International Journal of Clinical Medicine, 2013, 4, 525-531
Published Online December 2013 (
Open Access IJCM
Assessing Healthcare Facilities Preparedness for Mass
Fatalities Incident
Marisol Peña-Orellana1,2, Ralph Rivera-Gutiérrez1,2, Juan A. Gónzalez-Sánchez3, Nilsa Padilla-Elías1,
Heriberto Marín Centen o1,2, Héctor Alonso-Serra1, Liza Millán-Pérez1, Patricia Monserrate-Vázquez1
1Center for Public Health Preparedness, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico, San
Juan, Puerto Rico; 2Department of Health Services Administration, Graduate School of Public Health, Medical Sciences Campus,
University of Puerto Rico, San Juan, Puerto Rico; 3Department of Emergency Medicine, School of Medicine, Medical Sciences
Campus, University of Puerto Rico, San Juan, Puerto Rico.
Received September 19th, 2013; revised October 17th, 2013; accepted November 15th, 2013
Copyright © 2013 Marisol Peña-Orellana et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Any healthcare facility must be prepared to handle a dramatic increase in deaths that can be produced by
a catastrophic disaster. A mass fatality incident (MFI) will significantly increase the usual number of deaths that hospi-
tals or forensic science services can manage on a daily basis. A survey was conducted to assess the hospital emergency
department level of preparedness to deal with an MFI. Objective: To examine healthcare facilities lev el of preparedness
for an MFI and morgue capacity. Methods: A total of 39 ou t of a sample of 44 hospitals participated in the study. Seven
questionnaires were administered to explore: hospital general characteristics; emergency plans; equipment and infra-
structure; collaborative agreements; personnel trainings; emergency communications; laboratory facilities; treatment
protocols; security; and, ep idemiolo gic surv eillance. Results: Three-fourths (79.5%) of the health care facilities reported
having a morgue, their average storage capacity was of three bodies. More than two-thirds (66.7%) of the institutions
stated that they could not increase their morgue’s capacity. Most installations without a morgue do not possess an
agreement with any other institution for the management of bodies. Hospitals have a very limited number of body bags
utilized for the handling an d transport of bodies. Conclusion: Most of healthcare facilities have morgues, but there are
limitations with the current capacity and the lack of resources to increase their capacity in case of a disaster. Manage-
ment of an MFI must be part of every hospital’s emergency plan, and must include collaborative agreements with fo-
rensic authorities, emergency management and pub lic health agencies, and the community.
Keywords: Hospitals; Morgues; Mass Casualties; Mass Fatalities; Puerto Rico
1. Introduction
Disaster events, caused by natural hazards or manmade,
can occur anywhere in the world at any time. Emergen-
cies are not entirely predictable, but when these occur
they can cause an immediate demand for public health
resources and health care services [1-3]. The capabilities
of the affected coun try can be compromised to the maxi-
mum exposing deficiencies at various levels of the disas-
ter mitigation process. Most local governments are not
adequately equipped to support preventive measures be-
fore the disaster’s occurrence. In addition, government
agencies have limited capacities to respond to disasters,
basically due to budget constraints, and are often unable
to provide the locations needed for temporary or perma-
nent relocation sites for those whose homes and settle-
ments were destroyed or severely damaged or to store
large numbers of corpses [4-6]. Recent major disasters
have yielded important evidence regarding how the num-
ber of mass casualties and fatalities can overwhelm the
capacity of a country’s public health and healthcare sys-
tem to effectively respond to the emergency [7-10]. One
of the most difficult aspects of a catastrophic disaster is
related to the management of a large number of dead
bodies, due to the processes involved in the recovery,
identification, and disposal, as well as the effectiveness
of disaster preparedness plans and communication be-
tween respective agencies and the affected population
[11]. Morgan and colleagues [12] conducted a descrip-
tive study to document how the dead were managed in
Assessing Healthcare Fa cilitie s Prepa r e dne ss for Ma ss Fa talities Incident
Thailand, Indonesia and Sri Lanka, after the 2004 Indian
Ocean Tsunami, which resulted in the death of 165,000
people. The researchers used participant observations
from post-tsunami response teams, conducted semi-
structured interviews, and collected information from
published and unpublished documents. Results from this
study showed issues such as: the absence of refrigeration
for preserving human remains soon after the d isaster; the
need to use other refrigeration methods, such as dry ice
and the challenges this brought given that it did not pro-
vide enough cooling to stop decomposition; insufficient
forensic personnel for identification; variability among
the countries in dealing with corpses; rapid decomposition
of corpses; and a lack of a national mass fatality plan.
