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Coping With a Mass Casualty: Insights into a Hospital’s Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion

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Objective The study provides a comprehensive insight into how an initial receiving hospital without adequate capacity adapted to coping with a mass casualty incident after the Formosa Fun Coast Dust Explosion (FFCDE). Methods Data collection was via in-depth interviews with 11 key participants. This was combined with information from medical records of FFCDE patients and admission logs from the emergency department (ED) to build a detailed timeline of patients flow and ED workload changes. Process tracing analysis focused on how the ED and other units adapted to coping with the difficulties created by the patient surge. Results The hospital treated 30 victims with 36.3% average total body surface area burn for over 5 hours alongside 35 non-FFCDE patients. Overwhelming demand resulted in the saturation of ED space and intensive care unit beds, exhaustion of critical materials, and near-saturation of clinicians. The hospital reconfigured human and physical resources differently from conventional drills. Graphical timelines illustrate anticipatory or reactive adaptations. The hospital’s ability to adapt was based on anticipation during uncertainty and coordination across roles and units to keep pace with varying demands. Conclusion Adapting to beyond-surge capacity incident is essential to effective disaster response. Building organizational support for effective adaptation is critical for disaster planning.
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Coping With a Mass Casualty: Insights into a Hospitals
Emergency Response and Adaptations After the
Formosa Fun Coast Dust Explosion
Sheuwen Chuang, PhD; David D. Woods, PhD; Hsien-Wei Ting, PhD, MD;
Richard I. Cook, MD; Jiin-Chyr Hsu, PhD, MD
Objective: The study provides a comprehensive insight into how an initial receiving hospital without
adequate capacity adapted to coping with a mass casualty incident after the Formosa Fun Coast
Dust Explosion (FFCDE).
Methods: Data collection was via in-depth interviews with 11 key participants. This was combined with
information from medical records of FFCDE patients and admission logs from the emergency department
(ED) to build a detailed timeline of patients flow and ED workload changes. Process tracing analysis
focused on how the ED and other units adapted to coping with the difficulties created by the patient surge.
Results: The hospital treated 30 victims with 36.3% average total body surface area burn for over 5 hours
alongside 35 non-FFCDE patients. Overwhelming demand resulted in the saturation of ED space and
intensive care unit beds, exhaustion of critical materials, and near-saturation of clinicians. The hospital
reconfigured human and physical resources differently from conventional drills. Graphical timelines
illustrate anticipatory or reactive adaptations. The hospitals ability to adapt was based on anticipation
during uncertainty and coordination across roles and units to keep pace with varying demands.
Conclusion: Adapting to beyond-surge capacity incident is essential to effective disaster response. Building
organizational support for effective adaptation is critical for disaster planning.
Key Words: disaster planning, emergency response, Formosa Fun Coast Dust Explosion, mass
casualty incident
The Formosa Fun Coast Dust Explosion
(FFCDE) was the largest man-made mass casu-
alty incident in the history of Taiwan. A medi-
cal emergency with many severely burned victims
presents enormous medical, logistical, and organiza-
tional challenges because specialized treatment and
large quantities of resources are required, and the rapid
progression of burn patientsinjuries creates great time
The FFCDE started when a flammable, colored powder
was sprayed from a stage onto the audience around
8:30 PM on Saturday, June 27, 2015, at the Formosa
Fun Coast Park in New Taipei City. Victims, average
age of 23, wore flammable swimwear resulting in large
total body surface area (TBSA) burns (average 44%;
281 people with TBSA burns >40%, 41 people with
TBSA burns >80%). Nearly 300 emergency vehicles
were dispatched. Within 6 hours, 499 victims were
delivered to 34 hospitals.3Many victims were sent to
lower level hospitals that lacked adequate burn care
capacity because of the unavailability of medical
resources.4The medical system, hospitals, and emer-
gency departments (EDs) all adapted to accommodate
the treatment demands for the many burn victims in a
short period of time. The medical response to the
tragedy resulted in an overall death rate of 3% (2016
National Burn Repository of the United States reports
a rate of 3.7%).5The satisfactory patient outcomes
were achieved by the immediate treatment of pati-
ents, despite the treating hospitals being lower level
After the famous 911 US terrorist attacks occurred in
2001,6man-made mass casualty incidents seemed
increasingly common. Knowledge of hospitalsprompt
and effective response will help guide response leaders
and staff to offer victims the most appropriate care
when lives are at stake.7The FFCDE disaster involving
a large number of severely burned victims is a sudden
onset no-notice event. It has led to several studies that
document different aspects of the medical response.
Some of these provide a general account of the system
response to the mass burn casualty incident (MBCI),8-9
whereas others focus on the clinical details of the burn
injuries and the appropriate treatment for those
burned.10-11 For the lower level hospitals, they were
pushed into a position that needed to stand on their
Disaster Medicine and Public Health Preparedness 1
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own to provide resuscitation and life support for the mass
casualties arriving from the FFCDE disaster site; however, a
paucity of detailed study of how they effectively responded
to the mass casualties was found.
The study examines how one of the initial receiving lower
level hospitals dealt with victims arriving from the FFCDE
disaster site to reveal the difficulties that challenged the
hospital as the ED provided resuscitation and life support for
the influx of burn patients. The study examines the potential
for overload, the potential bottlenecks that resulted, how
personnel adapted normal practices and reconfigured human
and physical resources in a variety of ways to cope with the
potential for these bottlenecks to degrade patient care, given
time pressure and uncertainty. This article aims to provide
comprehensive insight on how effective emergency response
to the sudden influx of burn patients exceeded the hospitals
burn care capacity for future disaster planning.
Hospital Setting
The hospital studied was selected from 17 initial receiving
lower level hospitals with similar scale and capacity. The hos-
pital received the largest number of victims compared with
other 16 hospitals. It is a regional community hospital with
medium-level emergency response capacity and is affiliated
with the Ministry of Health and Welfare (MOHW). It has
584 beds in total, including 104 surgical general acute beds,
7 surgical intensive care unit (ICU) beds, 23 medical ICU
beds, and others. The average number of patient visits in
the ED is about 70 during the daytime and about 40 at night.
