2.1.1. Desk review team composition.

The desk analysis was conducted by a multidisciplinary team of six experts with complementary clinical, managerial, and public health expertise in MCI preparedness and response. The team included a Senior Medical Officer and Project Manager- Health advisor for Emergency Preparedness and Response; a Consultant General Surgeon and certified instructor in internationally recognized MCI training programs (including ICRC Mass Casualty Incident Training (MCIT), ICRC Health Emergencies in Large Populations (HELP) course, and WHO Mass Casualty Management); an ICRC Head Nurse with expertise in mass casualty management; an MCI trainer who is also the RHUH Nursing Director and Head of the Public Health Emergency Operations Center (PHEOC); a Quality Officer and Nursing Supervisor from RHUH; and a public health specialist with a Master of Public Health (MPH) in Epidemiology and Biostatistics.

2.1.2. Document selection.

1. a. Internal Documents Selection

Internal documents were sourced through direct access to hospital archives and requests from relevant departments. The selected documents include:

1. The most recent version of the Code Orange plan
2. Procedural guidelines and protocols
3. Training manuals and educational materials for staff
4. After-action reports from past MCI or disaster drills
5. Hospital policies and memos on emergency preparedness

These documents were handled with strict confidentiality, and permissions were obtained from relevant authorities for accessing and analyzing internal hospital documents.

1. b. External Documents

A literature review was conducted using targeted keyword searches related to MCI, including “mass casualty,” “MCI,” “disaster response,” “emergency management,” “triage,” “mass casualty preparedness,” “emergency response plan,” “crisis management,” “disaster management,” and “emergency preparedness.” Additional keywords focused on hospital preparedness, such as “hospital preparedness,” “hospital response plan,” “emergency protocols,” “Code Orange,” “hospital emergency plan,” “hospital disaster plan,” and “healthcare facility readiness.”

The search strategy incorporated multiple databases and global resources to ensure comprehensive coverage of MCI and emergency preparedness. Peer-reviewed literature was identified through databases such as PubMed and Google Scholar, including relevant studies, reviews, and articles on disaster preparedness and hospital emergency response. In addition, grey literature sources were consulted to capture practical frameworks and guidelines, including publications from the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), National Incident Management System (NIMS), and the Association for Professionals in Infection Control and Epidemiology (APIC).

2.1.3. Data analysis.

The team of experts reviewed the documents to identify gaps and areas requiring enhancement. The evaluation centered on four key aspects: the presence of necessary components and protocols within the document, the clarity of procedures and responsibilities, alignment with established guidelines to ensure adherence to best practices, and the applicability of the plan to current operations. To validate the findings, the identified gaps and weaknesses were cross verified with insights from key stakeholders, including ICRC staff and RHUH department heads. This cross-verification process ensured that the desk review’s findings were consistent with practical experiences and observations from those directly involved in emergency preparedness and response.

2.2.1. Design and participants.

A cross-sectional study was conducted among staff at RHUH, with participant recruitment taking place from 01/05/2022 to 30/06/2022. The RHUH hospital employs 1,000 health care workers (HCW) from various professional backgrounds, including medical personnel such as physicians, nurses, pharmacists, laboratory, and radiology technicians, as well as non-medical personnel such as administrative staff, maintenance workers, housekeeper supervisors, security personnel, and information technology (IT) staff. The survey targeted all active staff members, excluding those in managerial positions and employees with inactive contracts during the data collection period. Managerial staff was excluded to avoid potential bias, as their perspectives and experiences might significantly differ from those in non-managerial roles. Employees with inactive contracts were excluded to ensure that the data accurately reflected the current working environment and practices within the hospital.

2.2.2. Sampling methodology.

The sampling methodology for the study involved a two-step process. First, stratified sampling was used to divide the RHUH staff into two main categories: medical personnel (including physicians, nurses, pharmacists, laboratory, and radiology technicians) and non-medical personnel (including administrative staff, maintenance workers, housekeeper supervisors, security personnel, and IT staff). Second, Sampling within these strata was conducted using a convenience sampling approach, where participants were selected based on their availability and willingness to respond to the survey.

