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HEALTH CARE EMERGENCY MANAGEMENT
PRINCIPLES AND PRACTICE
Editors
Michael J. Reilly, DrPH, MPH, NREMT-P
Director, Graduate Program in Emergency Preparedness
Assistant Director, Center for Disaster Medicine
Assistant Professor, Public Health Practice
New York Medical College
School of Health Science and Practice
Valhalla, New York
and
David Markenson, MD, FAAP, FACEP, EMT-P
Medical Director and Vice President
Disaster Medicine and Regional Emergency Services
Westchester Medical Center
Director, Center for Disaster Medicine
Associate Professor, Public Health Practice
Professor of Pediatrics
New York Medical College
Valhalla, New York
55133_FMxx_Reilly:Achorn Int'l
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Cover Image: Top left: Courtesy of Andrea Booher/FEMA; Top Right: Courtesy of Win Henderson/FEMA;
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Library of Congress Cataloging-in-Publication Data
Health care emergency management : principles and practice / [edited by] Michael J. Reilly and David S.
Markenson.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-7637-5513-3 (pbk.)
ISBN-10: 0-7637-5513-3 (pbk.)
1. Emergency medical services. 2. Emergency management—Planning. 3. Hospitals—Emergency services.
I. Reilly, Michael J. II. Markenson, David S.
[DNLM: 1. Disaster Planning—organization & administration. 2. Emergencies. 3. Emergency Service,
Hospital—organization & administration. WX 185 H4336 2011]
RA645.5.H38 2011
362.18068—dc22
2010001554
6048
Printed in the United States of America
14 13 12 11 10
10 9 8 7 6 5 4 3 2 1
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Dedication
MICHAEL REILLY
I dedicate this text to my family and friends who have supported me
throughout this project. I especially thank my parents, who have provided their unwavering advice and support throughout my life and career. I also dedicate this text to my professional mentors Dr. Linda Degutis
and Dr. Robyn Gershon, who continue to give me invaluable guidance
throughout my professional development. Finally, I dedicate this book to
my coauthor David, who has provided me with the opportunity to pursue academic emergency and disaster medicine professionally, and who
continues to encourage and support my development as a scientist and
scholar in this evolving area of medicine and public health.
DAVID MARKENSON
This text is dedicated to my parents, who have always guided, supported,
and encouraged me, and who, as physicians, have shown me through
their work that providing care to others in a compassionate and knowledgeable way can be a rewarding endeavor. This text is also dedicated to
my brothers, sister, and sisters-in-law, who are a constant source of advice, support, and energy; without their help and involvement in my life
none of my efforts could have been accomplished. Most importantly
this text is dedicated to my wife Heidi and my wonderful children, Emily,
Rachel, and George, who not only support me but who were willing to
give of their time with me to allow me to write this text.
iii
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iv | Dedication
MICHAEL REILLY AND DAVID MARKENSON
Lastly, this text is dedicated to all healthcare providers, emergency managers, and those in their care. Healthcare providers and emergency
managers work each day in an environment that is unpredictable, often
dangerous, and constantly challenging. They have become champions in
changing the system to become better prepared. They dedicate their lives
to aid the sick and the injured and prepare for any disaster, terrorism
event, or public health emergency, driven only by their care for others and
their devotion to this profession we call healthcare emergency management. We salute all of you in your professionalism and dedication. Also,
we dedicate this to our patients who, in allowing us the privilege to provide them care, teach us each day about humanity.
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Contents
About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Section
I
Chapter
1
Chapter
2
Principles of Emergency Management for
Healthcare Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction to Hospital and Healthcare
Emergency Management. . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Michael J. Reilly, DrPH, MPH, NREMT-P and
David S. Markenson, MD, FAAP, FACEP, EMT-P
Healthcare Incident Management Systems . . . . . . . . . . . . . 21
Arthur Cooper, MD, MS
v
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vi | Contents
Chapter
3
Chapter
4
Chapter
5
Chapter
6
Chapter
7
II
Chapter 8
Section
Chapter
Chapter
9
10
Section
III
Chapter
11
Chapter
12
Improving Trauma System Preparedness for Disasters
and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . 47
Michael J. Reilly, DrPH, MPH, NREMT-P
Legal Issues and Regulatory Compliance . . . . . . . . . . . . . 67
Doris R. Varlese, JD
Developing the Hospital Emergency Management Plan . . . 89
Nicholas V. Cagliuso, Sr., MPH; Nicole E. Leahy, RN, MPH;
and Marcelo Sandoval, MD
Introduction to Exercise Design and Evaluation . . . . . . . . 111
Garrett T. Doering, MS, EMT-P, CEM, MEP
Integration with Local and Community Resources . . . . . . 143
Isaac B. Weisfuse, MD, MPH
Hospital Workforce Issues . . . . . . . . . . . . . . . . . . . . . . . . 161
Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Sean M. Kelly, MA, CCEMT-P and
Lindsey P. Anthony, MPA, CEM, CHEC-III
Functional Roles of Hospital Workers in Disasters
and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . 187
Tony Garcia, RN, CCEMT-P
Credentialing and Management of Volunteer
Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Deborah Viola, PhD, MBA and Peter Arno, PhD
Hospital Operations During Disasters and
Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . 221
Quantitative Planning for Epidemic and Disaster Response:
Logistics and Supply Chain Considerations . . . . . . . . . . . 223
Nathaniel Hupert, MD, MPH; John A. Muckstadt, PhD;
and Wei Xiong, PhD, MS
Risk Communication and Media Relations . . . . . . . . . . . . 233
Linda C. Degutis, DrPH, MSN and Lauren Babcock-Dunning, MPH
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Contents | vii
Chapter
13
Chapter
14
Chapter
15
Chapter
16
IV
C h a p t e r 17
Section
Chapter
18
V
C h a p t e r 19
Section
Chapter
20
Chapter
21
Chapter
22
Security and Physical Infrastructure Protections. . . . . . . . . 271
Robert Michael Schuler, BGS, NREMT-P and
Veronica Senchak Snyder, MHS, MBA
Hospital Decontamination and Worker Safety . . . . . . . . . . 299
Michael J. Reilly, DrPH, MPH, NREMT-P
Pharmaceutical Systems Management in Disasters. . . . . . 317
David S. Markenson, MD, FAAP, FACEP, EMT-P
Laboratory Preparedness. . . . . . . . . . . . . . . . . . . . . . . . . 331
Ramon Rosal, PhD
Clinical Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Principles of Disaster Triage . . . . . . . . . . . . . . . . . . . . . . . 341
E. Brooke Lerner, PhD and Richard B. Schwartz, MD
Managing an Infectious Disease Disaster:
A Guide for Hospital Administrators . . . . . . . . . . . . . . . . . 353
Ariadne Avellino, MD, MPH
Special Topics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Vulnerable Populations and Public Health
Disaster Preparedness. . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Elizabeth A. Davis, JD, EdM; Rebecca Hansen, MSW;
and Jennifer Mincin, PhD (ABD)
Altered Standards of Care in Disasters and
Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . 401
John Rinard, BBA, MSCPI
Mass Fatality Management . . . . . . . . . . . . . . . . . . . . . . . 423
Barbara A. Butcher, MPH and Frank DePaolo, RPA-C
Research in Emergency and Disaster Medicine . . . . . . . . 447
Kobi Peleg, PhD, MPH and Michael Rozenfeld, MA
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .463
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .469
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About the Authors
MICHAEL J. REILLY, DRPH, MPH, NREMT-P
Dr. Michael Reilly is currently the Assistant Director of the Center for
Disaster Medicine at New York Medical College in Valhalla, New York.
Additionally, he is an Assistant Professor of Public Health Practice and the
Director of the Graduate Program in Emergency Preparedness at the
School of Health Science and Practice.
Dr. Reilly has over a decade of multidisciplinary experience in
emergency preparedness, public safety, intergovernmental relations,
public health, and emergency management. He has been published in
the world’s leading disaster medicine and public health preparedness
journals, and received international awards and recognition for his
work on trauma systems and health systems in the context of disaster
and public health preparedness. Dr. Reilly is an internationally recognized expert in the areas of emergency medical services, and health system preparedness and response, with direct experience in responding
ix
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x | About the Authors
to mass casualty events and public health emergencies. Dr. Reilly is frequently called upon to provide expert consultation, subject matter expertise, and to evaluate healthcare systems preparedness, emergency
planning, and drills and exercises.
Dr. Reilly has designed numerous educational curricula and training programs for a variety of preparedness functional roles for public
health, emergency management, and public safety audiences at the
professional and graduate levels. He is a senior lecturer for multiple
federal agencies including the Department of Justice, Department of
Homeland Security, and the Occupational Safety and Health
Administration. Additionally, he is an active member of several state and
national committees on homeland security and emergency management programs.
He received his undergraduate education at Northeastern University in paramedic technology and health science. He earned his
Masters of Public Health from Yale University, and a doctorate in public health from New York Medical College.
Dr. Reilly remains active as a paramedic in the Metro New York City
region and maintains numerous specialty and technical certifications
and instructor credentials in the areas of emergency medical services,
worker safety, environmental health, hazardous materials emergency
response, emergency management, counterterrorism, and weapons of
mass destruction preparedness and response.
DAVID SAMUEL MARKENSON, MD, FAAP, FACEP, EMT-P
Dr. David Markenson is a board-certified pediatrician with Fellowship
training in both pediatric emergency medicine and pediatric critical care.
