Chapter 5: Management of State Response and Coordination of Intrastate Jurisdictions (Tier 4)

Medical Surge Capacity and Capabilities (MSCC) Handbook

Jurisdiction Incident Management (Tier 4)

Tier 4 encompasses all State agencies that are responsible for emergency management, public health, and public safety preparedness and response. It addresses situations in which the State is considered the lead incident command authority, and those in which the State coordinates multijurisdictional incident management (Tier 3).

Key Points of the Chapter

The role of State Government in providing MSCC will vary based on incident circumstances and State-specific regulations. In general, however, States may enhance MSCC by:

• Assisting jurisdictional incident management (Tier 3) when local resources are severely challenged
• Providing primary incident command in widespread emergencies that reach to a state-wide level of responsibility
• Providing State resources to assist the local response
• Coordinating with incident management in other affected States
• Integrating State and jurisdictional response efforts with Federal support (Tier 6).

The State Emergency Management Program (EMP) should fully integrate public health and acute-care medicine with traditional response disciplines (e.g., fire/EMS, law enforcement). This will benefit State emergency health initiatives, such as bioterrorism preparedness, by promoting interdisciplinary cooperation. It will also benefit non-health-related emergency response by providing an integrated public health and medical perspective. An important focus of the State EMP should be developing management processes that facilitate integration between State-based and local or jurisdictional authorities. Experience has shown that coordination across jurisdictional boundaries must be carefully addressed to promote an effective emergency or disaster response.

State-level incident management can strengthen multijurisdictional response by coordinating management teams in affected jurisdictions. This is best accomplished through a robust Tier 4 information management function, established in the Planning Section of the State's incident management team, or alternatively, in the State's Multiagency Coordination Center (MACC). In addition, the coordination of tactical mutual aid between intrastate jurisdictions brings health and medical resources to areas of greatest need. Strategic or "master" mutual aid guidelines developed by the State during preparedness planning facilitate this aid distribution. In incidents where the State has primary incident command authority, State public health and medical managers should organize as part of the State's unified command, rather than attempt to manage incident response through Emergency Support Function (ESF) positions in the State Emergency Operations Center (EOC).

5.1 The Role of the State in MSCC

At the State level, authority and responsibility for emergency management typically reside within an Emergency Management Agency (EMA), although variations exist. Before 9/11 and the anthrax attacks in 2001, it was common for States to consider public health and medical emergencies to be distinct from other emergencies, thus requiring separate processes for response that were not all centrally supported by the EMA and public safety agencies.  However, this approach has begun to change, as current State and Federal initiatives (including HHS bioterrorism preparedness programs) call for the development of management processes to improve coordination among State agencies, and between the State and intrastate jurisdictions.

Another issue post-9/11 has been the growth of State level homeland security agencies and how they integrate with existing emergency management and public health programs. While homeland security programs generally focus on terrorism, emergency management traditionally has taken an all-hazards approach. It is important for public health and medical emergency planners to understand how these programs are structured within their jurisdiction, and where authority lies for emergency or disaster response.

The role of States in MSCC will vary based on their individual laws and regulations. In general, however, State authorities may assume several key responsibilities during emergency preparedness and response. The following paragraphs describe four such responsibilities.

1. Assist jurisdictional incident management (Tier 3) when local response resources become severely challenged. The bulk of this operations support is commonly provided through the State level MACC at the State EOC. Assistance may include:when local response resources become severely challenged. The bulk of this operations support is commonly provided through the State level MACC at the State EOC. Assistance may include:
   
• Providing assets or funding for the purchase or use of additional resources
• Assisting with the coordination of intrastate mutual aid
• Facilitating interaction, information flow, and strategic planning between affected intrastate jurisdictions.

