Hospital Incident Command System

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Hospital Incident Command System

• Milton Hospital
• Hospital Incident Management
• Meg Femino
• Emergency Management Program

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It is a clear, crisp spring afternoon at Milton
Hospital. At 407pm, you are thrown from your
office chair to the floor by a sudden and violent
earthquake. Electrical power in your office is
immediately lost as the severe shaking continues
for well over 1 minute.
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Objectives

• Discuss how the life cycle of an incident is
  managed through
• Incident notification
• Situation analysis and monitoring
• Emergency Operations Plan (EOP) activation
• Operation of the Hospital Command Center (HCC)
• Hospital Incident Command System Team (HICS)
• Incident Action Planning
• Communication and coordination
• Demobilization
• System recovery

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Initial Incident Notification

• An incident is
• An emergent event that disrupts or threatens to
  disrupt normal operations-explosions vs. outbreak
• A planned event in the hospital or community
• Notification may come from
• Law Enforcement, EMS, Fire, Public Health
• Weather forecast
• Emergency Management

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Incident Notification

• Critical information to obtain
• Type of incident, including specific hazard/agent
• Location of incident
• Numbers and types of injuries
• Special actions being taken (e.g.,
  decontamination)
• Estimated time of arrival of first EMS units
• Pre-hospital treatment

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Internal Incident Notification

• Notification
• Communication to relevant personnel of important
  information regarding an actual or potential
  hazard impact and the response status of the
  organization
• Code Disaster
• Activates our internal Emergency Operations Plan
• Authorized by the Administrator on Duty

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Code Disaster Levels

• Code Disaster FYI
• Informational alert only
• Code Disaster MINI
• Limited in scale or scope
• Activates Command, Chiefs and Key Leaders
• Code Disaster MAXI
• Extensive response action required
• Large incident

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Incident Notification

• Response
• Measures to protect safety of staff and patients
• Timely notification of incident management
  personnel via multiple communication systems
• For incidents recognized by hospital,
  notification of appropriate external agencies,
  such as
• Law Enforcement, Fire, EMS, Public Health, Other
  hospitals, Emergency Management

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Emergency Operations Plan Activation

• Decisions based on situation assessment, often
  with incomplete information include
• Activate emergency response or maintain normal
  operations
• Partial or complete activation
• Revision of clinical care practices as needed
• Considerations
• Scope of incident
• Impact or likely impact on the facility
• Impact on normal operations

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Emergency Operations Plan Activation

• Actions following activation decisions
• Timely notification to other key hospital
  personnel, by rehearsed procedures for multiple
  communication systems
• Potential opening of the Hospital Command Center,
  not all incidents require the use of an HCC
• A Incident Command Post may be established near
  the event to manage the event initially

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Emergency Operations Plan Activation Authority

• Identified personnel with decision making
  authority per EOP
• Administrator on Duty
• Nursing supervisor
• Senior emergency department physician
• Senior emergency department nurse

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The Hospital Command Center (HCC)

• The HCC is pre-identified location for a
  hospitals incident management team to convene
  and coordinate response activities, resources,
  and information
• Nangeroni Conference Room
• 617-696-0275

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The Hospital Command Center (HCC)

• Designated space for
• Coordination among incident management team
  members
• HICS personnel to access position-specific tools
• Radio, telephone, and support equipment
• Decision-making information (electronic and
  written display boards)
• Plans, reference manuals, directories, maps,
  supplies, etc.

