Incident Management Systems for Hospitals Kristi L Koenig, MD, FACEP Professor of Clinical Emergency...

Incident Management Systems Incident Management Systems for Hospitalsfor Hospitals

Kristi L Koenig, MD, FACEPKristi L Koenig, MD, FACEP

Professor of Clinical Emergency MedicineProfessor of Clinical Emergency Medicine

Director of Public Health PreparednessDirector of Public Health Preparedness

University of California at IrvineUniversity of California at Irvine

University of California at IrvineUniversity of California at IrvineDepartment of Emergency MedicineDepartment of Emergency Medicine

Why Management Aspects?Why Management Aspects?

Incident Management new to health Incident Management new to health care systemscare systems– Not traditionally used in some types of Not traditionally used in some types of

events, e.g. biological, nursing strikeevents, e.g. biological, nursing strike Clinical is relatively familiarClinical is relatively familiar ““Emergency Management” unfamiliar Emergency Management” unfamiliar

to most cliniciansto most clinicians ED is “soft target”ED is “soft target”


Are We Prepared?Are We Prepared?

Post 9/11Post 9/11– Prior Secretary of Department of Prior Secretary of Department of

Homeland Security said “yes!”Homeland Security said “yes!”– Experts quoted in New York Times said Experts quoted in New York Times said

“no!”“no!” Lack of BenchmarksLack of Benchmarks


Why do hospitals need to be prepared?Why do hospitals need to be prepared?

Disaster are Local!Disaster are Local!– Most casualties arrive to the hospital Most casualties arrive to the hospital

within 1 ½ hourswithin 1 ½ hours– Civilian volunteers and local first Civilian volunteers and local first

responders rescue most victimsresponders rescue most victims

(95%) within first 24 hours(95%) within first 24 hours– Critical care and trauma surgery managed Critical care and trauma surgery managed

without State or Federal assistancewithout State or Federal assistance


Disaster CasualtiesDisaster Casualties

Most planning focuses on Most planning focuses on injuriesinjuries Victims need treatment for other Victims need treatment for other

conditionsconditions– Lack of access to primary careLack of access to primary care– Exacerbation of chronic conditionsExacerbation of chronic conditions– Psychological effectsPsychological effects– Increased incidence of childbirth, heart Increased incidence of childbirth, heart

attacksattacks


Sudden Impact EventsSudden Impact EventsStudy of 29 U.S. DisastersStudy of 29 U.S. Disasters

Most trauma victims have Most trauma victims have minorminor injuriesinjuries– Accidents occur during recovery phaseAccidents occur during recovery phase

10-15% of victims hospitalized10-15% of victims hospitalized– Half admitted for non-medical reasonsHalf admitted for non-medical reasons– Sent home next daySent home next day

6% supply shortages6% supply shortages 2% personnel shortages2% personnel shortages


Lack of Resources?Lack of Resources?

Studies of recent disasters in the US Studies of recent disasters in the US show a lack of a show a lack of a management systemmanagement system to to organize available resourcesorganize available resources

Hurricane KatrinaHurricane Katrina– An exception?An exception?


Key PrinciplesKey Principles

All-HazardAll-Hazard– Hazards Vulnerability Analysis (HVA)Hazards Vulnerability Analysis (HVA)

Comprehensive Emergency ManagementComprehensive Emergency Management– MitigationMitigation– PreparednessPreparedness– ResponseResponse– RecoveryRecovery

Incident Management SystemIncident Management System


Why Incident Management Why Incident Management Systems for Hospitals?Systems for Hospitals?