He is the Vice President and Medical Director of Disaster Medicine and
Regional Emergency Services at the Westchester Medical Center and Maria
Fareri Children’s Hospital. In addition, he is the Director of the Center for
Disaster Medicine and the Interim Chair of Epidemiology and Community
Health at the School of Health Sciences and Practice at New York Medical
College. Dr. Markenson is also a Professor of Pediatrics and an Associate
Professor of Public Health at the School of Health Sciences and Practice
at New York Medical College in Valhalla, New York.
He is an active member of, and has served in leadership positions
within, multiple professional societies, including the American
Academy of Pediatrics (AAP), the American College of Emergency
Physicians, the Society of Critical Care Medicine, the American College
of Physician Executives, and the National Association of EMS Physicians.
Dr. Markenson has been actively involved with the American Red Cross
for over 20 years and currently serves as the National Chair of the
Advisory Council which oversees disaster health, preparedness, and
health and safety. In this role he directs the scientific and technical as-
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About the Authors | xi
pects of all programs and products in these areas including their development, implementation, and research. Prior to coming to
Westchester Medical Center and New York Medical College he was the
Deputy Director of the National Center for Disaster Preparedness at
the Mailman School of Public Health, Columbia University, and was
also the Director of the Program for Pediatric Preparedness of the
National Center, a program dedicated to improving the care children
receive in times of disasters or acts of terrorism.
His career has been dedicated to improving the approach to pediatric care, disaster medicine, EMS, and emergency medicine. He is the
principal investigator on several federal grants related to pediatric disaster medicine, including Model Pediatric Component for State Disaster
Plans and National Consensus Conference on the Needs of Children in
Disasters. He has also addressed the needs of other special and vulnerable populations and directed a federal grant to develop the first and only
national guidelines for emergency preparedness for persons with disabilities. In addition to this, he has conducted research on healthcare preparedness and healthcare provider and student education. In this area he
was the principal investigator for a federal grant which developed the first
competencies for all healthcare students in emergency preparedness and
then piloted this set of competencies in a medical, dental, public health,
and nursing school. Dr. Markenson has been recently appointed to the
FEMA National Advisory Council as the In-Patient Medical Provider representative. The FEMA NAC is comprised of emergency management
and law enforcement leaders from state, local, and tribal government
and the private sector to advise the FEMA Administrator on all aspects of
disaster preparedness and management to ensure close coordination
with all partners across the country.
He is a frequent presenter and lecturer at medical conferences
across the country, serves in editorial roles for multiple professional scientific journals, and has authored numerous articles and books on pediatric care, disaster medicine, and prehospital medicine. His work in
disaster medicine started during his college career when he worked in
disaster services in upstate New York providing direct services and education to other disaster services workers on behalf of the local Red
Cross and county office of emergency management. Dr. Markenson is
a graduate of Albert Einstein College of Medicine in the Bronx,
New York.
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Contributors
Lindsey P. Anthony, MPA, CEM, CHEC-III
Operational Medicine Education Coordinator
Center for Operational Medicine
Medical College of Georgia
Augusta, Georgia
Peter Arno, PhD
Professor
Department of Health Policy and Management
New York Medical College
School of Health Sciences and Practice
Valhalla, New York
xiii
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xiv | Contributors
Ariadne Avellino, MD, MPH
Research Associate
Center for Disaster Medicine
New York Medical College
Valhalla, New York
Lauren Babcock-Dunning, MPH
Research Associate
Center for Transportation Safety, Security and Risk
Rutgers, The State University of New Jersey
New Brunswick, New Jersey
Barbara A. Butcher, MPH
Chief of Staff
Office of the Chief Medical Examiner
City of New York
New York, New York
Nicholas V. Cagliuso, Sr., MPH
Corporate Director
Emergency Management
Continuum Health Partners, Inc.
New York, New York
Arthur Cooper, MD, MS
Professor of Surgery
Columbia University College of Physicians & Surgeons
Director of Trauma and Pediatric Surgical Services
Harlem Hospital
New York, New York
Elizabeth A. Davis, JD, EdM
Principal
EAD & Associates, LLC
Brooklyn, New York
Linda C. Degutis, DrPH, MSN
Associate Professor of Surgery (Emergency Medicine) and Public
Health
Director, Center for Public Health Preparedness
Yale University School of Medicine
New Haven, Connecticut
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Contributors | xv
Frank DePaolo, RPA-C
Director
Special Operations Division
Office of the Chief Medical Examiner
City of New York
New York, New York
Garrett T. Doering, MS, EMT-P, CEM, MEP
Director of Emergency Management
Westchester Medical Center
Valhalla, New York
Tony Garcia, RN, CCEMT-P
Training Specialist
Texas Engineering Extension Service
Texas A&M University System
College Station, Texas
Rebecca Hansen, MSW
Senior Project Manager
EAD & Associates, LLC
Brooklyn, New York
Nathaniel Hupert, MD, MPH
Associate Professor of Public Health and Medicine
Weill Cornell Medical College
New York, New York
Sean M. Kelly, MA, CCEMT-P
Lecturer
New York Medical College
School of Health Sciences and Practice
Valhalla, New York
Nicole E. Leahy, RN, MPH
Manager
Burn Outreach and Professional Education
New York-Presbyterian Hospital / Weill Cornell Medical Center
New York, New York
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xvi | Contributors
E. Brooke Learner, PhD
Associate Professor
Department of Emergency Medicine
Department of Population Health
Medical College of Wisconsin
Milwaukee, Wisconsin
David S. Markenson, MD, FAAP, FACEP, EMT-P
Medical Director and Vice President
Disaster Medicine and Regional Emergency Services
Westchester Medical Center
Director, Center for Disaster Medicine
Associate Professor, Public Health Practice
Professor of Pediatrics
New York Medical College
Valhalla, New York
Jennifer Mincin, PhD (ABD)
Senior Project Manager/Director
EAD & Associates, LLC
Brooklyn, New York
John A. Muckstadt, PhD
Acheson/Laibe Professor
Business Management and Leadership Studies
School of Operations Research and Industrial Engineering
Cornell University
Ithaca, New York
Kobi Peleg, PhD, MPH
Director, Israel National Center for Trauma and Emergency Medicine
Gertner Institute for Epidemiology and Health Policy Research
Sheba Medical Center
Co-chair, The Multi-disciplinary Program for Emergency and
Disaster Management
School of Public Health
Tel-Aviv University
Tel-Aviv, Israel
Michael J. Reilly, DrPH, MPH, NREMT-P
Director, Graduate Program in Emergency Preparedness
Assistant Director, Center for Disaster Medicine
Assistant Professor of Public Health Practice
New York Medical College
School of Health Sciences and Practice
Valhalla, New York
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Contributors | xvii
John Rinard, BBA, MSCPI
Milano, Texas
Ramon Rosal, PhD
Chemical Response Director
Public Health Laboratory
New York City Department of Health and Mental Hygiene
New York, New York
Michael Rozenfeld, MA
Researcher
National Center for Trauma & Emergency Medicine Research
Gertner Institute for Epidemiology and Health Policy Research
Sheba Medical Center
Tel Hashomer, Israel
Marcelo Sandoval, MD
Faculty, Department of Emergency Medicine
Co-Chair, Emergency Management Committee
Beth Israel Medical Center / Petrie Division
New York, New York
Robert Michael Schuler, BGS, NREMT-P
Training Coordinator
Texas Engineering Extension Service
The Texas A&M University System
College Station, Texas
Richard B. Schwartz, MD
Chair and Professor
Department of Emergency Medicine
Medical College of Georgia
Augusta, Georgia
Veronica Senchak Snyder, MHS, MBA
Emergency Management Coordinator
Emergency Management Services
Geisinger Health System
Geisinger Medical Center
Danville, Pennsylvania
Doris R. Varlese, JD
Visiting Lecturer
New York Medical College
School of Health Sciences and Practice
Valhalla, New York
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xviii | Contributors
Deborah Viola, PhD, MBA
Associate Professor of Public Health Practice
Department of Health Policy and Management
New York Medical College
School of Health Sciences and Practice
Valhalla, New York
Isaac B. Weisfuse, MD, MPH
Deputy Commissioner
Division of Disease Control
New York City Department of Health and Mental Hygiene
New York, New York
Wei Xiong, PhD, MS
Instructor in Public Health
Weill Cornell Medical College
New York, New York
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Acknowledgments
he material contained in this text reflects the contributions of many
authors, editors, emergency managers, healthcare providers, reviewers, and others who provided assistance and valuable suggestions. While here we acknowledge them, our sincere appreciation for all
of their efforts is truly hard to express in this limited space. In addition,
we could not possibly acknowledge all those who participated in this
important endeavor, and so we would like to also extend our sincere appreciation to every person who helped with this project, whether listed
by name or not.
Many talented people at Jones & Bartlett Learning have been involved in developing and producing this new text. As authors and editors, we turned our manuscript to the exceptional editorial staff and
publishers at Jones & Bartlett Learning to create this finished product.
We are fortunate to have been able to work with this team of people,
who have contributed so much and had such a tremendous impact on
T
xix
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xx | Acknowledgments
the quality of the textbook you now have in your hands. Specifically
Michael Brown, Publisher, assisted by Catie Heverling and Kate Stein,
has been our support at Jones & Bartlett Learning. As Publisher, Mike
is committed to publishing quality books; his energy, intelligence, patience, and helpful efforts have enabled us to create an exceptional
product. With the additional day-to-day support and guidance of both
Catie Heverling and Kate Stein we were able to keep our project on track
and ultimately produce this important text.