States can also assist the medical sector by providing regulatory relief during incident response (Exhibit 5-1). Relevant State laws or regulations that may need to be revised or temporarily suspended in a public health or medical emergency should be identified during preparedness planning, and processes for their revision or temporary suspension should be formally described. Some examples include:

• Professional licensure, permit, or fee requirements for:
• State medical, nursing, or other healthcare providers
• Out-of-State medical, nursing, or other healthcare providers
• Pharmacists or pharmacy services
• Medical examiners
  
• Statutes governing the number of licensed or staffed beds allowed in healthcare organizations (HCOs)
  
• Statutes governing access to and disclosure of protected medical information
  
• Regulations stipulating provider-to-patient ratios and other standards of care parameters
  
• Regulations surrounding processing the remains of the deceased (e.g., in the event of overwhelming mass fatalities).
  

Exhibit 5-1. Emergency Medical Regulatory Relief

In the aftermath of Hurricane Katrina, the Governor of Louisiana declared a state of public health emergency and issued an Executive Order temporarily suspending State licensure laws, rules, and regulations for out-of-State medical professionals and personnel offering medical services in Louisiana, provided that these out-of-State medical personnel possessed current State medical licenses in good standing in their respective State(s) of licensure. In addition, the Executive Order designated out-of-State medical professionals and personnel as agents of the State of Louisiana for tort liability purposes.

2. Provide primary incident command in response to certain emergencies or disasters. State Government (led by the Governor or his/her designee) provides management oversight of the unified command (UC) and directs response activities according to a State Emergency Operations Plan (EOP).^[55] Scenarios that might necessitate State-based incident command include:
   
• Diffuse or widespread incidents involving multiple jurisdictions (but incorporating recognition of authority at the local level)
  
• Incidents requiring response assets that are primarily State resources (e.g., public health epidemiology expertise)
  
• Public health incidents and other types of emergencies designated by State laws or regulations.
  
3. Coordinate among multiple States to promote a consistent response strategy across State boundaries. The State may also work with States not affected by a hazard to facilitate receipt and distribution of tactical mutual aid to affected communities. Interstate coordination is addressed in more detail in Tier 5.
   
4. Provide the requisite interface with Federal authorities so local jurisdictions can request and receive Federal support (see Tier 6). The Governor or his/her designee declares a formal public health or general emergency and adheres to established procedures to request, receive, and distribute Federal assistance to affected jurisdictions. These procedures should be defined during preparedness planning.
   

5.2 State Emergency Management Program

State activities conducted through the EMA to mitigate, prepare for, respond to, and recover from emergencies or disasters constitute the State EMP.^[56] It is recommended that the State EMP fully integrate public health and acute-care medical entities with other response disciplines (e.g., fire/EMS, emergency management). This will enhance special public health initiatives, such as bioterrorism preparedness programs, by promoting interdisciplinary cooperation and integration.

State EMPs often include exercises to test the State EOP. Even if an exercise scenario does not have a primary public health or medical focus, planners should include public health and medical representatives at the outset of the exercise planning process. This enhances integration by allowing personnel from all disciplines to familiarize themselves with the plan and with each other. It may also benefit non-health responders, since almost every incident response has public shealth and medical implications, even if they are not immediately realized. Information that contributes to maintaining the health of responders can be critical, regardless of whether the event involves human victims. An example would be health examination of food sources for field providers on an extended environmental incident.

An important aim of the State EMP should be to bridge any coordination gap that may exist between public health and public safety agencies. Because public health has evolved primarily as a State-based authority, it may be difficult during disaster or emergency response to effectively coordinate with public safety, which usually manages events from the local jurisdictional government level. In addition, public health personnel historically are not well experienced in the ICS processes practiced by public safety and emergency management agencies (though this is changing). Therefore, preparedness planning should examine the operational methods necessary to integrate State public health with local emergency management and public safety during incident response.

The State EMP may contain strategic or "master" guidelines that govern tactical mutual aid arrangements. ^[57] The master guidelines stipulate operational requirements for activation of tactical mutual aid (described in Section 5.3.2), such as standardized criteria for designated resources. As applied to medical assistance, master mutual aid guidelines might specifically resolve such major issues as professional licensure, liability risk, worker compensation, and resource mobilization. Moreover, they should specify the processes to request and receive medical and health aid from other States (see Tier 5).