In a research study conducted by Sahelangi and Novita
[13], several challenges with dead bodies after the Indo-
nesian tsunami in 2004 were reported. These findings
revealed that forensic equipment was limited, and there
was a lack of or non-existing body bags to store corpses.
Moreover, refrigeration for preserving bodies was not
available, thus victims were wrapped using their own
clothes, and there was a need to quickly identify the
bodies due to religious beliefs.
During Hurricane Katrina, more than 1300 deaths
were reported [14]. In a report describing the situations
faced by a community hospital in the Mississippi Gulf
Coast during the hurricane, Babar and colleagues [15]
pointed out that the hospital suffered significant damage
in the surrounding area. Although the hospital had an
effective emergency plan, it faced serious and unforeseen
challenges at the time of the event. This particular disas-
ter highlighted several challenges, such as the shortage of
personnel to provide services, the inability of rescue
personnel to enter the area, the lack of internal and ex-
ternal communication, the lack of appropriate supplies
and fuel reserves, and the dramatic reduction of resources
in the emergency room, and although, the hospital had
power generators, these could not supply the energy de-
mand that was needed. To further complicate the situa-
tion, the hospital did not have enough space for the stor-
age of dead bodies. Right after the hurricane, the hospital
experienced a sudden increase in the number of dead
bodies that were brought in by relatives. This, in turn,
caused the hospital to exceed the morgue’s capacity,
which led to the borrowing of a refrigeratio n truck from a
local company to supply the storage for the dead bodies
arriving at the hospital. The 2010 Haiti earthqu ake led to
222,750 deaths and over 300,000 injuries. Approxi mately
1.5 million people were left homeless, and more than 3
million persons were affected. The earthquake left a de-
vastated city, a collapsed hospital, and a recovery process
with a cost of more than $4 billion [16,17].
Disasters such as the Great East-Japan earthquake and
tsunami caused almost 16,131 deaths [18], and seriously
affected a nuclear power plant, which added an addi-
tional threat to the disaster [19]. This disaster is consid-
ered to have had one of the worst impacts on the medical
system. It destroyed hospitals and clinics in the coastal
area leaving the public health system severely damaged
and functioning inadequately in the affected areas [18,
19]. In addition to the deaths and missing people in Japan,
the tsunami had an impact all over the Pacific Ocean
causing additional deaths in Indonesia and California
[20]. Although the death toll was lower than in other dis-
asters in other areas, unnecessary death and casualties
must be prevented through early interventions in evacua-
tion on primary healthcare centers, rapid search and res-
cue, and collaborative agreements between agencies.
When a healthcare facility suffers the impact of major
disasters, to the extent where extensive damage is gener-
ated, it cannot continue to offer services and sign ificantly
increase the number of mass casualties and fatalities that
hospitals can manage on a regular basis. Attempts to un-
derstand hospital preparedn ess for mass fatalities are nec-
essary in order to design contextually culturally and ap-
propriate interventions, prevention efforts and plans that
address the possible challenges that hospitals might face.
The present study also provided an opportunity to en-
hance our understanding of the hospitals’ preparedness
for mass fatality.
2. Methods
2.1. Sample and Procedures
This study used data from a descriptive survey of hospi-
tal emergency rooms in 2011, to assess their level of
preparedness and response to an event or disaster that
produces mass casualties. The selection of the hospital
emergency rooms that participated in the study were ob-
tained from a list of hospitals provided by the Puerto
Rico Department of Health Office of Public Health Pre-
paredness and Response (OPHPR). The list consisted of
49 hospitals grouped into six coalitions.
These coalitions emerged as an initiative to create col-
laborative arrangements between healthcare facilities in
Puerto Rico and the OPHPR to improve disaster prepar-
edness. The coalition groups were clustered by regional
location as follows: North, South, East, West and Metro,
which was divided into Metro A and Metro B. Although
49 hospitals constituted the coalition’s first phase, only
44 of these institutions had emergency departments. The
distribution of the facilities was: forty-one (41) hospitals
and, three (3) community health centers, such as Diag-
nostic and Treatment Center (DTC) or Family Health
Centers, Primary Health Centers or Federally Qualified
Health Centers (FQHC’s) (330). All these healthcare
facilities were located in 23 municipalities throughout
Puerto Rico. A total of 39 hospital facilities agreed to
participate in the study, yielding a response rate of
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Assessing Healthcare Fa cilitie s Prepa r e dne ss for Ma ss Fa talities Incident 527
Given the complex managerial structure of healthcare
facilities, it was determined that several hospital person-
nel would be interviewed, given that it was deemed
highly unlikely that a single staff p erson within the insti-
tution would know all the information required and be
able to respond to all questions. Therefore, the staff per-
sons contacted to answer the questionnaires were: the
hospital administrator; hospital medical director; emer-
gency department director; the Emergency Plan Com-
mittee chairperson; the Human Resources Department
director; the laboratory director; the epidemiologist or
nurse-epidemiologist; the security officer; and the engi-
A computerized interview modality (computer assisted
personal interview, CAPI) was used for data gathering
[21]. Trained interviewers conducted the computerized
personal interviews. Seven (7) electronic instruments,
using CAPI, were constructed considering ten (10) di-
mensions identified through the scientific literature.