A significant amount of coordinating and operational support in
moving this project forward would not have been possible without the
tireless work of our administrative assistant Patience Ameyaw. We thank
her for her hard work and support of this project along with Geordana
Roa, Nina Luppino, and our numerous disaster medicine interns over
the past several years.
Components of this text have been based on the exceptional work
of the Center for Disaster Medicine at the New York Medical College,
School of Health Sciences and Practice for which we serve as the
Director and Assistant Director. Without the support of our Center, the
prior research and models developed, and the strong and supportive
academic environment of New York Medical College, this work would
not have been possible. We would like to specifically thank Dean Robert
Amler of the New York Medical College, School of Health Sciences and
Practice, who in his own right is an internationally recognized expert
in public health and healthcare preparedness, for providing his personal
expertise and his leadership in creating an academic environment
where work such as this text is not only encouraged but supported, and
for his continued dedication to providing education to improve emergency preparedness.
We would like to also acknowledge the Westchester Medical Center
and its Maria Fareri Children’s Hospital, which serves as the regional
center for healthcare emergency preparedness. The source and realworld testing of many of the theories and models in this text come
from the preparedness efforts of this institution, which is recognized
as not only a regional but as a national leader in emergency preparedness. We would like to thank the leadership of this institution for allowing us to use the wonderful preparedness work they have done as
models for others to follow. While not being able to list all, we would
like to acknowledge the members of the senior leadership who day in
and day out support the preparedness activities: Mr. Michael Israel,
Mr. Gary Brudnicki, Dr. Renee Garrick, Dr. Michael Gewitz, Ms. Marsha
Casey, and Mr. Anthony Costello. Lastly, we would especially like to
thank the institution’s Director of Emergency Management and chapter contributor Mr. Garrett Doering for sharing his professional insight and experience with us as we completed this project.
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Acknowledgments | xxi
Finally, we are extremely grateful to the numerous healthcare
providers, emergency managers, educational consultants, and members
of the preparedness academic community who carefully critiqued the
manuscript to ensure that the information in this text would be both
relevant and appropriate. Many more dedicated professionals than we
could name here gave unstintingly of their own time and expertise.
Their enthusiastic participation has been a motivating force behind
this project, and they received no compensation beyond the knowledge
that they were helping to create a greatly needed resource. We hope the
final product lives up to their efforts, hopes, and expectations.
Our warmest and kindest regards,
Michael and David
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Page 1
Section
I
Principles of
Emergency
Management
for Healthcare
Facilities
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Page 3
Chapter
1
Introduction to Hospital and
Healthcare Emergency
Management
Michael J. Reilly, DrPH, MPH, NREMT-P and
David S. Markenson, MD, FAAP, FACEP, EMT-P
Photo by Jocelyn Augustino/FEMA News Photo
Learning Objectives
■
Describe the need for and responsibilities of healthcare
emergency management.
■ Describe the role of the hospital emergency manager.
■ Identify the activities performed by healthcare emergency
management.
Emergence and Growth of Healthcare Emergency
Management
The concept of healthcare emergency management is not entirely new,
but may seem strange and foreign to those who have worked in healthcare or emergency management and, until recently, have not known
anyone working in this profession. If one looks back more than 30 years,
it would be almost impossible to find a hospital role called hospital
3
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emergency management or even a position for a healthcare emergency
manager in a hospital or medical center.Yet healthcare emergency management responsibilities have always been addressed by hospitals, such
as fire safety, backup power, and the ability to handle victims from a
mass casualty event.
A fundamental tenet of emergency management is that institutions
must prepare for events that may rarely occur while taking protective
actions to mitigate any likelihood that they will occur at all. Due to the
low frequency of events testing the health system’s ability to respond
to a disaster, an act of terrorism, or a public health emergency, the
ability to evaluate the strengths and weaknesses of hospital emergency
preparedness is limited. In addition, the public has strong expectations of the roles hospitals should play during times of disaster.
Healthcare institutions are expected to provide both emergency care
and continuance of the day-to-day healthcare responsibilities regardless of the volume and demand. Recently, they have also become sites of
community refuge, bastions of safety in a threatening and dangerous environment. The public believes that hospitals will have light, heat, air conditioning, water, food, and communications capabilities, regardless of the
fact that the institution may itself be affected by the calamity. During
the terrorist attacks in the fall of 2001 and the Northeast Blackout of
2003, the public flocked to hospitals, even when they did not require
medical care. Furthermore, with increased intelligence of the vulnerabilities of the healthcare infrastructure and the desire of terrorists to
exploit this, institutions have been forced to focus limited resources on
safety and security rather than on comprehensive emergency management efforts.
A major change in the way hospitals plan for hazards and vulnerabilities includes less planning for specific single issues or threats but
rather the adoption of an all–hazards comprehensive emergency management planning process. Additionally, hospitals need to look beyond
their emergency department doors and engage community stakeholders to assist in this process, reaching out to local and regional emergency
planners to assist in larger communitywide emergency preparedness
planning. The interest of nonhospital entities in health system emergency preparedness can be seen through several examples, including
emergency management and public health initiatives on mass vaccination, pandemic planning, increasing hospitals’ ability to perform decontamination of casualties contaminated with hazardous materials, etc.
Recent reflection of the role of the hospital in emergency management
and population health can been seen in revised laws, regulations, and
even accreditation standards. An example of this is The Joint Commission
on the Accreditation of Healthcare Organizations’ (JCAHO) change
from placing emergency preparedness standards in the Environment
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of Care section to placing the standards in a separate and distinct section with specific goals and requirements, as well as the release of the
Occupational Safety and Health Administration (OSHA) document Best
Practices for Hospital-Based First Receivers.1–3
Over the past eight years we have embarked on an interesting
marriage of these two separate disciplines—health care and emergency management—whose common ground has historically been
brought together in the street or on the disaster scene by emergency
medical services workers, or sometimes brought into the emergency
departments of hospitals and trauma centers across the country. Both
disciplines have separate roles and responsibilities, but where the seemingly disparate goals of these fields come together is the reduction of
morbidity and mortality following disasters, acts of terrorism, and
public health emergencies.
Emergency management agencies have traditionally been responsible for bringing first responders, government agencies, and community stakeholders together to assist with comprehensive emergency
planning or disaster response and recovery. A common cornerstone of
emergency management has been to protect life, then property, then the
environment. As a result, when conducting emergency planning activities, the health and medical needs of the population are among the most
significant and are considered with basic public health and human
needs including sheltering, mass care, sanitation, environment health,
food and water, and other essential services. In addition, as public health
professionals, we also believe that population health activities include
the mitigation of increased morbidity and mortality during and following a disaster, act of terrorism, or public health emergency.
In healthcare delivery, we attempt to meet the health and medical
needs of the community by providing a place for individuals to seek
preventative medicine, care for chronic medical conditions, emergency
medical treatment, and rehabilitation from injury or illness. While a
healthcare institution serves the community, this responsibility occurs at
the level of the individual. Each individual expects a thorough assessment
and treatment if needed, regardless of the needs of others. This approach
is different than that practiced by emergency managers, whose goal is
to assist the largest number of people with the limited resources that are
available. As such, emergency management principles are focused on
the needs of the population rather than the individual. When either planning for a disaster or operating in a disaster response mode, the hospital should be prepared at some point to change its focus from the
individual to the community it serves and to begin weighing the needs
of any individual patient versus the most good for the most patients
with scarce resources. Moving from the notion of doing the most for each
individual to doing the best for the many is a critical shift in thinking
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for healthcare institutions considering a program of comprehensive
emergency management. While the initial planning for emergencies by
hospitals is focused on maintaining operations and handling the care
needs of actual or potential increased numbers of patients and/or different presentations of illness or injury than is traditionally seen, there
is also the need to recognize that at some point during a disaster, act of
terrorism, or public health emergency there may be an imbalance of
need versus available resources. At this point the approach to delivering
healthcare will need to switch from a focus on the individual to a focus
on the population. This paradigm shift is one of the core unique aspects
of hospital emergency management that allows the hospital to prepare
to maximize resources in disasters and then to know when to switch to
a pure disaster mode of utilizing its limited and often scant resources to
help the most people with the greatest chance of survival.
The healthcare delivery system is vast and comprised of multiple
entry points at primary care providers, clinics, urgent care centers, hospitals, rehabilitation facilities, and long-term care facilities. The point of
entry for many individuals into the acute healthcare system is through
the emergency department (ED). Since the late 1970s, the emergency
medical services (EMS) system has allowed victims of acute illness and
injury to receive initial stabilization of life-threatening medical conditions on the way to the emergency department. Among the many
strengths of the ED is the ability to integrate two major components of
the healthcare system: prehospital and definitive care. The emergency
department maintains constant communications with the EMS system
and serves as the direct point of entry for prehospital providers into the
hospital or trauma center. Emergency physicians represent a critical link
in this process by anticipating the resources that ill and injured patients
will need upon arrival at the ED, and initiating appropriate life-saving
medical care until specialty resources become available.4–11 In this context, the healthcare system is an emergency response entity.
Healthcare Emergency Management Activities
Hospital emergency management activities vary and can be categorized in many ways, however some common areas of focus within
healthcare emergency management include the following areas:
■
■
■
■
■
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■
communication
surge capacity
volunteer management
security issues
hazmat/CBRNE preparedness
collaboration and integration with public health
education and training
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■
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■
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equipment and supplies
worker safety
drills and exercises
emergency department disaster operations
trauma centers
COMMUNICATION
Communication issues in disaster preparedness and response are
cited throughout the literature as a major source of frustration and
inadequacy for coordinating and executing disaster operation
plans.4–5,8,11–16 By identifying the vulnerabilities in the existing system of healthcare communication systems, we can take steps to address these issues and further increase our health system preparedness.