Continuity of Business Operations PlanContinuity of Business Operations Plan– Meet responsibilities to employees, patients, and Meet responsibilities to employees, patients, and

communitycommunity– Reduce insurance/workers compensation costsReduce insurance/workers compensation costs– Protect capital investmentProtect capital investment– Regulatory complianceRegulatory compliance

Ultimate goal to reduce morbidity and Ultimate goal to reduce morbidity and mortalitymortality

JCAHO requirementJCAHO requirement


JCAHO RequirementsJCAHO RequirementsJanuary 2001January 2001

All-HazardAll-Hazard– Hazard Vulnerability Analysis (HVA)Hazard Vulnerability Analysis (HVA)

Comprehensive Emergency ManagementComprehensive Emergency Management Community-Wide PlanningCommunity-Wide Planning Incident Management SystemIncident Management System

Example - Hospital Emergency Incident Example - Hospital Emergency Incident Command System (HEICS)Command System (HEICS)

Consistent with Consistent with communitycommunity standards standards


Incident Management SystemIncident Management System

Command, Control, LeadershipCommand, Control, Leadership Flexible process for ongoing assessmentFlexible process for ongoing assessment

– Incident Action PlansIncident Action Plans Unified CommandUnified Command for multi-jurisdictional events for multi-jurisdictional events Federal LevelFederal Level

– National Incident Management System (NIMS)National Incident Management System (NIMS) Hospital LevelHospital Level

– Hospital Emergency Incident Command System (HEICS)Hospital Emergency Incident Command System (HEICS)– Change to Hospital Incident Command System (HICS)Change to Hospital Incident Command System (HICS)


Disaster Disaster Management Management AgenciesAgencies

Federal Federal StructureStructurePre 9/11Pre 9/11


National Incident National Incident Management System (NIMS)Management System (NIMS) Established post 9/11 by Homeland Established post 9/11 by Homeland

Security Presidential Directive 5Security Presidential Directive 5 Ensures all levels of government have Ensures all levels of government have

capability to work efficiently together capability to work efficiently together using a national approach to domestic using a national approach to domestic incident managementincident management


Incident Command System Incident Command System (ICS)(ICS) Component of the National Incident Component of the National Incident

Management System (NIMS)Management System (NIMS) Provides a universal structure and Provides a universal structure and

process to manage the organization’s process to manage the organization’s response and recovery activitiesresponse and recovery activities


External ScenariosExternal Scenarios

1.1. Nuclear Detonation—10-Kiloton Improvised Nuclear DeviceNuclear Detonation—10-Kiloton Improvised Nuclear Device2.2. Biological Attack—Aerosol AnthraxBiological Attack—Aerosol Anthrax3.3. Biological Disease Outbreak—Pandemic InfluenzaBiological Disease Outbreak—Pandemic Influenza4.4. Biological Attack—PlagueBiological Attack—Plague5.5. Chemical Attack—Blister AgentChemical Attack—Blister Agent6.6. Chemical Attack—Toxic Industrial ChemicalsChemical Attack—Toxic Industrial Chemicals7.7. Chemical Attack—Nerve AgentChemical Attack—Nerve Agent8.8. Chemical Attack—Chlorine Tank ExplosionChemical Attack—Chlorine Tank Explosion9.9. Natural Disaster—Major EarthquakeNatural Disaster—Major Earthquake10.10. Natural Disaster—Major HurricaneNatural Disaster—Major Hurricane11.11. Radiological Attack—Radiological Dispersal DevicesRadiological Attack—Radiological Dispersal Devices12.12. Explosives Attack—Bomb Using Improvised Explosive DeviceExplosives Attack—Bomb Using Improvised Explosive Device13.13. Biological Attack—Food ContaminationBiological Attack—Food Contamination14.14. Cyber AttackCyber Attack


Internal ScenariosInternal Scenarios

1.1. Bomb ThreatBomb Threat2.2. Evacuation, Complete or Partial FacilityEvacuation, Complete or Partial Facility3.3. FireFire4.4. Hazardous Material SpillHazardous Material Spill5.5. Hospital OverloadHospital Overload6.6. Hostage/BarricadeHostage/Barricade7.7. Infant/Child AbductionInfant/Child Abduction8.8. Internal FloodingInternal Flooding9.9. Loss of Heating/Ventilation/Air ConditioningLoss of Heating/Ventilation/Air Conditioning10.10. Loss of PowerLoss of Power11.11. Loss of WaterLoss of Water12.12. Severe WeatherSevere Weather13.13. Work StoppageWork Stoppage


ICS - ComponentsICS - Components

Adaptable to any type of emergencyAdaptable to any type of emergency Common organizational/procedural Common organizational/procedural

standardsstandards Common TerminologyCommon Terminology– Integrated CommunicationsIntegrated Communications

