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Patient Movement, MOCCs, and Tracking
Topic Collection
April 14, 2025

Topic Collection: Patient Movement, MOCCs, and Tracking

 

During a mass casualty incident or hospital evacuation, local emergency responders will be faced with the challenge of identifying, categorizing, and tracking large numbers of patients. As the scale of the incident increases, so does the need for expanded assistance—from the local, state, regional, and federal levels, including health care coalitions and other health systems. Organizing transport resources and matching appropriate patients to available transportation can be challenging. The COVID-19 pandemic spurred innovations in patient load balancing that have application to managing patient movement during other patient surges and disasters requiring distribution of patients with specialty care needs (e.g., pediatric, burn). Medical Operations Coordination Center (MOCC) is a general term for these transfer/load management hubs.

Patient tracking is challenging in all disasters and takes a coordinated effort with all involved to implement a system that works in specific jurisdictions.

Patients known or suspected to be infected with special pathogens require additional patient movement considerations and a National Special Pathogen System has been established to guide clinical and logistical considerations.

This Topic Collection includes resources on patient movement from area healthcare facilities and tracking that can help emergency planners and responders learn more about various levels of assistance available, how to request it, how it is activated, and lessons learned from recent incidents.

This Topic Collection was updated in November 2022. It does not include resources specific to transport to the initial receiving hospital; those can be found in the ASPR TRACIE Pre-Hospital Topic Collection. Pre-hospital triage methods can also be important when not enough transportation resources are available from the scene; access the Pre-Hospital Mass Casualty Triage and Trauma Care Topic Collection for more information. Patient movement is also distinct from hospital evacuation, but important overlapping concerns and coordination issues exist. The Healthcare Facility Evacuation/Sheltering Topic Collection may be a valuable complementary resource.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.

 

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Must Reads

ASPR TRACIE. (2019). Evacuating, Treating, and Tracking People on Dialysis.
After Hurricane Irma struck the U.S. Virgin Islands (USVI), many patients were evacuated to Puerto Rico (PR) to ensure continuity of care. Once Hurricane Maria ravaged PR, however, many USVI residents were evacuated a second time, including renal dialysis patients. This article highlights lessons learned from the evacuation of these patients from a federal patient movement perspective.
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ASPR TRACIE. (2023). Managing a Pediatric Tripledemic: Lessons Learned from 2022.
During the winter months in 2022-2023, hospitals in the state of Washington were overwhelmed by pediatric patients suffering from three respiratory viruses. In this article, subject matter experts provide an overview of the healthcare coalition, the state's pediatric capabilities, and how they used their Medical Operations Coordination Center (MOCC) and healthcare coalitions to balance patient loads throughout the state during this "tripledemic."
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ASPR TRACIE. (2024). Medical Operations Coordination Centers Toolkit (Third Edition).
This Medical Operations Coordination Centers Toolkit, updated in 2024 to include burn and pediatric annexes, offers considerations that can help state, local, tribal, and territorial governments; cooperative entities such as health care coalitions or trauma/emergency medical services regions; and health care systems ensure optimal balancing of patients across health care facilities and systems.
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Hopper, K., Hrdina, C., and Case, C. (2016). Patient Movement Following a Radiological Mass Casualty Incident.
The speakers in this webinar discuss the effects of a nuclear detonation on infrastructure, human beings, and medical resources. They then explain field evacuation of three groups (those with combined injuries, radiation exposure, and limited injuries) to four types of healthcare facilities (medical centers, assembly centers, evacuation centers, and centers set up for “national care” purposes). The Radiation Injury Treatment Network is discussed at the end of the webinar.
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Institute of Medicine. (2015). Regional Disaster Response Coordination to Support Health Outcomes: Surge Management—Workshop in Brief.
This document summarizes three regional workshops on effective medical and public health response to large-scale disasters. Challenges, opportunities, and lessons learned related to patient tracking and evaluation are included. The first section of the document provides some important bullet points to consider when planning large-scale patient movement.
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Lamana, J. (2016). An Introduction to ESF #8 Patient Movement.
The presenter discusses the evolution of patient movement from a federal perspective, summarizes the functional areas under ESF #8, and explains how plans can help responders manage scarce resources.
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McGovern, J. and Bogucki, S.. (2015). Mass Casualty Evacuation and Patient Movement. Emergency Medical Services: Clinical Practice and Systems Oversight, Clinical Aspects of EMS, Second Edition.
The author provides an overview of the planning and activation steps in a catastrophic scenario requiring mass evacuation that overwhelms local and state resources. The chapter has several sections: Planning Cycle (which examines planning for various types of threats); Characteristics of the Area (which encourages planners to consider demographics and structural integrity of healthcare facilities); Estimating Requirements for Medical Evacuation; Planning; Execution; Patient Evacuation from Medical Facilities; and Patient Evacuation Using the National Disaster Medical System.
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Tavakoli, N., Yarmohammadian,, M., Safdari, R., and Keyvanara, M. (2016). Health Sector Readiness for Patient Tracking in Disaster: A Literature Review on Concepts and Patterns. International Journal of Health System & Disaster Management. 4(3): 75-81.
In this literature review of 44 articles published between 2003 and 2015 that focused on patient tracking, the authors explained how the concept varies in emergency medicine and shared findings and experiences with electronic triage and online and wireless tracking systems in various disaster settings.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2016). NDMS Patient Movement Exercise.
This brief video highlights the benefit of holding exercises that test the National Disaster Medical System.
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Ambulance Strike Teams

