Incident Management Systems for Hospitals Kristi L Koenig, MD, FACEP Professor of Clinical Emergency Medicine Director of Public Health Preparedness University of California at Irvine Terminology – Marine definition of HICS and securing the building

Why Management Aspects? Incident Management new to health care systems Not traditionally used in some types of events, e.g. biological, nursing strike Clinical is relatively familiar “Emergency Management” unfamiliar to most clinicians ED is “soft target” University of California at Irvine Department of Emergency Medicine

Are We Prepared? Post 9/11 Lack of Benchmarks Prior Secretary of Department of Homeland Security said “yes!” Experts quoted in New York Times said “no!” Lack of Benchmarks University of California at Irvine Department of Emergency Medicine

Why do hospitals need to be prepared? Disaster are Local! Most casualties arrive to the hospital within 1 ½ hours Civilian volunteers and local first responders rescue most victims (95%) within first 24 hours Critical care and trauma surgery managed without State or Federal assistance University of California at Irvine Department of Emergency Medicine

Disaster Casualties Most planning focuses on injuries Victims need treatment for other conditions Lack of access to primary care Exacerbation of chronic conditions Psychological effects Increased incidence of childbirth, heart attacks University of California at Irvine Department of Emergency Medicine

Sudden Impact Events Study of 29 U.S. Disasters Most trauma victims have minor injuries Accidents occur during recovery phase 10-15% of victims hospitalized Half admitted for non-medical reasons Sent home next day 6% supply shortages 2% personnel shortages University of California at Irvine Department of Emergency Medicine

Lack of Resources? Studies of recent disasters in the US show a lack of a management system to organize available resources Hurricane Katrina An exception? University of California at Irvine Department of Emergency Medicine

Key Principles All-Hazard Comprehensive Emergency Management Hazards Vulnerability Analysis (HVA) Comprehensive Emergency Management Mitigation Preparedness Response Recovery Incident Management System University of California at Irvine Department of Emergency Medicine

Why Incident Management Systems for Hospitals? Continuity of Business Operations Plan Meet responsibilities to employees, patients, and community Reduce insurance/workers compensation costs Protect capital investment Regulatory compliance Ultimate goal to reduce morbidity and mortality JCAHO requirement University of California at Irvine Department of Emergency Medicine

JCAHO Requirements January 2001 All-Hazard Hazard Vulnerability Analysis (HVA) Comprehensive Emergency Management Community-Wide Planning Incident Management System Example - Hospital Emergency Incident Command System (HEICS) Consistent with community standards University of California at Irvine Department of Emergency Medicine

Incident Management System Command, Control, Leadership Flexible process for ongoing assessment Incident Action Plans Unified Command for multi-jurisdictional events Federal Level National Incident Management System (NIMS) Hospital Level Hospital Emergency Incident Command System (HEICS) Change to Hospital Incident Command System (HICS) University of California at Irvine Department of Emergency Medicine

Disaster Management Agencies Federal Structure Pre 9/11 Does not include VA or NDMS University of California at Irvine Department of Emergency Medicine

National Incident Management System (NIMS) Established post 9/11 by Homeland Security Presidential Directive 5 Ensures all levels of government have capability to work efficiently together using a national approach to domestic incident management University of California at Irvine Department of Emergency Medicine

Incident Command System (ICS) Component of the National Incident Management System (NIMS) Provides a universal structure and process to manage the organization’s response and recovery activities University of California at Irvine Department of Emergency Medicine

External Scenarios Nuclear Detonation—10-Kiloton Improvised Nuclear Device Biological Attack—Aerosol Anthrax Biological Disease Outbreak—Pandemic Influenza Biological Attack—Plague Chemical Attack—Blister Agent Chemical Attack—Toxic Industrial Chemicals Chemical Attack—Nerve Agent Chemical Attack—Chlorine Tank Explosion Natural Disaster—Major Earthquake Natural Disaster—Major Hurricane Radiological Attack—Radiological Dispersal Devices Explosives Attack—Bomb Using Improvised Explosive Device Biological Attack—Food Contamination Cyber Attack The Department of Homeland Security has disseminated National Planning Scenarios for use by state and local communities to promote integrated preparedness HICS materials include 14 relevant National Planning Scenarios (external) and 13 internal hospital disaster scenarios Provided to assist with hospital planning and training efforts, as indicated by their hazard vulnerability assessment University of California at Irvine Department of Emergency Medicine

