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Chapter 2: Management of Individual Healthcare Assets (Tier 1)

Medical Surge Capacity and Capabilities (MSCC) Handbook

Management of Individual Healthcare Assets (Tier 1)

Image shows figure 1-2: MSCC Management Organization Strategy​ with emphasis on lowest level, Tier 1: Healthcare asset managemen

Tier 1 is the primary site for point-of-service (i.e., hands-on) medical evaluation and treatment. It includes hospitals, integrated healthcare systems, clinics, community health centers, alternative care facilities, private practitioner offices, nursing homes and other skilled nursing facilities, hospice, rehabilitation facilities, psychiatric and mental health facilities, and Emergency Medical Services (EMS).[33] The Medical Reserve Corps and State and Federal healthcare assets (e.g., Veterans Affairs Hospitals) that are co-located within a jurisdiction also fall into Tier 1 because they may become local assets for emergency response.

Key Points of the Chapter

In a mass casualty and/or mass effect incident, the vast majority of medical care is provided at the local level in hospitals, outpatient clinics, community health centers, and private physician offices. The success of an incident response, therefore, depends in part on how well these and other point-of-service healthcare organizations (HCOs)[34] are managed and their ability to coordinate with other response agencies.

The ability of an HCO to optimally manage its resources and to integrate with the larger response community is driven by its Emergency Management Program (EMP). The EMP includes all activities undertaken by the HCO to mitigate, prepare for, respond to, and recover from potential hazards. An integral component of the EMP is the Emergency Operations Plan (EOP), which defines the management structure and methodology to be used by an HCO during emergency response. The EOP is critically important because it also describes the management processes that enable the HCO to coordinate its actions with other responders.

The two Incident Command System (ICS) functions that facilitate cooperation among HCOs and integration with the larger response community are the Command element and the Planning Section:

  • HCO Incident Command: As an incident unfolds, the HCO incident management team must rapidly transition from reactive to proactive management by establishing HCO incident objectives and setting an overall HCO strategy for response. Information will have to be obtained from both inside and outside the HCO to conduct adequate response planning. A defined management structure that specifies roles for HCO personnel facilitates internal organization and external integration.
  • HCO Planning Section: The development of incident action plans (IAPs) and support plans allows the HCO incident management team to remain proactive, even as the incident parameters change. Likewise, a well-defined information function that is always operational (even at a minimal baseline during times of non-response) allows an HCO to rapidly process and disseminate vital incident- related data to divisions within the HCO and to outside responders. This promotes coordination with other entities and consistency across the response system. 

2.1 The Role of the HCO in MSCC

Patient evaluation and care in emergencies or disasters is provided primarily at community-based hospitals, integrated healthcare systems, clinics, community health centers, private physician offices, and other point-of-service medical facilities. These assets, therefore, must be centrally involved in the development of MSCC strategies. To maximize overall MSCC, efforts must extend beyond optimizing internal HCO operations and focus on integrating individual HCOs with each other and with non-medical organizations. Such integration ensures that decisions affecting all aspects of the community response are made with direct input from medical practitioners, thus establishing medical care, along its continuum, as an essential component of incident management.[35] This chapter examines management processes that effectively integrate HCOs into the larger response community. It is not intended to describe a comprehensive internal management system for individual HCOs.[36]

2.2 HCO Emergency Management Program

To adequately provide MSCC, individual HCOs must have a comprehensive EMP that addresses mitigation, preparedness, response, and recovery activities for major public health and medical incidents. A valid hazard vulnerability analysis (HVA)[37] forms the cornerstone of the EMP. The HVA is conducted by HCOs to define and prioritize a strategy for mitigation preparedness, response, and recovery based on the perceived risk (i.e., likelihood of hazard occurrence and vulnerability to the hazard impact) posed by potential hazards to HCO.

The primary objective of an HVA is to identify hazards and the vulnerability (i.e., susceptibility) to hazard impacts, and to prioritize EMP initiatives. Many models and guides are available to develop an HVA, but the critical components may be accomplished through the following steps:

  • Hazard identification. Identify and list, by type, all hazards that could affect the location or asset of interest, and the relative likelihood of each hazard's occurrence ("threat").
  • Vulnerability determination. For each hazard, develop an assessment of both the community and the response system's susceptibility to the hazard impact. For MSCC, this includes:
    • The community vulnerability in terms of potential post-impact health and medical needs of the population
    • The medical response system's vulnerability to each hazard (both the vulnerability of the system's baseline operations and its ability to surge).
  • Analysis of the vulnerabilities. Use a systems-based approach to:
    • Break down each hazard vulnerability into its key components
    • Identify components that are common across multiple hazards
    • Identify issues that create extremely high-stakes weaknesses
    • Compare relative cost-benefit ratios between the many possible mitigation and preparedness interventions.