2.2.3. Ethical consideration.

Ethical approval was sought from the Ethics Review Board (ERB) at the ICRC (OP_CORE 22/00004 – CGB/bap) and the institutional review board of RHUH (18-Jan-2022). Participation was completely voluntary and anonymous, with no incentives provided. A detailed explanation of the study’s purpose was presented on the initial page of the online questionnaire. Informed consent was obtained electronically from all participants before their involvement. Participants were required to actively indicate their consent by selecting “Yes” before accessing the questionnaire, and they were informed of their right to withdraw at any time without any repercussions. All collected data were kept strictly confidential and anonymized to protect participants’ privacy.

2.2.4 Data collection.

The questionnaire designed to assess KAP regarding MCI was carefully developed with two distinct versions tailored for medical and non-medical staff. Both versions were crafted following an extensive review of guidelines as well as a thorough analysis of previously conducted studies in similar contexts. Additionally, the questionnaires were made available in both English and Arabic to ensure accessibility and comprehensiveness. The English version has been uploaded as a supplementary file for reference. The survey includes:

1. Demographic Information: Collects data on age, gender, profession, department, years of experience, and education.
2. Staff Experience and Training in MCI: Gathers information about work shifts, the nature and extent of training received, past involvement in MCI, and the number of such incidents experienced. It also explores staff participation in planning and drafting the MCI plan at RHUH Hospital, including details on the most recent training or drill.
3. Self-Reported Awareness of MCI and RHUH Preparedness Plan: This section included questions to evaluate the participants’ general awareness of critical concepts and procedures related to MCI and the RHUH Code Orange Plan. The questions were primarily closed-ended, with response options such as “Yes,” “No,” and “Prefer Not to Answer.”
4. Knowledge of MCI Procedures: This section comprised multiple-choice questions aimed at evaluating participants’ understanding of specific MCI procedures, including the concept of triage, the role of the initial responder, and the characteristics of an MCI. For non-medical staff, only one question about the characteristics of an MCI was included. Respondents were asked to select the correct answer from a list of possible options. Each question had one correct answer, and participants received one point for each correct response. Incorrect answers, “I don’t know,” and “No answer” options were scored as zero. For the medical staff, the total score for this section was calculated by summing the points for all questions, with higher scores indicating a greater understanding of mass casualty procedures.
5. Knowledge of Procedures Related to Code Orange Protocols: Participants were queried about the purpose of Code Orange, the triage types used during normal times and MCI, and the specific procedures for triage and activation of the plan. The survey also covered the location of the Code Orange protocol, the contents of the Code Orange kit, and the communication channels for activation. Additionally, HCWs were asked about their responsibilities related to ER evacuation, contacting the Internal Security Forces, and the closure protocols following a Code Orange. Some questions in this section were tailored specifically for non-medical staff, reflecting their distinct roles in the Code Orange protocol. Each question was designed to gauge awareness and understanding, with correct answers receiving points to assess overall knowledge and readiness.
6. Attitude toward MCI Training, Planning, and Code Orange Responsibilities: Participants were queried about their training on the MCI plan, their participation in meetings and planning, and their views on the necessity and reasonableness of the MCI plan and Code Orange responsibilities. Key areas also included the necessity of theoretical and practical MCI training, the frequency and adequacy of training and drills, and the coordination between different staff groups.
7. Practice Response Efficiency and Communication during the application of the Code Orange: Key questions of this section addressed whether staff knew whom to communicate with during Code Orange, the accessibility of receiving and sorting areas, the existence of evacuation provisions, and the organization of medical records and admissions. Additionally, respondents rated the efficiency of casualty management areas, the sufficiency of resources for casualty movement, and their overall practice response to MCI. The involvement of support departments like dietary, social work, housekeeping, and security during MCI response was also evaluated. Responses were collected through categorical options and Likert scales, where staff rated various aspects of their preparedness and response from 0 (not applicable/not sufficient) to 5 (fully applicable/sufficient).
8. Staff perceptions regarding their knowledge and involvement in the MCI plan and Code Orange procedures at the hospital: This section evaluates staff perceptions regarding their knowledge and involvement in the MCI plan and Code Orange procedures at the hospital. Participants rated the extent to which they believe all staff are well-informed about the MCI plan, the clarity and accessibility of the Code Orange protocol, and their own level of involvement in MCI preparedness. Additionally, respondents assessed the hospital’s preparedness for mass casualty events, their personal readiness to respond during an MCI, and the applicability and manageability of the triage system. Ratings were provided on a Likert scale, with mean and standard deviation (SD) used to gauge overall staff perceptions and readiness.
9. Applicability of Code Orange by Referring to the Beirut Blast: This section begins by confirming whether the respondent was working at RHUH during the Beirut Blast. It assesses their knowledge of specific roles as documented in the Code Orange protocol during the response. The section investigates the notification methods of the MCI situation, the use of the Code Orange kit, and the organization of the emergency room into zones according to the protocol. It also evaluates the admission department’s ability to handle the patient influx and identifies any challenges faced while applying the Code Orange protocol. Finally, respondents rate the overall applicability of the Code Orange protocol during the Beirut Blast on a scale from 0 (not applicable) to 5 (highly applicable).