5.3 Support to Local Jurisdiction Response

Because incident management is usually based at the local level, the role of State Government in a mass casualty and/or mass effect incident is often to support the jurisdictional (Tier 3) response effort when local resources are severely challenged. This may come in the form of coordinating incident management activities among affected jurisdictions, and/or coordinating tactical mutual aid support between local jurisdictions.

5.4 Primary Incident Command

In a catastrophic event (e.g., major earthquake, hurricane, or terrorist attack), State Government may assume primary responsibility for incident command. A common belief among many States is that the structure of the State EOC is adequate for managing medical and public health response. In reality, however, this may not represent an ideal arrangement since the ESF structure and function are designed to support incident management (hence the name, Emergency Support Function). Thus, States that assume primary incident command authority should establish a separate incident management team, incorporating ICS principles, to manage response functions. This concept was effectively demonstrated by Illinois public health during TOPOFF 2.

The State of Illinois response in Top Officials 2 (TOPOFF 2)—a bioterrorism exercise in May 2003—provides an excellent example of how a State can effectively assume primary incident command responsibility. In TOPOFF 2, Illinois successfully implemented a State public health Incident Command Post (ICP) that was supported by the nearby State EOC. This response organization demonstrated the significant incident command responsibility of State medical and health authorities in response to a major incident. It also emphasized that medical and public health managers can organize as incident managers, rather than attempt to manage from a support position (i.e., an ESF) in the State EOC. This example also serves to highlight the differences between ICPs and MACCs.

The State's incident management team should be composed of State officials from across the range of response disciplines, including State medical and public health authorities. This team defines incident goals (known as "control objectives" in NIMS), operational period objectives, and the overall response strategy for the State. In addition, the State performs the lead information management function. It collects data from intrastate jurisdictions (Tier 3), collates the data and conducts analyses, and then disseminates the aggregate information back to jurisdictional managers to provide the "big picture" of how the incident and response are unfolding.

In a catastrophic event, the role of the State as the primary incident command authority is relatively straightforward. However, in a subtle incident (e.g., onset of an unknown infectious disease), primary command will likely be based initially at the jurisdictional (Tier 3) level. As information begins to emerge on the potential size and scope of the incident, a decision might be made to transfer primary command authority to the State. This decision is made through a meeting of the jurisdiction UC or, if multiple jurisdictions are involved, a meeting of the lead agency authorities from the multiple jurisdictions as coordinated by the State. An alternative may be to develop an "area command"^[60] that coordinates assets across the involved incident management teams.

The role of State political leaders in incident management should be clearly understood.^[61] The Governor bears ultimate responsibility for the safety and well-being of the State population. For events with potentially serious medical or public health implications, the Governor may declare a public health emergency; this generally activates the formal State public health response. The Governor may also temporarily suspend relevant State laws or regulations that impede response activities. Preparedness planning should identify regulations that might need to be revised or temporarily suspended and the legal procedures required to carry out these actions. In addition, as the elected spokesperson for his/her State, the Governor plays a critical role in public information management by:

• Maintaining public confidence: This is accomplished by providing the visible message that the State Government is focused on the incident response, has the intention to assist victims and their families, and is bringing all available resources to bear.
  
• Providing a context to the incident: This may be established in part by:
  
• Recognizing publicly the size and complexity of the incident
  
• Describing that the response will take time and extraordinary effort
  
• Providing other information that helps the victims and the public understand what has happened. For example, by expressing community outrage after an intentional hazard impact such as terrorism, and verbalizing both the mass impact of the event and the community's commitment to recover, the political leader may help the community come together for both response and recovery.
  
• Establishing and managing public expectations for the response: This is critically important in medical and public health events, where response is often complicated and solutions are not easily or rapidly achieved. Regularly informing the media and public of ongoing response efforts can help to shape behavior, and promote a better public understanding of how to best measure "progress" in complex events. This can also help to calm fears and minimize psychological impact.
  

State medical and public health officials (serving in a management role) should consider developing a briefing for the Governor (serving in an Agency Executive role) and his/her staff that describes key MSCC management and response issues. One critical area to explain is that "measures of effectiveness" used to evaluate a medical response may not be directly related to obvious outcomes, such as mortality or disease prevalence rates. For example, if all victims in a radiation incident were exposed to a fatal dose of radiation, the ongoing death of victims over days is not a measure of response effectiveness: the mortality rate had been unalterably set in motion prior to incident recognition and response. True measures of effectiveness for each type of medical incident should be developed during preparedness planning, and then reviewed and revised as indicated as a specific incident unfolds.

