Management of Individual Healthcare Assets (Tier 2)
The healthcare coalition (Tier 2) is composed of healthcare organizations (HCOs) and other assets described in Tier 1 that form a single functional entity to maximize MSCC in a defined geographic area. It coordinates the mitigation, preparedness, response, and recovery actions of medical and healthcare providers, facilitates mutual aid support, and serves as a unified platform for medical input to jurisdictional authorities (Tier 3).
Key Points of the Chapter
In a mass casualty and/or mass effect incident, HCOs may lack the necessary resources and/or information to individually provide adequate MSCC. The healthcare coalition (Tier 2) attempts to maximize MSCC by coordinating mitigation, preparedness, response, and recovery activities among all HCOs in a jurisdiction. This allows existing medical and public health resources to be optimally leveraged, and it promotes interfacility cooperation and support. Tier 2 also promotes coordination with jurisdictional authorities (Tier 3) by providing a unified platform for medical and public health asset integration into the community response.
The healthcare coalition (Tier 2) emphasizes coordination and cooperative planning rather than a truly "unified command" of all public and private medical and health assets. This is because health and medical assets retain their individual management autonomy during incident response. However, they participate in information sharing and incident planning to promote consistent management strategies. The management organization and decision process of Tier 2, therefore, is less structured than in Tiers 1 and 3 since decision authority resides primarily at the level of each HCO. Rather than "commanding" HCOs, Tier 2 brings them together to collaborate on strategic issues and to coordinate incident planning, response, and recovery activities. Tier 2 is essentially a NIMS-consistent Multiagency Coordination System (MACS), with the coalition providing the Multiagency Coordination Center (MACC) functions, and intermittent conferencing of HCO decision-makers providing the Multiagency Coordination Group (MAC Group) component. Ideally, these efforts are closely integrated with the jurisdiction's (Tier 3) preparedness planning and response activities.
The function in Tier 2 that collects, processes, and disseminates data and information is referred to as a "clearinghouse function." It ensures that all HCOs have the information they need to adequately prepare for and respond to major events. This information exchange builds consistency in response activities and in the public message. It also allows the Tier 2 coalition to effectively integrate with non-medical responders at the jurisdiction level (Tier 3) by providing timely and accurate "snapshots," or composite situation updates of local HCO operations.
An integral component of the coalition response is medical mutual aid—the redistribution of personnel, facilities, equipment, or supplies to HCOs in need during times of crisis. Mutual aid provides surge capacity and capability that is immediately operational, reliable, and cost-effective. The Tier 2 coalition provides a mechanism to formally establish processes for requesting and receiving mutual aid during preparedness planning. It also allows such issues as staff credentialing, liability, reimbursement, and transfer of patient responsibility to be addressed in preparedness planning, thus ensuring a rapid distribution of aid when it is needed.
3.1 The Role of the Healthcare Coalition in MSCC
Research has shown that most individual HCOs possess limited surge supplies, personnel, and equipment, and that vendors or anticipated "backup systems" for these critical assets are often shared among local and regional HCOs. This "double counting" of resources diminishes the ability to meet individually projected surge demands across multiple institutions during a medical emergency. To address this, the healthcare coalition (Tier 2) integrates all medical and health assets in a jurisdiction to coordinate their mitigation, preparedness, response, and recovery activities. In this way, HCOs work together to maximize MSCC rather than compete against one another for limited resources.
Much of the benefit gained from the healthcare coalition is evident in participant HCOs' Emergency Management Programs (EMPs) well before a major event occurs. Joint planning and preparedness efforts with geograph-ically related facilities are possible, even though the HCOs may normally be business competitors. Areas of mutual benefit include the following:
- Distributing the mitigation and preparedness workload among facilities, since many of the solutions found during preparedness planning may be applicable to multiple HCOs in a jurisdiction
- Establishing familiarity and trust among HCOs that promote cohesive response actions during an emergency
- Fulfilling regulatory and accreditation requirements for community emergency planning and for establishing and maintaining management systems that integrate into the jurisdiction (Tier 3) response (as required by the Centers for Medicare and Medicaid Services, State survey agencies, the Joint Commission on Accreditation of Healthcare Organizations, and other accreditation organizations)
- Promoting close integration with jurisdictional (Tier 3) authorities for mitigation and preparedness planning, and for pre-planning of scheduled unusual events, such as mass gatherings (e.g., fireworks display) or high-security events (e.g., political demonstrations).
