During a disaster, the person responsible for leading the response effort is the incident:

HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM

The HEICS is an emergency management system for hospitals and is made up of positions on an organizational chart (Fig. 30-3). Each position represented in Fig. 30-3 has a specific mission, and each position has an individual checklist designed to direct the assigned individual in emergency response tasks. These checklists are called job action sheets. In addition, the HEICS design includes standardized forms to simplify and enhance the overall system. Every job action sheet begins with the job title, the supervising officer, where the location of the section operations center is, and a mission statement to define the position responsibility.7

HEICS core attributes, some of which are based on basic ICS principles, include the following:

HEICS provides a manageable scope of supervision for all personnel, similar to the ICS principle of manageable span of control.

HEICS is a flexible system by virtue of its “modular organization”—another core ICS principle. It can be expanded or scaled back to meet the demands of a variety of crises, regardless of complexity.

Job action sheets are position descriptions that have a prioritized list of emergency response tasks. They also serve to remind personnel of the standard established lines of reporting.7

The job action sheets and the associated forms promote documentation of details and the overall response to the crisis. Such comprehensive documentation proves essential when trying to recuperate expenses and reduce liability.7

The HEICS organizational chart (see Fig. 30-3) imposes structure and understandable lines of authority within the hospital system. Just as in the original ICS, HEICS incorporates four sections of command under the overall leadership of an emergency incident commander. Each of the four sections—planning, operations, logistics, and finance—has a chief, appointed by the emergency incident commander, who is responsible for his or her section and the resources directly involved.*

Hospital Incident Command System IV (HICS IV)

In October 2004, the Emergency Medical Services Authority (EMSA) launched a project to review and revise the current version of HEICS. The HEICS IV project was sponsored by the California EMS Authority, with contract support from the Washington Hospital Center Institute for Public Health and Emergency Readiness (WHC IPHER) and Kaiser Permanente. HEICS IV was created by a multi-disciplinary 27-member national work group with representatives from the American Hospital Association (AHA), the American Society of Chemical Engineers (ASCHE), the Joint Commission, the Department of Health and Human Services (DHHS), and the National Integration Center (NIC).

The HEICS III, published in 1998, served as a foundation for the revision. There was additional material review and input from a multi-disciplinary, approximately 80-member secondary review group that included vendors. They were tasked with reviewing draft materials and providing comments. The entire group had to:

Collaborate through face-to-face meetings and teleconferences

Build a consensus document

Update and incorporate current emergency management practices into the system

Enhance the system by integrating chemical, biological, radiological, nuclear and explosive (CBRNE) events into the management structure

Address and develop a standardized configuration of HEICS to address rural and small hospital needs

Develop a standardized HEICS IV curriculum and teaching aids (CD or video)

Develop an instructor credentialing and certification process to ensure standardization in all hospitals across the nation

Clarify the components of HEICS and its relationship to the National Incident Management System (NIMS)

The HEICS IV project strove to ensure the applicability of HEICS in hospitals across the nation. In order to accomplish that goal, the HEICS (HICS) IV project committee membership included healthcare professionals from across the nation. The project continues to be funded by the State of California Hospital Bioterrorism Preparedness Program with monies allocated to the State from the Health Resources and Services Administration (HRSA) Bioterrorism Hospital Preparedness Program. As part of this project, HEICS was officially renamed simply HICS for Hospital Incident Command System.

Hospital Incident Command System

The ICS was developed in the 1970s following a series of catastrophic fires in California’s urban interface. Property damage ran into the millions, and many people died or were injured. The ICS met the needs of the fire-fighting community, which was reasonable. However, spreading the use of ICS outside of that application caused confusion. Initial ICS courses were taught by fire personnel since they had the most experience using the tool. Unfortunately the material was not always presented as discipline blind and was heavily skewed toward a fire or hazardous materials world. This created some doubt as to whether to use the ICS among nonfire organizations.