The Model State Emergency Health Powers Act (MSEHPA) provides one basic template for State authorities to define their major responsibilities in emergency or disaster response.^[62] Developed after the 9/11 attacks, MSEHPA suggests that States have a comprehensive plan in place for coordinated, appropriate response to incidents that threaten the public's health. It identifies specific laws or regulations that may need to be developed (or revised if already existing) to protect the health and safety of the general population. Key issues addressed that may be relevant for health and medical response include:

• Requirements for reporting illness or health conditions (including animal disease)
  
• Patient tracking and facility or materials examination
  
• Examination and decontamination of facilities or materials
  
• Information sharing
  
• Quarantine and isolation of persons or property
  
• Access to and disclosure of public health information
  
• Licensing and appointment of health or medical personnel
  
• Public information management
  
• Financial accounting, liability, and compensation.
  

In the years since the MSEHPA was published, experience has altered how it is applied. Readers are encouraged to review the published materials on this topic for a better understanding of its current application.

5.5 Integration With Other Tiers

Management of the State response (Tier 4) requires effective integration of State public health and medical assets with jurisdictional incident management (Tier 3). This function may be provided under the guidance of State public health using the infrastructure capability (e.g., manpower, computing resources, communications equipment) of the State EOC.^[63] In this way, State emergency management personnel collect and analyze public health and medical data generated by jurisdictional (Tier 3) unified command teams, as well as investigative findings from law enforcement and other agencies. The ability to examine these data, in real time, and rapidly return aggregate information to jurisdictions facilitates incident planning and promotes a consistent multijurisdictional strategy. It also enables the State to maintain accurate and updated records of resource availability—a crucial factor in coordinating mutual aid support.

A challenging aspect of the State response is coordinating the efforts of multiple jurisdictions without infringing on their responsibility in incident management. This is best accomplished by establishing key information requirements for all State jurisdictions through the Planning Section of the State incident management team or the MACC (i.e., State EOC). Standardized procedures should be developed for reporting medical and public health data (i.e., what, when, where, and how) and for requesting mutual aid. Reports should include strategies and tactics being used by local jurisdictions through their jurisdictional IAPs. This integrates the State with jurisdictional incident management (Tier 3) and facilitates coordination between affected jurisdictions. It also reduces the chance that conflicting strategies between jurisdictions may occur, causing anxiety and weakening public confidence in the response. A well-defined information management function enables local medical and public healthcare providers to access guidelines for patient evaluation and treatment from State public health authorities. This capability can be critical in a rapidly evolving infectious disease outbreak.

The State (Tier 4) also provides the interface between jurisdictional incident management (Tier 3) and Federal public health and medical assistance (Tier 6). For example, the State Governor makes the formal request to HHS for the Strategic National Stockpile (SNS) if the need for SNS assets is identified. If the SNS is deployed, State officials work closely with SNS coordinators and jurisdictional managers to coordinate its distribution to affected jurisdictions. The information management (i.e., knowing what support is needed) and incident management (i.e., working with local incident managers) facilitates this process.

How a State organizes its emergency services to promote integration will depend on many factors, including its geography, population distribution, and historical hazard experience. Some States favor a decentralized approach with the expectation that most hazards will be managed by relatively sovereign local jurisdictions. Other States have established detailed State-driven management procedures that are outlined in extensive regulations. The Standardized Emergency Management System (SEMS) in California provides an excellent example of the latter situation and is briefly described here.

California established SEMS in the early 1990s as a Statewide management system for use by public safety personnel (e.g., firefighters, police) and other emergency responders. State agencies are required by law to use SEMS for incidents involving multiple agencies or multiple jurisdictions. In addition, local governments must use SEMS in multiagency or multijurisdiction response to be eligible for State reimbursement for response-related personnel costs.^[64] SEMS is flexible to meet the demands of all hazards, and it is based on ICS functions (Command, Operations, etc.) and a five-level organization of response.