Modular OrganizationModular Organization Unified Command StructureUnified Command Structure– Maintains autonomy of jurisdictionMaintains autonomy of jurisdiction


ICS - ComponentsICS - Components

Manageable Span of ControlManageable Span of Control Consolidated Action PlansConsolidated Action Plans– Represent Incident Action Planning ProcessRepresent Incident Action Planning Process

Comprehensive Resource Comprehensive Resource ManagementManagement

Designated Incident FacilitiesDesignated Incident Facilities


ICSICS5 Major Functional Areas5 Major Functional Areas Command or ManagementCommand or Management OperationsOperations Planning Planning LogisticsLogistics FinanceFinance


Operations

‘Doers'

Planning

Address "what if?"

Logistics

Supports Operations

Requirements

Finance / Admin

Tracks Expenses

Incident Command

Leadership & DirectionAuthorization of Expenses


Health Care FacilitiesHealth Care Facilities

Victims arrive unannouncedVictims arrive unannounced May not arrive by EMSMay not arrive by EMS Family and friends overwhelm system Family and friends overwhelm system

with inquirieswith inquiries VolunteersVolunteers MediaMedia


Health Care FacilitiesHealth Care Facilities

Convergence of injured persons, Convergence of injured persons, relatives & friends, the general public relatives & friends, the general public (volunteers), off-duty staff & medical (volunteers), off-duty staff & medical personnel, and mediapersonnel, and media

NotNot a Scarcity of Resources a Scarcity of Resources Lack of Lack of Incident Management SystemIncident Management System


Critical Hospital ResourcesCritical Hospital Resources

Physical plantPhysical plant PersonnelPersonnel SupervisionSupervision Supplies and EquipmentSupplies and Equipment CommunicationCommunication TransportationTransportation


Brief History of HEICSBrief History of HEICS

1980’s – FIRESCOPE1980’s – FIRESCOPE– Southern California wildfires use ICSSouthern California wildfires use ICS

1987 - Hospital Council of Northern 1987 - Hospital Council of Northern California adapts ICS to hospitalsCalifornia adapts ICS to hospitals

1991 - HEICS I1991 - HEICS I 1992/93 – HEICS II1992/93 – HEICS II 1998- HEICS III1998- HEICS III 2006- HEICS IV2006- HEICS IV August 2006- August 2006- HICSHICS Guidebook Guidebook


HEICS I - IIIHEICS I - III

Areas needing improvementAreas needing improvement– Not NIMS compliantNot NIMS compliant– Medical Officer not directly under ICMedical Officer not directly under IC– Labor pool in Planning, not OperationsLabor pool in Planning, not Operations– Damage assessment in Logistics, not OperationsDamage assessment in Logistics, not Operations– Operations sectionOperations section

Only focus on medical requirementsOnly focus on medical requirements Designed around department, not incident functionsDesigned around department, not incident functions

– No concept of Incident Action PlanningNo concept of Incident Action Planning– Existed separately from hospital disaster planExisted separately from hospital disaster plan


The New HICSThe New HICS

HEICS IV/HICS has different HEICS IV/HICS has different organizational chartorganizational chart– Simpler and smallerSimpler and smaller– More flexible and adaptableMore flexible and adaptable

NIMS compliantNIMS compliant Enhanced Job Action SheetsEnhanced Job Action Sheets– Extended operations and recovery sectionsExtended operations and recovery sections


HICS GuidebookHICS Guidebook

#1: High-level guidance for developing a hospital #1: High-level guidance for developing a hospital Emergency Management Program (EMP)Emergency Management Program (EMP)

Key considerationsKey considerations Planning and response assumptionsPlanning and response assumptions Provides guidance for use of the incident command Provides guidance for use of the incident command

systemsystem– Adapted to incident specific situationsAdapted to incident specific situations– Modular and scalable based on availability of Modular and scalable based on availability of

personnelpersonnel


HICS GuidebookHICS Guidebook

#2: A HICS training curriculum #2: A HICS training curriculum Specific instructional guidance and teaching Specific instructional guidance and teaching

outlines outlines Curriculum materials designed to provide variable Curriculum materials designed to provide variable

methods of training hospital staffmethods of training hospital staff– Emergency response principlesEmergency response principles– Incident commandIncident command