This volume of service is provided by 2 shifts of attending
physicians and 3 shifts of nursing care per day. One ED physi-
cian is responsible for medical patients and another provides
trauma (injury) care. Six nurses plus 1 nurse practitioner are
assigned for each nursing shift. The ED is divided into 4 major
treatment areas totaling 23 staffed beds. One area is equipped
and staffed for seriously ill patients (CPR area), 2 are dedicated
to injured cases (trauma area) and to medical patients (medical
area), and the remaining area is used only for minor cases or as
an observation area. The maximum severe patients that can be
treated simultaneously is 3. This hospital has no burn care
capacity (no burn units and only 1 plastic surgeon).
Preceding the incident, the hospital used standard operating
procedures during periodically practiced mass casualty scenar-
ios, which included a cluster of around 15 patients with food
poisoning and 5 patients arriving from a fire or car accident.
The hospital had no plan for an MBCI, no experience with
an incident involving 30 patients, and no experience
with an incident where a surge would develop over time with
uncertainty about the number and severity of patients who
would continue to arrive.
Data Collection and Analysis
Hospital response was studied using the critical incident
method.12-14 An interview procedure of applying a question-
naire with open-ended questions was developed based on
(1) a review of the literature and relevant documents on treat-
ment of burn victims in the context of an MBCI and (2) inter-
views with 2 experts in managing mass casualty incidents.
Hospital records were reviewed prior to the interviews. For
FFCDE patients, age, gender, percentage of TBSA burned,
ED arrival time, and departure time (transfer to ICU/wards
or discharge) were recorded. ED admission logs were reviewed
for non-FFCDE patients arriving between the arrival of the
first burn victim and the transfer of the last burn patient.
ED arrival time, departure time, and triage level were recorded.
These data were used to develop and graph the timeline for use
during the interviews.
The open-ended questions probed for difficulties encountered
during the incident, how and when they recognized these dif-
ficulties, how they coped with them, and general questions
about the ED environment during the incident. The question-
naire and the graphic timeline were used in interviews with 11
key participants beginning with the ED director. The inter-
viewer used the timeline to trigger recall by participants and
capture their roles, experiences, and perspectives on the chal-
lenges and adaptations. Interviews were conducted by the lead
researcher between September 2016 and May 2017. Six physi-
cians and 5 nurses were interviewed. Each interview lasted
from 2 to 3 hours. Conflicts and ambiguities arising over the
course of the interviews were addressed by later telephone
or e-mail exchanges.
Interviews were transcribed into time-binned spreadsheets
(Excel, Microsoft Corp, Seattle, WA) along with patient
data. The resulting data collection was used for process trac-
ing analysis, a standard cognitive systems engineering
method for characterizing human performance in critical
incidents.15-16 The analysis focused on how the ED and
other units adapted to cope with the potential bottlenecks
created by the patient surge. The study was approved by the
Institutional Review Board.
Basic Sequence of Events
The earliest awareness among ED personnel of an impending
mass casualty came around 9:40 PM when ED staff was
informed by the Fire Department that there had been fire at
the Formosa Fun Coast facility. The staff believed their ED
would receive only a few additional patients. Around
9:45 PM, the hospital vice president (VP), who was riding
on a train, saw news reports describing almost a hundred vic-
tims on the scene.The VP called the ED nurse leads and
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instructed them to begin preparing for a surge. The VP also
called her assistant and the medical secretary who was a physi-
cian and liaison for physicianscommunication, as well as
texted the physician group via the message platform LINE.
The initiatives were to inform them and ensure that the key
physicians can receive a returning instruction, especially to
the chief physicians of both the ED and surgical departments
(SD). This communication triggered mobilization of physi-
cians at the beginning of the MBCI.
Figure 1displays the flows of surge patient into and out of the
ED. In total, 30 burn patients came to the ED. The first victim
arrived at 10:04 PM, 1.5 hours after the disaster occurred,
about 20 minutes after the alerting call from the hospital
VP. At this point, 17 non-FFCDE patients were already
present in the ED. Six of the first 7 patients to arrive were
severely burned (TBSA 50%72%). Twenty additional vic-
tims arrived over the first hour. After the ED had received
about 10 burn patients, the SD director initiated a call to
the Emergency Operation Center (EOC) to request that the
emergency services stop sending victims to the hospital
because the ED was reaching saturation. The ED received
an uncertain answer. After 20 burn patients arrived at the
ED, the SD director called the EOC again but the answer still
was uncertain. Eight additional patients arrived between
11:05 PM and 12:20 AM. Non-FFCDE patients continued
to arrive during this time period. In total, 68 patients visited
the ED in this period (see Figure 1).
The ED started the transfer of burn patients to the ICU and
other wards around 11:35 PM. The last burn patient was
transferred out of the ED at 3:45 AM according to the ED
log; however, this record is different from the time (around
2:30 AM) that 3 interviewees remembered. At the first wave
of transfer, 5 burn patients were sent to the ICU, 24 were sent
to 7 general wards, and 1 was discharged. The ED resumed to
the normal operation around 2:30 AM on June 28. After the
re-evaluation of admitted burn patients, 6 high-acuity patients
in general wards were transferred to other hospitals with burn
units in the first wave of the referral. This was followed by 16
high-acuity patients referred within 36 hours after the first
victim arrived to the ED. Five patients with TBSA of
12%26% and 2 patients with TBSA of 6%10% remained
in the hospital in the surgical ICU that was reconfigured as
a temporary burn ICU. The patients were treated based on
burn care protocol and discharged before July 31, 2015.
Patient Characteristics
The average age of burn patients was 25.2 years, and injuries
ranged from TBSA of 5% to 72% mainly on extremities
(Table 1). Of the 30 burn patients received, 29 were admitted
and 1 was discharged. Besides the 17 non-FFCDE patients
already present in the ED, 35 new non-FFCDE arrived to
the ED during the time period, including 6 with severe
conditions (triage 1 and 2), and 29 were in triage 3.
Cumulative Arrival of All Patients and Burn Patients in the ED, and Cumulative Transferred Burn Patients to ICU/Wards
Coping With a Mass Burn Casualty
Disaster Medicine and Public Health Preparedness 3
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Difficulties With Dealing With Mass Burn Casualty
The ED was quickly overcrowded with burn patients, non-
FFCDE patients, clinicians, and patientsfamilies and friends.
Figure 2shows the ED census over time. Three stages are iden-
tified before the ED resumed normal operation: (1) initial
surge, (2) period of overload, and (3) period of patient transfer
out of the ED. The challenges that the ED personnel faced
changed dramatically over time.