California Emergency Medical Services Authority. (2023). Disaster Medical Services Division — Ambulance Strike Team.
This webpage defines Ambulance Strike Teams and how they are used in California and includes links to related resources (e.g., the Ambulance Strike Team [AST]/Medical Task Force [MTF] System Manual and a reimbursement schedule).
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Florida Department of Health. (2018). Florida Ambulance Deployment Standard Operating Procedure.
These state-specific standard operating procedures cover issues such as the request process for ambulance strike teams (AST) (for incidents with and without notice), activation processes, resource management, logistical support, and demobilization. Supporting appendices include position descriptions, Florida Standards for an Ambulance Strike Force and Ambulance Task Force, and an equipment list for ground/air ambulance personnel.
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Goss, J., McDonough, M., and Messina, M. (2006). Ambulance Strike Teams. EMSWorld.
The authors explain the development of California’s ambulance strike teams (AST) and medical task forces. They highlighted how ASTs were able to evacuate medical facilities, support cities that were overwhelmed by response activities and address the surge of calls related to the 2003 San Bernardino fires. Sections on concepts of operations, necessary training, and lessons learned are also included.
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Federal Patient Movement

ASPR TRACIE. (2016). Federal Patient Movement: Overview Fact Sheet. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This fact sheet provides an overview of the three levels of patient movement and highlights the functions and support agencies involved in patient movement.
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ASPR TRACIE. (2016). Noble Lifesaver Patient Movement Workshop: Promising Practices and Lessons Learned. United States Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This document summarizes findings from the "Noble Lifesaver Patient Movement (PM) Workshop Series," held in 2015. These Workshops were designed to test and examine the scope of federal assistance for PM functions and the specific requirements among local, state, regional, and federal emergency support function #8 partners to execute PM.
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* ASPR TRACIE. (2019). Evacuating, Treating, and Tracking People on Dialysis.
After Hurricane Irma struck the U.S. Virgin Islands (USVI), many patients were evacuated to Puerto Rico (PR) to ensure continuity of care. Once Hurricane Maria ravaged PR, however, many USVI residents were evacuated a second time, including renal dialysis patients. This article highlights lessons learned from the evacuation of these patients from a federal patient movement perspective.
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Hopper, K. (n.d.). Federal Patient Movement. (Accessed 11/2/2022.)
This presentation highlights the various modes of patient evacuation and transport and tracking, federal coordination centers, the national ambulance contract, and factors that need to be considered when planning and activating federal patient movement. (Note: some content may be outdated, but overall, this presentation provides a robust overview of federal patient movement.)
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Kearns, R., Hubble, M., Holmes, J., et al. (2014). Disaster Planning: Transportation Resources and Considerations for Managing a Burn Disaster. (Abstract only.) Journal of Burn Care and Research. 35(1):21-32.
The authors reviewed literature on burn patient movement, with a focus on federal and military resources, capabilities, and limitations of state resources, both internal and when coordinating between states. The authors examined specialty care, ground and air ambulances, ambulance buses, and hospital-based ambulances and concluded the article by highlighting limitations and barriers to patient movement during a mass casualty burn incident.
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Lamana, J. (2016). An Introduction to ESF #8 Patient Movement.
The presenter discusses the evolution of patient movement from a federal perspective, summarizes the functional areas under ESF #8, and explains how plans can help responders manage scarce resources.
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* McGovern, J. and Bogucki, S.. (2015). Mass Casualty Evacuation and Patient Movement. Emergency Medical Services: Clinical Practice and Systems Oversight, Clinical Aspects of EMS, Second Edition.
The author provides an overview of the planning and activation steps in a catastrophic scenario requiring mass evacuation that overwhelms local and state resources. The chapter has several sections: Planning Cycle (which examines planning for various types of threats); Characteristics of the Area (which encourages planners to consider demographics and structural integrity of healthcare facilities); Estimating Requirements for Medical Evacuation; Planning; Execution; Patient Evacuation from Medical Facilities; and Patient Evacuation Using the National Disaster Medical System.
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National Disaster Medical System. (2018). National Disaster Medical System Federal Coordinating Center Guide.
This document is intended to provide guidance to Federal Coordinating Center (FCC) Directors and staff, as well as local officials who will be receiving and providing care to patients evacuated through NDMS. It includes an overview of NDMS; addresses NDMS activation, operations, and training; and identifies FCC roles and responsibilities.
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    12/4/2019 3:32:08 PM
U.S. Department of Defense. (2016). DoD Instruction 6010.22: National Disaster Medical System (NDMS).
The roles of the U.S. Department of Defense as they pertain to the National Disaster Medical System (NDMS) are summarized in this issuance. The document includes a list of Federal Coordinating Centers and explains how they are selected and activated.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2016). NDMS Patient Movement Exercise.
This brief video highlights the benefit of holding exercises that test the National Disaster Medical System.
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U.S. Department of Veterans Affairs. (2022). VHA Participation in Federal Patient Movement and Definitive Care.
This directive states policy and responsibilities of the Veterans Health Administration related to participation in federal patient movement activities of the National Disaster Medical System and Department of Veterans Affairs-Department of Defense Contingency Hospital System.
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Guidance