During incident response, coalition participants benefit through cooperative planning, information sharing, and management coordination. As surge demands challenge individual HCOs, the coalition facilitates mutual aid assistance through arrangements with nearby HCOs. Mutual aid is a timely, cost-effective, and reliable method to obtain added surge capacity and capability (via equipment, facilities, supplies, and personnel) that is immediately operational. It distributes health and medical assets to areas of greatest need, thereby enhancing overall jurisdictional MSCC.
3.2 Coalition Emergency Management Program
The backbone of the healthcare coalition (Tier 2) is a comprehensive EMP that formally defines the mitigation, preparedness, response, and recovery efforts of participating HCOs. The preparedness and response architecture of the coalition EMP differs significantly from that found in individual HCOs (Tier 1) and at the jurisdiction level (Tier 3). For example, the Tier 2 leadership during an emergency or disaster response does not have an incident commander's decision authority for the coalition. Instead, the leadership acts to ensure optimal coordination and information sharing among participants. In this fashion, the coalition (Tier 2) functions like a MACS. If leadership decisions are necessary, the MAC Group component of Tier 2 should be activated.
Several important considerations for the coalition EMP include:
- Establish an emergency management committee that includes representatives of each participating facility. These individuals should be knowledgeable in their respective organization's EMP and Emergency Operations Plan (EOP).
- Address relevant issues related to mitigation, preparedness, response, and recovery. An example would be clearly defining the processes for how the Tier 2 leadership (the Tier 2 MAC Group) will be designated and activated during an incident response, or identifying how major decisions will be made on issues that affect all coalition participants. The MACC component must also be clearly delineated, for both the "clearinghouse" information function, as well as mutual aid and other important coordination tasks. This involves specifying during preparedness planning which personnel will perform these functions, the location where coordination will occur, the procedures for receiving, processing, and disseminating information, and the processes by which mutual aid will occur.
- Develop formal processes to administer the coalition EMP and to conduct emergency management committee meetings:
- The committee should meet regularly (at least once a month during startup and at times of high threat, or immediately after a response to receive input from all participants).
- An agenda should be distributed to participants before all meetings, and minutes should be recorded for future reference.
- An official vote should be taken to decide issues that affect all members.
- Meeting locations may be rotated among participating HCOs to promote familiarity with each other's response plans and facilities, to encourage sharing of best practices, and to distribute costs.
- Involve jurisdictional (Tier 3) authorities (e.g., EMS, public safety, emergency management, public health) in Tier 2 proceedings to ensure a close partnership between Tiers 2 and 3. Similarly, a Tier 2 liaison should participate in jurisdictional preparedness meetings and represent the Tier 2 coalition in the jurisdiction's EOC and (ideally) within the Tier 3 incident management team (if one exists separate from the EOC).
The coalition EMP should be sponsored by an established entity that can provide the administrative infrastructure (clerical support, meeting space, etc.) for the EMP. This "sponsor" must promote equal participation among member HCOs and should not convey a competitive business advantage to any coalition member. Potential sponsors may include local hospital associations, local or regional EMS councils, and Local Emergency Planning Committees (LEPCs).
The Tier 2 coalition may include HCOs from beyond a single jurisdiction. This may be desirable especially in rural areas, where health and medical assets are scattered, or in complex metropolitan areas with overlapping hospital catchment areas. In such cases, the Tier 2 coalition should closely coordinate its preparedness planning with each Tier 3 jurisdiction covered by the coalition's resources. During response, the jurisdiction that is primarily responsible for the medical incident response (i.e., for the victims generated within its boundaries) would be the primary support to the Tier 2 coalition, ideally in close coordination with other involved jurisdictions.
It is important for the coalition to retain the responsibility and authority for the Tier 2 response infrastructure. This helps to maintain the private sector perspective and ensures that the coalition has priority access to resources (e.g., radio, telecommunications) during response.
Early in the development of the Washington, DC Hospital Association-based Hospital Mutual Aid System (HMAS), the District Government offered the use of its 800-megahertz radio system and the Mayor's conference-call resource to hospitals for use in times of crisis. HMAS participants declined, recognizing the need to establish communications to which HCOs always had primary access, regardless of the evolving circumstances. The HMAS low-tech radio system worked exceptionally well on 9/11, when other radios were committed or overwhelmed. The privately established conference-call service also worked well during subsequent weeks of the 9/11 recovery effort and the anthrax crisis.