Initial Surge (10:04 PM to 10:25 PM)
1. The ED nearly reached the margin of normal capacity in beds
(23 beds), space, medical materials, and clinicians.
2. The clinical staff on duty at this time had limited experience
with burn care.
3. There was high uncertainty about how many victims would
continue to arrive.
4. There was a risk that necessary materials would run out.
5. The available physical space in the ED was becoming
6. The victims were needed ICU-level care, but there were no
ICU beds immediately available, and there was high uncer-
tainty about whether ICU transfers would be possible.
Overload (10:25 PM to 12:25 AM)
1. Acute shortage of supplies
2. Not enough clinical staff to care for patients
3. Uncertainty about when and how many more victims would
4. Anticipated risks to patient care with overload
Period of Patient Transfer Out of the ED
(12:25 AM to 2:10 AM)
1. Deciding which patients to transfer and where they should go
2. Providing adequate information to the caregivers receiving
these patients
3. Deciding how to follow up patients who were transferred
Adaptation to Challenges
The overall responses were synthesized into 14 key func-
tional adaptive activities (Figure 3). These activities were
interacted and interdependent among units and staff. The
adaptations are classified into 4 categories: (1) First aid
treatment, including F1, F3-1, F3-2, and F11, provided
resuscitation and life support for the victims; (2) mobiliza-
tion and deployment of relevant resources, including F4F9
labeled in the gray area, mobilized or reconfigured space,
personnel, and material resources to extend the surge capa-
bilities to support resuscitation; (3) rearrangement of regu-
lar emergency services, including F2-1, F2-2, F13, F14, gave
less priority to conducting no urgent or great important
activities, such as to postpone or simplify the documenta-
tion of medical care related record; and (4) public commu-
nication, including F10 and F12, were to build sensitive
communication with non-FFCDE patients, ICU/ED
patientsfamilies, authorities, and media. In addition, the
study revealed that 4 key staff the VP, the SD director,
an ED medical physician, and the on-duty head nurse were
the real engines behind all adaptive efforts to drive
coordination, integration across units and roles, and decision-
making, while the ED was filled with a large number of
The overload manifested in 3 ways: (1) saturation of ED space
and ICU beds (see Figure 2), (2) workload saturation or near
saturation of clinicians, and (3) exhaustion of critical medical
materials (Figure 4). A variety of adaptations was deployed to
meet each of these manifestations.
Saturation of ED Space and ICU Beds
During the initial stage, demand for beds within the
ED exceeded supply. During the overload stage, demand
for ICU beds exceeded supply. Coping with these was
accomplished by adaptations reconfiguring space, giving
personnel additional authority and encouraging them to
act independently, and reducing the workload from
the admitted non-FFCDE patients in the ED (see Figure 2,
codes 16).
Early on, ED staff transferred 1 acute non-FFCDE patient to
the ICU to open resources for the initial surge of burn patients
(see Figure 2, code 1). One ED medical physician instructed
his nurses to organize moving 16 non-FFCDE patients to an
ED adjacent area in the hospital lobby as an ad hoc observation
area (see Figure 2, code 2; also see Figure 3, F5 and F10) and
discharged them later (see Figure 2, code 4). The ED still
admitted 35 non-FFCDE patients before the last burn patient
was transferred at 3:45 AM on June 28. Six acuity non-FFCDE
patients were treated in the ED medical area, and other 29
non-FFCDE patients were managed in the hospital lobby area
and served by 1 ED physician and nurse team (see Figure 2,
code 5; also see Figure 3, F14).
FFCDE Patient Characteristics (n =30)
Variable No. (%) Mean (SD)
Age (1834) 25.2 (4.7)
20 5 (16.7)
20 <age 30 9 (63.3)
>30 6 (20)
Female 18 (60)
Male 12 (40)
Severity (TBSA 5%72%) 36.3 (19)
5% 1 (3.3)
5% <TBSA 20% 8 (26.7)
20% <TBSA 40% 9 (30.0)
40% <TBSA 60% 10 (33.3)
TBSA >60% 2 (6.7)
Total 30
FFCDE =Formosa Fun Coast Dust Explosion.
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Three Stages Before the ED Resumed to Normal Operation
Holistic Emergency Response Framework
Coping With a Mass Burn Casualty
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While still offsite, the hospital VP initiated clearing beds in the
ICU and general wards to prepare for receiving victims after
initial treatment in the ED. She mobilized post-ED resources
at the beginning of the overload stage in anticipation of the
arrival of additional victims (see Figure 2, code 3; also see
Figure 3, F8). As a result, 5 ICU beds were open for the
high-acuity burn patients before 11:30 PM. During Stage II,
when there were about 20 burn patients in the ED, the SD
director who spontaneously acted as an initial local incident
commander decided they would need to move burn patients
out of the ED to cope with the current ED overcrowding.
Adequate working spaces in the ED had to be preserved to pro-
vide for continuous severity assessment and consolation for the
victims already there and immediate treatment for the victims
possibly still to arrive (see Figure 3, F3-1 and F3-2).
Given insufficient available ICU beds, provisions needed to be
made to move and treat burn patients in the general wards as
well (see Figure 3, F11). The SD director had to wrestle with
the balance of multiple risks given the resources already avail-
able or being mobilized as the ED became overloaded. The
judgments to transfer burn patients to the ICU or general
wards were made upon the assessment of patient severity,
mainly the level of TBSA and consciousness. The SD director
anticipated that difficulties would arise managing the care of
burn patients as they arrived in the ICU and wards. Before
physically transferring burn patients, he mobilized both the
on-duty physicians in the wards and early recruited nurses to
immediately re-evaluate the transferred patients (see Figure 2,
code 6; also see Figure 3, F9). The effectiveness and flexibility
of the arrangement of general acute beds and ICU beds allowed
for early admission and distribution of all burn patients in 1.5
to 5 hours.
Workload Saturation or Near Saturation of Clinicians
The surge of arriving FFCDE victims challenged the capacity
of the clinical staff to provide care. The number and severity of
injuries overwhelmed the capacity of the ED, and additional
capacity had to be mobilized and deployed. The major adap-
tations that occurred to mobilize additional capability were
as follows.