ASPR TRACIE. (2019). Mass Casualty Trauma Triage: Paradigms and Pitfalls.
This ASPR TRACIE white paper (developed after a national expert roundtable) can help emergency medical system (EMS) medical directors and EMS systems planners to understand and plan for key differences between “conventional” MCIs and mass violence events when: the scene is dynamic; the number of patients far exceeds usual resources; and usual triage and treatment paradigms may fail.
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Hopper, K., Hrdina, C., and Case, C. (2016). Patient Movement Following a Radiological Mass Casualty Incident.
The speakers in this webinar discuss the effects of a nuclear detonation on infrastructure, human beings, and medical resources. They then explain field evacuation of three groups (those with combined injuries, radiation exposure, and limited injuries) to four types of healthcare facilities (medical centers, assembly centers, evacuation centers, and centers set up for “national care” purposes). The Radiation Injury Treatment Network is discussed at the end of the webinar.
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Institute of Medicine. (2013). Nationwide Response Issues After an Improvised Nuclear Device Attack: Medical and Public Health Considerations for Neighboring Jurisdictions: Workshop Summary, Chapter 9: Roles of Regional Healthcare Coalitions in Planning and Response. National Academies Press.
This report summarizes the presentations from a 2013 workshop held by the Institute of Medicine and the National Association of County and City Health Officials focused on response requirements faced by public health and healthcare systems in response to an improvised nuclear device (IND) detonation. Chapter 9 specifically discusses the roles and work of healthcare coalitions to advance regional planning for IND incidents. The specific challenges of patient forward movement unique to a nuclear event are discussed.
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* Institute of Medicine. (2015). Regional Disaster Response Coordination to Support Health Outcomes: Surge Management—Workshop in Brief.
This document summarizes three regional workshops on effective medical and public health response to large-scale disasters. Challenges, opportunities, and lessons learned related to patient tracking and evaluation are included. The first section of the document provides some important bullet points to consider when planning large-scale patient movement.
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Johnsen, A., Fattah, S., Sollid, S., et al. (2016). Utilisation of Helicopter Emergency Medical Services in the Early Medical Response to Major Incidents: A Systematic Literature Review. BMJ Open. 6(2).
This systematic review describes the use of helicopter ambulances during major incidents to treat or transport patients, rescue personnel, and equipment in the prehospital phase of responding to an incident. The authors found that helicopters are useful in the early response to an incident, and detail challenges encountered by helicopter response to these incidents, including inclement weather, lack of landing sites, insufficient air traffic control, and errors in communication.
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* McGovern, J. and Bogucki, S.. (2015). Mass Casualty Evacuation and Patient Movement. Emergency Medical Services: Clinical Practice and Systems Oversight, Clinical Aspects of EMS, Second Edition.
The author provides an overview of the planning and activation steps in a catastrophic scenario requiring mass evacuation that overwhelms local and state resources. The chapter has several sections: Planning Cycle (which examines planning for various types of threats); Characteristics of the Area (which encourages planners to consider demographics and structural integrity of healthcare facilities); Estimating Requirements for Medical Evacuation; Planning; Execution; Patient Evacuation from Medical Facilities; and Patient Evacuation Using the National Disaster Medical System.
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Rich, T., Biddinger, P., Zane, R., et al. (2011). Recommendations for a National Mass Patient and Evacuee Movement, Regulating, and Tracking System.
The authors explain the development of recommendations for a national mass patient and evacuee movement, regulating, and tracking system that could be used during a mass casualty or evacuation incident for the purposes patient tracking and movement. The system could also be used to support decision making for those responsible for patient and evacuee movement and care, healthcare and transportation resource allocation, and incident management.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Response. (2012). Planning for Psychiatric Patient Movement During Emergencies and Disasters.
This tip sheet highlights basic considerations that can help public health and medical planners prepare for the movement of patients of psychiatric facilities in the event of a disaster.
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Lessons Learned