While no HVA instrument can provide precise stratification of hazard threat and vulnerability for an asset or community, the HVA exercise should provide a basis for developing priorities among the many options that can reduce risk and enhance preparedness. From the HVA findings, the HCO can prioritize initiatives for mitigation and preparedness, and develop plans to address the identified vulnerabilities during response and recovery. If approached in this fashion, the HVA has maximum applicability to an EMP. In addition to guiding internal HCO mitigation and preparedness, the HVA activities can foster relationships with other local HCOs (Tier 2), with jurisdictional authorities (Tier 3), and with non-health-related organizations by highlighting common threats facing them.

Universities and other educational facilities may find it beneficial to address some aspects of preparedness planning in partnership with a nearby HCO. Because the threats they face may be similar, each should understand the other's vulnerability in order to effectively plan. For example, the HCO should have a sense of the number of students and staff that might be affected by identified hazards, and the university should know the patient-receiving capacity of the HCO so that it can plan for additional resources if necessary. This relationship can extend to the preparedness phase, with each organization's strengths offered to help address the other's vulnerabilities. The university may provide housing and temporary staging facilities for HCO evacuation, whereas the HCO's patient tracking and family assistance mechanisms may be used to rapidly inform the university of the location and status of students transported there for care (which addresses a significant area of university vulnerability in meeting parental expectations).

Senior executives at HCOs have ultimate responsibility for the development, implementation, and maintenance of their institution's EMP, and often appoint an emergency management coordinator to perform EMP activities.[38] In addition, an EMP committee composed of senior-level representatives from major departments within an HCO is usually established to review all EMP-related work and to provide expert input into the development of the HCO's EOP. The following are brief descriptions of key activities in the four phases of the EMP that promote integration with the larger response community.

2.3 HCO Emergency Operations Plan

In the past, the HCO EOP was commonly (and inaccurately) referred to as the disaster plan. Fortunately, this has begun to change as the EOP evolves into a guide to address less overwhelming emergencies and hazard threats. For early response activities, the EOP uses operational checklists (or job action sheets) for designated functions. Later stages of response, and initial stages of recovery, should be addressed by a proactive management method that emphasizes documentation of response objectives, strategies, and specific tactics.

Key Components of the HCO EOP:

  • The management structure and methodology that will be used in an emergency, including the organization and operation of the internal HCO Incident Command Post (ICP). This should be easily identifiable to external coordinating agencies.
  • General organizational descriptions of Operations, Planning, Logistics, and Administration/Finance Sections, which personnel perform them, and the processes/procedures to be used.
  • Essential activities to be performed during each stage of emergency response. These activities should be coordinated with other HCOs (through Tier 2) and with jurisdictional incident management (Tier 3) to maximize MSCC across the system.
  • Methods for adequately processing and disseminating information during an emergency, including names and contact information for external liaisons and contacts at other HCOs and the jurisdictional level (Tier 3).
  • Processes to promote continuity of HCO operations, including patient care, business continuity, and pre-identified sources for external support (e.g., mutual aid partner facilities).
  • Guidance on how to develop and release public messages during emergencies, including coordination with the jurisdiction (Tier 3) public information function.
  • Guidance for very unusual hazards or for special circumstances, such as hospital evacuation or "shelter in place." Typically addressed in annexes to the EOP, this guidance should use the same processes established for other emergencies.

The structure of the EOP in emergency management is becoming more standardized, and HCOs should consider conforming to this structured approach. Figure 2-1 provides a synopsis of the EOP structure demonstrated in the National Response Plan (NRP)[40] and the example below provides an EOP structure and format specifically for HCOs.

Figure 2-1. Organization of the National Response Plan
Figure 2-1 shows the organization of the Emergency Operations Plan from Healthcare Organizations as depicted in the national response plan from the Department of Homeland Security.

The material developed for the EOP should be formatted for ease of use during response and recovery yet must remain comprehensive. This EOP format is consistent with the common format of other disciplines and is consistent with the NRP format[41]:

It is important to recognize that many private physician offices, neighborhood clinics, and other "smaller" Tier 1 assets do not have the management infrastructure or personnel necessary to establish complex processes for incident preparedness and response. However, these entities may find themselves, during a major incident, compelled to participate in the community response beyond simply referring patients to a hospital or closing down their clinical operations. This is because:

  • Victims often seek medical care in settings they are familiar with, such as a personal physician's office
  • When medical surge demands severely challenge hospitals, patients may seek care at alternative facilities
  • Some victims' treatment requirements, or persons with medical special needs, may be adequately managed in these smaller settings
  • Certain events, such as a biological agent release, may be prolonged in duration and generate patients that can be safely evaluated in these settings, thus relieving some of the burden on larger HCOs.