The California Emergency Medical Services Authority first released the Hospital Emergency Incident Command System (HEICS), in the late 1980s. The intent was to present the ICS with a hospital focus. They have revised this system a number of times—the latest in 2014. Job action sheets for every imaginable position that might be needed in the hospital environment were created. Part of the idea behind developing these job action sheets was to allow a just-in-time utilization by hospital staff as most do not use the ICS daily like fire service personnel do. While the job task sheets, along with the incident planning guides and incident response guides, that were developed can be useful tools, most will need to customize them for an organization.

The difficulty with the job action sheet concept is that the ICS is built on the premise that personnel assigned to any specific functional area have been trained in how to perform the duties associated with that function. Imagine a trauma team activation is called at your hospital. Instead of each person arriving to perform specific duties based upon their skill set, you hand out job action sheets based on the order they enter the Emergency Department. The first person to arrive will be the anesthesiologist, the second the trauma surgeon, followed by imaging, and then the trauma nurse. Instead of assigning everyone to known and understood responsibilities the attention is placed on unfamiliar job action sheets. Throw in foreign-looking HICS forms and make staff wear a colored vest so everyone by function, and you will have a recipe for chaos. I know a number of my readers are laughing—they have been there, done that. The point is that positions on your Incident Management Team are just as important as those on your trauma team. Each brings a specific skill of perishable skills if not maintained.

What I find when I work with facilities who have bought into the packaged HICS system is that personnel spend more time trying to figure out how to do their HICS assigned job and fill out forms than to manage the response to the event. There are a couple of solutions. First, take the time to customize the generic HICS to conform to your hospital’s way of doing business, not the other way around.

Job action sheets are a great place to start, but each organization needs to determine for themselves what functions are most likely to be filled and the duties they will perform. Or, you can do as I suggest—drop the H from HICS and simplify. The ICS is discipline blind by design. I have seen public health, public works, law enforcement, hospitals, and other organizations put their discipline initials in front of ICS and think they have solved something. All this does is make using the ICS harder than it needs to be.

16 What is the Incident Command System (ICS)?

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The ICS was first introduced in the 1970s in an effort to more effectively coordinate the response to large-scale wildfires in the West.

The ICS is a modular system that provides a command structure to disaster scenes. It assembles the key components of a response (i.e., fire, EMS, law enforcement) to an individual event at a location in close proximity to the scene.

Although the size and scope of an ICS vary, five functional requirements are inherent to the organization. They are command, operations, planning, logistics, and finance and administration.

Although the ICS is commonly a prehospital concept, many medical centers have a hospital emergency ICS (HEICS) set up in the event of a disaster or mass casualty situation.

The Development of Incident Management Systems

The Incident Command System (ICS) was conceptualized more than 30 years ago, in response to a devastating wildfire in California. The Congress mandated that the U.S. Forest Service design a system that would improve the ability of wildland fire-protection agencies to coordinate interagency action effectively and to allocate suppression resources in dynamic situations. This system became known as the Firefighting Resources of California Organized for Potential Emergencies (FIRESCOPE) ICS. Although FIRESCOPE ICS was originally developed to assist in the response to wildland fires, it was quickly recognized as a system that could help public safety responders provide effective and coordinated incident management for a wide range of situations, including floods, hazardous materials accidents, earthquakes, and aircraft crashes. In 1982 all FIRESCOPE ICS documentation was revised and adopted as the National Interagency Incident Management System (NIIMS). In Homeland Security Presidential Directive 5 (HSPD-5), President Bush called on the Secretary of Homeland Security to develop a national incident management system (NIMS) to provide “a consistent nationwide approach for federal, state, tribal, and local governments to work together to prepare for, prevent, respond to, and recover from domestic incidents,” regardless of cause, size, or complexity.5

Incident Command System

Although the ICS structure proved effective in managing a large multifactorial response, there were challenges related to data sharing and multisectoral collaboration. Communications outside the ICS related to IMT members’ day jobs reflected differences in organizational perspectives and created challenges. To some degree, these issues can be addressed through more extensive training about ICS goals and procedures. CCPH and the DOH might also consider, in advance of the next outbreak, the role assignments that are most appropriate for a disease outbreak scenario. Finally, it must be recognized that infectious disease outbreaks are different from other public health emergencies; in particular, they are typically of longer duration and require different approaches at the beginning, middle, and end. While ad hoc solutions such as the epi-to-epi calls were implemented during the outbreak were effective, other approaches to expert-to-expert communication and managing relationships outside the ICS appropriate for disease outbreaks might be developed in advance.