For reasons explained earlier(section 1.3.1), preparedness committees, processes, and procedures should be distinguished from those used during response. For example, the Tier 2 emergency management/preparedness committee would not be the appropriate structure for managing Tier 2 during an actual event.
3.3 Coalition Emergency Operations Plan
Similar to individual HCOs, the coalition (Tier 2) has an EOP that guides actions during response. However, the Tier 2 EOP emphasizes coordination among coalition members (via the MACC) rather than direct management of individual assets. This reflects the fact that HCOs retain their management autonomy during a response, while they collaborate with other medical assets to strengthen overall MSCC in the jurisdiction or region. In addition, the EOP should guide members on how to incorporate Tier 2 tenets into their respective HCO EOP. For example, the coalition EOP might provide instructions on such issues as how to request and integrate mutual aid assets into an HCO's incident operations, and what designated communication methods to use between HCOs during response.
The management organization of Tier 2 is less structured when compared with individual HCOs (Tier 1) and the jurisdiction (Tier 3) because decision authority is based primarily at the management level of each coalition member. For example, an HCO may grant or deny a request for mutual aid based on perceived ability to adequately maintain its own operations. Decisions that affect all coalition members are made by consensus through moderated meetings or teleconferences. Major strategic or policy-level decisions necessary during incident response may be relegated to meetings or teleconferences between the senior executives of the participating coalition HCOs. This forum may be designated as a MAC Group function to distinguish it from the MACC coordination function accomplished by the other Tier 2 activities. An example of a MACC activity might be the development of a consistent strategy for patient evaluation in all Tier 2 HCOs (e.g., risk/prophylaxis stratification of potentially exposed victims after a biological incident). An example of the MAC Group function may be a decision by all HCOs to buy an expensive technology necessary to address a newly recognized illness in the community. Despite the diffuse decision authority at Tier 2, each HCO should recognize the importance of its response actions and public message being consistent with those of other HCOs in the coalition.
Depending on incident circumstances, the Tier 2 coalition may elect to write a comprehensive incident action plan (IAP) that summarizes each participant's HCO IAP (Figure 3-1). This is most likely to occur when the response will be drawn out over an extended period of time (days or weeks). In other cases, the coalition IAP may simply aggregate action plans from individual HCOs into a pre-designated format. At the Tier 2 level, this is typically accomplished through a clearinghouse function that receives data from HCOs, collates them, and returns the aggregate data to HCOs.
Figure 3-1. Tier 2 Coalition Action Plan
The Tier 2 coalition IAP developed for each operational period requires approval by each coalition member. This type of unifying document, which describes common response goals and strategies, the situation at individual HCOs, the resources available, and other parameters, could facilitate integration with incident management at the jurisdictional level (Tier 3).
The Tier 2 coalition clearinghouse function ensures that HCOs have the information they need at a level of detail that enables them to provide adequate MSCC in situations where jurisdictional incident management (Tier 3) may not yet be involved. Its primary function is to gather, collate, and disseminate aggregate information; it is not intended to analyze or filter information to make independent jurisdiction-level decisions (which is the purview of Tier 3).
The Tier 2 coalition must have adequate systems in place to collect data from HCOs and rapidly return aggregated information to coalition members. Communication procedures should be as simple as possible. For example, it may be beneficial to develop spreadsheets that allow data to be electronically collated and the aggregate data quickly returned to the HCOs. To promote integration with jurisdictional incident management (Tier 3), the clearinghouse function must have a mechanism available to simultaneously provide data/information to Tier 3 for processing and further analysis. This "real time" flow of information enables HCOs to rapidly assist each other during response and to identify common needs and issues for presentation to jurisdiction support assets.
Some important preparedness phase considerations include:
- Select a site to support the Tier 2 information function that has 24-hour operations and the requisite support equipment (e.g., computers, radios, facsimile). Options include a hospital-based communications center for medical transport services, a private EMS service, or other entity.
- Designate personnel to process and manage incident-related information so that the capability is available 24/7. Examples could include personnel from the organizing body of the coalition or representatives designated on a rotating basis from individual HCOs.
- Pre-identify the type of information that might be important to collect and share across the coalition. Examples could include HCO action plans, initial and updated bed counts, patient volumes, and status of personnel, supplies, and equipment.
- Establish preferred methods of communication, such as radio, telephone, Internet, and facsimile.
