We are publishing these materials now because the ongoing conflict with Iran and the elevated threat environment have generated renewed interest in mass casualty preparedness across the hospital and emergency management community. The lessons documented here are not specific to any one incident or adversary. They are foundational to how any healthcare system should prepare for and respond to sudden-impact, high-volume trauma events.

This week we are publishing the complete Route 91 document library: the original 2018 case study produced by the Nevada Hospital Association in the immediate aftermath of the incident, the companion presentation that has been shared with hospital and emergency management audiences across the country since 2018, and a peer-reviewed article published in Trauma Surgery and Acute Care Open in 2025 that formally documents the findings for the academic and clinical literature.

Taken together, these three documents trace the full arc from field documentation to peer-reviewed research and represent one of the most comprehensive analyses of a mass casualty hospital response ever produced.

What the research found:

Traditional surge capacity planning, built around achieving 20% above licensed bed capacity, proved largely irrelevant when hundreds of critically injured patients began arriving simultaneously via private vehicles, rideshare services, and pickup trucks, without prehospital triage, without advance notification, and while the shooting was still active. The hospitals that performed best were not those with the most beds. They were the ones that optimized throughput: the speed at which patients could move through the emergency department and into surgery, admission, or transfer.

Three paradigm shifts emerged from the response. First, patient throughput replaced surge capacity as the defining metric of hospital readiness during sudden-impact mass casualty events. One hospital treated 124 gunshot wounds in under 24 hours. The limiting factor was never beds. It was operating room turnover. Second, combat-style triage protocols replaced traditional START triage in real time. Surgeons moved to the emergency department entrance for rapid evaluation, patients requiring hemorrhage control went directly to the operating room, and specialty-specific cohorting modeled on military forward combat hospitals allowed surgical teams to move efficiently from case to case within their discipline. Third, resource management assumptions failed in almost every category. Critical supplies expected to sustain 96 hours were depleted within 2 to 4 hours. Clean linens required replacement four to six times per hour per bed. Even ballpoint pens and triage tags became contaminated and ran short.

One area that did not fail was blood product management. Nearly 500 blood components were transfused in the first 24 hours. Public donors gave almost 800 units of blood immediately after the shooting. The success reflected robust pre-existing blood bank inventory and effective regional coordination, a model that holds direct lessons for how hospitals should approach blood product planning today.

The response also revealed a critical gap in existing hospital capacity tracking systems. Automated bed-tracking tools proved essentially useless during the event. They tracked beds, not the human resources, specialty practitioners, and supplies that actually determine whether a hospital can receive and treat mass casualty patients. The real-time system status watchboards developed in the aftermath of October 1 were designed specifically to address this gap.

About the documents:

The 2018 case study is the foundational field report, produced by the Nevada Hospital Association from direct interviews with hospital staff and emergency management personnel across the Southern Nevada region. It documents observations, insights, and lessons across every domain of the response including triage, communications, surge, mortuary care, and mental health and wellness.

The companion presentation distills those findings into a training and briefing format that has been shared nationally since 2018.

The 2025 peer-reviewed article, published in Trauma Surgery and Acute Care Open, formally validates and extends the case study findings for the clinical and academic literature.

All three documents are available below. The peer-reviewed article is published under a Creative Commons Attribution Non-Commercial 4.0 (CC BY-NC 4.0) license and is free to share, distribute, and adapt for educational and non-commercial purposes as long as it is properly cited. The case study and presentation are likewise available for educational use with appropriate attribution.

If your team has questions about mass casualty preparedness, situational awareness infrastructure, or how the Nevada WatchBoard supports real-time coordination during surge events, reach out at watchboard@nvha.net.

Case Study - Harvest Festival Shooting

Trauma Surgery & Acute Care

Harvest Festival Triage Presentation

What is the biggest gap you see in your facility’s mass casualty planning: throughput, triage, supply chain, or communications? Drop your answer in the comments. It will help shape future content.