Addressing the vulnerabilities in communication systems and planning
how to overcome them is an essential responsibility of a hospital
emergency manager. Many of the criticisms of the current state of
health systems’ communication systems center around the inability to
communicate easily with external agencies and share critical information. Disaster after-action reports and exercise improvement plans almost universally cite poor communication as one of the problems
associated with incident management and the event being reviewed.
Infrastructure support is an important consideration when examining whether adequate safeguards are in place to support the systems
we will rely upon during a disaster. On September 11, 2001, while one
New York City hospital was preparing to treat a large number of (anticipated) casualties from the disaster, they experienced a loss of their computer and information systems.17 This unplanned event arose because the
communication system line that supported their system’s infrastructure
ran beneath the World Trade Center.17 Additionally, other reports have
cited problems with battery failure and the lack of a prolonged power
supply as limiting communication systems’ abilities during an event.14
This example illustrates a major point in emergency communication
systems: hospitals need the ability to connect all significant parties during a disaster or other emergency and the system should be based on a
redundant infrastructure.5 Clearly, from a planning perspective, this
would be a desirable option. However, the reality remains that investing
in communication systems is a significant financial burden on already
underfunded hospitals and healthcare systems.
Risk communication is often overlooked during the planning phase
of an event, and this can lead to frustration and confusion during disaster
operations. Risk communication is sometimes the only way for the public to gain an understanding of the scope and severity of an incident.
Additionally, risk communication information provided by hospitals
may be used to help families of disaster victims find information about
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their loved ones’ condition. Reviews of risk communication have shown
that a predesignated public information officer (PIO), who will liaise
with the media and the public and who has specific training and experience in giving briefings and fielding questions, should perform all
risk communication tasks during disaster operations.13 Specific elements
of risk communication that may be conveyed to the public may include
information on evacuations, scope and breadth of the event, where and
how to obtain assistance if needed, whom to call for specific information, location of postexposure prophylaxis or vaccination clinics, and
what to expect over the next several hours and/or days of the event.
This is discussed in more detail in Chapter 12.
SURGE CAPACITY
The General Accounting Office (GAO), which changed its name to
the Government Accountability Office (GAO) in 2004, finalized reports during 2003 on the public health and hospital preparedness for
bioterrorism and emerging infectious diseases.9,16 These reports found
that most hospitals in the United States do not have the means to care
for a surge of patients during a public health emergency.9,16 They
stated that, based on the national emergency department diversion
rates in urban and suburban areas, shortages in the healthcare workforce, and the general lack of available supplemental medical equipment and supplies in hospitals, the medical community is not prepared
to handle a patient surge caused by an infectious disease outbreak or
bioterrorism related event.9,16 Emergency departments are being utilized more often as urgent care centers because the growing population utilizes the ED as their point of primary care. This increasing
phenomenon is contributing to ED overcrowding and diversionary
status (hospital EDs asking that ambulances refrain from bringing patients to their facility for a period of time) in virtually every healthcare
and trauma system in the country. The current state of affairs in the nation’s EDs makes it very difficult to prepare for surge capacity when
many hospitals cannot effectively handle their daily patient volume.18
Referral patterns of patients presented to medical facilities will
vary in terms of how they arrive at the facility (EMS or self-transport)
as well as which facilities they access (hospital ED or physician’s office),
depending on the type of disaster or public health emergency. In cases
of natural disasters, explosions, and acute catastrophic events where
there is a clear and defined “scene,” many patients will be triaged,
treated, and perhaps transported to hospitals or trauma centers by EMS
personnel. In cases of bioterrorism or infectious disease outbreaks,
patients would normally exhibit minor signs and/or symptoms of an
illness (e.g., fever, rash, flu-like symptoms, etc.). These patients may be
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presented to their primary care physician or an urgent care center to
receive initial diagnosis and treatment. The patients that can be expected to arrive at the ED in these cases would be those who could not
access a private physician, those too acutely ill to seek care in an office setting, those referred to the ED by their physicians, and those patients who called EMS for assistance. This latter group would yield the
least number of ED arrivals.19–20
Incidents of chemical and biological terrorism as well as pandemic or epidemic incidents of infectious diseases may arguably produce the most significant burden on the healthcare system.9,13,16,18,21
A main reason for this is the unpredictable referral patterns of patients
who fall victim to a chemical or biological hazard. Although some disaster after-action reports do suggest that even victims of conventional
disasters will self-refer to medical facilities, the issues of delayed onset
of symptoms, cross-contamination, and person-to-person disease transmission that are associated with a chemical, biologic, or radiologic
incident call for more detailed contingency plans. An example of hospital referral patterns after a chemical agent event can be seen in the
post-event summary of the sarin attack in the Tokyo subways in March
of 1995.22 In this incident 12 people were killed, but more than 5000
people sought medical attention, and only 688 of them were medically
transported to area hospitals.22
At some point during the evolution of a disaster or other public
health emergency, patients will converge on acute care hospitals. Studies
have consistently shown that despite rigorous planning initiatives, hospitals and emergency departments are not prepared to handle the mass
influx of patients that a bioterrorism event or infectious disease outbreak would produce.9,16,19–20 During the sarin attack on the Tokyo
subway in 1995, the nearest hospital had 500 patients in the first hour
after the incident and more than 20% of its staff was secondarily contaminated.22 It is important that planners additionally recognize that in
certain catastrophic disasters involving bombings, building collapse, etc.,
mass injuries and a patient surge may not occur as anticipated because
of the high rate of mortality.17,23 The hospital emergency manager and
all those involved in hospital emergency management must ensure that
their hospital has adequate plans for the surge of patients that will arrive
during a disaster, terrorism event, or public health emergency.
VOLUNTEER MANAGEMENT
The use of volunteers in disasters and public health emergencies presents
a unique set of considerations for the hospital emergency manager.
Volunteers can be utilized in several ways to assist in disaster relief services. However, the problems of volunteer management, credentialing,
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safety, and security often preclude their utility in the acute disaster environment unless significant pre-planning for their use has occurred
and their arrival is through a pre-defined system. Cone et al. describe
“convergent volunteerism” (the influx of citizens and/or health providers to a major incident) as a “critical problem” in disaster management.24 Intuitively, you may think that the outpouring of community
support to assist in rendering aid during a disaster or other public
health emergency is a welcome show of support for disaster victims.
However, the reality is that convergent volunteerism brings with it
security, resource, and worker safety problems that require personnel
and critical resources to manage.
In their discussion of convergent volunteerism in the September 11
terrorist attacks in NYC, Cone and colleagues discuss the myriad of additional challenges and problems that the unsolicited and often intrusive behavior of “Good Samaritans” imposed on the NYC responders.
Issues included the unsupervised practice of medicine and paramedicine; credential verification of certified and/or licensed personnel; the
performance of search and rescue operations by lay responders; the
need to feed, shelter, and provide sanitary facilities for volunteers; potential injury and illness to volunteers who were unsupervised and
lacked proper personal protective equipment; and personal vehicle congestion on scene access and egress.24
Many of these concerns may seem trivial to some who view a
community response to a disaster as being the quintessential demonstration of altruism and support for fellow citizens. However, as mentioned by Cone and colleagues, untrained and unauthorized volunteers
can ultimately put themselves and others in danger, and deplete emergency response resources by attempting to provide assistance at disaster scenes. This was most poignantly illustrated during the 1995
bombing of the Alfred P. Murrah Federal Building in Oklahoma City,
when an untrained and unprotected volunteer nurse was crushed by
falling debris while trying to assist with urban search and rescue
operations.24
SECURITY ISSUES
Hospitals frequently overlook the need to maintain adequate security of
the healthcare facility and overall medical operations as part of both daily
operations and emergency planning. The concept of “locking down” or
restricting access to a healthcare facility is often contradictory to the typical hospital design and approach of open access to both patients and
their families and other visitors. But during a disaster this type of control
is essential for many reasons, which include but are not limited to: control of the flow of patients to the areas where care will be provided; access to the facility only by authorized staff; accounting for staff and patients
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in time of evacuation; prevention of potentially contaminated patients
entering the hospital from contaminating staff, other patients, and facilities; and prevention of acts of terrorism.
Security resources generally vary among hospitals. Some hospitals
and trauma centers have sworn police officers present in their facilities
24 hours a day, and others may hire a private security firm to maintain
safety or simply serve a concierge or customer service role. Security concerns during disasters and public health emergencies can become significant when considering the potential vulnerabilities associated with the
chaotic response environment.15,17,24–25 Specifically cited issues with
security during the response to a disaster or public health emergency include access control to medical facilities; credentialing of employees, responders, and volunteers; crime scene and evidence preservation;
infrastructure and resource protection; and crowd control.15,17,24–25
HAZMAT/CBRNE PREPAREDNESS
There is no question that in the current state of health system and public health preparedness the medical community is ill-prepared
to deal with an incident that involves the management and treatment
of multiple potentially contaminated victims, including those from
chemical, biological, radiological, nuclear, and explosive (CBRNE)
events. Multiple recent reports of hospital preparedness cite decontamination capabilities as a serious weakness of disaster readiness
plans.4–5,8–9,11,15–16,26–27 One study cites as few as 6% of Level I
trauma centers as having the necessary equipment on hand to safely decontaminate a single patient.26 Planning for these events has traditionally centered around the fallacy that patients will be decontaminated
at the scene by first responders and then be triaged, treated, and transported to the ED. The decontamination process serves a dual purpose.