Before and during the initial stage, the VP began mobilizing
off-duty physicians about 9:45 PM, and a few minutes later
(9:50 PM), the on-duty ED physician and head nurse activated
the local hospital disaster alarm to trigger preparations for
emergency management (333 signal) to call for on-hospital
staff. This led to physicians coming to the hospital from home
and moving to the ED from within the hospital.
After the second victim came, the normal triage process was
abbreviated. On entry into the ED, a triage nurse and/or ED
medical physician checked the level of consciousness and
gauged the TBSA of burn patients and then directed the
transporters to deliver the patients to a particular ED area
(see Figure 3, F1), while a nursing supervisor or the ED nurse
leader assisted the triage and registration for non-FFCDE
patients (see Figure 3, F2-1 and F2-2). In each area, small
groups of physicians and nurses provided immediate treatment
and resuscitation.
The organization of clinical teams changed over time as
victims and staff arrived to the ED. A nurse would always
stay behind to provide continuous care until the patient
was transferred to the ICU or general wards. The reorgani-
zation of the clinical teams was mostly spontaneous. The
groups provided immediate medical treatment (see Figure 3,
F3-1 and F3-2), including air-way checking, flushing
patients wound area by using normal saline, early burn
wound assessment and initiation of fluid resuscitation based
on TBSA and coating, followed by continuous monitoring
of their status and providing consolation to relieve patients
stress including pain control (see Figure 3, F3-2). No
patients were intubated in the ED; 2 patients were intubated
in the ICU.
Most staff did not have specialized expertise in burn treatment.
Surgeons and a few burn-experienced nurses provided direc-
tion for those with less experience. Surgeons directed others
(ie, pediatric physicians, internal medicine physicians) in
severity assessment and other tasks. The SD director super-
vised the working groups as they treated individual patients
and decided which patients should be transferred to the
ICU or ward (see Figure 3, F3-2 and F4). The SD director
called the ward physicians (see Figure 3, F3-2 and F9) to
ask them to re-evaluate the transferred patients immediately
on arrival. This resulted in the second transfer within 18 hours
after admission, where 8 high-acuity burn patients in the
general wards were transferred to the ICU. During the transfer
from the ED to the ICU or general wards, individual patients
were accompanied by the ED nurse who cared for them. This
nurse provided a verbal report to the receiving physicians and
nurses. Brief medical records of the individual transferred
patients were documented after the ED resumed to normal
Normal nursing shift boundaries were relaxed. Night shift
nurses worked for up to 3 hours past their normal end time
and late-night shift nurses came early to assist the response.
This produced a 3-hour shift overlap that substantially
increased the nursing coverage (see Figure 3, F9). During
the overlap of 3 hours in the ICU and wards, about 50 nurses
cared for burn patients.
After 29 burn patients were transferred, the tempo of ED work
slowed. The VP organized 5 change dressing teams and
recalled 9 nurse practitioners to support dressing changes for
the coming morning and afterward until the patients were
referred to other hospitals. Overall, 88 health care staff (14
physicians, 61 nurses, and 13 administrative staff) presented
in the ED after the initial wave of victims arrived. Five
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attending surgeons and 6 attending doctors in other specialties
were the main force to provide immediate treatment and later
re-evaluation for the patients.
Exhaustion of Critical Medical Materials
Treating burn patients requires large amounts of specific medi-
cal materials, especially for patients with greater than 50%
body surface area burns. Existing stocks of normal saline,
1000 cc/bot (cleaning purpose), silver sulfadiazine (tube and
jar), large size gauze, tetanus toxoid booster, and especially
IV fluid (normal saline, 500 cc/bot), were all quickly con-
sumed. The most critical were burn dressing/ointment (silver
sulfadiazine) and large-size gauze. Figure 4shows that the ED
used up its own materials quickly in Stage I. Then the hospi-
tals pharmacy inventory was emptied of ointment in Stage II,
in the period of 11:00 PM to 11:30 PM.
The on-duty head nurse recognized the shortages. She coordi-
nated with the pharmacy and general supply staff to borrow
materials from their inventories for quickly fulfilling the EDs
need (see Figure 4, code 1; also see Figure 3, F4 and F6). The
resourcefulness of the nursing staff was notable: an ICU nurse
doing immediate care in the ED, returned to her ICU to
liberatesome packs of burn ointment (see Figure 4, code 3).
The VP returned to the hospital around 10:50 PM and took
on the responsibility of incident commander (see Figure 4,
code 2). Anticipating that medical supplies would run out
soon, she requested authorization of the MOHW hospitals
alliance to activate the administrative mechanism that allows
staff to request a variety of supplies from other hospitals (see
Figure 3, F7). Supplies from a nearby hospital arrived at around
11:30 PM and from others throughout the night. The early
decision to request sharing of supplies by other hospitals main-
tained minimal supply levels during the incident and over the
following days.
The FFCDE disaster caused multiple MBCIs in several hospi-
tals simultaneously. The study revealed real difficulties that the
hospital never faced before and found many examples of
successful adaptations implemented by staff when the ED
was overwhelmed by the influx of severely injured patients.
Findings from this study have highlighted that several impor-
tant factors may contribute to future disaster planning and
preparedness, as covered and described in the following texts.
Effective Coordination
In practice, EDs are used to performing strategic standard
adaptations, including relocating patients, adjusting processes
or equipment use, and providing additional or flex staffing to
cope with workload changes or exercise scenarios.17 These
attempt to increase capacity and efficiency for a variety of sit-
uations. However, additional unique adaptations were imple-
mented during this event, such as moving the non-FFCDE
patients to the lobby, rotating clinical teams with great gaps
in experiences and profession over time to treat victims
Shortage in Critical Medical Material and the HospitalsResponses
Coping With a Mass Burn Casualty
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promptly, mobilizing highly irregular medical materials from
alliance hospitals. The successful adaptations found depend
on effective coordination and integration across roles
and units.
The immediate stabilization care for mass burn casualties in the
ED was highly distributed and specialized, thereby relying on
interdependent functions to complete the mission.2Despite
the criticality of staff, stuff and structure to a mass casualty inci-
dent, putting them into context with policies and procedures
as a system approach to seamlessly integrate capability is imper-
ative. Operational efficiency and effectiveness is dependent on
the dynamic linkage of all of the subcomponents of the inter-
woven domains.18
The hospitals 14 functional adaptive activities worked as a sys-
tem approach to resolve resource limitation in real time.