These dimensions were: 1) general hospital characteris-
tics; 2) emergency plans; 3) collaborative agreements
between agencies; 4) infrastructure and equipment; 5)
epidemiologic surveillance; 6) protocols for medical
treatment; 7) laboratory; 8) personnel training; 9) com-
munications; and, 10) hospital security. This study was
reviewed and approved by the University of Puerto Rico
Medical Sciences Campus Institutional Review Board.
2.2. Measures
In order to obtain the required information, several ques-
tions were asked regarding the morgue’s capacity, quan-
tity of body bags available, and the existence of collabo-
rative agreements for the handling of bodies in the
healthcare facility. The questions included were the fol-
1) Does this healthcare facility have a morgue?
2) What is the storage capacity of the morgue?
3) Can this healthcare facility increase its morgue’s
capacity? If so, by how much?
4) Does this healthcare facility have body bags to man-
age a large number of corpses produced by a mass fatal-
ity event? If so, how many bags?
5) What type of agreements does this healthcare facil-
ity have with other mortuary services in case of a mass
fatality event?
6) How does the healthcare facility deal with mass
mortality event in their emergency plan?
7) Describe any limitation that this healthcare facility
may have to deal with during a mass casualty or fatality
2.3. Statistical Analysis
All data management and statistical analyses were per-
formed using the Statistical Analysis System [22]. Fre-
quencies and univariate analyses were carried out to de-
scribe the overall characteristics of the sample popula-
3. Results
Findings of the study showed limitations in terms of the
availability of space and storage capacity of the health-
care facilities’ morgues. Regarding the mortuary area
(Figure 1) more than three-fourths, constituting 79.5% (n
= 31) of the healthcare facilities, reported having a
morgue, whil e 20 .5 % (n = 8) rep ort ed not having one.
Additional questions about the characteristics of the
morgues were also asked of the healthcare facilities that
stated that they had a morgue (Table 1). Related to the
storage capacity of the morgue among healthcare facili-
ties, almost three-fourths (74.2%, n = 23) informed that
its morgue can only store three to four corpses in the
morgue, while 25.8% (n = 8) had the capacity for five or
mor e corp ses. Th e maximu m aver age current cap acity of
the morgues among healthcare facilities was three to four
corpses, with a range varying from one to twenty cadav-
ers. About the capacity to increase the healthcare facil-
ity’s morgue, more than two-thirds (66.7%, n = 18) of the
healthcare facilities indicated the lack of resources to
increase their capacity. Only nine (33.3%) can increase
the capacity from four to seven additional corpses. All
participants indicated that although their morgue’s ca-
pacity was limited, they did not need additional space,
because external mortuary services were used to collect
the corpses. Results related to the current availability of
body bags to manage a large number of corpses produced
by a mass fatality event in the healthcare facility show ed
that sixteen (16) facilities (57.1%) indicated they had no
body bags at all, while 12 facilities (42.9%) indicated to
have body bags. Of those that reported having body bags,
only nine healthcare facilities indicated the number of
available body bags. The average number of bags was 45,
and these ranged from a minimum of one bag to a maxi-
mum of 90 bags.
With morgue
(n=31, 79.5%)
(n=8, 20.5%)
W ith mor g ueW ith out mor g ue
Figure 1. Distribution of participant healthcare facilities
with a morgue.
Open Access IJCM
Assessing Healthcare Fa cilitie s Prepa r e dne ss for Ma ss Fa talities Incident
Table 1. Characteristics of healthcare facilities’ morgues.
Characteristics of morgues n %
Morgue capacity
1 to 4 corpses (23) 74.2
5 corpses or more (8) 25.8
Capacity to increase morgue space*
No (18) 66.7
Yes (9) 33.3
Availability of body bags
No (16) 57.1
Yes (12) 42.9
*Four healthcare facilities could not specify their capacity to increase their
morgue. Only 28 healthcare facilities answered this q u estion.
