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Metropolitan areas must be prepared to manage large numbers of casualties related to a major incident. Most US cities do not have adequate trauma center capacity to manage large-scale mass casualty incidents (MCIs). Creating surge capacity requires the distribution of casualties to hospitals that are not designated as trauma centers. Our objectives were to extrapolate MCI response research into operational objectives for MCI distribution plan development; formulate a patient distribution model based on research, hospital capacities, and resource availability; and design and disseminate a casualty distribution tool for use by emergency medical services (EMS) personnel to distribute patients to the appropriate level of care.Working with hospitals within the region, we refined emergency department surge capacity for MCIs and developed a prepopulated tool for EMS providers to use to distribute higher-acuity casualties to trauma centers and lower-acuity casualties to nontrauma hospitals. A mechanism to remove a hospital from the list of available resources, if it is overwhelmed with patients who self-transport to the location, also was put into place.The number of critically injured survivors from an MCI has proven to be consistent, averaging 7% to 10%. Moving critically injured patients to level 1 trauma centers can result in a 25% reduction in mortality, when compared with care at nontrauma hospitals. US cities face major gaps in the surge capacity needed to manage an MCI. Sixty percent of “walking wounded” casualties self-transport to the closest hospital(s) to the incident.Directing critically ill patients to designated trauma centers has the potential to reduce mortality associated with the event. When applied to MCI responses, damage-control principles reduce resource utilization and optimize surge capacity. A universal system for mass casualty triage was identified and incorporated into the region’s EMS. Flagship regional coordinating hospitals were designated to coordinate the logistics of the disaster response of both trauma-designated and undesignated hospitals. Finally, a distribution tool was created to direct the flow of critically injured patients to trauma centers and redirect patients with lesser injuries to centers without trauma designation. The tool was distributed to local EMS personnel and validated in a series of tabletop and functional drills. These efforts demonstrate that a regional response to MCIs can be implemented in metropolitan areas under-resourced for trauma care.