ASPR TRACIE. (2019). Evacuating a Region: How a Healthcare Coalition Helped Evacuate 1504 Patients from 45 Facilities after Hurricane Harvey.
Floodwaters from Hurricane Harvey inundated 23 out of 25 southeast Texas counties covered by the Southeast Texas Regional Advisory Council’s (SETRAC) Regional Healthcare Preparedness Coalition (RHPC). Many hospitals and nursing homes were evacuated while others closed their submarine doors, sheltered in place, and received critical supplies via helicopter and high-water vehicles. ASPR TRACIE interviewed Lori Upton (RN, BSN, MS, CEM), Director of Regional Preparedness and Operations for SETRAC, to learn more about healthcare facility evacuation from a regional perspective.
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* ASPR TRACIE. (2019). Evacuating, Treating, and Tracking People on Dialysis.
After Hurricane Irma struck the U.S. Virgin Islands (USVI), many patients were evacuated to Puerto Rico (PR) to ensure continuity of care. Once Hurricane Maria ravaged PR, however, many USVI residents were evacuated a second time, including renal dialysis patients. This article highlights lessons learned from the evacuation of these patients from a federal patient movement perspective.
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ASPR TRACIE. (2020). Moving Patients in a Pandemic: A Hybrid California Model Rescues Overwhelmed Hospitals.
Imperial County, located in southeastern California, has a population of approximately 181,000, and shares borders with Arizona and Mexico. El Centro serves as the county seat, and the county's economy is based primarily on agriculture. Two hospitals serve the county: El Centro Regional Medical Center and Pioneers Memorial Healthcare District. Imperial County was a COVID-19 "hot spot," and in May 2020, Mexicali's hospitals reached capacity and announced that they would divert American patients to El Centro, creating a near-instant patient surge, and necessitating the movement of over 625 patients. This article details that process.
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* ASPR TRACIE. (2023). Managing a Pediatric Tripledemic: Lessons Learned from 2022.
During the winter months in 2022-2023, hospitals in the state of Washington were overwhelmed by pediatric patients suffering from three respiratory viruses. In this article, subject matter experts provide an overview of the healthcare coalition, the state's pediatric capabilities, and how they used their Medical Operations Coordination Center (MOCC) and healthcare coalitions to balance patient loads throughout the state during this "tripledemic."
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ASPR TRACIE. (2025). Medical Operations Coordination Centers (MOCC)/Patient Load-Balancing: Summary of Lessons Learned during COVID-19.
In Spring 2022, ASPR TRACIE reviewed lessons learned from 10 states that utilized a MOCC or similar patient load-balancing structure during the COVID-19 pandemic. This document provides a summary of key findings from select MOCCs established prior to and during the COVID-19 pandemic and highlights challenges, and gaps and potential opportunities/considerations for other jurisdictions establishing MOCCs in the future.
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Aviles Mendoza, G., Finne, K., Torre Leon, F., et al. (2021). Observations from the Emergency Management of Dialysis Patients Evacuated from the U.S. Virgin Islands to Puerto Rico Following Hurricane Irma. BMC Health Services Research. 21.
The authors discuss patient evacuation from the U.S. Virgin Islands to San Juan, Puerto Rico or Miami, Florida after Hurricanes Irma and Maria during 2017. The authors discuss variable associated with managing these patients in a shelter for patients with certain medical needs.
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Brassfield, M. (2018). Texas Children's Mission Control Manages Real-time Patient Movement. Ashe Health Facilities Management.
This article discusses how Texas Children’s Hospital managed patient safety amid flooding, accepting NICU patients from smaller overwhelmed hospitals, outpatients requiring dialysis, and other challenges during Hurricane Harvey in 2017. It also discusses how a streamlined patient transfer process accelerated patient movement.
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Dorsey, D., Carlton, F., and Wilson, J. (2012). The Mississippi Katrina Experience: Applying Lessons Learned to Augment Daily Operations in Disaster Preparation and Management. Southern Medical Journal. 106(1).
The authors share how lessons learned in patient movement and other planning and response capabilities have been incorporated since Hurricane Katrina struck the Gulf Coast. The authors highlight the development of Mississippi MED-COM, a statewide medical communications center, to serve as a “hub for patient coordination and movement during emergency incidents.”
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Hillman, M. (2018). 2017 Hurricane Season MN-1DMAT Deployments. Metro Health Ready.
These slides describe the National Disaster Medical System (NDMS) deployments in response to the 2017 hurricane season. The author comments on the NDMS mission, patient movement, and additional activities during Hurricanes Harvey, Irma, and Maria.
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* Institute of Medicine. (2015). Regional Disaster Response Coordination to Support Health Outcomes: Surge Management—Workshop in Brief.
This document summarizes three regional workshops on effective medical and public health response to large-scale disasters. Challenges, opportunities, and lessons learned related to patient tracking and evaluation are included. The first section of the document provides some important bullet points to consider when planning large-scale patient movement.
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Institute of Medicine of the National Academies. (2011). Case Examples: 2008 Mexican Hat, Utah, Incident and 2010 Albert Pike, Arkansas, Flood. Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary.
This chapter presents two case studies of rural mass casualty incidents and includes sections on challenges and successes and lessons learned related to patient movement and tracking.
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Kearns R.D., Holmes J.H., Skarote M ., et al. (2014). Disasters; The 2010 Haitian Earthquake and the Evacuation of Burn Victims to U.S. Burn Centers. (Abstract only.) Burns. 40(6):1121-1132.
The authors describe how burn victims from the 2010 Haitian earthquake were evacuated to the southeastern U.S. as part of the international relief effort. The article highlights intricacies of burn patient movement and related logistics and briefly covers how reimbursement was handled.