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The Hospital Command Center (HCC)

• Communication and information management
  resources
• Voice systems (landline, cellular, satellite,
  commercial two-way radio)
• Data systems- computers
• Television
• Incident information displays (large projection
  screens, white boards, maps, chart pads on
  easels)
• HICS forms and general office supplies
• Fax machine
• Photocopier

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The Hospital Command Center (HCC)

• HICS personnel in the HCC
• Command staff and Section Chiefs
• Medical/Technical Specialists
• External agency representatives
• Administrative support staff
• Others in nearby rooms assigned to Sections or in
  business offices
• Numbers expand and contract according to the
  course and needs of the incident

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What have we done?
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Situation Analysis and Monitoring

• Sources of external situation information
• WebEOC
• EMS incident reports by radio, telephone,
  personnel
• Public Health
• Law Enforcement
• Health and Medical Services (ESF 8) in local
  Emergency Operations Center (EOC)
• On-scene Incident Command Post
• Local and national media

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Situation Analysis and Monitoring

• Sources of internal situation information
• Periodic updates from incident management team
  members, as scheduled or as situation warrants
• Limited tours of key areas within facility
• Real-time or recorded surveillance of critical
  areas
• Local and national media

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Incident Command System (ICS)

• Component of the National Incident Management
  System (NIMS)
• Provides a universal structure and process to
  manage the organizations response and recovery
  activities
• TJC requirement

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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

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What is HICS?Hospital Incident Command System

• It is a standardized, all-hazard incident
  management concept
• Allows its users to adopt an integrated
  organizational structure
• Matching the complexities and demands of a single
  or multiple incidents
• Not hindered by jurisdictional boundaries

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Purpose of HICS

• Using best practices, HICS ensures
• Safety of responders and others
• Achievement of tactical objectives
• Efficient use of resources

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History of HICS

• Weaknesses in incident management before HICS
• Lack of accountability
• Poor Communication
• Lack of planning process
• Overload Incident Commanders
• No method to integrate interagency requirements

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History of HICS
1980s FIRESCOPE used ICS for Southern CA
wildfires
1987 CA adapts ICS to hospitals
Since 1987 Revised four (4) times
HICS Provides organized system to manage
incidents addresses weaknesses
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Basic Features of HICS

• Adaptable to any type of emergency
• Common terminology
• Modular organization
• Management by objectives
• Reliance on a Incident Action Plan (IAP)
• Chain of command and unity of command
• Unified command

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Basic Features of HICS

• Manageable span of control
• Comprehensive resource management
• Information and intelligence management
• Integrated communications
• Transfer of command
• Accountability
• Mobilization

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Milton HICS Chart


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HICS 5 Major Functional Areas
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HICS Management Command

• Command
• Sets the objectives
• Devises strategies and priorities
• Maintains overall responsibility for managing the
  incident

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HICS Command Roles
INCIDENT COMMANDER
SAFETY OFFICER
PUBLIC INFORMATION OFFICER
LIAISON OFFICER
MEDICAL/TECHNICAL SPECIALIST
FINANCE/ADMIN SECTION CHIEF
PLANNING SECTION CHIEF
LOGISTICS SECTION CHIEF
OPERATIONS SECTION CHIEF
PATIENT CARE BRANCH DIRECTOR
SITUATION TEAM LEADER
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HICS Management Operations

• Operations
• Conducts the tactical operations
• Carries out the plan using defined objectives
• Directs all needed resources
• Business continuity
• Safety and security
• Health and medical

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HICS Management Planning

• Planning
• Collects and evaluates information for decision
  support
• Maintains information on current and forecasted
  situation
• Maintains resource status
• Prepares documents such as the Incident Action
  Plan
• Maintains documentation for incident reports

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HICS Management Logistics

• Logistics
• Provides support to incident
• Order all resources from off-site locations
• Provide facilities, transportation, supplies,
  equipment maintenance, fueling, feeding,
  communication and medical services for responders

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HICS Management Finance

• Finance
• Monitors cost related to the incident
• Provides accounting, procurement, time recording,
  and cost analyses

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HICS Job Action Sheets (JAS)

• Each position has a prioritized job action sheet
• These forms should be tailored to BIDMC for
  optimal functionality
• Specific actions that are immediate, intermediate
  and extended
• At bottom of each JAS is correlating HICS forms
  to be used
• These forms are available in the HCC

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HICS Functional Responsibility

