The unconventional transport of Aurora shooting victims to hospitals using police cars saved lives, but it also created confusion for hospitals, which had no way of knowing what casualties were coming at them, the report on response to the shootings concluded.

Every person who could have survived wounds they suffered inside the Century Aurora 16 theater did, the report said. It said two people probably survived because police took them to the hospital in their cars.

“Someone made a decision they had never made before — to allow patients to be taken to hospitals by police cars, two or three in a car. It was a leadership moment, and it unequivocally saved lives,” agreed Dr. Richard Zane, chair of the University of Colorado School of Medicine’s Department of Emergency Medicine.

“Time to hospital is most important … because of blood loss,” he said.

Of the 12 people who died that night, 10 died inside the theater. Two, described as having unsurvivable injuries, were pronounced dead at hospital emergency rooms. One was dead on arrival, and the other pronounced dead after a “short resuscitation attempt,” the report said.

Attending paramedics, the three emergency medical-services directors for the fire department and ambulance contractor, and hospital medical staffs agreed that the two who died had nonrecoverable injuries and nothing would have made any difference, according to the report by System Planning Corporation’s TriData division.

Zane said lack of ambulance transport didn’t hurt even those patients suffering spinal cord or brain injuries.

More than 100 people, who were bloodied and unsure if they were wounded, were triaged by fire department and other emergency personnel.

But triage ribbons — black, red or yellow to indicate severity of injury — weren’t attached to victims. And patient ID tags were not used at the site. The report concludes this made it more difficult for hospitals and emergency medical personnel to track the most seriously wounded.

“All (six) area hospitals that received victims provided outstanding emergency care without having much forewarning to prepare for the influx of 60 victims who arrived at their doors, most with gunshot wounds and many in critical condition,” the report said.

The majority of the wounded — 23 — went to University of Colorado Hospital. The Medical Center of Aurora received 21 patients, Children’s Hospital Colorado treated six, Denver Health treated five, and the rest went to Parker and Swedish hospitals.

All transports to hospitals were made within 52 minutes of the first 911 call.

A fluke meant that CU Hospital had double staff numbers when casualties arrived.

“There were some things that were incredibly lucky for us,” Zane said. “We were in the middle of a change of shifts and had all the right people in place.”

Without that, he said, the hospital would have struggled to notify all the needed teams. That’s not the case today, he said. The new system, when activated, notifies all team members simultaneously by e-mail, home and mobile phones.

The Medical Center of Aurora emergency department was under construction and had fewer treatment rooms available than usual.

It received its first notice of the incident from an unknown cellphone caller. A hospital security guard monitoring a police radio heard about the shooting and told emergency staff. Then the center finally heard from dispatch. The official mass-casualty incident-notification system was not used, the report says.

The report was critical of hospitals in one respect. Families had to wait too long, the report says, to hear the status of their wounded loved ones. An overwhelmed central dispatch was telling worried people to call the hospitals.

University of Colorado Hospital spokesman Dan Weaver said the hospital activated a new phone bank during the crisis. The phone bank and main switchboard fielded 2,000 calls in the hours after the shooting, Weaver said. But privacy laws limit the amount of information that can be provided over the telephone.

And callers often didn’t know which hospital had the patient they were calling about. One theatergoer said the three friends she went to the movie with that night ended up at three different hospitals.

The report also says that University Hospital could have coordinated better with victim advocates.

Victim advocates who showed up for follow-up visits “were not permitted access to the victims,” the report says. “It took almost 36 hours and a personal call from the Aurora police chief before the hospital allowed advocates to meet with victims there.”

The report recommends that a lead advocate be assigned to each hospital to coordinate all victim advocates responding to that location. Hospitals should include a point of contact in their mass-casualty plans who would work with that victim-advocate coordinator.

Victim advocates were welcomed at ERs the night of the shooting, the report notes.

One victim advocate described the hospitals as looking “like a war zone,” with police cars parked everywhere and people wandering around.

Electa Draper: 303-954-1276, edraper@denverpost.com or twitter.com/electadraper