First, it removes the potential agent that is causing harm to the patient, and second, it prevents the spread of secondary contamination
to other patients and hospital staff. We have come to realize from recent incidents involving victim contamination that many ambulatory
victims will leave the scene and bypass EMS decontamination and
triage, seeking medical care on their own.11,15,19–20 The reality of
dealing with an intentional release of chemical, biological, or radiological agent is that by the time acute care facilities can be made aware
that an event has taken place, they may have already been contaminated themselves.22 The specifics of hospital decontamination and
worker safety are discussed in Chapter 14.
Throughout the nation, trauma systems, acute care hospitals, and
first responders are unprepared for handling an event involving the release
of a nuclear, biological, or chemical (NBC) agent.8,15,26 Largely, this is due
to ineffective planning and relying on resources that may not be available
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during a disaster or public health emergency.15 The most often cited
weaknesses are an overall lack of training, lack of personal protective
equipment (PPE), lack of resources and equipment to rapidly and reliably
perform preliminary agent detection, and lack of appropriate medical facilities, equipment and supplies to effectively isolate infectious patients
and manage them through the course of their illnesses.8,15,21–22,26
COLLABORATION AND INTEGRATION WITH PUBLIC HEALTH
In order for disaster preparedness and response to be successful, it must
involve interagency resources and consider the 3C’s of emergency
response planning: Collaboration, Cooperation, and Coordination.
Response plans cannot be designed and implemented in a vacuum.
Disaster response and recovery operations will certainly consist of a multiagency response at the local, state, and federal levels. In order to ensure
that the response plan is valid, and will operationally integrate with
other key responding agencies, the planner must collaborate with fellow
agencies and develop plans that involve aspects of interagency response.
Interagency planning groups, such as the Local Emergency Planning
Committee (LEPC), operate under the assumption that if a hazardous
event occurs, all key public safety and health agencies will respond in a
unified approach with common goals to protect the welfare and safety
of the community. These principles of collaboration, cooperation, and
coordination among the agencies that will likely respond to a disaster or
other public health emergency will minimize unnecessary redundancy
in response plans and create partnerships with agencies that can provide
expertise and resources during the public health emergency response.
In a large-scale disaster or act of terrorism, such as the World Trade
Center attacks in 1993 and 2001, the Oklahoma City bombing in
1995, and the 1994 and 1995 sarin attacks in Tokyo, continuous medical monitoring and follow-up of the survivors, responders, and participants in these events is needed to detect the associated long-term
health effects. With the exception of large academic medical institutions
that may perform epidemiologic analysis on specific cohorts of individuals, the public health community must recruit and maintain a
database of affected individuals so they can study the long-term impact of these events on the health of the population. It is important to
note that although the imminent threat of danger may no longer be
present, the need for medical care, disease surveillance, and follow-up
studies is essential to the completion of the public health role in a disaster or other public health emergency.
Additionally, public health agencies at the federal, state, and local
levels have the responsibility under the National Response Framework
(NRF) to coordinate and serve as the lead agency for disasters involv-
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ing mass care. This may include assisting both hospitals and communities to establish alternate care sites (ACS) where patients can be directed to receive medical treatment during a public health emergency,
which will allow a hospital to use its resources to treat higher acuity
patients and remain open to handle routine emergencies during a pandemic or other public health emergency.
EDUCATION AND TRAINING
Reports have suggested that healthcare workers lack the knowledge
to detect and manage a patient who has been exposed to a chemical
or biological agent.6,27–28 The Health Resources and Services Administration (HRSA) survey helped to illustrate the lack of training
and education among trauma center and hospital staff by reporting that
only eight states required employees to be trained in disaster-related
topics, two states required training in biological agent topics, and two
states required training for chemical-related topics.8 Additionally, training for EMS personnel was equally poor because only six states required prehospital providers to have education on disaster-related
topics, only one state required biological agent training, and three
states required education on chemical agents.8
EQUIPMENT AND SUPPLIES
In the GAO’s report of hospital preparedness in August 2003, they reported several findings on hospital equipment and supply resources.
The survey showed that for every 100 beds, 50% of hospitals had fewer
than 6 ventilators, fewer than 3 PPE suits, fewer than 4 isolation beds,
and could only handle fewer than 6 patients per hour through a
5-minute decontamination shower, given their current state of preparedness.9 Additionally, the GAO reports that most first responders lack
a reliable means to detect chemical and/or biological agents in the field,
and do not typically have the proper PPE to protect themselves from
agent exposure.9 The HRSA evaluation of state trauma systems showed
that the availability of PPE for healthcare workers was significantly lacking among states because only one state (Ohio) had enough PPE resources immediately available for its EMS personnel, and only one state
(New Jersey) had enough PPE resources immediately available for its
hospital personnel if a chemical or biological agent release occurred.8
In addition to PPE issues, hospitals and trauma centers often lack
the inventory of equipment and supplies necessary to effectively treat
an influx of potentially affected patients.8–9,14–16,26 Many hospitals,
in a strategy to reduce overall costs, replenish their central supply on
a “just-in-time” basis, clearly ineffective in preparing to treat a mass
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influx of patients.18 Pharmaceutical access is another concern among
healthcare facilities. As demonstrated in the fall 2001 anthrax scare,
hundreds of postal and healthcare workers required postexposure prophylaxis after potential exposure to the agent. Maintaining an adequate pharmaceutical stock of essential antibiotics, antidotes, and
specialty medications in case of a disaster is often viewed as cost prohibitive due to the shelf life and daily usefulness of certain drugs.18
Although this has improved slightly over the past 6 years, hospitals
around the country still struggle to build the internal capacity necessary to perform emergency decontamination of patients from hazardous substance incidents and properly protect their staff, patients, and
visitors from secondary contamination.
WORKER SAFETY
A report released by HRSA on the national state of the trauma system
and EMS preparedness for disasters and mass causality events showed
that only one state in the country thought that its hospital workers
would be adequately protected in the event of a biological (but not
chemical) agent attack.8 Additionally, only one state reported that its
EMS system would have access to PPE in the event of a bioterrorism
event.8 Similar research has underscored a general lack of protection
for the public health workforce against any type of chemical, biological, or radiological contamination in the event of a disaster.8 A major
role for the public health community during an event is to ensure the
health and safety of all disaster workers.13,15
DRILLS AND EXERCISES
Criticisms regarding drills and exercises are notable throughout the
preparedness literature.6,9,11,15,21,26 Comments include statements that
exercises are not realistic, drills tend to be conducted with advanced
warning on shifts with favorable staffing levels, and with equipment and
resource levels at their best, etc. Therefore, the drills bias any useful results from the exercise.15 The purpose of conducting drills and exercises (besides remaining in compliance with accrediting bodies) is to
assess whether or not a facility is adequately prepared to handle an incident with relatively low probability, but with extremely significant
impact on the health system, and to identify areas that need improvement on an operational and planning level.15 Exercises that simply go
through the motions or are conducted with limited realism, under optimal conditions, or are simply haphazardly conducted to meet regulatory or legal requirements are futile and worthless assessment tools that
will only perpetuate a hospital’s state of unpreparedness.15
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EMERGENCY DEPARTMENT DISASTER OPERATIONS
The importance of the ED’s role in disaster and emergency preparedness is discussed in several sources.4–12 The American College of
Surgeons mentions that the ED is a major strength of a trauma center.12
They refer to the ED staff as “highly competent” and often “experts”
in the medical management of chemical, biological, and radiological
casualties.12 Among the many strengths of the ED is the ability to integrate two major components of the trauma system: prehospital and
definitive care. The emergency department maintains constant communications with the EMS system and serves as the direct point of entry
for prehospital providers into the hospital or trauma center. Emergency
physicians represent a critical link in the chain of survival by anticipating the resources that ill and injured patients will need upon arrival at
the ED, and initiating appropriate lifesaving medical care until specialty resources become available.4–11
TRAUMA CENTERS
The roles of trauma centers during a disaster or public health emergency are consistent with their daily activities in the treatment of injured patients. Triage and treatment of injured victims after a disaster
is frequently discussed as a central role of the trauma center in the aftermath of a disaster.6,8–11,13,15–16,18,23,25–29 It is well documented
that trauma centers are adept at the care of the injured victim, and are
viewed as the best choice for the triage and treatment of disasterrelated injured victims.4–10,12,14,17,23,25–31 Trauma care is identified
most frequently as the major strength of the trauma center and the
trauma system. Another expectation is that trauma centers and acute
care hospitals will be able to treat mass numbers of affected patients
as well, including the rapid triage and treatment of all casualties (including those from CBRNE events), decontamination and/or isolation, and quarantine of contaminated or potentially infectious patients.