The approach to emergency preparedness and response for these Tier 1 assets can be relatively simple. They may elect to integrate with each other and with the community response in one of two ways:

  • Associate with a larger Tier 1 organization (e.g., hospital, integrated healthcare system, large outpatient facility) where they have privileges, or with a local professional medical society. The organizing body must have the ability to manage ongoing EMP activities and, during response, to perform incident management processes, such as incident action planning and disseminating information to its participants.
  • Participate in at least the information processing function of the ICS. For this to occur, the smaller Tier 1 asset must know where to obtain authoritative information and where to report information. The exchange of incident-related informaton should include the following:
    • Where to obtain information on personal protection and other incident-specific safety measures for practitioners, their staff, and patients.
    • Where to obtain reliable incident information that allows anticipation of medical needs, such as unusual patient treatment requirements.
    • Where to obtain guidance on the specific medical evaluation of incident cases, such as the availability of confirmatory lab tests and the test limitations.
    • Where to obtain pertinent information on populations at risk (e.g., for a biological event, understanding the community- wide approach to risk stratification for potentially exposed patients).
    • Where to obtain information on whether public health emergency powers have been invoked, allowing release of private patient information, and other deviations from standard medical practice.
    • Where to send reports and what information to transmit on patients who have been evaluated and/or treated at the practitioner's location. This helps jurisdictional authorities (Tier 3) determine the size and scope of the event and monitor incident parameters.

2.4 Integration With Other Tiers

The comprehensive EMP should establish processes that enable the HCO to coordinate and integrate with other response entities. This helps the HCO adequately provide MSCC and becomes critically important when an asset is severely challenged and must seek external assistance.

Why is it important for individual health and medical assets to have an effective interface with other tiers?

Consider the scenario of a bombing incident with large numbers of casualties. Patients may self-refer or be transported by official jurisdictional assets to multiple treatment locations. This occurred after the Pentagon attack on 9/11, as patients were transported to hospitals around the region and others self-referred to hospitals and at least two clinics (one of which was in the Pentagon). Having individual HCOs effectively integrated with other tiers will facilitate:

  • Patient tracking: location of individual patients within a community's medical system.
  • Tracking the status of healthcare assets to determine:
    • HCOs that received large numbers of casualties that require outside support and diversion of additional patients
    • Individual assets that may be available to assist other HCOs
    • HCOs that can accept additional patients.
  • Notification of response actions that could affect an individual asset's operations, such as street closures that limit a facility's ability to get personnel to work.

The two major functional areas that facilitate cooperation among HCOs and integration of individual HCOs with non-medical responders at the jurisdiction (Tier 3) level are the Command element and Planning Section.

33. EMS is not usually included in this category and is not a facility per se. In a major emergency or disaster, however, EMS may provide definitive medical care in the field and should be integrated into Tier 1. 
34. In contrast, the traditional Incident Command System (ICS) model assumes that incident management is no longer responsible for patients once EMS transports patients to HCOs.
35. In this document, an HCO is any hospital, integrated healthcare system, private physician office, clinic, nursing home or other skilled nursing facility, or other resource that may provide point-of-service medical care.
36. Many other descriptions exist for individual HCO management, including the Hospital Incident Command System (HICS), State of California, Emergency Medical Services Authority, and Emergency Management Principles and Practices for Healthcare Systems, The Institute for Crisis, Disaster, and Risk Management (ICDRM) at the George Washington University; for the Veterans Health Administration (VHA)/U.S. Department of Veterans Affairs (VA), Washington, D.C., June 2006.
37. For a detailed discussion of the HVA for healthcare systems, see Emergency Management Principles and Practices for Healthcare Systems: Unit 1, Lessons 1.3.3 and 1.3.2.
38. J. A. Barbera and A. G. Macintyre. Jane's Mass Casualty Handbook: Hospital. Surrey, UK: Jane's Information Group, Ltd., 2003.
39. "Control objectives" is the NIMS term for overall incident response goals and are not limited to any single operational period (thus distinguishing them from operational period objectives).
40. U.S. Department of Homeland Security, National Response Plan, August 2004
41. Emergency Management Principles and Practices for Healthcare Systems: Unit 1.
42. A more detailed description of incident action plans, including an example of a hospital IAP, is provided in Appendix C.

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