• Command- pointers
• Strategy, global responsibility
• Define mission, ensure completion
• Operations- doers
• Implements plan, direct tactics
• Planning- thinkers
• Collect/analyze data, direct planning
• Continuity of operations

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HICS Functional Responsibility

• Logistics- getters
• Support resource
• Environment and materials
• Finance- counters
• Track Money, ensure documentation
• Maximize recovery, reduce liability

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HICS Sections

• Sections
• Organizational levels with responsibility for a
  major functional area of the incident
• The person in charge is the Chief

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HICS Branches and Units

• Branches
• Established if the number of Divisions or Groups
  exceeds the span of control
• Have functional or geographical responsibility
  for major parts of incident operations
• Managed by a Branch Director
• Units
• Organizational elements that have functional
  responsibility for a specific activity

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HICS Transfer of Command

• Moves the responsibility for incident command
  from one Incident Commander to another
• Must include a transfer of command briefing
• Oral
• Written
• Both oral and written

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Staffing the Incident Management Team

• Activating HICS positions
• The Incident Commander (IC) is the first to
  respond
• IC determines level of staffing according to the
  functional needs of the hospital response
• Positions might be filled initially by in-house
  mid-level staff until senior personnel arrive
• Some individuals might function in multiple
  positions simultaneously throughout the entire
  response or until additional personnel become
  available

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Staffing the Incident Management Team

• Incident briefing of the General Staff to
  include
• Response priorities
• Initial problems
• Answers to initial questions and concerns
• Updated operational briefings to be provided at
  regular intervals

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Incident Action Planning

• The Incident Action Plan (IAP)
• A document intended to help the incident
  management team establish and communicate
  response objectives, identify response needs, and
  resolve obstacles associated with meeting
  objectives
• A useful tool for transition of operations
  activities to relief personnel
• Understanding policy and direction
• Assessing the situation
• Establishing incident objectives

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The Incident Planning Process

• Determining appropriate strategies to achieve the
  objectives
• Providing tactical direction and ensuring that it
  is followed
• Example The correct resources assigned to
  complete a task and their performance monitored
• Providing necessary back-up
• Assigning more or fewer resources
• Changing tactics

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Reports of widespread damage throughout the
hospital, on 2 North patient rooms have staff and
patients killed, trapped or injured inside.
Flooding is reported in the basement and Pharmacy
needs to evacuate.Now, what is the situation?
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HICS Key Points

• Benefits of HICS are
• Manages routine or planned events
• Establishes a clear chain of command
• Provides a a common structure
• Provides logistical and administrative support to
  operational personnel
• Ensures key functions are covered and eliminates
  duplication

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HICS Key Points

• HICS is modular and scalable to the scope and
  magnitude of the incident
• Incident Commander always activated
• Other positions activated as needed
• There are five management functions
• Command
• Operations
• Planning
• Logistics
• Finance

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HICS Key Points

• HICS provides a common terminology and position
  titles to enhance standardization among agencies
  and responders
• HICS structure is flexible
• Span of control
• Integrates with other hospitals and responding
  agencies

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Communication and Coordination

• Information exchange within the hospital and/or
  healthcare system
• Phone, intranet, email, or fax to and from
  departments
• Assigned radio channels to and from specific
  areas
• Online or printed forms to and from hospital
  personnel
• Situation updates and/or response guidance via
  radio, internet, print material, or face-to-face
  meetings

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Communication and Coordination

• Information exchange within the hospital and/or
  healthcare system
• Wireless communication devices, teleconferencing,
  2-way radio
• Town Hall meetings, involving key incident
  management personnel and appropriate
  Medical/Technical Specialists

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Communication and Coordination

• Information for patients and visitors
• Situation status and actions undertaken by
  hospital
• Public address system announcements
• Situational signage at entrances
• Posted bulletins
• Print material on meal trays
• Personal conversations with staff

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Communication and Coordination