Successfully implementing these adaptions during the critical
stage of the mass casualty incident demonstrated not only the
mutually understandable internal communication between
staff for mobilization and deployment of resources, but also
the staff was willing to take additional workload and risk for
others. In addition, 4 key personnel who were not the
appointed leaders in the formal emergency response organiza-
tion structure spontaneously drove the activities, assigned
tasks, and decision-making.
The coordination is to implement various mechanisms that
allow team members to manage interdependencies between
their roles and tasks, and conflicts between their goals.19
Burstein argued that response failures to a mass casualty inci-
dent was led by coordination rather than simply communica-
tion problems, and an effective coordination is built on people
practices in regular and simple drills frequently, this allowing
staff to communicate correctly in disasters.20
The Best Possible Care to Patients
In the FFCDE disaster, there were arguments about the triage
performed in the ED, such as when burn wound was estimated
quickly by who was not a burn specialist, an underestimate of
burn wound area would result in inadequate resuscitation and
misplacement of the patients.9In addition, whether the emer-
gency care in the ED for burn patients should include preven-
tive intubation and use of burn dressing for wound care, and
what level of medical care for the non-FFCDE patients were
also argued. This hospital provided the best possible care to
patients, and the satisfactory outcome was achieved based
on their available resources and the presence of personnel,
equipment, and supplies in the ED and wards.
Hospitals with different levels of surge capacity following a
mass casualty incident fall into 3 basic categories, depending
on the magnitude of the event: conventional, contingency,
and crisis surge capacity. Note that the same event may result
in conventional care at a major trauma center, but crisis care at
a smaller, rural facility.21 Besides, there is not one golden
medical emergency system, there are no goldentimelines,
and no goldenskills applicable for different situations.
This hospital proved that a medical system should be flexible
and be able to adjust on each specific, local situation, and
that, in the front line, several methods are suitable to give
medical care as soon as possible.22 For disaster planning, all
health care entities should have plans to provide optimal
care for achieving the greatest good for the greatest number
of people.23 The lower level entities use their available
resources to hold the patients awaiting transfer and to use
them most effectively.24-25
Anticipatory Ability
Either unsuccessful communication with the EOC or absence
of needed information about burn patients from the EOC and
ICU beds from other hospitals caused high uncertainty to the
hospitals in this disaster.3,26 To overcome the challenge of
uncertainty was found to depend on the staffanticipatory abil-
ity. Multilevel managers the VP (high-level manager), the
SD director (middle-level manager), and the head nurse
(the base-line manager) showed their anticipatory abilities
to make effective decisions throughout the responses.
Effective response in this beyond-surge capacity incident, espe-
cially under the context of uncertainty, depended on the
anticipation of potential bottlenecks ahead and on dynami-
cally reconfiguring coordination across roles and units.27
The anticipatory ability of individuals or an organization looks
ahead to read the signs that its adaptive capacity, as it currently
is configured and performs, is becoming inadequate to meet the
demands it will or could encounter in the future.28 The
Disaster Research Center only found evidence of communica-
tion between the disaster site and any ambulance or hospital in
33% of disasters.29 This implies that anticipatory ability of staff
is an imperative core ability for disaster response. The ability
not only comes from experienced staff who have greater famili-
arity with the hospitals resources and conditions, but also
relies on routine practice of typical actions and becoming
ingrained or experienced to cope with the unexpected or to
improvise unconventional solutions to difficult situations.20,29
Retrospective critical incident studies have several limits.12,14
Participant interviews are conducted with some time lag fol-
lowing the incident; in this case, the interviews occurred
15 months after the FFCDE disaster. Besides, in-depth individ-
ual interviews often are not feasible to clarify the story truth-
fully in a short interview. This study tried to collect data from
multiple participants and from multiple roles to build a com-
prehensive picture from multiple perspectives and to cross-
check across participant reports to build a definitive account.
This increased the difficulties of extending the research in an
expected speed to other hospitals that handled their share of
the victims from the FFCDE disaster. Critical incident studies
Coping With a Mass Burn Casualty
8Disaster Medicine and Public Health Preparedness
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are valuable when they are part of a larger effort to build a cor-
pus of cases that permit pattern extraction across the set,
despite the uniqueness of each case.15 This study is based on
interviews with 11 participants who represent a sample of
the clinical staff involved in the response. However, it provides
a start on building such a corpus on how hospitals respond to
mass casualty incidents to plan preparation and practice.
The study provides insight into how the hospitals responses
actually played out against a detailed timeline for the MBCI.
This captures the real difficulties and adaptive behavior. The
graphical timeline-based models (see Figures 1,2,and4)
demonstrate the dynamically detailed responses to the
MBCI. Figure 3systematically illustrates the overall interac-
tive and interdependent adaptations in a system approach.
Furthermore, the study reveals that effective response in this
beyond-surge capacity incident depended on anticipating
potential bottlenecks ahead and dynamically reconfiguring
coordination across roles and units. Man-made mass casualty
incidents seem increasingly common. It is important to be
aware that if and when a situation presents itself in practice
differently than expected, plans need to be changed.
Adapting to unforeseen circumstances is essential to an effec-
tive disaster response. An effective disaster response requires
competent responders and leaders.27 Building organizational
support for adaptations is a critical need for disaster planning.
About the Authors
Graduate Institute of Data Science, Health Policy and Care Research Center, Taipei
Medical University, Taipei, Taiwan (Dr Chuang); Department of Integrated
Systems Engineering, The Ohio State University, Columbus, Ohio (Drs Woods,
Cook); Department of Neurosurgery, Taipei Hospital, Ministry of Health and
Welfare, New Taipei City, Taiwan (Dr Ting); and Department of Chest
Medicine,Taipei Hospital, Ministry of Health and Welfare, New Taipei City,
Taiwan (Dr Hsu)
Correspondence and reprint requests to Sheuwen Chuang, 12F, No. 172-1, Sec 2
Keelung Rd., Taipei, 10675, Taiwan (e-mail:
The authors thank the hospital and all interviewees for allowing the investi-
gation to be conducted, as well as Dr Yun Yen for his strong support on the
planning of the project, and field experts Dr Hsian-Jenn Wang and
Dr Kuo-Song Chang for sharing their expertise in mass burn casualty disaster.