Trauma centers are also expected to have access to essential equipment, supplies, and pharmaceutical agents.4–6,8,14–15,17,23,27–29,32
The Role of the Hospital/Healthcare Emergency
Manager
What then, is a hospital or healthcare emergency manager? A hospital or
healthcare emergency manager is an individual employed by a healthcare
organization whose job is to coordinate the emergency management
functions of the hospital. This may include many responsibilities
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depending on the hospital or healthcare system, the location of the facility, the size and type of facility or organization, and specific local issues or threats and activities. While there may be variation in the role,
almost universally the hospital/healthcare emergency manager will
perform hazard vulnerability analysis, planning activities, coordination of the hospital’s disaster and other emergency management planning groups or committees, design and conduct training programs,
perform drills and exercises, interact with other agencies and organizations involved in healthcare emergency management (e.g., local public health department, local office of emergency management, EMS,
local law enforcement, and state agencies), and maintain compliance
with regulatory agencies and accreditation organizations such as the
JCAHO. Many hospital or healthcare emergency managers are individuals who have these duties in addition to their normal occupational
roles in the healthcare organization. Typical positions within healthcare organizations that also perform emergency preparedness activities
include nursing managers, educators, administrators, security managers, environmental health and safety administrators, facilities or
physical plant directors, or emergency medical services coordinators.
Few hospitals have taken the initiative to hire a full-time emergency preparedness coordinator for several reasons. First, there is no
direct revenue return on investment in hospital preparedness.
Emergency management is rather a fixed but necessary operating cost.
In the United States, hospitals and healthcare organizations need to
generate a profit. Even in not-for-profit hospitals, CEOs need to be
able to show that profit increased in order to justify growth and add
services for their patients. Activities that cannot improve the profitability of the organization often remain unfunded. Second, there is a shortage of qualified individuals to fill these positions. As mentioned before,
most hospitals have added the duties and responsibilities of preparedness onto an existing full-time employee and this individual had to
teach themselves how to perform these added duties. Most individuals who serve in full-time hospital emergency manager positions have
a public safety background or a clinical background and have had to
learn the discipline of emergency management.
Until recently there have been few higher educational opportunities for people who wish to learn the discipline of healthcare emergency management. In 2010, the Federal Emergency Management
Agency’s (FEMA) Higher Education Program listed only 10 undergraduate and graduate programs combined that focus on both healthcare and emergency management. Many of these are new programs that
have only been in existence for a few years. There have been degree programs in general emergency management, but only a few that apply
this discipline to the public health or hospital environment.
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References | 17
If you don’t seek out a formal degree, how do you become knowledgeable in hospital emergency planning? Initially, it begins with your
current role. If you are a healthcare worker who needs to learn the
finer points of emergency planning, drills and exercises, and incident
management, then you could benefit from FEMA’s independent study
program or professional development series. On the other hand, if
you are an emergency management professional with little knowledge
of the healthcare environment, you may benefit from continuing education in health and medical issues such as the strategic national
stockpile, emerging infectious diseases and pandemics, the health and
medical impact of terrorism and weapons of mass destruction, and
the health impact on populations displaced as the result of disasters.
This text is designed specifically for individuals who wish to learn
the applied discipline of healthcare emergency management, and for all
other personnel in a hospital or from other disciplines who will work
with either a hospital or any other aspect of a healthcare system in planning for and responding to disasters, terrorism, and public health emergencies. Whether you are a college or graduate student learning the
fundamentals of public health or healthcare emergency management, or
a current healthcare professional looking to increase your current knowledge in order to apply emergency management principles to your trade,
this book is designed to meet your needs. There is a lot to learn, and this
text is just the beginning. This emerging field is exciting, challenging,
and rewarding. We wish you luck on your journey!
References
1.
2.
3.
4.
5.
6.
U.S. Department of Labor, Occupational Safety and Health Administration. Best
Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the
Release of Hazardous Substances. Washington, DC: OSHA; 2005. OSHA publication
3249–08N.
Joint Commission Resources. Emergency management standards. Environ Care
News. 2007;10(12):2–8.
Joint Commission Resources. Preparing for catastrophes and escalating emergencies. Environ Care News. 2008;11(1):1–3, 11.
American College of Surgeons. Resources for Optimal Care of the Injured Patient: 1999.
Chicago: American College of Surgeons; 1999.
American Trauma Society and U.S. Department of Transportation, National
Highway Traffic Safety Administration. Trauma System Agenda for the Future. National
Highway Traffic Safety Administration; October 2002. Report #3P0138.
American College of Surgeons. [ST-42] Statement on disaster and mass casualty
management [by the American College of Surgeons]. American College of
Surgeons Web site. http://www.facs.org/fellows_info/statements/st-42.html.
Published 2003. Accessed December 28, 2009.
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7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
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Introduction to Hospital and Healthcare Emergency Management
Bledsoe BE, Porter RS, Cherry RA. Essentials of Paramedic Care. Upper Saddle River,
New Jersey: Brady/Prentice Hall Health; 2003.
U.S. Department of Health and Human Services, Health Resources and Services
Administration. A 2002 National Assessment of State Trauma System Development, Emergency
Medical Services Resources, and Disaster Readiness for Mass Casualty Events. Washington, DC:
Health Resources and Services Administration; 2002.
U.S. General Accounting Office. Hospital Preparedness: Most Urban Hospitals Have Emergency
Plans but Lack Certain Capacities for Bioterrorism Response. Washington, DC: U.S. General
Accounting Office; August, 2003. Report GAO-03-924.
Frykberg ER. Disaster and mass casualty management: a comment on the ACS
position statement. Bulletin of the American College of Surgeons. 2003;88(8):12–13.
White SR. Hospital and emergency department preparedness for biological,
chemical, and nuclear terrorism. Clin Occup Environ Med. 2002;2(2):405–425.
Trunkey DD. Trauma centers and trauma systems. JAMA. 2003;289:1566–1567.
Landesman LY. Public Health Management of Disasters: The Practice Guide. Washington,
DC: American Public Health Association; 2001.
May AK, McGwin G Jr, Lancaster LJ, et al. The April 8, 1998 tornado: assessment
of the trauma system response and the resulting injuries. J Trauma. 2000;
48(4):666–672.
Rubin, JN. Recurring pitfalls in hospital preparedness and response. J Homeland
Security. January, 2004. http://www.homelanddefense.org/journal/Articles/
rubin.html. Accessed August 18, 2009.
U.S. General Accounting Office. SARS Outbreak: Improvements to Public Health Capacity
Are Needed for Responding to Bioterrorism and Emerging Infectious Diseases. Washington, DC:
U.S. General Accounting Office; May 7, 2003. Publication GAO-03-769T.
Feeney J, Parekh N, Blumenthal J, Wallack MK. September 11, 2001: a test of preparedness and spirit. Bulletin of the American College of Surgeons. 2002;87(5).
Barbera JA, Macintyre AG, DeAtley CA. Ambulances to nowhere: America’s critical shortfall in medical preparedness for catastrophic terrorism. In: Howitt
AM, Pangi RL, eds. Countering Terrorism: Dimensions of Preparedness. Cambridge, MA: MIT
Press; 2003:283–297.
Reilly MJ, Markenson D. Hospital emergency department referral patterns in a
disaster. Prehosp Disast Med. 2009;24(2):s29–s30.
Reilly MJ. Referral patterns of patients in disasters—who is coming through your
emergency department doors? Prehosp Disast Med. 2007;22(2):s114–s115.
Kellerman A. A hole in the homeland defense. Modern Healthcare. 2003;33(16):23.
U.S. Department of Defense, Army, SBCCOM, Federal Domestic Preparedness
Program. NBC Domestic Preparedness Senior Officials’ Workshop (SOW) [CD-ROM].
SBCCOM; 1999.
Cushman JG, Pachter HL, Beaton HL. Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma.
2003;54:147–155.
Cone DC, Weir SD, Bogucki S. Convergent volunteerism. Ann Emerg Med.
2003;41(4):457–462.
Feliciano DV, Anderson GV Jr, Rozycki GS, et al. Management of casualties from
the bombing at the Centennial Olympics. Am J Surg. 1998;176(6):538–543.
Ghilarducci DP, Pirallo RG, Hegmann KT. Hazardous materials readiness of
United States Level 1 trauma centers. J Occup Environ Med. 2000;42(7):683–692.
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References | 19
27.
28.
29.
30.
31.
32.
American College of Surgeons. Disasters from biological and chemical terrorism—what should the individual surgeon do?: a report from the Committee on
Trauma. American College of Surgeons Web site. http://www.facs.org/
civiliandisasters/trauma.html. Accessed December 30, 2009.
American College of Surgeons. Statement on unconventional acts of civilian
terrorism: a report from the Board of Governors. American College of Surgeons
Web site. http://www.facs.org/civiliandisasters/statement.html. Accessed
December 30, 2009.
Jacobs LM, Burns KJ, Gross RI. Terrorism: a public health threat with a trauma
system response. J Trauma. 2003;55(6):1014–1021.
MacKenzie EJ, Hoyt DB, Sacra JC, et al. National inventory of hospital trauma
centers. JAMA. 2003;289:1515–1522.
Mann NC, Mullins RJ, MacKenzie EJ, Jurkovich GJ, Mock CN. Systematic review
of published evidence regarding trauma system effectiveness. J Trauma. 1999;
47(3);S25–S33.
Peterson TD, Vaca F. Commentary: Trauma systems: a key factor in homeland preparedness. Ann Emerg Med. 2003;41(6):799–801.
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Chapter
2
Healthcare Incident
Management Systems
Arthur Cooper, MD, MS
Photo by Jocelyn Augustino/FEMA News Photo
Learning Objectives
■
Discuss the fundamental principles of healthcare incident
management systems.
■ Describe the incident command system structure and its application to the healthcare environment.
■ Discuss the importance of interagency cooperation and collaboration when managing disasters and public health emergencies that impact the healthcare system.