New HICS ElementsNew HICS Elements

A more compact and versatile incident A more compact and versatile incident management team structuremanagement team structure– ModularModular– Scalable to the eventScalable to the event

Updated Job Action Sheets (JAS)Updated Job Action Sheets (JAS) Revised, National Incident Management Revised, National Incident Management

System (NIMS) consistent forms System (NIMS) consistent forms


New HICS ElementsNew HICS Elements

Incident Planning Guides (IPG)Incident Planning Guides (IPG)– Assist in evaluating and writing emergency plansAssist in evaluating and writing emergency plans– Scenario basedScenario based

Incident Response Guides (IRG)Incident Response Guides (IRG)– Key considerations and response actions for Key considerations and response actions for

command staffcommand staff– Scenario basedScenario based

Expanded information and toolsExpanded information and tools– Guidebook and Appendices Guidebook and Appendices – ResourcesResources


HICS SummaryHICS Summary

The HEICS IV/HICS project updated HEICS III to The HEICS IV/HICS project updated HEICS III to current emergency management practices and current emergency management practices and principlesprinciples

Developed by hospital and incident command expertsDeveloped by hospital and incident command experts HICS Guidebook assists hospitals in implementationHICS Guidebook assists hospitals in implementation HICS provides new materialsHICS provides new materials

– Job Action SheetsJob Action Sheets– Incident Planning GuidesIncident Planning Guides– Incident Response GuidesIncident Response Guides


Hospital ICSHospital ICS

Public Inform a tion O fficerC om m unity R ela tions Mgr

SecuritySecurity D irector

Sa fety O fficerIndustria l H ygeine

Lia isonEm ergency Ma na ger

Fa cilitiesC om m unica tions

T ra nsporta tionSupply

LogisticsFa cilities D irector

S itua tionLa bor Pool

Medica l S ta ffPa tient T ra cking

P la nningVP Adm ininstra tion

Medica l ca reAncilla ry SrvicesH um a n Services

O pera tionsVP O pera tions

T im eProcurem ent

C la im sC ost

Fina nceC FO

Incident C om m a nderAdm inistra tor

Public Inform a tion O fficerC om m unity R ela tions Mgr

SecuritySecurity D irector

Sa fety O fficerIndustria l H ygeine

Lia isonEm ergency Ma na ger

Fa cilitiesC om m unica tions

T ra nsporta tionSupply

LogisticsFa cilities D irector

S itua tionLa bor Pool

Medica l S ta ffPa tient T ra cking

P la nningVP Adm ininstra tion

Medica l ca reAncilla ry SrvicesH um a n Services

O pera tionsVP O pera tions

T im eProcurem ent

C la im sC ost

Fina nceC FO

Incident C om m a nderAdm inistra tor


Command SectionCommand Section

LeadershipLeadership Incident CommanderIncident Commander– Organize and direct Emergency Organize and direct Emergency

Operations Center and all positions Operations Center and all positions throughout the ICS structurethroughout the ICS structure

– Overall direction for hospital operationsOverall direction for hospital operations– Authorizes evacuationsAuthorizes evacuations


Command (Management) Command (Management) SectionSection Responsible for overall incident Responsible for overall incident

managementmanagement Command Staff PositionsCommand Staff Positions– Information (Public Affairs) OfficerInformation (Public Affairs) Officer– Safety OfficerSafety Officer– Liaison OfficerLiaison Officer

Single vs. Unified CommandSingle vs. Unified Command


Operations SectionOperations Section

Reduction of immediate hazardReduction of immediate hazard Establish situation controlEstablish situation control Restore normal operationsRestore normal operations FunctionsFunctions– Staging areasStaging areas– ResourcesResources– Organization of operations divisions, Organization of operations divisions,

groups, and branchesgroups, and branches


Operations SectionOperations SectionKey ComponentsKey Components

Business ContinuityBusiness Continuity EquipmentEquipment Plant and UtilitiesPlant and Utilities Safety and SecuritySafety and Security Health and MedicalHealth and Medical