Conflict of Interest
The authors have no conflicts of interest to declare.
Financial Support
The study was funded by the Care Fund for the Formosa Fun Coast Dust
Explosion, Taipei Medical University (project no:105-07-01), and the
Ministry of Science and Technology (project no: MOST 107-2119-M-
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... Some hospitals experienced severe difficulties due to insufficient surge capacity in the aftermath of the FFCDE. According to the findings of the FFCDE studies [5][6][7][8], the hospitals' emergency response plans did not fully support emergency medicine in the events. The hospitals relied on adaptive responses to deal with the patient surge to generate adequate emergency care resources accordingly. ...
... Next, the researchers conducted extensive, in-depth, semi-structured interviews with 34 participants across multiple levels of each of the four hospitals. The content of the interviews is described in more detail in individual publications regarding two of the hospitals [6,7]. Finally, the data were corroborated with detailed patient information from hospital records. ...
... They can use Fig. 1 (overload patterns) and Tables 3, 4 and 5 for the planning to capture an overall understanding of what challenges could occur over time and how hospitals responded to these difficulties to extend emergency care in each category. Also, emergency planners can consult the responses described in more detail in individual publications regarding two hospitals at an extreme and high level [6,7]. ...
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Background Large-scale burn disasters can produce casualties that threaten medical care systems. This study proposes a new approach for developing hospital readiness and preparedness plan for these challenging beyond-surge-capacity events. Methods The Formosa Fun Coast Dust Explosion (FFCDE) was studied. Data collection consisted of in-depth interviews with clinicians from four initial receiving hospitals and their relevant hospital records. A detailed timeline of patient flow and emergency department (ED) workload changes of individual hospitals were examined to build the EDs' overload patterns. Data analysis of the multiple hospitals' responses involved chronological process-tracing analysis, synthesis, and comparison analysis in developing an integrated adaptations framework. Results A four-level ED overload pattern was constructed. It provided a synthesis of specifics on patient load changes and the process by which hospitals' surge capacity was overwhelmed over time. Correspondingly, an integrated 19 adaptations framework presenting holistic interrelations between adaptations was developed. Hospitals can utilize the overload patterns and overload metrics to design new scenarios with diverse demands for surge capacity. The framework can serve as an auxiliary tool for directive planning and cross-check to address the insufficiencies of preparedness plans. Conclusions The study examined a wide-range spectrum of emergency care responses to the FFCDE. It indicated that solely depending on policies or guidelines for preparedness plans did not contribute real readiness to MCIs. Hospitals can use the study's findings and proposal to rethink preparedness planning for the future beyond surge capacity events.
... Many people suffered severe burns and within 6 hours, 499 victims were delivered to 34 hospitals. The study concluded that "The hospital's ability to adapt was based on anticipation during uncertainty and coordination across roles and units to keep pace with varying demands" (Chuang et al., 2019). It was recommended to build organisational support for effective adaptation during critical situations and disasters. ...
A fundamental safety management assumption is the need to learn from accidents, to identify their causes, and to take steps to prevent their recurrence. Safety by prevention is, however, not the only solution. Since something cannot go well and fail at the same time, another approach is to learn from situations where things go well and where “nothing” seems to happen. In the present case a computer breakdown led to the loss of most of the information in an air traffic control system. The operators managed to compensate for the missing information and keep traffic flowing, although with reduced capacity, while the technical staff managed to restart the system. The same breakdown occurred two more times during the day but in both cases the operators were able to compensate. In the evening the computer system was restored and no further breakdowns happened. The organisation investigated the event but since it focused on the technical issues the lessons learned were in terms of new checklists, improved procedures, and stricter precautions. The paper presents an analysis from a different perspective that looks at what went well. This identifies a number of things that may contribute to make performance in the future even safer.
... Strategic leadership requires the ability to make appropriate decisions based on scarce, and possibly unreliable information (Chuang et al., 2019;Wallenius et al., 2019). ...
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Aims To explore registered nurses’ experiences as disaster preparedness coordinators of hospital incident command groups’ during a major incident. Design A qualitative descriptive design using semi-structured interview. Methods This was a qualitative study based on one focus group discussion and six individual follow-up interviews. Participants were registered nurses in their capacity as disaster preparedness coordinators with experience from Major Incident simulations and a real-life Major Incident. The interviews were transcribed verbatim and analysed using content analysis. The COREQ checklist was used for reporting the findings. Results The analysis of data generated the main category: Expectations, previous experience and uncertainty affect hospital incident command group response during a Major Incident and three categories, (I) Gaining situational awareness (containing two subcategories), (II) Transitioning to management (containing three subcategories) and (III) Actions taken during uncertainty (containing two subcategories).
... The multiple mass-casualty incidents caused several hospitals to overload in the same period of time. Without a shared information system among hospitals, the hospitals had to check the available beds with other hospitals one by one through phone calls for hospital transfers for 5 days after the incident occurred (Pan 2016;Chuang et al. 2019b). Table 4 summarizes the failures encountered during disaster response phase of FFCDE. ...
... The multiple mass-casualty incidents caused several hospitals to overload in the same period of time. Without a shared information system among hospitals, the hospitals had to check the available beds with other hospitals one by one through phone calls for hospital transfers for 5 days after the incident occurred (Pan 2016;Chuang et al. 2019b). Table 4 summarizes the failures encountered during disaster response phase of FFCDE. ...
Taiwan is located on the earthquake-prone circum-Pacific belt and seasonal typhoon impact zone. Given Taiwan's large population and high urban density, disasters can have serious consequences on its economy, environment, and public health. This paper traces the evolution of Taiwan's disaster management system into its current framework under the national Disaster Prevention and Response Act and examines the coordination experiences across different actors in involved in disaster response. Through two case studies. Typhoon Morakot and the Formosa Fun Coast Dust Explosion incident, this paper investigates the coordination that occurred in the various phases of disaster management and indicates coordination successes and failures, as well as factors leading to coordination breakdowns in the response stage of the two cases. These factors include unclear responsibilities for mobilization, lack of real-time information systems sharing across sectors, ineffective communication mechanism, inadequate disaster management structure, and lack of disaster drills/exercises for integrating multiple organizations. Understanding how coordination successes and breakdowns occur will provide useful learning points on which future policy changes and education can improve.