Overview
Making method out of madness
The aim of this chapter is to arm the busy healthcare staff, clinician, or
emergency manger with a basic understanding of incident management
21
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Healthcare Incident Management Systems
systems as applied to the healthcare and hospital environment, including the Hospital Incident Command System (HICS), not as a substitute,
but as a rationale for incident management training and the need to
understand the application to a hospital or healthcare system. This
chapter will cover the fundamental principles of healthcare incident
management systems, including one system modified specifically for
the hospital, the Hospital Incident Command System. Such systems
are vital to the management of disasters, acts of terrorism, and public
health emergencies involving healthcare organizations because, without the effective coordination of resources achieved through use of a
healthcare incident management system, chaos, rather than order, will
prevail. After a concise introduction to set the stage, the chapter will
consider the historical background, foundational principles, incident
leadership, command structures, HICS organization, training systems,
HICS implementation, logistic concerns, practical concerns, and interagency relationships essential to successful healthcare incident management, before delivering its conclusions.
Case Study
A Cloud in the Midnight Sky
You are the administrator on duty (AOD) when you are called by the
physician in charge of the emergency department, who reports that numerous arriving patients are exhibiting spasms of severe coughing triggered by “something in the air.” While you consider your next steps,
your spouse calls to tell you there has been a large explosion at a nearby
tank farm adjacent to a large industrial facility. Television reports document widespread panic at the scene and in the immediate vicinity of
your hospital, which is located about two miles (three kilometers) east
of the site. It is past midnight; only caretaker staff are on duty (except in
your critical and acute care units) and hospital staff await your orders.
The following questions race through your mind. How would
you begin to answer them?
■
■
■
■
■
■
■
■
■
■
Does a bona fide disaster exist?
Should I declare a disaster now?
Should I seek additional information before declaring a disaster?
Should I implement the hospital’s emergency operations plan?
Should I activate the hospital’s command center?
How will I ensure the safety of staff and patients?
Should I mobilize additional hospital staff?
Should I lock down the facility?
Should all emergency patients be decontaminated?
Should public health agencies be notified?
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Historical Background | 23
■
■
■
Who should I ask for necessary additional resources?
Are there potential threats to the hospital itself?
How will I coordinate and supervise all the staff?
The decisions are yours to make. The answers may be found in this
chapter.
Introduction
“Who’s in charge? They’re all in charge!”1
Understanding the Incident Command System (ICS) applied during
disasters may prove a daunting task, even for healthcare executives experienced in interpreting complex tables of organization that baffle
other managers, clinicians accustomed to solving and treating complex
medical problems, and staff prepared to work in the complex healthcare environment. However, as recently stated so eloquently by
Lieutenant Thomas Martin of the Virginia State Police in the illuminating video, The Many Hats Of Highway Incident Command (http://cts
.virginia.edu/incident_mgnt_training.htm), the principles of incident
command are fundamentally no different from the everyday manners
children learn as youngsters, as elegantly and clearly described in the
poignant work by author Robert Fulghum, All I Really Need To Know I
Learned In Kindergarten.1,2 Within this simple framework, the responsible
healthcare emergency manager can readily answer the question, “Who’s
in charge?” The answer, of course, is that they’re all in charge, of what they’re
in charge of—because all those involved in the disaster response are responsible for their immediate tasks, their communication with others,
and first and foremost, their own and others’ safety.
Historical Background
“The best way to predict the future is to create it.”3
Modern incident command grew from the experience of firefighters in
combating the California wildfires of the mid 1970s. Inadequate communication and ineffective collaboration between the numerous agencies battling these natural disasters led to the deaths of many firefighters
whose lives need not have been lost. The subsequent after-action reports identified numerous critical weaknesses in the organization and delivery of many responders’ agencies and efforts, including lack of
accountability, barriers to communication, poor planning processes,
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Healthcare Incident Management Systems
overloaded incident commanders, and absent response integration. The
dawning realization that deficient and defective command and control
were mostly responsible for these tragic fatalities led California fire chiefs
to develop an “interoperable” system for emergency response, whereby
all the involved agencies could communicate with one another and collaborate in the field, based upon a common organizational structure that
all such agencies could understand and apply.
This new system, called FIRESCOPE (Firefighting Resources of
California Organized for Potential Emergencies), was based upon principles gleaned from military experience and management theory, especially the management by objectives concepts introduced in 1954 by Peter
F. Drucker in his classic work, The Practice of Management.4 Its core purpose
was to provide a standardized, on-scene, all-hazard incident management dogma that allowed its users to quickly implement an integrated
organizational structure that was not impeded by jurisdiction boundaries,
and was flexible and scalable enough to match the needs and resources
for single, expanding, multiple, and complex incidents, despite their special circumstances and unique demands. It rapidly evolved into the
Incident Command System (ICS) that has gradually been adopted by
most fire and emergency services nationwide, the purposes of which are
to ensure the (1) safety of responders and others, (2) achievement of tactical objectives, and (3) efficient use of resources. As a result, ICS was subsequently designated for use throughout the United States by the federal
Superfund Amendments and Reauthorization Act (SARA) of 1986
(PL 99-499), Occupational Health and Safety Administration (OSHA)
rule 1910.120, and, most recently, Homeland Security Presidential
Directive 5 (HSPD 5),5 in addition to numerous other state and local regulations. Its early success also led the California Emergency Medical
Services Authority to adapt and periodically revise it for use in all disasters involving hospitals, such that it now serves as the basis of the Hospital
Incident Command System (HICS) used by most hospitals in the
Americas and, increasingly, worldwide. Specific instruction in HICS is
available through both the California Emergency Medical Services
Authority HICS Web site (http://www.emsa.ca.gov/HICS/default.asp),
and the Emergency Management Institute’s Web site (http://training
.fema.gov), within the independent study ICS courses IS-100.HC and
IS-200.HC revised in 2007 for healthcare providers.6
Foundational Principles
“Management by objectives”4
The three key strategies of the disaster response, in order, are to (1) protect and preserve life, (2) stabilize the disaster scene, and (3) protect and
preserve property. Healthcare providers intuitively understand the first
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Incident Leadership | 25
purpose, and intellectually understand that the third purpose is essential
to the first because healthcare providers cannot perform their lifesaving
tasks without the appropriate facilities, equipment, and resources. The
second purpose, however, may be less obvious. This is because an organized disaster response can occur only within the context of a stable work
environment—an environment that is difficult to achieve in the first minutes after disaster strikes, when chaos is the rule, even in greatly complex
work environments, such as hospitals, that are highly self-regulated.
Thus, an incident management system is needed to bring order
to the chaos, the sine qua non of which is an incident command structure characterized by the three key tactics that must underlie all of incident command—unity of command, span of control, and clarity of text. Unity
of command refers to the principle that sharing of information among
all personnel involved in a disaster response is vital, but such individuals receive formal orders from, and make formal reports to, a single
supervisor in order to preserve the viability of the chain of command.
Span of control refers to the principle that in a high stress environment,
no line supervisor can effectively coordinate the efforts of more than
three to seven, and ideally no more than five, subordinate personnel.
Clarity of text refers to the principle that all communications, written
and spoken, must be transmitted in the simplest, most generic language
possible, avoiding the use of words or jargon likely beyond the understanding of many emergency responders, so as to ensure that all personnel involved in the disaster response understand both the general
strategy of the Emergency Operations Plan (EOP) and the special tactics being applied to combat the disaster.
Incident Leadership
“Coordination, Communication, Cooperation”1
Healthcare incident management systems achieve their goals by ensuring what have been termed the “3 Cs” of incident command: coordination, communication, and cooperation, of which the most important is
cooperation, because it makes coordination and communication feasible. However, effective incident management requires not only universal education in disaster management appropriate to the functional
job description of the individual healthcare employee—awareness,
technical, and professional—but also frequent drilling in the implementation of the hospital disaster plan, especially its incident command structure. Most texts and training rightly emphasize that the
individuals designated to fulfill specific functional job descriptions
must be appropriately trained to do so; therefore, hospital executives
who perform similar tasks during routine hospital business must step
aside and yield these responsibilities to those who have been trained
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Healthcare Incident Management Systems
to do so. However, this notion ignores long-established realities of
human behavior—the boss is still the boss, even if untrained in disaster management—so every effort should be made by senior executives to ensure that all hospital executives receive training in disaster
management and incident command that will enable supervisors to
function in their assigned roles even when disaster strikes.
Physicians commonly presume that because the first key purpose
of incident management is to protect and preserve life, they should be
in charge of emergency operations. However, physicians often overlook
the fact that while they must clearly be in charge of all aspects of medical care, they generally comprise no more than approximately 10% of
the total number of hospital personnel. Typically, the healthcare needs
of the hospitalized patient require an average of 10 other personnel to
support the treatments prescribed and the operations performed by a
single physician or surgeon. Moreover, the physician’s expertise—and
most valuable contribution to the hospital disaster response—lies in the
medical care of the hospitalized patient, rather than its operational,
logistical, or planning support.