Questions about the type of agreements with other
mortuary services for the disposal of bodies in case of a
disaster were asked to healthcare facilities without mor-
gues (Table 2). More than half (n = 5) of the healthcare
facilities without morgues reported th ey did not have any
agreement with mortuary services for the disposal of
bodies in case of a disaster, while one facility reported to
have a verbal agreement, and two reported to have a
written agreement to address this need. Although this
question was not examined among the healthcare facili-
ties that reported having a morgue, all indicated the lack
of an agreement with mortuary services in order to
transport corpse s in case of a major di saster.
Information about how the healthcare facility includes
in their emergency plan situations related to patient d eath
information and body handling in mass mortality situa-
tions caused by a disaster event were also assessed (Ta-
ble 3). More than half (59.5%, n = 22) reported that their
emergency plan includes a protocol to release informa-
tion about deceased patients to other health facilities in
the nearest municipalities; 81.1% (n = 30) include in
their plan the release of information about deceased pa-
tients to other health organizations, the municipality, the
Puerto Rico Department of Health, police, etc. More than
three-thirds (67.6%, n = 25) reported including the man-
agement of situations related to mass mortality in their
emergency pl an.
Healthcare facilities reported several limitations in
dealing with a mass casualty or fatality event. These top -
ics were assessed as open-ended questions. The common
response was related to not having enough experience
dealing with mass fatalities or mass casualties. Although
participants indicated that their healthcare facility is pre-
pared with specialized resources and committed staff, the
lack of a mass fatality and casualties plan and the lack of
trainings may prevent an adequate response in case of a
Table 2. Agreements with other mortuary services for the
disposal of bodies in case of a disaster.
Characteristics of morgues n %
Agreements with mortuary
services—facilities with no morgue
No agreements (5) 62.5
Verbal agreements (1) 12.5
Written agreements (2) 25.0
Question aske d for healthcare facilities without morgue.
Table 3. Healthcare facility emergency plans for the release
of information on deceased patients and body handling in
mass mortality situations.
Emergency plan includes: Yes%
*Release of information about deceased patients to
other health facilities in the nearest municipalities 22 59.5
*Release of information about deceased patients to
other health organizations, the municipality, the
health departm ent, police, etc. 30 81.1
*Managing situations with mass mortality 25 67.6
*Only 37 healthcare facilities answered each question. Two reported they
did not know if situations dealing with mass fatality are included in their
emergency plan.
disaster. In addition, most healthcare facilities perceived
communication barriers between the governmental agen-
cies and hospitals during a major incident. Another con-
cern of healthcare facilities was related to the daily surge,
because these are at maximum capacity most of the time,
and in the case of a major disaster th ey will be limited in
offering healthcare services, unless there is immediate
external help.
4. Discussion
Most of the healthcare facilities have morgues, although
there are limitations with the current capacity and the
lack of resources to increase their capacity in case of a
disaster. In addition, all healthcare facilities rely on ex-
ternal mortuary services to collect the corpses on a daily
basis. Moreover, two-thirds of the healthcare facilities
without morgues do not have casual agreements or any
informal agreement with mortuary services for the dis-
posal of bodies in case of a major disaster, a similar
situation that occurs among those which reported having
a morgue. In most healthcare facilities, morgues are lim-
ited in space and cannot increase their capacity. This
situation is mostly associated with the hospital’s budget
being assigned to other priority areas. Moreover, the
maintenance of a morgue requires dedicated personnel
and materials for the preservation of corpses, which will
require a budget allocation .
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Assessing Healthcare Fa cilitie s Prepa r e dne ss for Ma ss Fa talities Incident 529
Disasters can strike at any moment causing a satura-
tion of the systems and affecting the response. Healthcare
facilities are complex institutions and their resources are
limited [23,24]. Therefore, it is extremely important to
strengthen hospital preparedness for mass fatalities. Ef-
forts dedicated to preparedness would help in prevention,
intervention and planning processes and dealing with
corpses using appropriate guidelines in case of a major
disaster [18,19].
The availability of body bags among nine healthcare
facilities was limited, with an average of 45 body bags,
ranging between one to ninety bags. A study conducted
by Sahelangi and Novita [13], demonstrated several
situations and challenges that occurred after the Indone-
sian Tsunami. This study assessed the speed with which
resources became scarce, time it took for hospitals to
become overwhelmed, loss of hospital personnel, lack of
body bags for the amount of corpses and the challenge
that the weather conditions created, given that it acceler-
ated the decomposition of bodies, making it impossible
to identify them.