Internal Scenarios Bomb Threat Evacuation, Complete or Partial Facility Fire Hazardous Material Spill Hospital Overload Hostage/Barricade Infant/Child Abduction Internal Flooding Loss of Heating/Ventilation/Air Conditioning Loss of Power Loss of Water Severe Weather Work Stoppage University of California at Irvine Department of Emergency Medicine

ICS - Components Adaptable to any type of emergency Common organizational/procedural standards Common Terminology Integrated Communications Modular Organization Unified Command Structure Maintains autonomy of jurisdiction University of California at Irvine Department of Emergency Medicine

ICS - Components Manageable Span of Control Consolidated Action Plans Represent Incident Action Planning Process Comprehensive Resource Management Designated Incident Facilities An org chart and a job action sheet are insufficient for managing an incident Incident Action Planning is KEY University of California at Irvine Department of Emergency Medicine

ICS 5 Major Functional Areas Command or Management Operations Planning Logistics Finance University of California at Irvine Department of Emergency Medicine

Incident Command Operations Planning Logistics Finance / Admin ‘Doers' Address "what if?" Logistics Supports Operations Requirements Finance / Admin Tracks Expenses Incident Command Leadership & Direction Authorization of Expenses Planning: Situation Assessment and Incident Action Planning Logistics: Support requirements dictated by operations University of California at Irvine Department of Emergency Medicine

Health Care Facilities Victims arrive unannounced May not arrive by EMS Family and friends overwhelm system with inquiries Volunteers Media University of California at Irvine Department of Emergency Medicine

Health Care Facilities Convergence of injured persons, relatives & friends, the general public (volunteers), off-duty staff & medical personnel, and media Not a Scarcity of Resources Lack of Incident Management System University of California at Irvine Department of Emergency Medicine

Critical Hospital Resources Physical plant Personnel Supervision Supplies and Equipment Communication Transportation University of California at Irvine Department of Emergency Medicine

Brief History of HEICS 1980’s – FIRESCOPE Southern California wildfires use ICS 1987 - Hospital Council of Northern California adapts ICS to hospitals 1991 - HEICS I 1992/93 – HEICS II 1998- HEICS III 2006- HEICS IV August 2006- HICS Guidebook HEICS was not the only game in town, e.g. VHA was applying ICS to health care in 1993 (published guidance) University of California at Irvine Department of Emergency Medicine

HEICS I - III Areas needing improvement Not NIMS compliant Medical Officer not directly under IC Labor pool in Planning, not Operations Damage assessment in Logistics, not Operations Operations section Only focus on medical requirements Designed around department, not incident functions No concept of Incident Action Planning Existed separately from hospital disaster plan University of California at Irvine Department of Emergency Medicine

The New HICS HEICS IV/HICS has different organizational chart Simpler and smaller More flexible and adaptable NIMS compliant Enhanced Job Action Sheets Extended operations and recovery sections University of California at Irvine Department of Emergency Medicine

HICS Guidebook #1: High-level guidance for developing a hospital Emergency Management Program (EMP) Key considerations Planning and response assumptions Provides guidance for use of the incident command system Adapted to incident specific situations Modular and scalable based on availability of personnel University of California at Irvine Department of Emergency Medicine

HICS Guidebook #2: A HICS training curriculum Specific instructional guidance and teaching outlines Curriculum materials designed to provide variable methods of training hospital staff Emergency response principles Incident command Each hospital has the prerogative to implement the entire program or the parts they believe will best assist them in teaching HICS to their staff. A new set of implementation materials has been developed and included as part of the HICS package so that those responsible for implementing the system have the background, expertise, and needed familiarization. University of California at Irvine Department of Emergency Medicine