Mutual aid is assistance between HCOs through the provision of facilities, equipment, personnel, or supplies when individual resources cannot meet the surge demands generated by a specific incident.
Mutual Aid Memorandum of Understanding: Operational Description:
The term mutual aid refers to the establishment of a formalized compact between response entities from neighboring jurisdictions. Historically, this agreement allowed for the provision of emergency services, on a reciprocal basis, when individual resources were inadequate to deal with a specific incident. For example, the Emergency Medical Services System Act passed by Congress in 1973 identified mutual aid as one of fifteen essential components in the formation of EMS systems in the United States. This "helping hand" concept has become so incorporated into the fire service, EMS and law enforcement communities that failure to implement and update such agreements can constitute a violation of State regulations.
The HCO mutual aid memorandum of understanding (MOU) is commonly a voluntary commitment (not a legal agreement) by each participating HCO to share information and provide available assistance in a major emergency or disaster. The MOU describes a systematized approach to HCO response for disaster events, whether external or internal to an institution(s). It addresses the exchange of medical personnel, supplies, pharmaceuticals, and equipment, and the evacuation or admission of patients to or from any member facility in the event of a disaster. The mutual aid system is not a replacement for any individual hospital's emergency preparedness plan; rather, it is meant as a supplement that will augment an institution's capabilities. The MOU assumes that the HCO has implemented its own EOP prior to activating the mutual aid system, and that the adequacy of the affected organization's response has been exceeded. Any event requiring activation of the mutual aid system is expected to be of a magnitude that it also involves municipal emergency services and the jurisdiction's department of public health.
The Tier 2 coalition should identify mutual aid possibilities and formally establish mutual aid processes for a jurisdiction or region during preparedness planning. Important provisions in this arrangement include:
- Donor HCOs should send only credentialed/privileged staff in response to a request for assistance; the receiving HCO essentially accepts the credentialing process of the donor HCO.
- Donor HCOs should pay staff members who volunteer to assist other facilities; the requesting HCO then reimburses this cost within a specified period of time.
- Liability coverage is carried by the donor HCO, but any expenses associated with the liability coverage are guaranteed by the receiving HCO.
- Requesting HCOs agree to rehabilitate equipment before it is returned, to replace donated supplies, and to reimburse all associated costs.
- Requesting HCOs designate staff to receive, brief, assign, and supervise donated healthcare personnel.
- When patients must be moved between facilities, the HCO requesting assistance is responsible for arranging transport (including transmitting the patient's chart and other information):
- The transfer of responsibility for a patient occurs once the patient reaches the new facility.
- The accepting HCO has full authority to assign one of its physicians as the primary medical provider for the patient, but grants temporary courtesy staff privileges to the patient's usual physician.
- Additional issues are addressed in the
American Hospital Association's template, Model Hospital Memorandum of Understanding.
Once the mutual aid process is established and documented, coalition members should be educated and trained on how to request and/or receive support. This includes knowing the proper procedures to follow, which personnel should make a request, whom to notify, and how to receive and financially account for donated resources—the latter being important for reimbursement after response. A short briefing should be prepared for staff members who volunteer to deploy to other facilities.
3.4 Integration With Other Tiers
An important function of the Tier 2 coalition is to integrate community medical assets with non-medical response organizations in the jurisdiction. This is accomplished through a Tier 2 liaison function. Having one liaison to represent the collective interests of HCOs (Tier 2) at the jurisdiction (Tier 3) level enables non-medical response assets to more easily interface with and understand the concerns of the healthcare community. If the Tier 2 coalition covers multiple local jurisdictions, a Tier 2 liaison should be assigned to each Tier 3 incident command post or EOC (as indicated) to represent the coalition's interests.
Depending on specific incident circumstances, Tier 2 coordination with the following agencies might be considered:
- EMS—tactical and strategic issues may be addressed through formal liaison with EMS. For example, Tier 2 may provide frequent status reports to EMS with each HCO's up-to-date receiving capacity. This promotes a more equitable distribution of patients by accounting for patient walk-ins, of which EMS transport officers might otherwise be unaware. At a strategic level, the Tier 2 liaison could have important input into action planning occurring within EMS.
- Public Health—presenting HCO concerns in a single, organized format to public health promotes a more timely response. This association is mutually beneficial because patient numbers, symptoms, or other patient-related information that is collected and formatted in a standardized manner by Tier 2 can be invaluable to public health epidemiological investigations.