• Information exchange with external response
  partners
• Outreach to Law Enforcement, Public Health, Fire,
  and EMS when no notification is received, to
  communicate situation and any request for
  assistance
• Periodic joint decision-making with hospitals
  receiving victims
• Patient tracking information with Health and
  Medical Services
• Communicate resource needs (e.g., medications,
  staffing, transportation)

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Demobilization

• Demobilization planning to begin at the outset of
  response
• Planning Section Demobilization Unit Leader is
  responsible for preliminary plan
• Timing for full demobilization will vary by
  situation
• IC decides when to transition from response mode
  to demobilization

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Demobilization

• Criteria includes
• Hospitals ability to manage numbers of incoming
  patients
• No anticipated secondary rise in patient volume
• Demobilization by other responders
• Return to normal operations by other critical
  community infrastructure

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Demobilization

• Consultation with Command and General Staff and
  external decision-makers (e.g., other hospitals,
  local EOC)
• Communication of demobilization decision to
• Hospital staff
• Appropriate external agencies (e.g.,
• Fire/EMS, Law Enforcement, Public Health)
• Patients and families
• General public (e.g., when curtailed hospital
  operations to resume)

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System Recovery

• Return to routine patient care activities
• Return of extra equipment, supplies and
  medications
• Return to normal or new normal operational
  levels
• Formal debriefing of hospital personnel

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System Recovery

• Medical surveillance of personnel exposed to
  hazardous materials or infectious diseases
• Financial, psychological and medical care issues
  of personnel who became injured or ill on duty
• Behavioral/mental health support
• Potential for staff absenteeism or resignations

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System Recovery

• Restoration of physical plant
• Disposal of hazardous waste
• Clean-up of contaminated areas
• Safety survey
• Reimbursement of personnel, patient care,
  resources, equipment repair and replacement, and
  facility operations costs
• Rebuilding public trust

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Key Considerations
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Staff Health and Safety

• Safety Officer has primary responsibility for
  monitoring safety of incident operations and
  identifying and resolving health and safety risks
• Trained and authorized personnel with medical
  clearance may use Personal Protective Equipment
  (PPE) and must be monitored

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Staff Health and Safety

• Instruction on proper infection control
  precautions provided to staff and patients and
  updated in multiple formats
• Mass prophylaxis for staff, in coordination with
  local Public Health
• Effects of fatigue and psychological stress

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Extended Emergency Operations

• Issues related to extended operations
• Personnel impacts
• Patient care
• Equipment and supplies
• Behavioral/mental health
• Security
• Infrastructure support
• Information sharing
• Media relations

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Extended Emergency Operations

• Manage issues through use of Incident Action Plan
• Coordinate extended operations planning with
  other area hospitals, and local EOC
• Balance incident response needs with maintenance
  and/or adjustment of normal services and
  operations
• Provide for relief of hospital staff and rotation
  of HCC personnel

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Law and Ethics

• Consult hospital attorney, medical ethicist,
  and/or risk manager in preplanning or response to
  issues such as
• Managed degradation of care in response to
  surging patient volume
• Revised scope-of-practice guidelines
• Confidentiality of patient information
• Credentialing, privileging, utilization, and
  supervision of volunteers
• Responsibility for patients who die from illness
  or injury
• Evidence chain of custody

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Response Evaluation and Organizational Learning

• During an incident, time outs can be taken to
  identify and implement adjustments to incident
  management team staffing or policy and procedures
• Following an incident, debriefings or hot
  washes can be held at various levels

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Response Evaluation and Organizational Learning

• After Action Report (AAR) Process
• Formal record of what worked well and what needs
  improvement
• AAR draft for submission to Emergency Management
  Committee with improvement recommendations
• Revisions to Emergency Operations Plan as
  approved and staff training
• Participation in community AAR process
• Sharing lessons learned through formal
  presentations

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Review Key Points

• The life cycle of an incident is managed through
  HICS functions
• Critical considerations during incident
  management include staff health and safety,
  extended emergency operations, and law and ethics
• Improvements to the hospitals emergency
  management program and emergency operations plan
  can be achieved through response evaluation and
  organizational learning