Mass casualty incident preparedness and response: A desk review of the Code Orange Plan and Assessment of Healthcare Workers’ Knowledge, Attitudes, and Practices in a Lebanese Tertiary Government Hospital

Linda Abou-Abbas; Rima Kashash; Mustapha Khalife; Mohamad Shafic Ramadan

doi:10.1371/journal.pone.0348176

Peer Review History

Original SubmissionJanuary 19, 2026
17 Mar 2026 Decision Letter - Hans-Peter Simmen, Editor Dear Dr. Abou-Abbas, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. It is really a well written study dealing with a extremely important topic. Both reviewers recommend a minor revision only prior to definite acceptance. Please, clarify the statistics methods, as pointed out by reviewer 1. Reviewer 2 asked about a possible error in lines 521. I think, it will be quite simple to make any correction. Please submit your revised manuscript by May 01 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. 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Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.... We look forward to receiving your revised manuscript. Once again, your important manuscript deserves widespread distribution, as it deals with a very important topic. Kind regards, Hans-Peter Simmen, M.D., Professor of Surgery Academic Editor PLOS One Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. 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If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: No Reviewer #2: I Don't Know ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: No Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Thank you for the opportunity to review this interesting paper. The manuscript addresses an important and relevant topic. Focus of this manuscript is the evaluation of the mass casualty preparedness of the RHUH hospital via a desk review of the organizations Code Orange plan and an evaluation of staff knowledge via a cross-sectional KAP survey regarding MCI preparedness. Methods: Desk Review: The "team of experts" conducting the desk analysis shoud be described more clearly. How many experts? Which qualifications? Statistics: the manuscript aims to compare differences in percieved preparedness of non medical and medical staff - in the statistics section it is stated that a paired t-test was used for assessment. Please clarify whether an independent samples t-test was performed instead, as the groups appear to be independent? If a paired test was used, the statistical approach should be reconsidered. Conclusion: Right now the conclusion focuses on measures to improve the disaster preparedness at the RHUH - the authors should consider expanding the conclusion to include more generizable recomendations. Thus, it could be read more as a potential blueprint for other hospitals and provide a broader perspective, strengthening relevance of the findings. Figure 1: should be uploaded in better resolution, the text is not readable. A figure legend should be added. Other: Line 218: a ) is missing after IT staff Reviewer #2: Thank you for the opportunity to review this study. This study conducted a desk review and a survey of hospital staff in regard to the mass casualty contingency plan for a large tertiary government hospital in Lebanon. The paper highlights many improvements that can be made and that have been implemented that are important for all medical institutions worldwide to address. The survey well highlights the difficulty associated with staff awareness and training, in what is already a challenging and very strenuous work environment. How do we efficiently prepare staff for an MCI when resources in both time and money are limited? It’s a difficult question to answer, and this paper does a good job of addressing the difficulties inherent in planning for an MCI, which are of course exceptionally taxing and challenging. Further, it provides helpful inputs on where to focus energies and how to be better prepared. I would like to see two questions answered in the paper: 1) who specifically, performed the desk review? 2) was a debriefing performed after the Beirut Blast? How many patients did RHUH treat during this terrible explosion? What was learned from that event and how has this been applied to the current MCI plan? This would be very interesting to learn about, as the facility has the rare experience of handling a large MCI. Why did only 8 of 32 staff members use the code orange kit, for example? Addressing these questions will greatly enhance the paper as it provides actual data on MCI management. The previous MCI plan was revised in 2016. The Beirut Blast occurred in 2020. So it would be of great interest to discuss how the update to the current MCI contingency plan was influenced by a major real-world MCI. This should be a critical strength of this paper! There is an error on line 521: more medical staff had previous MCI experience than non-medical staff. On line 521, the rates of no previous exposure have erronously been reported. I would very briefly highlight, that the purpose of improving such protocols and procedures is not just ensuring safety for hospital staff, but for the benefit of patient care, this is lacking in the abstract, although it is well addressed in the introduction. Finally, the paper is well-written and requires no revision in this regard. Overall, this is a well performed study that provides valuable insights highlighting the importance of properly informing and training hospital staff about MCI contingency plans, so that staff are safe and as effective as possible in providing patient care. I thank the authors for their efforts and recommend that the study be accepted for publication with minor revisions. I would recommend strengthening the paper by highlighting the role that actual real-world experience in dealing with the Beirut Blast (and also Iranian Embassy Explosion) helped improve the current MCI protocol. ****** what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? 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If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. https://doi.org/10.1371/journal.pone.0348176.r001
Revision 1
7 Apr 2026 Author Response Reviewer #1: Methods: Desk Review: The "team of experts" conducting the desk analysis should be described more clearly. How many experts? Which qualifications? Author’s reply: We have revised the manuscript to provide a clearer description of the “team of experts” involved in the desk analysis. Specifically, we now indicate the number of experts (six) and detail their respective qualifications and roles, highlighting their multidisciplinary expertise in clinical care, nursing leadership, emergency preparedness, and public health. Statistics: the manuscript aims to compare differences in perceived preparedness of non-medical and medical staff - in the statistics section it is stated that a paired t-test was used for assessment. Please clarify whether an independent samples t-test was performed instead, as the groups appear to be independent? If a paired test was used, the statistical approach should be reconsidered. Author’s reply: Thank you for highlighting this point. The analysis was conducted using an independent samples t-test, as the comparison involved two independent groups (medical vs. non-medical staff). The