Command and Control

The Incident Command System or Unified Command System (ICS/UCS) provides a standard framework for responding to a chemical attack. The IC, located at the incident command post, establishes the incident action plan following general incident action guides. The NIMS provides guidance on these activities. The IC is responsible for crisis action planning, accountable for the safety and actions of all response personnel, and liable for actions during the response. As per the NIMS, the ICS creates a UCS as the national standard response structure. Under the ICS/UC system, the “best qualified” person initially on scene assumes the role of IC. Transition to a UCS occurs as soon as reasonably achievable. ICS training and Job Aids listing such things as organizational charts, roles, responsibilities, meetings, Response Action Guides, and sample forms are available from various sources and provide excellent guidance for developing response plans to chemical attacks.37–39 Handheld information technology emergency response tools are also commercially available.47–49

As in all incidents, the size and impact of the incident drive the manning of the positions in the ICS, with roles and responsibilities becoming more specific as the size increases. The IC establishes a command post in a safe place near the incident site, analyzes the incident, and incorporates detection and reconnaissance data, plume modeling, and weather effects as available, and then develops and implements the incident action plan and evaluates the progress. Ongoing hazard and risk assessments allow the IC to determine the threats and estimate the potential course and harm in order to develop strategic goals and tactical objectives, as well as to determine the required protective measures and PPE levels and assign team tasking goals and missions to the various response squads, teams, or units. The risk assessment also allows the IC to use experience and expertise to deviate from statutory regulations, if necessary. Leaders are expected to coordinate and integrate their teams into the IC’s incident action plan.

Because local resources are likely to become overwhelmed and additional state and federal response capabilities will be necessary to augment the local response capabilities, the community’s plan should clearly address how each will be notified/requested, as well as their expected response times and their role in the incident command structure. Every opportunity to build relationships with these response capabilities, such as exercises, will prove invaluable during a real crisis.

PITFALLS

The ICS system is a strong foundation that will assist agencies, jurisdictions, and/or municipalities in properly managing an incident. However, there are areas in which the system will fail if the incident management team and responders undermine the management process. Any pitfalls of the system should be seen as an area for improvement and addressed prior to the next incident. The following are some examples of situations that occur across the board that should be noted as to avoid repeating.

For many departments and organizations the application of ICS is not used on a regular or day-to-day basis. It therefore does not become second nature to assimilate into the roles and responsibilities as they are established by the system. Additionally, it is often difficult for individuals to relinquish their authority to act in a subordinate position within the structure. For example, during a full-scale exercise a participant assigned as the liaison officer was not familiar with the roles and responsibilities for that position. This in turn caused a failure in communication between the requesting agency and the IC. The participant’s knowledge of day-to-day operations was exceptional; however, that knowledge did not transfer over into the liaison position because of a lack of proper ICS training. One solution to overcoming such obstacles is to dedicate individuals to specific positions within the ICS system and have them trained and exercised in those specific positions. This, however, will require there be many layers of trained individuals for a single role, accounting for different shifts and vacations.

ICS is set up with a clear chain of command. Not following the proper reporting procedures established by the system can and will lead to a breakdown in communication, conflicting orders, reporting errors, and loss of personnel and/or resources. During a recent international response, an objective, set forth by the incident management team, was to provide medical care to each of the 100-plus community centers within the impacted area. However, the medical response teams in the field did not properly report back to the incident management team on which locations or what type of treatment they had provided during their operational period. As an initial result, some locations received multiple visits by different teams and other locations were not visited for several days, which caused a delay in care and duplication of effort.