2.2.5. Procedure.

Our questionnaire was piloted with 5 HCW to assess the readability of the questions and evaluate the overall feasibility of the study. Feedback from the pilot informed minor adjustments, but the pilot data were excluded from the final analysis. The original questionnaire, specifically developed for this study, was designed to be concise, requiring no more than 15 minutes to complete.

HCW were invited to participate in the online questionnaire, hosted on Microsoft Office surveys, via WhatsApp groups. The invitation included a consent form, and the questionnaire was available in both English and Arabic. To boost participation, reminders were sent at one-week intervals.

2.2.6. Statistical analysis.

For the descriptive analysis, continuous variables were summarized using means and standard deviations, while categorical variables were presented as proportions and percentages. Knowledge assessments were quantified by assigning points to each question, leading to separate percentage mean scores for medical and non-medical staff. Difference in the knowledge total score between medical and non-medical staff was assessed using independent Sample T-test. Attitude and perception assessments were reported as means and standard deviations, as well as frequencies and percentages. P-value less than 0.05 was considered significant. All statistical analyses were conducted using SPSS version 27.0.

3.1.1 Overview of the existing 2016 RHUH Code Orange Plan.

The RHUH Code Orange Plan, developed in 2013 and revised in 2016, was designed to guide the hospital’s response to MCI with a primary focus on medical services at the ER. This plan was crafted by the multidisciplinary Policy and Procedure Committee and is structured into eight key sections:

1. Policy Statement: stating that the hospital staff will be trained to manage patient surges exceeding ER capacity, with mandatory monthly Code Orange drills. Activation decisions are made by the ER supervisor or clinical supervisor in consultation with the ER chairman.
2. Purpose: Defines the objectives of the plan, specifically to establish a uniform procedure for managing Code Orange incidents effectively.
3. Scope and Applicability: The plan applies solely to the ER.
4. Responsibilities: Defines the key personnel responsible for coordinating and managing the hospital’s response during an MCI.
5. Definitions and Abbreviations: Provides clarity on terminology and abbreviations used throughout the plan.
6. Equipment and Tools: Lists the resources required for effective implementation of the plan, including those found in the Orange Kit.
7. Procedure: Describes the step-by-step actions to be taken when Code Orange is activated, including the procedures for mobilizing the ER team and managing the incident. This is organized as tasks for each key personnel responsible.
8. Flowchart: Offers a visual representation of the emergency response process, detailing the sequence of actions during an MCI.
9. References

In addition to these core sections, the document includes several annexes:

• Contents of the Orange Kit, including essential supplies and equipment.
• Details about the Code Orange team and their specific roles.
• Emergency extensions and pagers associated with the Code Orange response.
• The Code Orange file, which contains critical information and resources for managing incidents.
• A pharmacy drug list relevant to Code Orange, including anesthetic drugs.
• A map of the ER to aid in efficient navigation and resource allocation.
• Diffusion protocols for the distribution of resources and information.