Planning SectionPlanning Section

Collection, evaluation and dissemination of Collection, evaluation and dissemination of tactical information about the incidenttactical information about the incident

Maintains information on current and Maintains information on current and forecasted situationforecasted situation

Tracks status of resourcesTracks status of resources Primary unitsPrimary units– Section chief/deputy, resources unit, situation unit, Section chief/deputy, resources unit, situation unit,

documentation unit, demobilization unit, technical documentation unit, demobilization unit, technical specialistsspecialists


Logistics SectionLogistics Section

Provide support to incidentProvide support to incident Order all resources from off-incident Order all resources from off-incident

locationslocations Provide facilities, transportation, supplies, Provide facilities, transportation, supplies,

equipment maintenance, fueling, feeding, equipment maintenance, fueling, feeding, communication and medical services for communication and medical services for respondersresponders

SectionsSections– Chief/deputy, supply unit, facilities unit, ground Chief/deputy, supply unit, facilities unit, ground

support/transportation unitsupport/transportation unit


Finance SectionFinance Section

Procurement UnitProcurement Unit Time UnitTime Unit Compensation/Claims UnitCompensation/Claims Unit Cost UnitCost Unit– Capture costs for FEMA Capture costs for FEMA

reimbursements during State or reimbursements during State or Federal disaster declarationsFederal disaster declarations


ICS – Translated!ICS – Translated!

Command/Management…PointersCommand/Management…Pointers– Plans………………………ThinkersPlans………………………Thinkers

– Logistics…………………..GettersLogistics…………………..Getters

– Finance……………………CountersFinance……………………Counters

– Operations………………...DoersOperations………………...Doers


ICS Functional ResponsibilityICS Functional Responsibility

CommandCommand– Strategy, global responsibilityStrategy, global responsibility– Define mission, ensure completionDefine mission, ensure completion

OperationsOperations– Implement plan, direct tacticsImplement plan, direct tactics

PlanningPlanning– Collect/analyze data, direct planningCollect/analyze data, direct planning– Continuity of operationsContinuity of operations

LogisticsLogistics– Support responseSupport response– Environment and materialsEnvironment and materials

FinanceFinance– Track money, ensure documentationTrack money, ensure documentation– Maximize recovery, reduce liabilityMaximize recovery, reduce liability


ICS ImplementationICS Implementation

Unfolds in a modular fashionUnfolds in a modular fashion– Based on incident type and sizeBased on incident type and size– Single individual can simultaneously Single individual can simultaneously

manage all major functional areas or manage all major functional areas or independent management requiredindependent management required

Used to plan, organize, staff, direct and Used to plan, organize, staff, direct and control emergency situationscontrol emergency situations


ICS ImplementationICS Implementation

Incidents without warning (earthquake, Incidents without warning (earthquake, explosion)explosion)– Leadership and direction initially provided by any Leadership and direction initially provided by any

employee who first recognizes the dangeremployee who first recognizes the danger Incidents with warning (severe weather, cloud Incidents with warning (severe weather, cloud

of hazardous materials approaching facility)of hazardous materials approaching facility)– Director or designee provides initial leadership Director or designee provides initial leadership

and directionand direction


ICS ImplementationICS ImplementationIncident Management TeamIncident Management Team

IMT PositionIMT Position Hospital Position/ServiceHospital Position/Service

Incident CommanderIncident Commander Director’s OfficeDirector’s Office

Planning Section ChiefPlanning Section Chief Emergency ManagementEmergency Management

Logistics Section ChiefLogistics Section Chief Acquisitions and Material Acquisitions and Material Management ServiceManagement Service

Finance Section ChiefFinance Section Chief Fiscal ServiceFiscal Service

Operations Section ChiefOperations Section Chief Staffed based on incidentStaffed based on incident

Business Continuity Group LeaderBusiness Continuity Group Leader Associate DirectorAssociate Director

Equipment/Plant/Utilities Group LeaderEquipment/Plant/Utilities Group Leader Facilities/EngineeringFacilities/Engineering