mention of a paired t-test in the Methods section was a reporting error and has now been corrected. Conclusion: Right now the conclusion focuses on measures to improve disaster preparedness at the RHUH - the authors should consider expanding the conclusion to include more generalizable recommendations. Thus, it could be read more as a potential blueprint for other hospitals and provide a broader perspective, strengthening relevance of the findings. Author’s reply: Thank you for this valuable suggestion. The conclusion has been revised to include more generalizable recommendations beyond the RHUH context. Specifically, we have expanded the section to highlight key considerations for hospitals operating in similar settings, emphasizing the importance of comprehensive emergency planning, inclusive interdisciplinary training, and alignment between planning, training, and real-world implementation. Figure 1: should be uploaded in better resolution; the text is not readable. A figure legend should be added. Author’s reply: The figure has been uploaded in a higher resolution, as recommended by the journal. The figure legend is provided within the manuscript (Line 560). Other: Line 218: a) is missing after IT staff Author’s reply: Corrected. Reviewer #2: Thank you for the opportunity to review this study. This study conducted a desk review and a survey of hospital staff in regard to the mass casualty contingency plan for a large tertiary government hospital in Lebanon. The paper highlights many improvements that can be made and that have been implemented that are important for all medical institutions worldwide to address. The survey well highlights the difficulty associated with staff awareness and training, in what is already a challenging and very strenuous work environment. How do we efficiently prepare staff for an MCI when resources in both time and money are limited? It’s a difficult question to answer, and this paper does a good job of addressing the difficulties inherent in planning for an MCI, which are of course exceptionally taxing and challenging. Further, it provides helpful inputs on where to focus energies and how to be better prepared. I would like to see two questions answered in the paper: 1) who specifically performed the desk review? Author’s reply: We have revised the manuscript to provide a clearer description of the “team of experts” involved in the desk review. Specifically, we now indicate the number of experts (six) and detail their respective qualifications and roles, highlighting their multidisciplinary expertise in clinical care, nursing leadership, emergency preparedness, and public health. 2) was a debriefing performed after the Beirut Blast? How many patients did RHUH treat during this terrible explosion? What was learned from that event and how has this been applied to the current MCI plan? This would be very interesting to learn about, as the facility has the rare experience of handling a large MCI. Author’s reply: Thank you for this valuable comment. We have revised the Introduction to address these points. The manuscript has been updated accordingly: To strengthen preparedness for MCIs, RHUH established its mass casualty response plan, Code Orange, in 2016. The plan provides a structured framework for hospital response during large-scale emergencies, including activation criteria, triage processes, staff mobilization, and surge capacity management. RHUH has applied this plan in response to several large-scale events, most notably the Beirut Port explosion in 2020, during which approximately 220 casualties presented to the hospital, with 48 requiring admissions, including critical care. This event placed unprecedented strain on the hospital and provided critical insights into both the strengths and limitations of existing response mechanisms. Following the explosion, a formal debriefing was conducted to inform updates to the Code Orange plan and incorporate lessons learned from this real-world experience. Identified challenges—such as rapid patient influx, interdepartmental coordination, and resource limitations—led to targeted improvements in triage systems, surge capacity, and staff mobilization protocols, ensuring a more practical and adaptive response to large-scale MCIs. There is an error on line 521: more medical staff had previous MCI experience than non-medical staff. On line 521, the rates of no previous exposure have erroneously been reported. Author’s reply: Thank you for pointing out this issue. Corrected I would very briefly highlight, that the purpose of improving such protocols and procedures is not just ensuring safety for hospital staff, but for the benefit of patient care, this is lacking in the abstract, although it is well addressed in the introduction. Author’s reply: Added please refer to the abstract Finally, the paper is well-written and requires no revision in this regard. Overall, this is a well performed study that provides valuable insights highlighting the importance of properly informing and training hospital staff about MCI contingency plans, so that staff are safe and as effective as possible in providing patient care. I thank the authors for their efforts and recommend that the study be accepted for publication with minor revisions. Author’s reply: We sincerely thank the reviewer for this positive feedback and are pleased that the manuscript is considered well-written. We appreciate your time and thoughtful evaluation of our work. I would recommend strengthening the paper by highlighting the role that actual real-world experience in dealing with the Beirut Blast (and also Iranian Embassy Explosion) helped improve the current MCI protocol. Author’s reply: Thank you for your comment. We have revised the introduction to highlight how real-world experience from the Beirut Port explosion directly informed improvements to the Code Orange plan. The updated paragraph now emphasizes the formal debriefing, lessons learned, and how these insights were translated into practical updates to triage processes, surge capacity, and staff mobilization protocols. We believe this revision clearly addresses your suggestion and strengthens the link between operational experience and protocol enhancement. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0348176.r002
14 Apr 2026 Decision Letter - Hans-Peter Simmen, Editor Mass Casualty Incident Preparedness and Response: A Desk Review of the Code Orange Plan and Assessment of Healthcare Workers' Knowledge, Attitudes, and Practices in a Lebanese Tertiary Government Hospital PONE-D-26-02078R1 Dear Dr. Abou-Abbas, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Following minor revision your manuscript is really much better as well as more informative. Congratulations. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support.... If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Hans-Peter Simmen, M.D., Professor of Surgery Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0348176.r003
Formally Accepted
Acceptance Letter - Hans-Peter Simmen, Editor PONE-D-26-02078R1 PLOS One Dear Dr. AbouAbbas, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Hans-Peter Simmen Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0348176.r004

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