3.1.2. Findings of the search strategy.

The search strategy identified several critical hospital disaster preparedness tools developed by leading global institutions, which provided valuable insights for assessing the Code Orange plan and strengthening RHUH’s emergency preparedness protocols.

• ◦WHO’s extensive guidelines and technical reports on emergency preparedness, such as the Hospital Emergency Response Checklist and Mass Casualty Management Systems, offered a global perspective on best practices that were highly relevant to RHUH’s disaster planning [6].
• ◦CDC’s guidelines on emergency preparedness, including the Healthcare Preparedness and Response Capabilities and resources on bioterrorism, natural disasters, and pandemic response, were essential in evaluating RHUH’s current protocols and preparedness measures [25].
• ◦NIMS documentation, including the Incident Command System (ICS) guidelines, provided a structured approach to disaster management. This systematic framework was key in understanding how hospitals can organize and coordinate their response during MCI [26].
• ◦APIC’s resources, particularly those addressing infection control during MCI, helped in understanding how hospitals can manage surges in patient numbers, especially in situations involving infectious diseases. These guidelines offered vital insights into infection prevention protocols and their integration into disaster response [27].

Additionally, a 2020 study by Al-Hajj et al. was identified as a reference, offering specific criteria for assessing the Code Orange document and establishing foundational elements for RHUH’s MCI plan [28].

3.1.3. Categorization of Disaster Preparedness Components for the Code Orange Plan.

Using the referenced guidelines and tools, disaster preparedness components were systematically extracted and categorized into four main themes: Preparedness, Incident Command Systems (ICS) & Response, Communication, and Management. This structured framework was used to assess the RHUH Code Orange Plan, identifying various levels of alignment and deviations from established standards. Key components of the plan, detailing areas of adherence and pointing out deviations or gaps are highlighted in S1 Table.

3.1.4. Main findings.

• The Preparedness theme evaluates key areas including Planning & Activation, Surge Capacity, Continuity of Essential Services, Evaluation and Drills, and ER Evacuation Protocols. The 2016 RHUH Code Orange Plan aligns with WHO standards by defining the responsible team and activation procedures. However, it lacks critical details such as specific alert levels and thresholds for incident escalation. The plan does not address surge capacity or continuity of essential services during emergencies, and while it mandates monthly drills and training, it lacks detail on their evaluation. The absence of ER evacuation protocols further highlights significant gaps in the plan, as noted by CDC and APIC guidelines.
• The ICS & Response theme includes Command and Control, Triage Protocols, Surveillance, and Activation Procedures & Response. The 2016 RHUH Code Orange Plan addresses command and control by defining roles and responsibilities but lacks a structured action flow and a comprehensive Hospital Disaster Control Command Center plan. Triage protocols are mentioned but lack detail, resulting in unclear management during mass casualty incidents. The surveillance system for casualty tracking is inadequately defined, and the activation procedures are outlined only in terms of personnel responsibilities, lacking detailed activation and alert protocols. These gaps contrast with the comprehensive approaches recommended by WHO, CDC, NIMS, and APIC, which emphasize a clear command structure, adaptable triage protocols, robust surveillance systems, and well-defined activation procedures.
• ◦Communication: This component focuses on reviewing both internal and external communication systems. The 2016 RHUH Code Orange Plan does not specify alternative arrangements for situations where normal communication systems, such as telephones and pagers, fail or become overloaded. Although the plan includes an annex with “Code Orange” contacts, it falls short in detailing provisions for handling communication breakdowns. While the plan emphasizes internal communication, it lacks a comprehensive strategy for external communication with local authorities and media.
• ◦Management: The 2016 RHUH Code Orange Plan specifies security roles but fails to detail how to ensure safety and security effectively. While human resource management is largely aligned—with established roles and a Code Orange team—the plan lacks standard procedures for resource allocation and logistics. Attachments include a Code Orange file, pharmacy prescription list, and a Code Orange kit. However, the plan does not adequately address the recovery phase, lacking a comprehensive method for returning to regular operations and restocking inventory supplies. Additionally, the ER map is outdated and requires updating.

