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Appendix B: Incident Command System Primer for Public Health and Medical Professionals

Medical Surge Capacity and Capabilities (MSCC) Handbook

Traditionally, preparedness actions for public health and medical emergency or disaster response have focused on the operational (tactical) knowledge and skills required by individuals to respond. This has resulted in training programs developed primarily for such topics as victim triage or the characteristics of specific hazards (e.g., chemical or biological agents). Though this knowledge is important and has relevance, much of it is easily accessed during incident response and does little to maximize the capacities and capabilities of existing structures. In other words, teaching and training on these topics provides little in the way of strategic knowledge that improves the ability of individuals to respond as part of a cohesive system.

Management systems exist in most professional disciplines, but they have a wide range of primary objectives. Many businesses, for example, have developed systems with the primary objective of maximizing profits. The use of a well-described management system helps to optimally leverage available resources. It allows disparate personnel and resources to organize in a manner that allows them to achieve a desired outcome. Equally important is the ability of management systems to prevent discord and confusion among personnel, particularly when engaged in activities under stressful conditions. In emergency or disaster response, the primary objective of a management system should be to organize and coordinate disparate response assets to effectively address the incident issues, while minimizing risks (physical, financial, etc.) to responders. This was a primary motivation for the development of the Incident Command System (ICS).

The ICS was originally developed to help coordinate the multiple agencies and types of response personnel acting to control wild-land fires. The physical and financial risk in wild-land firefighting can be extreme when multiple agencies come together. Disparate organizations are able to work together effectively using ICS because, among other reasons, it establishes a common terminology and advocates a management-by-objectives philosophy.

The decision to participate in ICS is based on an understanding that, by doing so, an agency or individual can expect the following:

  • Enhanced collective security
  • Increased information sharing
  • Decreased confusion among responders due to coordination of response actions.

One of the main tenets of ICS is that a wide range of tasks is necessary in any incident response. These tasks can be grouped into categories that reflect similarities. For instance, all tasks that represent support of response personnel through the provision of accurate information can be grouped into the Planning Section. This approach has led to the description of five main functional areas that are necessary for response (Figure B-1):

  • Command: Provides overall direction of the response through the establishment of control and operational period objectives for the system. This functional area usually includes other activities that are critical to providing adequate management:
    • Public Information Officer manages information released to media and public
    • Safety Officer assesses hazardous and unsafe conditions and develops measures to ensure responder safety
    • Liaison Officer provides coordination with agencies outside the response system.
  • Operations Section: Achieves Command's objectives through directed strategies and execution of tactics.
  • Logistics Section: Supports Command and Operations with personnel, supplies, communications equipment, and facilities.
  • Planning Section: Supports Command and Operations with information management and the documentation of prospective plans of actions (also known as incident action plans, or IAPs). Critical components include the following:
    • Tracking of the status of resources and continual updates of the situation (event)
    • Development of contingency plans and long-range plans for Command staff
    • Early development of demobilization plans.
  • Administration/Finance Section: Supports Command and Operations through tracking of such issues as reimbursement and regulatory compliance.

Figure B-1. Incident Command System

Public health and medical disciplines have focused historically on the Operations functions necessary for response. Experience demonstrates that problems will arise if inadequate attention is paid to the other functional areas:

• Protection of responders: Inadequate initial consideration for personal protective equipment (PPE) could cause responders to be exposed to an infectious disease (a Safety function).

• Management of strategies: Inadequate coordination of strategies and tactics for screening for a disease might promote confusion in the patient population if people receive different evaluation or treatment at various healthcare facilities (a Command function).

• Management of information: Inadequate information management might result in the transportation of patients to a hospital that is already overwhelmed with walk-in patients (a Planning function).

Many of the most severe challenges during an incident response arise within the response system itself. Therefore, ICS devotes a large portion of its activities to supporting the response system, whether through Logistics, Planning, or Administration/Finance Sections.

The advantages of using ICS are not limited to organizing assets into similar tasks (functions and task groups).[90] This merely represents a "systems description." Another critical advantage provided by ICS is a "concept of operations," or a description of how the pieces function in a well coordinated manner through the sucessive stages of a response.

These are the critical processes that make ICS work. For example, a well-described goal of ICS is to transition from "reacting" to an incident to "proactively managing" an incident. Though many systems provide checklist procedures to be followed during the initial stages of a response, it is desirable to have commanders proactively establish overall objectives and strategies for response based on evolving incident and response parameters. Other, more finite, processes that allow ICS functions to interact are described as well. For instance, the simple act of holding an operations briefing can seem complex under the stress of response. In professionally conducted ICS, established "rules" are used for meetings to prevent confusion, limit disruptions, promote the capture of information, and adhere to time limitations. This contrasts with the less efficient tele-conference methods commonly used by the public health and medical disciplines during response to major events.[91]

With so many inherent advantages to the use of ICS, why has it not been readily adopted by many in the public health and medical disciplines? Part of the answer is that incident command systems can be complex to describe. When explained in an oversimplified manner, confusion results and there is a lack of understanding of the applicability of ICS. In addition, ICS principles are typically described in the terms used where it was originally developed—wild-land fire services. Many differences exist between this discipline and public health and medicine, most notably the existence of line authority. With inadequate explanations of ICS, personnel in public health and medical disciplines may be tempted to focus on the simple answers when preparing for an event. This leads them to concentrate on specific technologies that can be purchased as opposed to how to structure an incident response.

Increasingly, public health and medical entities are realizing the importance of organizing response according to ICS principles. Many hospitals have established response structures based on the Hospital Incident Command System (HICS), formerly known as the Hospital Emergency Incident Command System (HEICS). Others have implemented their own versions of hospital incident command. Some public health departments have begun to adopt systems approaches, using ICS principles, to manage complex health events. The adoption of these ICS principles is necessary to ensure consistency with the National Incident Management System (NIMS), which includes ICS. For public health and medicine to be considered equal partners and fully integrated into the response community, the concepts put forth in ICS should form the bas​is of their response systems. Without this foundation, it will become increasingly difficult for public health and medicine to maximize their roles in incident response. 

90. A critical shortcoming of many ICS training programs is that they provide only a description of functions without also providing a description of how the functions interact.
91. Personal observations of the MSCC project coordinators during the anthrax response in the National Capital Region in 2001, as well as during the TOPOFF I and II exercises and other incidents. 

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