If an incident is not properly managed, well-meaning responders may have the tendency to self-dispatch. Additionally, individuals may arrive at your incident scene without being requested. Both of these situations can lead to undermining the overall objectives of the response and cause a delay in tactics. Self-dispatching also leads to a lack of accountability, as well as compromising the safety of responders and patients. On-scene personnel should follow the objectives and tactics set forth by the incident management team, and individuals should never self-dispatch to an incident scene.

As incidents extend into multiple operational periods the documentation and tracking of resources becomes demanding and extensive. It is important that all documentation be retained, such as the IAP and resource request forms, to maintain accountability. If the ICS system is properly followed, this information will be collected by individuals in the planning and finance and administration sections. This documentation will also provide support for potential reimbursement from a disaster declaration. It is important to note that responders or equipment that is not properly documented will not be eligible for reimbursement. Therefore the local government or agency would be responsible for the costs and any damage incurred during the operation.

ICS is taught in a utopic setting where all the functions work seamlessly and there are minimal hindrances. Because it is so difficult to train on the unknown, ICS training focuses on the responsibilities of the management of the event. In reality, lines of communication may be lost, you may have no power, or the resources you were depending on may be unavailable. During a large-scale event at a major sporting venue the planning called for a large number of public safety resources. However, because of the time and day of the event the resources were not available. Therefore the planning team was forced to modify their objectives in order to meet the available resources. It is important to train to properly manage the situation that you are presented with and work through the limitations.

ICS provides an all-hazards response management system for both small-scale incidents and large incidents that involve multiple organizations and jurisdictions. ICS allows the entities involved with a response to manage the political, economic, social, environmental, and cost implications related to the incident. With a management system in place, individuals using ICS can focus on the development of strategies to address life safety, incident stabilization, accountability, and property preservation.

Statistically, many incidents will not require the structure to expand to activation of the general staff positions. It is therefore important to train and exercise the planning cycle, in order to become familiar with the system.

Incident Command System

With regard to establishing an organization with specific tasks and a method for utilizing resources, it should be noted that there exists a recognized system with a predetermined chain of command as well as a proven structure for an organized response to a critical incident. Referred to as the incident command system (ICS), it uses common terminology that is descriptive and decisive, yet not difficult to understand, in order to control personnel, resources, and communications at the scene of a critical incident.12–14

ICS was developed in the early 1970s after a series of major wildland fires in southern California resulted in a number of recurring problems among emergency responders. Some of these included nonstandard terminology, nonstandard and nonintegrated communications, unmanageable span of control, and lack of the capability to expand and contract as required by the situation.

Although originally a fire service control system, ICS has since been adopted by a wide variety of local, state, and national emergency management and law enforcement organizations due to its many documented successes. Today, it serves as a model all-risk, all-agency emergency management system. ICS principles have been proven over time in government, business, and industry. In fact, ICS has been endorsed by the International Association of Chiefs of Police (IACP) and the American Public Works Association (APWA).12,15

There is also a legal requirement for using ICS because there are federal laws that mandate its use by individuals responding to hazardous materials incidents. Specifically, the Occupational Safety and Health Administration (OSHA) rule 1910.120, which became effective from March 6, 1990, requires that all organizations that handle hazardous materials use ICS. Non-OSHA states are also required by the Environmental Protection Agency to use ICS when responding to hazardous materials incidents.12,15

In essence, ICS is a well-organized team approach for managing critical incidents, as well as preplanned special events. It uses common terminology, has a modular organization (which means that it can expand/shrink according to the needs of the situation), has a manageable span of control (the number of subordinates one supervisor can manage effectively; usually 3–7, the optimum is 5), and uses clear reporting and documentation procedures. In effect, emergency response personnel can view ICS as an incident management toolbox. Not every tool in the toolbox will be used for every situation, but the tools are available should they become necessary. Additionally, it is important to note that ICS can be used for all types of incidents regardless of size. However, it is essential that all emergency responders understand their specific roles when using ICS.12,13,15,16

The ICS structure is built around five major management activities or functional areas12,15:

Command: sets priorities and objectives and is responsible for overall command of the incident

Operations: has responsibility for all tactical operations necessary to carry out the plan