Objective The objective was to describe a feasible, multidisciplinary pediatric mass casualty event (MCE) simulation format that was less than 2 h within emergency department space and equipment constraints. Methods This was a prospective cohort study of an MCE in situ simulation program from June-October 2019. Participants rotated through 3 modules: (1) triage, (2) caring for a critical patient in an MCE setting, and (3) being in a disaster leadership role. Triage accuracy, knowledge, self-evaluation of preparedness, and MCE skills by means of pre- and post-test surveys were measured. Wilcoxon matched pairs signed rank test scores and McNemar’s matched pair chi-squared test were performed to evaluate for statistically significant differences. Results Forty-six physicians (MD), 1 physician’s assistant (PA), and 22 nurses participated over 4 simulation d. Among the MD/PA group, there was a statistically significant 7% knowledge increase (95% confidence interval [CI], 3%-11%). Nurses did not show a statistically significant knowledge difference (0.04, 95% CI, 0.04%, 14%). There was a statistically significant increase in triage and resource use preparedness ( P < 0.01) for all participants. Conclusion This efficient, feasible model for a multidisciplinary ED disaster drill provides a multi-modular exposure while improving both MD and PA knowledge and all staff preparedness for MCE.
The use of motor vehicles to initiate mass casualty incidents is increasing in frequency and such events are called intentional vehicular assaults. Perpetrators are inspired by a range of terrorist ideologies or have extremist views, criminal intent, or mental health issues. Assaults using a motor vehicle as the principal weapon of attack are easy to launch and require little to no forward planning. This makes them difficult for police and security agencies to predict, prevent, or interdict. With the increasing frequency of intentional vehicular assaults, anaesthesiologists in various settings may be involved in caring for victims and should be engaged in preparing for them. This narrative review examines the literature on vehicle assaults committed around the world and provides an overview of the unique injury patterns and considerations for the pre-hospital, perioperative, and critical care management of victims of these mass casualty events. The article discusses planning, education, and training in an attempt to reduce the mortality and morbidity of intentional vehicular assaults.
Business continuity planning and management (BCP/BCM) is crucial for enterprises such as hospitals and healthcare agencies. However, there is no established method to evaluate the effectiveness and resilience of BCP. In this study, we develop a model for the in-hospital medical processes and resource usage required in mass casualty events. The process model is based on records from two hospitals that accepted several people injured in the Formosa Fun Coast Dust Explosion that occurred in Taiwan in 2015. We conducted a simulation to replicate the situation in the two hospitals for model verification and validation and confirmed that the simulation results were consistent with the actual data to some extent. The model developed in this study can be used to observe and compare the details of the disaster medicine processes under different settings and scenarios; thus, the model may be utilized for BCP evaluations.
Background and Objective : To deal with burn mass casualty incidents (BMCIs), various countries have established national or regional BMCI emergency response plans (ERPs). A burn care capacity ranking model for hospitals can play an integral role in ERPs by providing essential information to emergency medical services for distributing and handling mass-burn patients. Ranking models vary across countries and contexts. However, Taiwan has had no such model. The study aims to develop a ranking model for classifying hospitals’ burn care capacity in preparation for the development of a national BMCI's ERP. Methods : Multiple methods were adopted. An expert panel provided consultations to data selections and clustering validation. 535 hospitals data with 116 variables were collected via the open data platforms under the Ministry of Health and Welfare. Data selection and streamlining process was conducted to determine 42 variables for cluster analysis. SAS 9.4 was used to analyze the data set through a hierarchical cluster analysis using Ward's method, followed by a tree-based model analysis to identify the criteria for each cluster. Both internal and external cluster validation were performed. Results : Four clusters of burn care capacity were determined to be a suitable number of clusters. All hospitals were arranged into capacity levels accordingly. Results of the Kruskal-Wallis test showed that the difference between clusters were significant. Tree-based model analysis revealed four determining variables, among them, the refined level of emergency care responsible hospital was the most influential factor for the clustering. Responses from the questionnaire were used as an external validation tool to corroborate with the cluster analysis results. Conclusion : The use of open government data and cluster analysis was suitable for developing a ranking model for determining hospitals’ burn care capacity levels in Taiwan. The proposed ranking model can be used to develop a BMCI emergency response plan, and can also serve as a reference for using cluster analysis with open government data to rank care capacity or quality in other domains.
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Background: Around 10%-20% of burned patients have inhalation injuries, and the severity of these injuries is correlated with mortality. Fiberoptic bronchoscopy is an important tool for the early diagnosis of inhalation injury. This study investigated correlations between the severity of inhalation injury and outcomes of patients involved in a cornstarch dust explosion in northern Taiwan in 2015. Methods: Patients with burns who were intubated after the explosion were enrolled. Their medical records were reviewed, and data including patient characteristics, percentage of total body surface area (%TBSA) burned, severity of the inhalation injury, mechanical ventilation settings, and outcomes were collected and analyzed. Results: Twenty patients underwent fiberoptic bronchoscopy during the first 24h to evaluate an inhalation injury. Their mean age was 22.4±5.5 years and the mean %TBSA burned was 55.7±19.4%. Fourteen patients had a grade 1 inhalation injury and six had a grade 2 injury. There was a higher %TBSA burned in the grade 1 group than in the grade 2 group, although the difference did not reach statistical significance (60.0±20.3% versus 45.5±13.5%, p=0.129). Compared to the grade 2 group, the grade 1 group had a significantly higher white blood cell count (29.4±9.3 versus 18.6±4.6, p=0.015) and frequency of facial burns (85.7% versus 33.3%, p=0.037). The overall intensive care unit mortality rate was 10% (n=2), with no significant intergroup difference (grade 1, 14.3% versus grade 2, 0%, p=0.192). Conclusion: Although the explosion resulted in a high rate of inhalation injuries in critically ill patients, there was no significant correlation between mortality and the severity of the inhalation injuries.