New HICS Elements A more compact and versatile incident management team structure Modular Scalable to the event Updated Job Action Sheets (JAS) Revised, National Incident Management System (NIMS) consistent forms A more compact and versatile incident management team structure. The new structure emphasizes the tactical role of the Operations Section in resolving an incident’s impacts and reinforces the principle of building an incident command organization based on a situation’s needs. Flexibility is further reflected in the addition of the Medical/Technical Specialist position. Another key change is the update of the original Job Action Sheets (JAS) with new linkages to the new Branch Directors and other positions new to HICS. The design has been modified to use the JAS as a documentation tool if desired, and the original timeframes are more clearly defined and expanded to include Demobilization and System Recovery. The revised forms included with HICS have been modified so they are consistent with current NIMS ICS forms for information sharing and documentation. University of California at Irvine Department of Emergency Medicine

New HICS Elements Incident Planning Guides (IPG) Assist in evaluating and writing emergency plans Scenario based Incident Response Guides (IRG) Key considerations and response actions for command staff Expanded information and tools Guidebook and Appendices Resources There is also a new series of Incident Planning and Response Guides (IPGs and IRGs) for specific external and internal scenarios. IPGs outlining strategic considerations have been designed to assist hospitals in evaluating or writing their response plans. IRGs have been created for use as “brain teasers” for command personnel to consider when managing a particular type of incident, including suggestions for incident command positions to activate. Expanded information and additional guidance is contained even in the HICS Guidebook you are now reading. Although HICS has an important role in helping a hospital meet its emergency preparedness responsibility, it continues to serve as a complement the facility’s Emergency Operations Plan (EOP). The EOP is the master response plan, while HICS describes the incident management team structure and processes. University of California at Irvine Department of Emergency Medicine

HICS Summary The HEICS IV/HICS project updated HEICS III to current emergency management practices and principles Developed by hospital and incident command experts HICS Guidebook assists hospitals in implementation HICS provides new materials Job Action Sheets Incident Planning Guides Incident Response Guides University of California at Irvine Department of Emergency Medicine

Hospital ICS The role of the “Agency Executive” is above the Incident Commander.  This is where the Administrator would be.  This person continues to run the agency and provides input to the IC.  The IC would be chosen from qualified candidates.  The Operations Section shows only medical – the full model considers 4 important areas – business continuity; equipment, plant and utilities; safety and security; and, health and medical. University of California at Irvine Department of Emergency Medicine

Command Section Leadership Incident Commander Organize and direct Emergency Operations Center and all positions throughout the ICS structure Overall direction for hospital operations Authorizes evacuations University of California at Irvine Department of Emergency Medicine

Command (Management) Section Responsible for overall incident management Command Staff Positions Information (Public Affairs) Officer Safety Officer Liaison Officer Single vs. Unified Command University of California at Irvine Department of Emergency Medicine

Operations Section Reduction of immediate hazard Establish situation control Restore normal operations Functions Staging areas Resources Organization of operations divisions, groups, and branches University of California at Irvine Department of Emergency Medicine

Operations Section Key Components Business Continuity Equipment Plant and Utilities Safety and Security Health and Medical University of California at Irvine Department of Emergency Medicine

Planning Section Collection, evaluation and dissemination of tactical information about the incident Maintains information on current and forecasted situation Tracks status of resources Primary units Section chief/deputy, resources unit, situation unit, documentation unit, demobilization unit, technical specialists University of California at Irvine Department of Emergency Medicine

Logistics Section Provide support to incident Order all resources from off-incident locations Provide facilities, transportation, supplies, equipment maintenance, fueling, feeding, communication and medical services for responders Sections Chief/deputy, supply unit, facilities unit, ground support/transportation unit University of California at Irvine Department of Emergency Medicine

Finance Section Procurement Unit Time Unit Compensation/Claims Unit Cost Unit Capture costs for FEMA reimbursements during State or Federal disaster declarations University of California at Irvine Department of Emergency Medicine