Puerto Rico has experienced several situations involv-
ing mass fatalities. The case of Mameyes on October 7,
1985 was associated with torrential rains, affecting the
Mameyes neighborhood disappeared under an avalanche
of mud. This mudslide caused the destruction of more
than 100 homes and 129 deaths. Many bodies were never
recovered or identified. As a result of this incident the
government approved Law No. 1 on December 12, 1985
(Act Declaring Deaths in Cases of Catastrophic Events)
[25,26]. Healthcare facilities from our study reported
dealing with the Mameyes disaster, and their morgue
exceeded its capacity, which led them to rent a refriger-
ated truck to place bodies and human remains. A year
later, another incident with mass fatalities occurred on
December 31, 1986, a fire caused by a union worker at
the Dupont Plaza Hotel, left 97 dead and 140 wounded,
most of them tourists [25]. Another mass fatalities inci-
dent occurred on November 21, 1996, when a gas line
explosion ripped through the Humberto Vidal building in
Río Piedras, injuring 85 people and killing 30. The bod-
ies of the dead were lined and covered with sheets in the
chapel of La Milagrosa Catholic School, located opposite
the site of the explosion [27].
A disaster event may cause the death of hundreds of
thousands of people, and the handling and disposal of
dead bodies is one of the most difficult aspects in the
response process [28]. Inappropriate management might
result in distress to families and communities, and may
divert attention from other situations with equal priority,
such as healthcare services or reducing the capacity of
disaster response personnel to rescue survivors [1,29].
Although more than half of the healthcare facilities
that participated in this study include in their plans areas
related to the release of information about deceased pa-
tients to health organizations, the health department, the
municipality, and the police department among others,
there is no specific plan for dealing with mass fatalities.
The healthcare facilities that participated in this study
had limited space for storage, and the need of training in
the areas of mass casualties and mass fatalities. The de-
velopment of specific plans for handling mass mortality
is important to help mitigate the effect that may occur in
case of a major disaster. Healthcare facilities’ mass fatal-
ity plans require systematic documentation regarding the
handling of corpses and the dissemination of information
regarding dead and missing persons [28,29].
Developing mass fatalities plans for healthcare facili-
ties requires not only suppo rt from the board of directors
of these institutions, but the need to establish collabora-
tive agreements allowing the development of prepared-
ness measures and coordinated planning in conjunction
with various agencies. In addition, mass fatalities plans
should include protocols that deal with identifying the
best methods of refrigeration, conservation, recovery and
storage of bodies, identification of corpses through me-
thods such as fingerprinting, dental records, DNA re-
cords, photographs, identification records, as well as in-
clude how corpses will be delivered to their families
[11,12,28]. Additionally, plans for mass fatalities should
be integrated into the legal system of the country where
the disaster occurs, but at the same time these must show
sensitivity to the customs of the victims affected and
consider the religious, ethnic, cultural aspects, and sup-
port mechanisms for surviving family members and re-
sponders [11,12,28].
Although some legal aspects are addressed in Puerto
Rico, this is not enough to deal with mass mortalities. It
is extremely important to develop a national plan, in
conjunction with all stakehold ers in government agencies
and hospitals, to create a nationwide mass mortality plan
that can meet the crisis standards of care that must be
followed in the even t of a major disaster.
5. Acknowledgements
Data for this study came from the Assessment of the
Emergency and Disaster Preparedness and Response
Capabilities of Hospital Emergency Rooms in Puerto
Rico, conducted during 2011. Funding was provided by
ASPR-USDHHS, administered by the Puerto Rico De-
partment of Health, Office for Public Health Prepared-
ness and Response under contract 2010-DS0609. We
acknowledge the support we received from the hospitals
that participated in the study and are grateful for the col-
laboration of the Hospital Association of Puerto Rico and
for their willingness to take into account data derived
from our studies in formulating health policy. We would
Open Access IJCM
Assessing Healthcare Fa cilitie s Prepa r e dne ss for Ma ss Fa talities Incident
like to thank Julieanne Miranda Bermúdez, Wined Ra-
mírez López and, Luisa M. Ortíz Labiosa for helping in
the edition of this manuscript. The authors also thank
Ana María Mercado Casillas, Yarí Valle-Moro for their
help during the survey.
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Assessing Healthcare Fa cilitie s Prepa r e dne ss for Ma ss Fa talities Incident
Open Access IJCM
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