This is not because the healthcare system was unaffected. It is because wildfire kills through a fundamentally different mechanism than structural fire, and that mechanism produces a distinct hospital footprint. People typically die in wildfires because they cannot evacuate, not because they arrive at hospitals with treatable injuries. The result is a paradox: catastrophic community impact with quiet emergency departments. But “quiet emergency departments” is not the same as “no healthcare system impact.” Our analysis of Nevada Watchboard (NWB) burn center reporting data during the Los Angeles fires identified more than 1,214 facility-level reports generated during the incident period alone. These were drawn from a broader dataset of over 44,000 assessment records across 120 facilities in 43 states and provinces. The data demonstrated activation of burn surge protocols across the Western Region. Burn centers escalated their reporting, coordinators began polling bed availability, and federal agencies started monitoring the network. The burn coordination infrastructure mobilized for a mass casualty event. But the expected influx of burn patients to those centers never materialized at scale.

To understand why this matters, we analyzed the LA fire data alongside a broader set of mass casualty incidents involving fire, explosions, and aviation disasters spanning 1980 to 2025. The combined data reveals that fire-related MCIs produce four distinct hospital footprints depending on the mechanism of injury: structural fires drive general ED surge through smoke inhalation; wildfires activate burn surge protocols but suppress both ED surge and the anticipated patient volume; explosions produce the highest-acuity burn patients requiring specialized transfer coordination; and aviation incidents with post-impact fire create mass fatality events with minimal hospital demand. Each requires a different exercise design. This briefing focuses on what the LA fires revealed about the wildfire pattern and what emergency planners should consider in response.

Read the entire article by clicking the link below:
What the LA Wildfires Revealed About Hospital Preparedness for Burns

Critical Access Hospitals face unique challenges in maintaining regulatory compliance, particularly in rural communities where staff may wear multiple hats and resources are limited. Emergency management coordinators, compliance officers, quality managers, and hospital administrators consistently expressed the need for a single, comprehensive reference that clearly outlines training requirements for the most commonly cited survey deficiencies.

This manual addresses that need by providing detailed guidance on E-Tag (Emergency Preparedness) and A-Tag (Physical Environment and Clinical Care) deficiencies that require staff training programs. It consolidates information from multiple regulatory sources—including CMS Conditions of Participation (42 CFR 482 and 485), Joint Commission Standards, and incorporated NFPA codes—into a practical, user-friendly format.

How to Use This Manual

This manual is designed as both a compliance reference and an implementation guide:

• For Compliance Officers and Quality Managers: Use this manual to verify that your facility’s training programs meet all regulatory requirements, identify gaps, and develop corrective action plans following survey deficiencies.

• For Emergency Managers and Safety Officers: Reference specific sections to design training programs, establish training schedules, and ensure proper documentation of emergency preparedness and life safety training.

• For New Staff and Those New to Emergency Management: This manual provides a comprehensive overview of training requirements in plain language, helping you quickly understand what’s required and why.

• For Training Coordinators: Use the implementation checklists, frequency tables, and documentation requirements to build and maintain compliant training programs.

The manual includes quick-reference tables, detailed training curricula for each tag requirement, documentation templates, and step-by-step implementation guidance. Appendices provide training frequency schedules, contact information, and glossaries of regulatory terminology.

Copyright and Availability

This manual is made freely available to all healthcare facilities under common copyright principles. RHPP believes that rural healthcare facilities benefit from shared resources and collaborative approaches to regulatory compliance. You may:

• Use this manual in its entirety or in part for your facility’s compliance efforts

• Share it with colleagues, consultants, and partner organizations

• Adapt the content to fit your facility’s specific needs and policies

• Reproduce sections for training purposes

We only ask that you reference RHPP and the Nevada Hospital Association when sharing this resource with others, to help connect rural facilities with additional preparedness resources and support.

Feedback and Continuous Improvement

While every effort has been made to ensure the accuracy and completeness of this manual, regulatory requirements evolve, and interpretations may vary. If you discover any errors, omissions, or areas that would benefit from clarification, please help us improve this resource by contacting:

Rural Healthcare Preparedness Partners Email: watchboard@nvha.net

Your feedback helps ensure this manual remains a valuable, accurate resource for Critical Access Hospitals across the region and beyond.

Acknowledgments

This manual represents the collaborative spirit of rural healthcare. It was developed through the combined expertise of emergency managers, compliance professionals, and hospital leaders who understand the practical realities of maintaining regulatory compliance in Critical Access Hospitals. We thank all RHPP members who contributed their insights, questions, and real-world experiences to shape this resource.

We hope this manual serves as a trusted companion in your compliance journey, helping your Critical Access Hospital maintain the highest standards of safety and preparedness for the communities you serve.

Download the full manual below.
COMPREHENSIVE TRAINING COMPLIANCE MANUAL