Command Structure
“[ICS is] the system to achieve the coordination necessary to carry out an effective and efficient response.”7
Two basic command structures, and variations thereof, are utilized
worldwide: (1) the Hospital Incident Command System (HICS), developed by the California Emergency Medical Services Authority and
promulgated both by its originator (http://www.ems.ca.gov/HICS/
default.asp) and by the Domestic Preparedness Consortium of the
Federal Emergency Management Agency (http://training.fema.gov),
has been adopted for use by most hospitals in the Americas (Figure 2-1),
while (2) nation-specific templates are used by hospitals in Europe
and Australasia, which are promulgated chiefly through the extensive
disaster medicine training programs of the Emergo Train System (ETS),
developed by the Linköping University Trauma Center in Sweden
(http://www.emergotrain.com)8,9 (Figure 2-2). These various systems differ chiefly in the relative independence of their medical operations units, and the specificity of their tables of organization, the
former tending to be more hierarchical and the latter tending to be
more collegial. In the United States, the Hospital Incident Command
System (HICS) has been adopted by the Department of Homeland
Security as the system most congruent with the Incident Command
System (ICS) designated by the National Incident Management System
(NIMS) under the authority of Homeland Security Presidential Directive
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Command Structure | 27
Figure 2-1
Hospital Incident Command System Incident Management Team Structure
Incident Commander
Operations Section
Chief
Public Information
Officer
Safety Officer
Liaison Officer
Medical/Technical
Specialist(s)
Planning Section
Chief
Biological/Infectious Disease
Chemical
Radiological
Clinic Administration
Hospital Administration
Logistics Section
Chief
Legal Affairs
Risk Management
Medical Staff
Pediatric Care
Medical Ethicist
Finance/Administration
Section Chief
Staging Manager
Personnel Staging Team
Vehicle Staging Team
Equipment/Supply Staging Team
Medication Staging Team
Medical Care
Branch Director
Inpatient Unit
Outpatient Unit
Casualty Care Unit
Mental Health Unit
Clinical Support Services Unit
Patient Registration Unit
Resources Unit
Leader
Personnel Tracking
Materials Tracking
Situation Unit
Leader
Patient Tracking
Bed Tracking
Infrastructure
Branch Director
Power/Lighting Unit
Water/Sewer Unit
HVAC Unit
Building/Grounds Damage Unit
Medical Gases Unit
Medical Devices Unit
Environmental Services Unit
Food Services Unit
HazMat Branch
Director
Service Branch
Director
Time Unit Leader
Communications Unit
IT/IS Unit
Staff Food & Water Unit
Support Branch
Director
Procurement Unit
Leader
Employee Health & Well-Being Unit
Family Care Unit
Supply Unit
Facilities Unit
Transportation Unit
Labor Pool & Credentialing Unit
Documentation
Unit Leader
Compensation/
Claims Unit Leader
Demobilization
Unit Leader
Cost Unit Leader
Detection and Monitoring Unit
Spill Response Unit
Victim Decontamination Unit
Facility/Equipment Decontamination Unit
Security Branch
Director
Access Control Unit
Crowd Control Unit
Traffic Control Unit
Search Unit
Law Enforcement Interface Unit
Business Continuity
Branch Director
Information Technology Unit
Service Continuity Unit
Records Preservation Unit
Business Function Relocation Unit
California Emergency Medical Services Authority
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Healthcare Incident Management Systems
5 (HSPD 5).5 However, it is less important which system is utilized than
the fact that the chosen system has the support of both hospital executives and hospital staff—cooperation depends upon acceptance of a single approach to hospital incident management by all hospital personnel,
because they are the ones who must implement it.
Regardless of which system is utilized, it is important to note that
there are far more similarities than differences between the various
systems. All systems must address the four key functions of the emergency management response: finance and administration, logistics,
operations, and planning and intelligence. Moreover, with the passage
of time, all disaster response systems have been evolving toward a
common model for incident command that emphasizes the fundamentally different tasks of medical and logistic operations. For example, the most recent iteration of HICS includes appropriate
medical/technical specialists within the command staff who assist and
advise the incident commander within the hospital command center,
thereby ensuring that medical concerns directly inform decisions made
by the incident command team in real time.
Figure 2-2
Emergo Train System Communication Structure for the Medical Service for a Major Incident
Political
Level
Local
Medical Management
Hospital
Strategic
Medical Command
Local
Medical Management
Hospital
Ambulance
Management
Rescue Service
(Strategic level)
Police
(Strategic level)
Initially
via
Alarm
Centre
At another location
At the scene
Fire IC
Medical IC
Ambulance IC
Police IC
Evacuation
Officer
Other sectors (areas)
at the incident site
Rüter A, Nilsson H, & Vikström T. Medical Command and Control at Incidents and Disasters. Lund:
Studentlittatur, 2006.
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Hospital Incident Command System (HICS) | 29
Hospital Incident Command System (HICS)
“[HICS is] a methodology for using ICS in a
hospital/healthcare environment.” 8
The functional job action categories that must be addressed under HICS
include incident command and staffing, finance and administration,
logistics, operations, and planning and intelligence. (Remember these
categories by the mnemonic “CFLOP,” for without ICS, one will “C”
[see] the disaster response “FLOP.”) The additional command staff
functions that must be addressed under HICS include liaison, medical/technical, public information, and safety. (Remember these categories by the mnemonic “[Mount O]LMPS,” indicating their physical
proximity to the incident commander.) Each of these categories is described in the following sections in greater detail. Utilization of HICS
in a disaster is not intuitive, and requires far more than anecdotal familiarity with its structure and terminology for its successful implementation. Detailed presentations and all requisite forms to guide the
implementation of HICS may be downloaded from its Web site free of
charge (http://www.emsa.ca.gov/HICS/default.asp).
COMMAND
A single incident commander (IC) is responsible for all aspects of the disaster response, whether operational or medical. The initial responsibilities of the IC are to declare an internal disaster (originating within
the facility) or an external disaster (originating outside the facility), to
activate the hospital emergency operation center (HEOC), to implement the
hospital Emergency Operations Plan (EOP), and, based upon the nature and
extent of the disaster, to organize the disaster response through designation of the various section chiefs (general staff) and staff officers
(command staff). All ICS section chiefs report directly to the IC and must
be in constant communication with the IC, either in person or by
telecommunications, for hospital incident command to be effective
and efficient. In addition to coordinating and supervising the disaster
response through the four ICS section chiefs, the IC is responsible for
the provision of the following four key command functions: liaison,
medical/technical, public information, and safety. The decision to designate section chiefs and staff officers to fulfill the various functional roles required
for incident command rests solely with the IC. Not every response will
require all positions to be filled, based on the size and scope of the event.
In addition, in the early stages there may insufficient personnel to fill all
roles, so several may be held by a single person. In fact, in the beginning
one could say the IC is fulfilling all roles until they are assigned. This is
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Healthcare Incident Management Systems
a key principle in that the IC must assume personal responsibility for
any function not so assigned.
Liaison
The liaison officer interfaces with all appropriate government and nongovernmental agencies and health system organizations. At a minimum, these should include local public health, office of emergency
management, police, fire, and emergency medical services, as well as
state, county, and local departments of public health, and regional
healthcare associations.
Medical/Technical
The medical/technical specialists are chiefly responsible for providing the
IC with medical and technical advice. The medical/technical specialists may vary based on the type of disaster (infectious disease specialist for biological agents, hazardous materials specialist or medical
toxicology physician for chemical agents, radiation safety physician
for nuclear agents, and trauma or burn surgeon for explosive or incendiary agents).
Public Information
The public information officer interfaces with all appropriate communications media to provide regular reports on the progress of the disaster
response. The public information officer also offers advice and assistance in developing and instituting communications to staff and families of patients potentially or actually hospitalized after a disaster to
ensure that information is accurate and uniformly presented, and to
provide regular reports of the outcome of each individual patient’s
care to the approapite parties.
Safety
The safety officer is chiefly responsible for the integrity of the disaster
response through situational awareness of potential hazards, surveillance of staff and victims safety, and making recommendations to the IC
with regard to safety. This is accomplished via review of the Situation
(of hospital facilities), Protection (of hospital personnel), Identification
(of possible risks), and Notification (of appropriate authorities), or
SPIN.
FINANCE
The finance and administration section monitors and tracks costs incurred
in mounting the disaster response. It also identifies potential legal issues and liabilities, and maintains the records of the HCC, such that ex-
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Training and Education in ICS | 31
traordinary expenses, legal risks, and after-action reports can be accurately determined, delineated, and developed for reimbursement, reconsideration, and review.
LOGISTICS
The logistics section is the “quartermaster” of the disaster response. It obtains and manages all staff, facilities, and equipment needed to support
the disaster response, such as food, supplies, equipment, facilities, and
sanitation, as well as transport vehicles, fuel, physical space, and equipment repair.
OPERATIONS
The operations section is the central component of the disaster response
and all other components are designed to support it. It executes the disaster plan and is responsible for all necessary medical, nursing, and ancillary functions at patient-care sites, as well as decontamination and
waste control, ground and air rescue, evacuation of casualties, and crisis management.
PLANNING
The planning and intelligence section formulates instant changes in the response plan based upon feedback obtained from administrative, logistical, and operation personnel. The role of this section is to always
be thinking several events ahead of the current time and providing
the IC with the information and approach to these future eventualities and possibilities. It is responsible for the collection, organization,
evaluation, and dissemination of information on the present status of,
and future needs for, staff, facilities, and resources in the disaster
response.
Training and Education in ICS
Talking the talk vs. walking the walk
Although disaster professionals and emergency managers have adopted
a nomenclature that is unique to disaster medical and mass casualty
management, it follows a pattern that can be compared to terms recognized by anyone in healthcare familiar with the principles of public
health and/or injury control. Still, one must be knowledgeable of the
specialized terminology used in emergency management for the
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principles of emergency preparedness to be fully mastered: (1) preparation is analogous to primary injury prevention, which seeks to avoid
injuries before they occur...
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