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Klein, K.R., and Nagel, N.E. (2007). Mass Medical Evacuation: Hurricane Katrina and Nursing Experiences at the New Orleans Airport. (Abstract only.) Disaster Management and Response. Apr-Jun;5(2):56-61.
The authors of this article describe the experiences and solutions of nurses and other personnel from three Disaster Medical Assistance Teams assigned to the New Orleans airport responsible for patient assessment, stabilization, and evacuation operation after Hurricane Katrina.
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Lee, A. (n.d.). Concept of Forward Movement of Patients. (Accessed 10/11/2022.)
In this PowerPoint presentation, the author provides an overview of forward movement of patients and highlights lessons learned from a 2002 tabletop exercise and Hurricane Katrina.
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Lemay, F., Vanderschuren, A., and Alain, J. (2020). Aeromedical Evacuations During the COVID-19 Pandemic: Practical Considerations for Patient Transport. Canadian Journal of Emergency Medicine. 22(5):584-586.
In this commentary, the authors describe five lessons learned from their aeromedical organization's experience transferring 50 confirmed or suspected COVID-19 patients.
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Lezama, N., Riddles, L., Pollan, W., and Profenna, L. (2011). Disaster Aeromedical Evacuation. (Abstract only.) Military Medicine. 176(10): 1128-1132.
The authors share lessons learned from Department of Defense patient movement during the 2008 hurricane season and the 2010 Haiti earthquake.
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Mason, W.. (2010). The Incomplete Circle of the National Disaster Medical System: What Arkansas Hospitals Learned From Hurricane Gustav. (Abstract only.) Biosecurity and Bioterrorism. 2: 183-91.
The author of this article describes the repatriation and reimbursement issues faced by NDMS hospitals in Arkansas that provided care to patients who were evacuated from Louisiana during Hurricane Gustav.
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Postma, I., Weel, H., Heetveld, M., et al. (2013). Patient Distribution in a Mass Casualty Event of an Airplane Crash. Injury. 44(11):1574-1578.
This article describes the patient distribution and transportation after a 2009 airplane crash near Amsterdam. The authors analyze the patient distribution to 14 different hospitals after the crash and note that while the patient distribution protocol was not followed, patient distribution worked well as zero patients died on the way to the hospital. They recommend updating the patient distribution protocol in consultation with emergency medical services.
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Rogers, N., Guerra, F., Suchdev, P., et al. (2006). Rapid Assessment of Health Needs and Resettlement Plans Among Hurricane Katrina Evacuees-San Antonio, Texas, September 2005. Morbidity and Mortality Weekly. 55(9): 242-244.
The authors conducted surveys with post-Hurricane Katrina evacuees (residing in evacuation centers). Key findings include: 42% had a household member with a chronic medical condition, 28% percent said they had a family member with access or functional needs, and 20% shared that they knew someone in need of post-Katrina counseling services. These findings support the need for healthcare facility emergency planners to bolster their mass casualty patient movement and tracking plans.
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Sanford, C., Jui, J., Miller, H., and Jobe, K. (2007). Medical Treatment at Louis Armstrong New Orleans International Airport after Hurricane Katrina: The Experience of Disaster Medical Assistance Teams WA-1 and OR-2. (Abstract only.) Travel Medicine and Infectious Disease. 5(4):230-5.
The authors describe the patient evacuation that occurred after Hurricane Katrina—the largest air evacuation in U.S. history. They also highlight the multiple factors that “diminished the effectiveness” of the entire operation (e.g., the length of time it took to stand up medical triage to track and move patients, understaffing, and failure to use the incident command system).
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Stuart, J. and Johnson, D. (2011). Air Force Disaster Response: Haiti Experience. (Abstract only.) Journal of Surgical Orthopaedic Advances. 20(1): 62-66.
In this article, the authors share medical response techniques and lessons learned from the U.S. Air Force patient movement effort that took place after the 2010 Haiti earthquake.
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Tavakoli, N., Yarmohammadian,, M., Safdari, R., and Keyvanara, M. (2016). Health Sector Readiness for Patient Tracking in Disaster: A Literature Review on Concepts and Patterns. International Journal of Health System & Disaster Management. 4(3): 75-81.
In this literature review of 44 articles published between 2003 and 2015 that focused on patient tracking, the authors explained how the concept varies in emergency medicine and shared findings and experiences with electronic triage and online and wireless tracking systems in various disaster settings.
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U.S. Government Accountability Office. (2019). HHS Should Address Deficiencies Highlighted by Recent Hurricanes in the U.S. Virgin Islands and Puerto Rico.
This webpage discusses gaps in the hurricane response conducted by the U.S. Department of Health and Human Services (HHS). It highlights shortcomings in the response (e.g., lack of awareness specific to supporting agency capabilities and challenges associated with primary and chronic care preparedness in the U.S. Virgin Islands and Puerto Rico). Seven recommendations that can help HHS bolster hurricane preparedness are included in the report.
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Vora, N., Grober, A., Goodwin, B., et al. (2018). Challenges of Service Coordination for Evacuees of Hurricane Maria through the National Disaster Medical System. Journal of Emergency Management. 16(3):203-206.
This article discusses how Hurricane Maria evacuees, especially those requiring dialysis, navigated the National Disaster Medical System. Many patients requiring dialysis were not able to return home to the U.S. Virgin Islands or Puerto Rico for some time after the storm due to the limited capability of dialysis centers on the islands.
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National Ambulance Contract Resources