3.1.5. Main recommendations.

Based on the findings from the desk review and analysis of the RHUH Code Orange plan, several key areas for improvement were identified. To enhance the hospital’s overall preparedness and response to MCI, the following recommendations are proposed. These suggestions aim to address existing gaps and ensure a more effective, coordinated, and comprehensive emergency response strategy across all levels of staff.

• Clarify the criteria for different stages of plan activation, ensuring staff understand the activation process.
• Provide detailed explanations of the sequence of activation steps.
• Expand SOPs to address surge capacity and ensure continuity of critical services during MCIs.
• Specify protocols for ER operations, including evacuation and triage, as organized processes, not just tasks.
• Properly document training and drill methods, specifying how they will be applied and assessed.
• Enhance the ICS and response plan by introducing an organized flow of operations, including a clear sequence of events and incident-specific actions.
• Define activation criteria with a comprehensive hospital response strategy.
• Strengthen safety and security measures to ensure the hospital’s operations remain functional during a disaster.
• Develop a detailed contingency plan addressing supply chain disruptions and other logistical concerns.
• Incorporate a recovery phase in the plan to restore regular operations post-MCI, including service restoration and inventory replenishment.
• Ensure all RHUH staff are informed about the Code Orange Plan, emphasizing preparedness for unexpected MCIs.
• Engage management and key personnel through presentations, internal communications, and workshops to collaboratively identify gaps and prioritize improvements.

The desk review was shared with RHUH management to facilitate the update of the Code Orange Plan through detailed presentations, internal communications, and workshops, ensuring that all relevant stakeholders are informed and engaged. By involving management and key personnel, we aimed to collaboratively identify gaps, prioritize improvements, and implement necessary changes effectively.

3.1.6. Update of the Code Orange Plan.

Following the desk review and recommendations, significant changes were made to the RHUH Code Orange Plan to enhance the hospital’s preparedness for MCI.

Key Changes and Actions Taken:

• Restructured Procedure Section: The procedure section has been reorganized into more action-oriented segments, with a defined sequence of events for responding to MCI. This new structure ensures that actions are clearly outlined, improving the efficiency and clarity of emergency responses.
• Clarified Command Structure and Notification Process: The command structure framework and notification process have been explicitly defined and clearly presented in the updated plan. This change ensures that roles and responsibilities during an MCI are well understood, leading to better coordination and communication across all teams.
• Expanded Safety, Triage, and Activation Procedures: Additional procedural actions have been introduced for safety, triage, and plan activation. These changes include detailed instructions on how to ensure safety during an MCI, a more organized approach to plan activation, and specific guidance on triage. Triage procedures now specify the type of triage to be used, with a visual representation of the integrated triage tool, based on the WHO and ICRC surge tool, included in the plan. This provides clear, standardized criteria for handling large numbers of casualties.
• Systematized MCI Phases: The different phases of an MCI are now more systematically defined and structured. This allows for a better-organized response, with clear transitions between the stages of incident management.
• ◦Post-Event Debriefing Section: A new section on post-event procedures has been added, outlining how debriefings will be conducted. This section ensures that lessons learned from each MCI can be effectively incorporated into future preparedness and response strategies.

Despite these improvements, some areas still require further attention. The ER map remains outdated and should be revised to reflect the current layout and resources of the emergency department. Additionally, further details on resource management, as well as comprehensive plans for regular drills and training, need to be incorporated into the plan to ensure that staff are well-prepared for real-life scenarios.

3.2.1. Baseline characteristics of the study participants.

The study sample included 100 hospital staff, of whom 66% were medical and 34% non-medical. Overall, 54% were female and 51% were aged 36–64 years. Educational attainment differed substantially between groups, with 44% of the total sample having ≤12 years of education, compared with 27.3% of medical staff and 76.5% of non-medical staff. More than 10 years of work experience was reported by 60.6% of medical staff versus 29.4% of non-medical staff.