Planning: responsible for the collection, evaluation, and dissemination of information concerning incident development as well as the status of all available resources

Logistics: responsible for providing the necessary support (facilities, services, and materials) to meet incident needs

Finance: responsible for monitoring and documenting all costs; provides the necessary financial support related to the incident

These five management activities or functional areas form the foundation of the ICS organizational structure. The activities can be managed by one individual in the event of a small incident, or a fully staffed ICS structure that addresses all five functional areas may be needed to manage larger or more complex events. In both cases, it is important to note that the incident commander is the individual in charge at the scene of a critical incident until properly relieved. The incident commander is also responsible for assigning personnel to the other functional areas (operations, planning, logistics, and finance) as needed.

ICS organizational structure (Figure 30.1) and procedures enable emergency response personnel to work safely together to take control of a critical incident. They can also assist organizations to effectively and efficiently manage the aftermath of a critical incident.

National Incident Management System

A difficult issue in any response operation is determining who is in charge of the overall response effort at the incident. This concept of control, or leadership, is most commonly referred to in the emergency management community as incident command. With the significant shift in legislation brought about by the creation of DHS, and the new emphasis on terrorism, the issue of incident command was in danger of becoming even more difficult and, likewise, confusing and even conflicting. To address the concerns that many officials at the local, state, and federal levels expressed in light of the changes that were occurring in the emergency management world, President George W. Bush called on the Secretary of Homeland Security, by means of Homeland Security Presidential Directive (HSPD)-5, to develop a nationally based ICS. The purpose of this system, it was assumed, was to provide a consistent nationwide approach for federal, state, tribal, and local governments to work together to prepare for, prevent, respond to, and recover from domestic incidents—regardless of their cause, size, or complexity.

NIMS was released in March 2004. It represents a core set of doctrine, principles, terminology, and organizational processes to enable the management of disasters at all government levels. One very important aspect of this new framework is that it recognized the value of an existing system, the ICS, and stressed the importance of effective incident command as a way of better managing disaster events. The well-known National Commission on Terrorist Attacks Upon the United States (the 9/11 Commission) identified ICS as an answer to many of the coordination problems that arose during the response to the September 11 attacks, and recommended a national adoption of ICS to enhance command, control, and communications capabilities during disaster response (Fig. 9-7).

To better understand the processes by which NIMS helps in the management of events requiring multiple levels of government, it is necessary to have a brief understanding of the ICS. The ICS was developed in California in 1970 after a devastating wildfire. During the after-action analysis of the response to the fire, which caused hundreds of millions of dollars in damage, killed 16 people, and left hundreds of families without homes, it was recognized that problems with communications and with coordination between different agencies made operations much less effective than they could have been. Following this analysis, Congress mandated that a system be created to address these coordination issues, and the result was a system called FIRESCOPE ICS, developed by the US Forest Service, the California Department of Forestry and Fire Protection, the Governor’s Office of Emergency Services, and several local and county fire departments.

FIRESCOPE ICS effectively standardized the response to wildfires in California. It resulted in a common terminology being used by all responding agencies, which significantly reduced the confusion. It established common procedures to be applied to firefighting, which significantly reduced the amount of time needed to coordinate between two or more agencies that would be working together on attacking a fire. Several field tests had shown that the system was effective, and by 1981 it was being applied throughout Southern California. So effective was FIRESCOPE ICS at standardizing coordination to wildfire events that departments began to apply its methods to other events unrelated to wildfires. It was soon recognized as being effective for the response to floods, hazardous materials’ spills and leaks, earthquakes, and even major transportation accidents.

There are multiple functions in the ICS, including common use of terminology, integrated communications, a unified command (UC) structure, resource management, and action planning. A planned set of directives includes assigning one coordinator to manage the infrastructure of the response, and assigning personnel, deploying equipment, obtaining resources, and working with the numerous agencies that respond to the disaster scene. In most instances, the local fire chief or fire commissioner is designated the incident commander.