ICS – Translated! Command/Management…Pointers Plans………………………Thinkers Logistics…………………..Getters Finance……………………Counters Operations………………...Doers University of California at Irvine Department of Emergency Medicine

ICS Functional Responsibility Command Strategy, global responsibility Define mission, ensure completion Operations Implement plan, direct tactics Planning Collect/analyze data, direct planning Continuity of operations Logistics Support response Environment and materials Finance Track money, ensure documentation Maximize recovery, reduce liability University of California at Irvine Department of Emergency Medicine

ICS Implementation Unfolds in a modular fashion Based on incident type and size Single individual can simultaneously manage all major functional areas or independent management required Used to plan, organize, staff, direct and control emergency situations University of California at Irvine Department of Emergency Medicine

ICS Implementation Incidents without warning (earthquake, explosion) Leadership and direction initially provided by any employee who first recognizes the danger Incidents with warning (severe weather, cloud of hazardous materials approaching facility) Director or designee provides initial leadership and direction University of California at Irvine Department of Emergency Medicine

ICS Implementation Incident Management Team IMT Position Hospital Position/Service Incident Commander Director’s Office Planning Section Chief Emergency Management Logistics Section Chief Acquisitions and Material Management Service Finance Section Chief Fiscal Service Operations Section Chief Staffed based on incident Business Continuity Group Leader Associate Director Equipment/Plant/Utilities Group Leader Facilities/Engineering Safety and Security Group Leader Police and/or Safety Service Health and Medical Group Leader Chief of Staff University of California at Irvine Department of Emergency Medicine

Command Post Consider establishing for incident that involves a distinct scene within the facility or its grounds Ad-hoc location where decisions are made concerning control of incident University of California at Irvine Department of Emergency Medicine

Emergency Operations Center Pre-designated location within facility Location where activates related to information collection, inter-service coordination, strategic decision-making and resource allocation are managed Not all incidents require the use of an EOC University of California at Irvine Department of Emergency Medicine

University of California at Irvine Department of Emergency Medicine

EOC Activities Gather information through ongoing assessments Brief EOC staff Establish shifts Set overall objectives for each shift Determine resource requirements Develop communications and traffic plans Keep complete documentation University of California at Irvine Department of Emergency Medicine

Life Cycle of an Incident Event recognition Incident notification Situation analysis and monitoring Emergency Operations Plan (EOP) activation Operation of the Hospital Command Center (HCC) Staffing the Incident Management Team Incident Action Planning Communication and Coordination Demobilization System Recovery University of California at Irvine Department of Emergency Medicine

It’s 3 a.m. and Disaster Strikes… Response Actions Control the scene Establish a Command Post Conduct internal notifications Develop initial strategy for protecting life and property Determine what resources are needed to control the problem Continue to organize and manage the situation until relieved University of California at Irvine Department of Emergency Medicine

Planning Meeting Develop strategies & tactics to Accomplish objectives Incident is recognized Notifications, assessment, Immediate needs are addressed Incident Manager Sets overall incident objectives & priorities Action Plan preparation & approval Management Meeting Evaluates & revises incident objectives On-going situation assessment & information processing Operations Briefing Briefs the operational leaders on the Action Plan Assess progress using measures of effectiveness Implement Action Plan University of California at Irvine Department of Emergency Medicine

Summary – Hospital ICS All Hazard Convergence at hospitals Hazard Vulnerability Analysis Comprehensive Emergency Management Convergence at hospitals Need for management system, not just resources Function based Command: Plans, Logistics, Finance, Operations University of California at Irvine Department of Emergency Medicine

References VA Emergency Management Program Guidebook (updated 6/28/05) http://www1.va.gov/emshg/page.cfm?pg=114 Emergency Management Principles and Practices for Healthcare Systems http://www.va.gov/emshg California EMS Authority http://www.emsa.ca.gov/hics/hics.asp University of California at Irvine Department of Emergency Medicine