are some of those lessons:

Lesson One: Prepare for Non-triaged Patients. EMS transported fewer than 20% of the victims from the Las Vegas shooting; most were self-transported or transported to healthcare facilities. Healthcare facilities must be ready to provide triage services at or outside the hospital to quickly identify where patients should be treated, and they should collaborate with EMS and other healthcare facilities throughout the region, as part of a health care coalition, to transfer patients based on acuity and available resources. This is especially important for trauma centers that may receive many “walking wounded” patients and hospitals that do not provide trauma services that may initially receive critically injured patients. EMS and other community partners should consider developing a re-distribution plan to move casualties between hospitals.

Lesson Two: Identify and Conduct Drills Using Personnel Notification Tools. Immediately after hearing about the shooting, many healthcare providers arrived at their respective hospitals to help. Make sure your facility has a plan and a tool or messaging solution in place to rapidly notify staff who should come to the hospital and when, based on the needs of the injured and the need for providing round-the-clock care, potentially for days to come. Be aware that no-notice incidents often overwhelm landline and cellular networks.

Lesson Three: Anticipate Challenges in Intake and Throughput. Immediately following the shooting, one hospital received more than 215 patients. Treating that number of patients with limited staff and resources presents inherent challenges. A disaster plan should address which areas of your facility are appropriate for use as expanded emergency department space; how best to group arriving patients, such as by the type and severity of injuries; moving non-incident patients to other areas of the hospital; modifying surgery schedules; and discharging or transferring non-emergent patients.

Lesson Four: Expand Traditional Healthcare Roles to Address Patient Surge. Healthcare facilities should consider having specialty providers and other personnel assume non-traditional roles to help address patient surge. For example, consider using anesthesiologists to manage secondary triage and using pediatric providers to care for ambulatory victims. Take advantage of EMS providers who may be at your facility and willing to assist. Also, consider dedicating certain personnel—respiratory therapist, pharmacist, hospitalists, and intensivist—to only manage the patients coming in from the incident.

Lesson Five: Coordinate Communications with Area Hospitals. Be Ready to Shelter Patients in Place. Community triage systems may be challenged in the immediate aftermath of a no-notice incident. All healthcare facilities in the area should prepare to treat what you can, coordinate patient transfers with other healthcare facilities, and shelter patients in place. Trauma centers may need to prioritize transfers due to the lack of EMS or trauma center resources. Traffic restrictions and misinformation resulting from the event may delay or prevent the timely transfer of patients.

Lesson Six: Review Your Existing Mass Fatality Plan. Determine if your existing mass fatality plan is adequate for a mortuary surge. Consider other areas of your facility where you can expand your mortuary space. Since the coroner or medical examiner may need to visit multiple hospitals after a mass casualty event, prepare for delays in the identification and notification processes. Remember: A no-notice incident resulting from an active shooting situation is also a crime. Collect evidentiary materials from patients and their clothing as per local standards.

Lesson Seven. Incorporate Family Notification in Planning Efforts. Expect loved ones to show up looking for patients, even if those patients are not being cared for by your facility. Designate a location away from treatment spaces where loved ones can wait and establish a process to provide regular updates even if there is no new information to give. Provide patient status information on a case-by-case basis in a room separate from the waiting location. Ensure social workers, clergy, and case managers are available to provide mental health support.

Lesson Eight. Plan for Intense Media Interest. The media will want access to your hospital, your staff, and patients and their families. Pre-identify a media staging area, away from where patients are entering/exiting the hospital. Have public affairs staff available to help coordinate media interviews utilizing hospital spokespersons. Provide regular updates even if there is nothing new to report. Know the story you want to tell, coordinate with other hospitals and responding organizations, and be consistent in messaging.

“Mass casualty emergencies require a coordinated response involving the entire healthcare community,” said Melissa Harvey, director of ASPR’s Division of National Healthcare Preparedness Programs. Ms. Harvey oversees ASPR’s Hospital Preparedness Program (HPP), the only source of federal funding for health care system readiness.

HPP prepares the health care system to save lives through the development of health care coalitions (groups of health care and response organizations that collaborate to prepare for and respond to medical surge events).

For more information about the lessons learned from the Las Vegas shooting, watch the webinar Healthcare Response to a No-notice Incident: Las Vegas . In addition, ASPR TRACIE has developed resources to help communities and health care coalitions save lives during mass violence incidents.