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Study objective: Escalation policies are used by emergency departments (EDs) when responding to an increase in demand (eg, a sudden inflow of patients) or a reduction in capacity (eg, a lack of beds to admit patients). The policies aim to maintain the ability to deliver patient care, without compromising safety, by modifying "normal" processes. The study objective is to examine escalation policies in theory and practice. Methods: This was a mixed-method study involving a conceptual analysis of National Health Service escalation policies (n=12) and associated escalation actions (n=92), as well as a detailed ethnographic study of escalation in situ during a 16-month period in a large UK ED (n=30 observations). Results: The conceptual analysis of National Health Service escalation policies found that their use requires the ability to dynamically reconfigure resources (staff and equipment), change work flow, and relocate patients. In practice, it was discovered that when the ED is under pressure, these prerequisites cannot always be attained. Instead, escalation processes were adapted to manage pressures informally. This adaptive need ("work as done") was found to be incompletely specified in policies ("work as imagined"). Conclusion: Formal escalation actions and their implementation in practice differed and varied in their effectiveness. Monitoring how escalation works in practice is essential in understanding whether and how escalation policies help to manage workload.
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In June 2015, nearly 500 concert attendees suffered injuries from smoke inhalation and severe burns following a color-dust explosion at a waterpark in Taiwan. We report on the progressions of the incident and government responses, share cross-departmental mobilization and case management lessons, and reflect on clinical and complex policy issues emerged. The timely and coordinated emergency responses, a high-quality universal health care system, and dedicated clinicians voluntarily working overtime resulted in an unprecedented 2.4% mortality rate (international statistics predicted 26.8%).
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Problems, issues, and challenges to disaster planning and selected disaster-planning principles are presented in this article. Methods of developing strategies to overcome resistance to disaster preparedness and measures to ensure that medical-response facilities will function are among the concepts discussed. Disaster-preparedness resources are provided. Language: en
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In cognitive work there is a mutual adaptation of agents' strategies, affordances of artefacts, and demands of the work setting. Regularities in cognitive work concern dynamic interactions across of these sets of factors. Since cognitive work systems are not decomposable into independent basic elements, different empirical tactics are necessary, though core values of observation, discovery, and establishing warrant remain fundamental guides. Functional analysis is a mode of research that can cope with the unique difficulties of studying and designing cognitive work in context. Functional analysis is a process that coordinates multiple techniques in order to unpack complex wholes to find the structure and function of the parts within the whole. Central to the empirical techniques orchestrated is observation. Three families of techniques emerge which vary in how they shape the conditions of observation: natural history or in situ observation, staged world or observation of performance in simulated situations as models of what is important in situ, and spartan labs settings where observation occurs in experimenter created artificial tasks. The chapter discusses how to coordinate these techniques in a discovery process that reveals the mutual adaptation of strategies, affordances, and demands and predicts how these dynamic processes will play out in response to change.
Objective: To describe the experience of distributing 499 burn casualties of an unexpected event and determine whether patient transfer is associated with patient outcomes measured 2 weeks after the incident. Methods: All 499 patients injured in the event were included. For the 138 patients transferred to other hospitals after primary distribution, we evaluated whether the transfers were associated with patient severity. Furthermore, we used multinomial logistic regression to investigate the association of patient transfer with patient outcomes after controlling for age, gender, total burn surface area (TBSA), final hospital level, wound infection, and patient pneumonia. Results: We determined that on-site triage differed significantly from hospital triage (p<0.001). Furthermore, the secondary distribution enabled the transfer of a high number of patients to medical centers based on the availability of beds; however, such transfers were not associated with patient outcomes (p>0.05). Factors associated with patient outcomes were wound infection and TBSA (p<0.001). Conclusions: In case of inadequate burn centers, satisfactory patient outcomes can be achieved by the immediate treatment of patients, despite the treating hospitals being lower-level hospitals. Regardless of the hospital level, immediate treatment of burn patients is crucial to reducing mortality.
Background: Despite major advances in therapeutic strategies for the management of patients with severe burns, significant morbidity and mortality is observed. Hyperbaric oxygen therapy (HBOT) increases the supply of oxygen to burn areas. The aim of this study was to determine whether HBOT is effective in the treatment of major thermal burns. Methods: On June 27, 2015 in New Taipei, Taiwan, a mass casualty disaster occurred as fire erupted over a large crowd, injuring 499 people. Fifty-three victims (20 women and 33 men) were admitted to Tri-Service General Hospital. Thirty-eight patients underwent adjunctive HBOT (HBOT group), and 15 patients received routine burn therapy (control group). Serum procalcitonin (PCT) level, a sepsis biomarker, was measured until it reached normal levels (<0.5μg/L). The records of all patients from June 2015 to March 2016 were analyzed retrospectively. Outcome measures that were compared between the groups included the use of tracheostomy and hemodialysis, total body surface area (TBSA) and the number of skin graft operations, length of hospital stay, infection status, and mortality. Results: The mean age of the patients was 22.4 years, and the mean TBSA was 43%. All the patients survived and were discharged without requiring limb amputation or being permanently disabled. Patient characteristics did not differ significantly between the groups. PCT levels returned to normal significantly faster (p=0.007) in the HBOT group. Conclusion: Multidisciplinary burn care combined with adjunctive HBOT improves sepsis control compared with standard treatment without HBOT. Prospective studies are required to define the role of HBOT in extensive burns.
BACKGROUND: This article reports the emergency management of a mass casualty disaster occurring on June 27, 2015, in New Taipei, Taiwan, as a fire erupted over a large crowd, injuring 499 people. Lessons learned in burn care treatment and disaster preparedness are analyzed through following the specific surgical response and patient outcomes of one hospital involved in the disaster response. METHODS: Information regarding the fire and emergency management was obtained from the Ministry of Health and Welfare of Taiwan. Patient-specific data were obtained from Chang Gung Memorial Hospital's patient records. RESULTS: A mass casualty management system was immediately initiated by the Ministry of Health and Welfare, which contacted local hospitals to prepare for the influx of patients with severe burn injuries. In response, Chang Gung Memorial Hospital called 336 medical personnel to the emergency room for the management of 49 burn patients and divided emergency management roles among chief physicians. The mean burn total body surface area of patients presenting to this hospital was 44.2 percent (range, 10 to 90 percent). No deaths occurred in the first 48 hours after the explosion. As of 3 months after the incident, only 12 deaths had resulted from this accident, all resulting from sepsis and organ failure. CONCLUSIONS: Taiwan's effective mass casualty preparation plans, highly trained medical personnel, and large centers capable of treating burn patients allowed 499 injured patients to be successfully transferred and treated in hospitals across Taiwan. Lessons learned from this disaster response can be integrated into existing disaster management plans to aid in the response to mass casualty tragedies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.