The ICS was designed to remain effective at each of the following three levels of incident escalation:

Single jurisdiction and/or single agency

Single jurisdiction with multiagency support

Multijurisdictional and/or multiagency support

There are five major management systems within the ICS. They include command, operations, planning, logistics, and finance. Each is described here:

Command: The command section includes developing, directing, and maintaining communication and collaboration with the multiple agencies on site, as well as working with local officials, the public, and the media to provide up-to-date information regarding the disaster.

Operations: The operations section handles the tactical operations, coordinates the command objectives, develops tactical operations, and organizes and directs all resources to the disaster site.

Planning: The planning section provides the necessary information to the command center to develop the action plan to accomplish the objectives. This section also collects and evaluates information as it is made available.

Logistics: The logistics section provides personnel, equipment, and support for the command center. This section handles the coordination of all services that are involved in the response from locating rescue equipment to coordinating the response for volunteer organizations such as the Salvation Army and the Red Cross.

Finance: The finance section is responsible for the accounting for funds used during the response and recovery aspect of the disaster. This section monitors costs related to the incident and provides accounting procurement time recording cost analyses.

Under the ICS, there is almost always a single incident commander. However, even under this single command figure, the ICS allows for something called a UC. UC is often used when there is more than one agency with incident jurisdiction or when incidents cross multiple political jurisdictions. Within this UC framework, agencies are able to work together through the designated members of the UC, often with a senior official from each agency or discipline participating in the UC, to establish a common set of objectives and strategies and a single plan of action. Due to the nature of disasters, multiple government agencies often need to work together to monitor the response and manage a large number of personnel responding to the scene. ICS allows for the integration of the agencies to operate under a single response management.

NIMS establishes standardized incident management processes, protocols, and procedures that all responders, whether they are federal, state, tribal, or local, can use to coordinate and conduct their cooperative response actions. Using these standardized procedures, it is presumed that all responders will be able to share a common understanding and will be able to work together with very little mismatch. The following are the key components of NIMS:

Incident Command System: NIMS establishes ICS as a standard incident management organization with five functional areas—command, operations, planning, logistics, and finance/administration—for management of all major incidents. To ensure further coordination, and during incidents involving multiple jurisdictions or agencies, the principle of UC has been universally incorporated into NIMS. This UC not only coordinates the efforts of many jurisdictions but also provides for and ensures joint decisions on objectives, strategies, plans, priorities, and public communications.

Communications and Information Management: Standardized communications during an incident are essential, and NIMS prescribes interoperable communications systems for both incident and information management. NIMS recognizes that responders and managers across all agencies and jurisdictions must have common access to the full operational picture, thereby allowing for efficient and effective incident response.

Preparedness: Preparedness incorporates a range of measures, actions, and processes accomplished before an incident happens. NIMS preparedness measures include planning, training, exercises, qualification and certification, equipment acquisition and certification, and publication management. NIMS stresses that each of these measures helps to ensure that preincident actions are standardized and consistent with mutually agreed-on doctrine. NIMS further places emphasis on mitigation activities to enhance preparedness. Mitigation includes public education and outreach; structural modifications to reduce the loss of life or destruction of property; code enforcement in support of zoning rules, land management, and building codes; and flood insurance and property buy-out for frequently flooded areas.

Joint Information System (JIS): The Joint Information System provides the public with timely and accurate incident information and unified public messages. This system employs JICs and brings incident communicators together during an incident to develop, coordinate, and deliver a unified message. This is performed under the assumption that it will ensure that federal, state, and local levels of government are releasing the same information during an incident.

NIMS National Integration Center (NIC): To ensure that NIMS remains an accurate and effective management tool, a NIMS NIC was established to assess proposed changes to NIMS, capture and evaluate lessons learned, and employ best practices. The NIC provides strategic direction and oversight, supporting both routine maintenance and continuous refinement of the system and its components over the long term. It also develops and facilitates national standards for NIMS education and training, first-responder communications and equipment, typing of resources, qualification and credentialing of incident management and responder personnel, and standardization of equipment maintenance and resources. Finally, the NIC uses the collaborative process of federal, state, tribal, local, multidisciplinary, and private authorities to assess prospective changes to NIMS.