- Law Enforcement—specific police support may be requested, or law enforcement may be alerted when their activities affect HCO operations (e.g., road closures that limit staff access to HCOs).
- Public Works—this is important in the event that loss of a specific utility affects HCO operations.
- Others—this may include the public school system, fire service/ HAZMAT, military, national guard, or others as indicated by incident circumstances.
To promote an organized response system, the Tier 2 liaison is best assigned to the local EOC (a MACC for Tier 3) or to the jurisdictional incident command post (Tier 3), depending on the incident. In a primarily non-medical event, the Tier 2 liaison will likely integrate at the EOC; in a major medical event, integration should occur within the jurisdiction's ICS (see Figure 4-1). If a jurisdiction operates using principles outlined in the next chapter, representatives from all of the just-listed agencies would be present and available to work with the Tier 2 liaison.
3.5 Illustrative Example
The following example demonstrates how the concepts presented in this chapter may be applied during an actual incident response. The various phases of response (as described in Chapter 1) highlight when critical actions should occur; however, the example extends only as far as incident operations, since this is the focus of the MSCC Management System.
While the following example demonstrates Tier 2 addressing specific activities, it should be noted that in some jurisdictions, many of these activities are addressed by Tier 3.
Background and Incident Description
- During MSCC preparedness planning, HCOs in Jurisdiction Y developed a sophisticated healthcare coalition (Tier 2) that is sponsored by the largest hospital in the city with support from the jurisdiction's Department of Health (DoH).
- The sponsoring hospital's primary contribution to the Tier 2 coalition is the commitment of its communications center, which during baseline operations coordinates helicopter and ground critical care transports for the hospital. During a major incident, the hospital assigns additional personnel to the communications center to ensure an operational capability for the Tier 2 coalition.
- A large incendiary explosion occurs at a subway station during evening rush hour. Calls to 911 report many burned casualties emerging from the underground station, which is on fire. Many victims flee the area before first responders arrive and organize the scene. The number of victims that may be trapped underground is a major concern.
Incident recognition is provided across the Tier 2 coalition by EMS dispatch. Multiple 911 calls describing "a large explosion with casualties" trigger a pre-determined threshold, and the EMS dispatcher notifies coalition hospitals as EMS units are sent to the scene. Almost simultaneously, initial media reports describe an explosion with casualties. Subsequently, the hospital closest to the blast site notifies the Tier 2 coalition that they have already received several walk-in burn patients from the event.
Notification/activation of the Tier 2 coalition occurs immediately and is accomplished by the initial EMS dispatch communication. The initial notification is sketchy and states only that an explosion has occurred at or near Station X, many casualties are expected, and EMS scene officers will call back shortly for an HCO bed availability count. Because of preparedness planning and training, the Tier 2 coalition partners know to immediately survey their HCO's bed availability and categorize additional patient capacity according to a predetermined format.
Mobilization involves the initial staffing of the Tier 2 call center (MACC), as well as the gathering of initial information from the various Tier 1 assets. This includes determining which Tier 1 assets are activating their respective EOPs. In addition, the coalition begins to gather additional incident information from Tier 3 for dissemination to the Tier 1 assets. Participating Tier 1 HCOs appoint a liaison from their organization as their primary contact with the MACC component of the Tier 2, and appoint a senior executive to participate in any potential MAC Group activities in Tier 2.
Incident operations begin within minutes, as initial bed counts are reported by each HCO. The Tier 2 information clearinghouse function collects and aggregates the data, and provides a composite of the data to EMS for use by triage and transport officers, and to the DoH communi-cations officer for jurisdictional (Tier 3) planning. Moreover, the composite is immediately distributed to all coalition HCOs and is used by hospital incident managers to anticipate surge needs for direct patient care or potential support needs for their partner HCOs.
- Shortly thereafter, the hospital closest to the blast site reports to the Tier 2 coalition that they are inundated with self-referrals from the scene. The composite hospital-receiving capacity is revised and transmitted to EMS so that triage and transport officers can adjust patient distribution accordingly. The revised composite is also sent to DoH and to all coalition HCOs.