Regarding MCI training, 51% of participants reported no prior training. Practical or drill-based training was reported by 30% overall and was more common among non-medical staff (50%) than medical staff (19.7%). Previous MCI experience was reported by 41% of participants, with higher exposure among medical staff compared to non-medical staff (50% vs. 23.5%). The Beirut Blast and the Iranian Embassy explosion were the most frequently cited incidents. Most participants (78%) reported no involvement in MCI planning, particularly among non-medical staff (85.3% vs. 74.2% of medical staff), while only 15% reported being involved, predominantly medical staff (19.7%) (Table 1).

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Table 1. Baseline characteristics of the study sample (N = 100).

https://doi.org/10.1371/journal.pone.0348176.t001

3.2.2. Medical Staff Self-Reported Awareness of MCI and RHUH Preparedness plan.

Fig 1 displays self-reported awareness of MCI and RHUH Preparedness plan of the medical and non-medical staff at RHUH. The survey results indicate that RHUH medical staff generally had a high level of awareness of basic MCI concepts, with 77% understanding what an MCI is. A significant majority (85%) were also aware of the Code Orange plan. However, gaps remain, particularly in preparedness and training; only 21% were aware of recent updates to the Code Orange plan, and just 21% believed that ongoing mandatory disaster training programs exist. In contrast, non-medical RHUH staff showed low awareness across key areas. Only 35% of the participants knew what an MC, and the same percentage were aware of the Code Orange plan. Awareness of the mass casualty plan, designated areas during triage, and recent updates to the Code Orange plan were even lower, at 18%. Additionally, only 6% were aware of ongoing mandatory disaster training programs.

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Fig 1. Awareness Levels of MCI and Code Orange Among Medical and Non-Medical Staff.

https://doi.org/10.1371/journal.pone.0348176.g001

3.2.3. Knowledge and practical procedures concerning MCI, triage, and the specific Code Orange protocols at RHUH.

Table 2 shows notable gaps in knowledge of MCI and Code Orange protocols among RHUH staff. Among medical staff, correct identification of triage was high (83.3%); however, knowledge of the initial responder’s role (59.1%) and appropriate recipients of first aid (50.0%) was lower. Awareness of MCI characteristics was limited, with a mean MCI knowledge score of 2.5 (SD = 1.18) (out of 4). Knowledge related to Code Orange was substantially lower: 27.9% correctly identified its overall purpose, 7.0% knew the type of triage used during MCI, no one identified who activates Code Orange, and only 1.5% knew where to locate the protocol. The mean Code Orange knowledge score among medical staff was 3.9 (SD = 1.6).

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Table 2. Knowledge and practical procedures concerning MCI, triage, and the specific Code Orange protocols at RHUH.

https://doi.org/10.1371/journal.pone.0348176.t002

Among non-medical staff, only 35.3% correctly identified MCI characteristics, and 8.8% knew the purpose of triage during Code Orange. No respondents correctly identified the location of Code Orange protocols, 2.9% knew the contents of the Code Orange kit, and 17.6% identified the emergency number for activation. The mean overall knowledge score for non-medical staff was 0.9 (SD = 1.5).

3.2.4. Attitude toward MCI Training, Planning, and Code Orange Responsibilities.

Table 3 summarizes attitudes of medical and non-medical staff toward MCI training, planning, and Code Orange responsibilities. Agreement that all staff should be trained on the MCI plan was reported by 86.4% of medical staff and 79.4% of non-medical staff. The need for greater involvement in MCI planning and training was supported by 90.9% of medical staff and 52.9% of non-medical staff. Regular updates of the MCI plan were considered necessary by 86.4% of medical staff, while 58.8% of non-medical staff disagreed. The MCI plan was considered essential by 95.5% of medical staff and 50.0% of non-medical staff. Regarding Code Orange responsibilities, 56.1% of medical staff reported that their roles were reasonable.