Federal Emergency Management Agency. (2008). Typed Resource Definitions. Emergency Medical Services Resources.
Emergency incident command staff can use the information in this document to request and receive resources through mutual aid during disasters or other emergencies.
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Federal Emergency Management Agency, National Integration Center. (n.d.). Resource Typing Library Tool. (Accessed 10/11/2022.) U.S. Department of Homeland Security .
This online catalog contains information on and links to National Incident Management Systems (NIMS) definitions, job titles/position qualifications and Position Task Books.
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U.S. Department of Homeland Security, American Medical Response, and U.S. Department of Health and Human Services. (2015). EMS Scope of Practice, Protocols, Reciprocity, and Medical Control and Direction for AMR/FEMA Federal EMS Deployments.
In a critical incident, emergency medical services responders from multiple states will likely be deployed under the National Ambulance Contract. This document includes clinical guidelines, a minimum scope of practice, and reciprocity procedures all responders must comply with regardless of their state of origin.
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Patient Load Balancing / MOCC

Administration for Strategic Preparedness and Response. (n.d.). Regional Disaster Health Response System. (Accessed 10/11/2022) U.S. Department of Health and Human Services.
This webpage provides information on the Regional Disaster Health Response System (RDHRS), which aims to create a tiered system of disaster health care. The RDHRS is intended to increase medical surge capacity, expand access to specialty clinical care, establish best practices, and address health care preparedness challenges. Activities include coordinating medical surge, supporting large-scale patient movement, expanding telemedicine capabilities, and developing deployable specialty medical teams.
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* ASPR TRACIE. (2023). Managing a Pediatric Tripledemic: Lessons Learned from 2022.
During the winter months in 2022-2023, hospitals in the state of Washington were overwhelmed by pediatric patients suffering from three respiratory viruses. In this article, subject matter experts provide an overview of the healthcare coalition, the state's pediatric capabilities, and how they used their Medical Operations Coordination Center (MOCC) and healthcare coalitions to balance patient loads throughout the state during this "tripledemic."
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ASPR TRACIE. (2023). The Evolution of Patient Load Balancing: The Southwest Texas Regional Advisory Council.
Regional patient load balancing is an art and science that has evolved across the U.S., particularly over the past few years. ASPR TRACIE interviewed Eric Epley of the Southwest Texas Regional Advisory Council— who was the Council’s first official hire in 1998 and currently serves as the executive director/chief executive officer (CEO)—to learn more about how the Council has evolved and promising practices in load balancing and other trauma-related efforts.
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ASPR TRACIE. (2024). Medical Operations Coordination Centers.
Healthcare systems were pushed to the brink during the pandemic, and many continue to experience abnormal levels of strain that often impact patient census, bed availability, and the ability of tertiary care centers to accept transfers. Many states primarily use two techniques to ensure patients have the best possible access to care: load balancing and transfer management systems. This brief describes the centers that provide these services (Medical Operations Coordination Centers, or MOCCs) that help avoid or mitigate crisis conditions.
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Baum, K., Vlaanderen, L., James, W., et al. (2024). The Minnesota Medical Operations Coordination Center. (Abstract only.) Chest Journal. 165(1): 95-109.
The authors describe how the state's medical operations coordination center (MOCC) augmented patient placement during severe capacity challenges due to the COVID-19 pandemic. They found that while the MOCC effectively placed patients during the first fall 2020 surge, placement of ICU and medical-surgical patients decreased during a subsequent surge, when resources were even more scarce.
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Dichter, J., Brown, D., Zamorano, C., et al. (2024). The Minnesota Critical Care Working Group 1: Monitoring and Coordinating Statewide Critical Care Surge Response in the COVID-19 Pandemic, March 2020 through July 1, 2021. (Abstract only.) CHEST (in press).
This article details the formation of the working group and how they collaborated to develop a statewide response to the COVID-19 pandemic that can serve as a model for future events.
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Franklin, B., Mitchell, S., Villarroel, L., et al. (2023). State Capacity Coordination Centers to Facilitate Access to Acute Care: A National Survey and Analysis. NEJM Catalyst Innovations in Care Delivery. 5(1).
The authors of this article discuss state capacity coordination centers (SCCC), also known as medical operations coordination centers (MOCCs), which are a tool to facilitate load balancing during surges. The authors surveyed SCCCs to understand their prevalence, design, and performance. They found that 43.2% of the 44 states that responded to the survey reported using an SCCC and all of those respondents planned to continue SCCC operations after the pandemic.
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Lentz, T., Groizard, C., Colomes, A., et al. (2021). Collective Critical Care Ambulance: An Innovative Transportation of Critical Care Patients by Bus in COVID-19 Pandemic Response. Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine. 29(1):78.
This article discusses the use of buses in France to move patients from hospitals experiencing surge to those which had space for additional COVID-19 patients, using critical care ambulances that could transport six intensive care patients; The authors describe a test in which four intubated patients were successfully transported in critical care ambulances without incident, demonstrating that this is an effective tool for load balancing during a pandemic or other patient surge scenario.
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Michelson, K., Rees, C., Sarathy, J., et al. (2020). Inter-Region Transfers for Pandemic Surges. Clinical Infectious Diseases.
Using estimates of inpatient and intensive care unit COVID-19 cases, the authors modeled the effects of transferring patients from regions with bed shortfalls to the nearest region with unused beds.
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Mitchell, S., Merkel, M., Eriksson, C., et al. (2023). Using Two Statewide Medical Operations Coordination Centers to Load Balance in Pediatric Hospitals During a Severe Respiratory Surge in the United States. (Abstract only.) Pediatric Critical Care Medicine. 24(9):775-781.
Authors from Washington and Oregon describe how two MOCCs were used to manage 183 pediatric requests from hospitals unable to transfer pediatric patients between November and December 2022. Most patients had acute viral respiratory disease; those older than 13 were primarily hospitalized for intentional drug ingestions. Nearly 60% of transfers were for critically ill children; 17% originated from critical access hospitals. The use of pediatric clinical expert consultation facilitated triage and the use of MOCCs improved the transfer process overall.
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Mitchell, S., Rigler, J., and Baum, K. (2022). Regional Transfer Coordination and Hospital Load Balancing During COVID-19 Surges. JAMA Health Forum. 3(2):e215048.
The three authors describe statewide initiatives in their respective states to load balance patients during the COVID-19 pandemic.
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Sarzynski, S., Mancera, A., Mann, C., et al. (2022). Frequency and Risk of Emergency Medical Service Interhospital Transportation of Patients with Acute Lower Respiratory Tract Illness During the COVID-19 Pandemic in the US. Journal of the American Medical Association. 327(9):874-877.
This article discusses challenges associated with transport of critically ill COVID-19 patients to manage patient surge and ensure patient loads are balanced among hospitals. The authors compared data before and during the pandemic pulled from an emergency medical services database to determine the association of patient transport with severe deterioration of a patient’s condition in patients with lower respiratory tract illness. They found that patient transport did not increase cardiac arrest, advanced airway placements, or noninvasive positive pressure ventilation, including during subsequent waves of COVID-19.
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Sarzynski, S., Mancera, A., Yek, C., et al. (2024). Trends in Patient Transfers From Overall and Caseload-Strained US Hospitals During the COVID-19 Pandemic. JAMA Network Open. 7(2)..
Based on a survey of 681 U.S. hospitals, the authors found that fewer than usual outgoing transfers to acute care hospitals occurred during periods of patient surge during the pandemic. They also found that rural hospitals with fewer than 200 beds were unable to load balance patients by transferring them. They emphasize the need to understand and plan to mitigate the effect of this challenge on patient safety and access to care during future public health emergencies.
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Patient Tracking