Through the Tier 2 communications mechanism, coalition HCOs (with DoH participating) receive an incident update from an assistant EMS Chief at the blast site. The total number of victims is unclear because underground areas have not been fully accessed by rescuers. The Tier 2 coalition decides to implement a formal reporting mechanism to facilitate distribution of incident information to the HCOs and to jurisdictional health authorities (Tier 3). The Tier 2 clearinghouse function provides an electronic reporting format for hospitals to use and initially requests submission on an hourly basis. Information from the reports is collated by the Tier 2 clearinghouse function and redistributed back to the HCOs to give them a more comprehensive perspective of the response. Essential elements of information in the reports include:
- Situation reports at HCOs (counts of victims at each facility)
- Resource status updates (e.g., available beds, staff, supplies, pharmaceuticals)
- A composite communications plan that describes how jurisdictional authorities (Tier 3) can contact individual HCO's incident management teams (Tier 1).
The Tier 2 coalition coordinates various services among the HCOs. For example, staffing agencies that supply healthcare personnel to more than one HCO are coordinated through the Tier 2 coalition to prevent serious shortages at any one facility. In addition, the coalition sends a liaison to the jurisdiction's EOC to convey the collective issues and concerns of the HCOs to the EOC management team and appropriate Emergency Support Functions (ESFs). For example, the liaison to the EOC informs the jurisdiction that law enforcement activities (e.g., street closures) have hindered the ability of off-duty staff to return to the hospitals to assist with the surge in patient volume. This problem is rapidly addressed.
The blast caused a significant number of eye, burn, and respiratory injuries, which severely challenge the response capability of several HCOs. The Tier 2 coalition assists in coordinating medical mutual aid to these facilities:
- Eye injuries: The Tier 2 coalition rapidly locates available ophthalmologic capacity at partner facilities and coordinates the transfer of some victims with eye injuries (who are otherwise stable) to those facilities.
- Burn injuries: The one burn center in the area is overwhelmed with victims that have significant burns. The Tier 2 coalition writes guidelines for early inpatient hospital treatment of burn patients, and these are distributed electronically to area hospitals. Burn and trauma experts from an adjoining, unaffected jurisdiction are made available through the hospital radio/conference call system to provide clinical guidance as requested by the non-trauma and non- burn facilities that are receiving burn casualties. This information sharing increases the capability of hospitals to provide adequate initial burn care until out-of-region transfers can be arranged.
- Respiratory injuries: One hospital has received a large number of victims that are progressing to respiratory failure due to smoke inhalation. The hospital reports an urgent need for additional critical-care airway management capacity (i.e., ventilators, respiratory therapists, and critical-care staff). Two HCOs farther away from the blast site volunteer their excess capacity, which was generated when the HCOs activated their respective EOPs. Credentialed staff, ventilators, and other supplies are dispatched to the requesting hospital. The jurisdiction's public health authority (Tier 3) is also notified that additional ventilators, supplies, and critical care staff are needed from outside the jurisdiction. Actions are initiated to obtain these resources.
As the blast scene is cleared of victims, the jurisdiction's defined "incident" transitions from focusing on fire/EMS rescue at the site to supporting HCOs as they surge to meet victims' medical needs. Medical representatives from the Tier 2 coalition are appointed as senior advisors to the Tier 3 incident management team. Input from these advisors to jurisdictional incident management will promote optimal support of the local HCOs in their efforts to address evolving surge demands.
43. In this document, an HCO is any hospital, integrated healthcare system, private physician office, clinic, community health center, nursing home or other skilled nursing facility, or other resource identified in Tier 1 that may provide point-of-service medical care.
44. Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response. GAO-03-924, August 2003..
45. Barbera, JA, Macintyre, AG, and DeAtley CA. "Ambulances to Nowhere: America's Critical Shortfall in Medical Preparedness for Catastrophic Terrorism." Executive Session on Domestic Preparedness, John F. Kennedy School of Government, Harvard University ESDP-2001-07 (October 2001). Updated and reprinted in Countering Terrorism: Dimensions of Preparedness, MIT Press, September 2003.
46. The issue of "double counting" also highlights the importance of including members of the HCO supply chain (pharmaceutical companies, equipment vendors, etc.) in preparedness planning.
47. LEPCs are mandated by the Superfund Amendments and Reauthorization Act (SARA Title III) for communities with risk of hazardous material incidents from local industry.
48. Gursky, E, Inglesby, T V, and O'Toole, T. "Anthrax 2001: Observations on the Medical and Public Health Response." Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, Volume 1, Number 2, 2003; 97-110.
49. Additional information on the key components of an incident action plan is provided in Appendix C.
50. In most cases, HCOs will first go through their normal supply chain to address surge demands. If this is not sufficient, mutual aid is a timely and cost-effective way to provide MSCC.