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
Why Management Aspects?

Incident Management new to health
care systems
– Not traditionally used in some types of
events, e.g. biological, nursing strike

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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
– 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

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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

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6% supply shortages
2% personnel shortages
University of California at Irvine
Department of Emergency Medicine
Lack of Resources?

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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
– 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

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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)

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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

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Command, Control, Leadership
Flexible process for ongoing assessment
– Incident Action Plans
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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
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)

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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
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
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
University of California at Irvine
Department of Emergency Medicine
Internal Scenarios
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
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
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Adaptable to any type of emergency
Common organizational/procedural
standards
Common Terminology
– Integrated Communications

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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

University of California at Irvine
Department of Emergency Medicine
ICS
5 Major Functional Areas
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Command or Management
Operations
Planning
Logistics
Finance
University of California at Irvine
Department of Emergency Medicine
Incident Command
Leadership & Direction
Authorization of Expenses
Operations
Planning
Logistics
‘Doers'
Address
"what if?"
Supports
Operations
Requirements
University of California at Irvine
Department of Emergency Medicine
Finance /
Admin
Tracks Expenses
Health Care Facilities
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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

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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
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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
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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
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

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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

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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
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

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Updated Job Action Sheets (JAS)
Revised, National Incident Management
System (NIMS) consistent forms
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
– Scenario based

Expanded information and tools
– Guidebook and Appendices
– Resources
University of California at Irvine
Department of Emergency Medicine
HICS Summary
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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
Incident Commander
Administrator
Public Information Officer
Community Relations Mgr
Security
Security Director
Safety Officer
Industrial Hygeine
Liaison
Emergency Manager
Logistics
Facilities Director
Planning
VP Admininstration
Operations
VP Operations
Finance
CFO
Facilities
Communications
Transportation
Supply
Situation
Labor Pool
Medical Staff
Patient Tracking
Medical care
Ancillary Srvices
Human Services
Time
Procurement
Claims
Cost
University of California at Irvine
Department of Emergency Medicine
Command Section
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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

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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
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Business Continuity
Equipment
Plant and Utilities
Safety and Security
Health and Medical
University of California at Irvine
Department of Emergency Medicine
Planning Section
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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
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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
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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

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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
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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
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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
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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
Incident is
recognized
Notifications,
assessment,
Immediate
needs
are
addressed
Incident Manager
Sets overall
incident objectives
& priorities
Management
Meeting
Evaluates
& revises
incident
objectives
Assess progress
using measures
of effectiveness
Planning
Meeting
Develop
strategies &
tactics to
Accomplish
objectives
On-going
situation
assessment
& information
processing
Implement
Action Plan
University of California at Irvine
Department of Emergency Medicine
Action Plan
preparation
& approval
Operations
Briefing
Briefs the
operational
leaders on the
Action Plan
Summary – Hospital ICS

All Hazard
– 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