Chan, T., Griswold, W., Buono, C., et al. (2011). Impact of Wireless Electronic Medical Record System on the Quality of Patient Documentation by Emergency Field Responders During a Mass-Casualty Exercise. (Abstract only.) Prehospital Disaster Medicine. 26(4):268-275.
The authors compared the efficiency and accuracy of a wireless, electronic patient documentation tool against a traditional paper-based tool during a mass casualty exercise. They found that the electronic tool performed better.
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Farcas, A., Zaidi, H., Wleklinski, N., et al. (2022). Implementing a Patient Tracking System in a Large EMS System. (Abstract only.) Prehospital Emergency Care. 26(2):305-310.
The authors share how Chicago first responder, public health, and 27 used a barcode system to track patients during a large event. While the system was successful in tracking patients from their initial contact with emergency medical services to the hospital, the authors discuss limitations and barriers encountered when implementing the system (e.g., logistical and technological barriers).
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InformationWeek Healthcare. (2014). Marathon Bombing Lessons: Boston Hospital Revamps Information Systems.
In this article, the Brigham & Women's emergency department leaders describe how they corrected system deficiencies revealed by the 2013 Boston Marathon bombing, including enhancing unidentified-patient naming conventions.
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Lenert, L., Kirsh, D., Griswold, W., et al. (2011). Design and Evaluation of a Wireless Electronic Health Records System for Field Care in Mass Casualty Settings. Journal of the American Medical Informatics Association. 18(6): 842–852.
Lenert et al. describe Wireless Internet Information System for Medical Response in Disasters (WIISARD), including the research that contributed to its development and testing. They found that applying the principles of electronic health records can help responders track patients in mass casualty incidents and that WIISARD could improve patient data collection and dissemination.
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Pediatric Resources

* ASPR TRACIE. (2023). Managing a Pediatric Tripledemic: Lessons Learned from 2022.
During the winter months in 2022-2023, hospitals in the state of Washington were overwhelmed by pediatric patients suffering from three respiratory viruses. In this article, subject matter experts provide an overview of the healthcare coalition, the state's pediatric capabilities, and how they used their Medical Operations Coordination Center (MOCC) and healthcare coalitions to balance patient loads throughout the state during this "tripledemic."
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Chung, S., Christoudias, C.M., Darrell, T., et al. (2012). A Novel Image-based Tool to Reunite Children With Their Families After Disasters. Academic Emergency Medicine, 19(11): 1227-1234.
This article reports the findings of tests completed to determine the accuracy of various child identification tools. One tool, “Feature-Attribute-Matching,” extracts facial features from photographs to be matched with a parent's description of their child. The other tool, "User-Feedback," allows parents to choose photographs resembling their child which then reprioritizes the images in the database.
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Emergency Nurse Association, Emergency Medical Services for Children, and Society of Trauma Nurses. (n.d.). Inter Facility Transfer Toolkit for the Pediatric Patient. (Accessed 6/6/2022.)
This toolkit can help staff develop safe and timely interfacility pediatric transfer guidelines. The resources contained within the document include best practices of hospitals from around the country.
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Texas Trauma Service Area (TSA) B. (2016). Trauma Service Area - B (BRAC): Regional Pediatric Plan.
This plan provides prehospital and hospital providers with regional standardized procedures for the treatment of pediatric patients. It addresses various issues to include: prehospital triage, helicopter activation, inter-hospital transfers, pediatric trauma triage/ transfer decision scheme, among other topics.
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Plans, Tools, and Templates

ASPR TRACIE. (2024). Medical Operations Coordination Centers Toolkit (Third Edition).
This Medical Operations Coordination Centers Toolkit, updated in 2024 to include burn and pediatric annexes, offers considerations that can help state, local, tribal, and territorial governments; cooperative entities such as health care coalitions or trauma/emergency medical services regions; and health care systems ensure optimal balancing of patients across health care facilities and systems.
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CT Department of Public Health, CT Department of Emergency Management and Homeland Security, and The Capitol Region Metropolitan Medical Response System, State of Connecticut. (2008). State of Connecticut: The Forward Movement of Patients Plan.
This state plan covers the medical management and transport of patients after a mass casualty incident (and before the National Disaster Medical System [NDMS] is implemented). It also includes steps for activating and implementing NDMS.
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Florida Department of Health. (2013). Patient Movement Support Standard Operating Guideline.
This guide describes how the state monitors and coordinates resources to support the care and movement of patients in areas where local capacity is exceeded and state assistance is requested.
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Hospital Incident Command System. (n.d.). Disaster Victim/Patient Tracking Form. (Accessed 10/11/2022)
Healthcare providers can use this HICS 254 form to track patients by triage tag number, demographics, area triaged to, location/time of procedure, time sent to surgery, and disposition within a healthcare facility.
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Hospital Incident Command System. (2014). Patient Tracking Manager.
This Job Action Sheet can be used to monitor the movement and document the location of patients. It also includes lists of other helpful Hospital Incident Command System forms and resources.
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Mace, S., Doyle, C., Askew, K., et al. (2018). Planning Considerations for Persons with Access and Functional Needs in a Disaster-Part 2: Evacuation and Sheltering. (Abstract only.) American Journal of Disaster Medicine. 13(3):195-206.
The authors discuss considerations for individuals with access and functional needs during a disaster as part of all-hazard preparedness. The article describes characteristics of individuals who meet this definition, legal considerations, evacuation and transportation, and general recommendations for planners considering these individuals in disaster preparedness.
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Orlando Health. (2018). Questions Every Hospital Must Ask About Whether They’re Supporting Their Non-resident/Foreign Citizen Patients.
This white paper is based on the significant experience Orlando Regional Medical Center had after the Pulse Nightclub shooting and can help health care facility emergency planners plan for and better support non-resident/foreign patients in general and after a mass casualty/mass fatality incident.
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TN Department of Health. (2018). Tennessee Emergency Patient Tracking Plan.
While specific to the State of Tennessee, this document can help regions in other states create and adopt a patient tracking system and plan to ensure coordination of relevant healthcare information during a surge event.
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Special Pathogen Patient Movement