Safety and Security Group LeaderSafety and Security Group Leader Police and/or Safety ServicePolice and/or Safety Service

Health and Medical Group LeaderHealth and Medical Group Leader Chief of StaffChief of Staff


Command PostCommand Post

Consider establishing for incident that Consider establishing for incident that involves a distinct scene within the involves a distinct scene within the facility or its groundsfacility or its grounds

Ad-hoc location where decisions are Ad-hoc location where decisions are made concerning control of incidentmade concerning control of incident


Emergency Operations CenterEmergency Operations Center

Pre-designated location within facilityPre-designated location within facility Location where activates related to Location where activates related to

information collection, inter-service information collection, inter-service coordination, strategic decision-making coordination, strategic decision-making and resource allocation are managedand resource allocation are managed

Not all incidents require the use of an Not all incidents require the use of an EOCEOC


EOC ActivitiesEOC Activities

Gather information through ongoing Gather information through ongoing assessmentsassessments

Brief EOC staffBrief EOC staff Establish shiftsEstablish shifts Set overall objectives for each shiftSet overall objectives for each shift Determine resource requirementsDetermine resource requirements Develop communications and traffic plansDevelop communications and traffic plans Keep complete documentationKeep complete documentation


Life Cycle of an IncidentLife Cycle of an Incident

– Event recognitionEvent recognition– Incident notificationIncident notification– Situation analysis and monitoringSituation analysis and monitoring– Emergency Operations Plan (EOP) activationEmergency Operations Plan (EOP) activation– Operation of the Hospital Command Center (HCC)Operation of the Hospital Command Center (HCC)– Staffing the Incident Management TeamStaffing the Incident Management Team– Incident Action PlanningIncident Action Planning– Communication and CoordinationCommunication and Coordination– DemobilizationDemobilization– System RecoverySystem Recovery


It’s 3 a.m. and Disaster Strikes…It’s 3 a.m. and Disaster Strikes…

Response ActionsResponse Actions– Control the sceneControl the scene– Establish a Command PostEstablish a Command Post– Conduct internal notificationsConduct internal notifications– Develop initial strategy for protecting life and Develop initial strategy for protecting life and

propertyproperty– Determine what resources are needed to control Determine what resources are needed to control

the problemthe problem– Continue to organize and manage the situation Continue to organize and manage the situation

until relieveduntil relieved


PlanningMeetingDevelop

strategies &tactics to

Accomplishobjectives

ImplementAction Plan

Assess progressusing measuresof effectiveness

ManagementMeeting

Evaluates& revisesincident

objectives

OperationsBriefingBriefs the

operationalleaders on the

Action Plan

Action Planpreparation& approval

Incident ManagerSets overall

incident objectives& priorities

On-goingsituation

assessment& information

processing

Incident isrecognized

Notifications,assessment,Immediate

needsare

addressed


Summary – Hospital ICSSummary – Hospital ICS

All HazardAll Hazard– Hazard Vulnerability AnalysisHazard Vulnerability Analysis

– Comprehensive Emergency ManagementComprehensive Emergency Management Convergence at hospitalsConvergence at hospitals Need for Need for management systemmanagement system, not just , not just

resourcesresources Function basedFunction based– Command: Plans, Logistics, Finance, OperationsCommand: Plans, Logistics, Finance, Operations


ReferencesReferences

VA Emergency Management Program VA Emergency Management Program Guidebook (updated 6/28/05)Guidebook (updated 6/28/05)– http://www1.va.gov/emshg/page.cfm?pg=114http://www1.va.gov/emshg/page.cfm?pg=114

Emergency Management Principles and Emergency Management Principles and Practices for Healthcare SystemsPractices for Healthcare Systems– http://www.va.gov/emshghttp://www.va.gov/emshg

California EMS AuthorityCalifornia EMS Authority– http://www.emsa.ca.gov/hics/hics.asphttp://www.emsa.ca.gov/hics/hics.asp

Incident Management Systems for Hospitals Kristi L Koenig, MD, FACEP Professor of Clinical Emergency...

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