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Table 3. Attitudes toward MCI Training, Planning, and Code Orange Responsibilities.

https://doi.org/10.1371/journal.pone.0348176.t003

Medical staff rated the necessity of theoretical MCI training with a mean score of 2.6 (SD = 0.8). The importance of training frequency scored 4.3 (SD = 0.9). Practical drills were rated at a mean of 4.3 (SD = 0.9), and the frequency of these drills scored 4.2 (SD = 0.9). Coordination between medical and non-medical staff during MCI planning received a mean score of 4.3 (SD = 0.9), while the need for more drills to apply the MCI plan was rated 4.3 (SD = 0.8). Among non-medical staff, the necessity of theoretical MCI training had a mean score of 1.7 (SD = 1.0). Training frequency scored 2.7 (SD = 1.8). Practical drills were rated 2.5 (SD = 1.7), and their frequency scored 2.6 (SD = 1.7). Coordination between staff received a mean score of 2.9 (SD = 1.8), and the need for more drills scored 2.6 (SD = 1.8).

3.2.5. Practice Response Efficiency and Communication during the Application of the Code Orange.

Among medical staff, 63.6% reported knowing whom to communicate with during Code Orange, and 48.5% indicated that the receiving and sorting areas were accessible and in close proximity to definitive care areas. Additionally, 60.6% of medical staff believed that the medical records and admission departments were organized to handle an influx of casualties. Regarding the sufficiency of equipment, supplies, and apparatus for efficient casualty movement, medical staff gave an average rating of 3.89 out of 5. The security department was perceived as highly involved in the MCI response, with a mean score of 4.3. Meanwhile, non-medical staff reported lower awareness and preparedness levels, with fewer indicating that the receiving areas were accessible (20.6%). The security department also received a high involvement rating from non-medical staff, with a mean score of 4.0. Both groups reported moderate practice response efficiency, with medical staff rating it at 3.5 and non-medical staff at 2.3 out of 5 (Table 4).

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Table 4. Medical and Non-Medical Staff Practice Response Efficiency and Communication during the Application of the Code Orange.

https://doi.org/10.1371/journal.pone.0348176.t004

3.2.6. Perceptions of Staff Regarding MCI Preparedness, Code Orange Clarity, and Role Applicability in the Hospital.

Table 5 summarizes the perceptions of medical and non-medical staff regarding various aspects of MCI preparedness and the Code Orange plan within the hospital. Medical staff reported a mean score of 2.6 for their knowledge of the MCI plan, while non-medical staff reported a mean of 1.7. Both groups rated the clarity and accessibility of the Code Orange plan with mean scores around 3.1 and 3.2, respectively. Involvement in MCI preparedness was reflected by mean scores of 3.7 for medical staff and 3.5 for non-medical staff. The hospital’s preparedness for MCI through Code Orange received mean scores of 3.6 from medical staff and 3.8 from non-medical staff. Both groups reported readiness to respond during an MCI with mean scores of 3.6 and 3.5, respectively, while the applicability of the triage system was rated 3.3 by medical staff.

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Table 5. Perceptions of Staff Regarding MCI Preparedness, Code Orange Clarity, and Role Applicability in the Hospital.

https://doi.org/10.1371/journal.pone.0348176.t005

3.2.7. Applicability of the code orange plan during the Beirut Blast.

Out of the total participants, 32 reported that they had been working at RHUH during the Beirut Blast, comprising 27 medical staff and 5 non-medical staff. Of these, 31 were aware of their roles as documented in the Code Orange during the Beirut Blast response. When asked how they were informed that they were in an MCI, 4 participants reported being informed through a phone call or a public address system. One participant mentioned being informed via email, another by being at the ER, and one more through other unspecified means. Only five medical staff reported using the Code Orange Kit during their response. Additionally, only eight reported that the ER was divided into zones according to triage, as per the map documented in the Code Orange protocol. Twenty-nine respondents indicated that the admission department was able to handle the influx of patients. However, two reported challenges in applying the Code Orange plan during the Beirut Blast, mainly due to changed infrastructure and supply deficiencies. When asked to rate the applicability of the Code Orange during the Beirut Blast, the mean score was 3.9, with an SD of 0.5.