ASPR TRACIE. (2023). EMS Infectious Disease Playbook.
This playbook (updated in 2023) synthesizes multiple sources of information in a single planning document addressing the full spectrum of infectious agents to create a concise reference resource for emergency medical services (EMS) agencies developing their service policies. The information can be incorporated into agency standard operating procedures and reviewed by the EMS medical director.
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  • Bridget Kanawati Thank you for your interest in this resource. Unfortunately, funding restrictions preclude our being able to provide printed versions of our resources so all of our products, including this one, are only available electronically. ASPR TRACIE Team
    3/26/2020 2:12:42 PM
  • Frances Thorpe I agree with Tracy, is there a way to order this publication in hard copy format? The information contained in this publication highlights agency infection control policies and is a great resource to have in the department library.
    3/26/2020 12:21:37 PM
  • Tracy Miller Is there any way to order a printed and bound version?
    8/9/2018 5:16:09 PM
ASPR TRACIE and NETEC. (2017). Highly Pathogenic Infectious Disease Exercise Planning for Regional Transport Webinar.
The speakers shared information on exercise templates (specifically tailored for regional transport) to test readiness for highly pathogenic infectious patients; explained how exercises support ASPR’s regional, tiered approach; and discussed tips from three jurisdictions on how to exercise plans.
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Centers for Disease Control and Prevention. (2016). Guidance for Developing a Plan for Interfacility Transport of Persons Under Investigation or Confirmed Patients with Ebola Virus Disease in the United States.
This document provides guidance on developing plans for interfacility air or ground transport of persons under investigation and Ebola patients.
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Department of Emergency Health Services. (2018). Emerging Infectious Diseases Videos for Prehospital Providers. University of Maryland Baltimore County.
This instructional series, comprised of nine modules (listed at the top of the page), includes an introduction to infectious diseases, basic infection control concepts, considerations for personal protective equipment (including donning and doffing), personnel decontamination, patient transport, and transfer of patient care for patients with Ebola and other highly infectious diseases.
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Federal Emergency Management Agency. (2015). Ebola Virus Disease Regional Network Coordination Table Top Exercise.
This exercise can help participants plan for coordinated transport of a person diagnosed with Ebola virus disease, between and within states, to the Regional Ebola Treatment Center in Texas.
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Isakov, A., Miles, W., Gibbs, S., et al. (2015). Transport and Management of Patients with Confirmed or Suspected Ebola Virus Disease. Annals of Emergency Medicine. 66(3):297-305.
This article discusses the Centers for Disease Control and Prevention, Emory University, and the University of Nebraska’s infection control practices developed in the early 2000’s for safely transporting and treating patients who may have Ebola Virus Disease. The authors describe the processes and procedures implemented so that other medical centers can also develop the capability to care for these patients.
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Lowe, J., Jelden, K., Schenarts, P., et al. (2015). Considerations for Safe EMS Transport of Patients Infected with Ebola Virus. (Abstract only.) Prehospital Emergency Care. 19(2):179-183.
The authors discuss the coordinated response between the Nebraska Biocontainment Unit (through the Nebraska Medical Center in Omaha) and Omaha Fire Department's EMS to transport patients with confirmed Ebola virus from West Africa from the airport to the high-level isolation unit. Three critical areas have been identified from their experience and are addressed in this article: ambulance preparation, appropriate selection and use of personal protective equipment, and environmental decontamination.
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Office of the Assistant Secretary for Preparedness and Response. (2017). Regional Treatment Network for Ebola and Other Special Pathogens.
This report provides information on the regional treatment network established for the management of patients with Ebola and other special pathogens, its oversight and financing, the current state of preparedness, and planning and future considerations.
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TALON Preparedness Partners. (2015). TALON Ebola Preparedness Tabletop Exercise: Situation Manual.
This situation manual was developed for participants of an Ebola Virus Disease Regional Network Table Top Exercise. It includes scenarios and related questions, and several appendices, including links to helpful resources.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2018). Exercise: Tranquil Terminus.
Safely moving patients with highly infectious diseases, like Ebola, to regional treatment centers takes teamwork, preparation, skill and training. Tranquil Terminus, the largest patient movement exercise in U.S. Department of Health and Human Services’ history, tested the nationwide ability to move patients with highly infectious diseases safely and securely to regional treatment centers.
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Agencies and Organizations

U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response. Definitive Care.
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U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response. NDMS Patient Movement Program.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, At-Risk Individuals, Behavioral Health, & Community Resilience. National Disaster Medical System.
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This ASPR TRACIE Topic Collection was updated in November 2022. It was comprehensively reviewed in February 2017 by the following subject matter experts (listed alphabetically):

Eric Alberts, CEM, CHS-V, FPEM, FPEM-HC, CDP-1, CHPP, CHEP, SEM, CFRP, FABCHS, Emergency Preparedness Manager, Orlando Health, Inc.; Julie Bulson, DNP, MPA, RN, NE-BC, Director, Emergency Preparedness, Spectrum Health; John Hick, MD, HHS ASPR and Hennepin County Medical Center; Alexander Isakov, MD, MPH Emory University; Mark P. Jarrett, MD, MBA, MS, SVP & Chief Quality Officer, Northwell Health; Jodi Keller, RN, Associate Director of Healthcare System Emergency Preparedness, Central Ohio Trauma System; Mary Russell EdD, MSN, Emergency Services, Boca Raton Regional Hospital; and Gamunu Wijetunge, Office of Emergency Medical Services, National Highway Traffic Safety Administration.

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