Figure 5-1. Generic SEMS Management Structure/span>

Information abstracted from Standardized Emergency Management System (SEMS) Guidelines for Special Districts.

Although SEMS provides a well-developed organization for public safety emergency services, it does not comprehensively address the incorporation of public health or private medical assets as the primary responders and incident managers. In addition, SEMS generally assumes a defined incident scene and relies on this to organize the initial response structure (this is understandable given the major hazard risks in California). However, because a defined scene is much less likely in a public health emergency, additional organizational guidance may prove helpful. The MSCC Management System was written to provide such guidance.

The Metropolitan Medical Response System (MMRS), described in more detail in chapter 4, is a Federal Department of Homeland Security (DHS) program that provides guidance for metropolitan areas to coordinate medical response across local jurisdictional borders.^[65]

5.6 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, as this is the focus of the MSCC Management System.

Background and Incident Description

• State Alpha is a southern State on the U.S. coast.
• A large Category 4 hurricane has struck the State, devastating multiple jurisdictions along the coast with extensive structural damage and flooding.
• In at least three separate low-lying jurisdictions with high population densities, HCOs have had their normal operations disrupted due to flooding.

In this scenario, the early stages of response unfold well before the event occurs:

• Incident recognition occurs several days prior to landfall when the National Weather Service issues a hurricane warning for the coast of State Alpha.
• Notification/activation occurs when the State EMA notifies State emergency response agencies, private response assets (e.g., HCOs), and the general public, and issues practical preparedness recommendations.
  
• Mobilization of State emergency/disaster services is characterized by the following steps:
  
• The primary ICP is established in the facilities that house the State's EOC. State-level incident comand is now co-located with, but physically separate from, its emergency management operations support at the EOC.
  
• A UC team composed of representatives from the primary response disciplines is established at the ICP. A senior health officer from the State's Department of Health (DoH) serves on the UC to represent public health and medical issues.
  
• The State ensures that weather-resistant communications are operating between the ICP/EOC and jurisdictional EOCs. The State issues short-term preparedness recommendations for State- level response agencies, and calls on jurisdictions directly in the storm's path to provide immediate post-landfall situation and resource status reports. Instruction is given on what to include in reports, where they should be sent, and how to format the information.
  

Incident operations are initially characterized by full evacuations of coastal areas and the pre-positioning of State response resources. State-level incident command works closely with Federal authorities to coordinate pre-positioning of Federal response assets. State action plans are issued for the two 24-hour operational periods preceding landfall. As the storm approaches, State Alpha switches to 12-hour planning cycles and fully staffs its ICP/EOC.

In the aftermath of the hurricane, affected areas report on storm-related injuries and physical/structural damage. It is quickly recognized that regular and emergency medical care has been compromised at multiple hospitals in several jurisdictions. The State UC assumes a primary incident command role and establishes overarching control objectives, operational period objective and response strategies. The State incident action plan (IAP) is developed and shared with affected jurisdictions, with other States (Tier 5), and with the Federal assistance liaison (Tier 6). This promotes the "common operating picture" described in NIMS. A key component of the State IAP is a public health and medical section that includes the following:

• Public health and medical situation assessments and resource status reports from data collected daily by affected jurisdictions; the assessments capture the number and types of victims directly affected by the event, as well as the medical special needs populations in the jurisdictions;
  
• Input into the safety message that includes public information messages to address such issues as displaced populations of wildlife and the handling of water in affected areas.
  

Based on initial reports, the State UC anticipates that local jurisdictions will need support and thus offers medical and public health resources to assist with unmet needs. State medical assets are provided to support the incident response being managed in the most heavily affected jurisdictions. This includes a State-sponsored Disaster Medical Assistance Team (DMAT). In addition, evacuation planning for some severely impacted HCOs is undertaken in conjunction with Federal partners (Tier 6) and State medical and health personnel are deployed to support locally affected health departments. The latter integrate through the jurisdictional (Tier 3) Logistics function and are assigned to the appropriate Operations Section positions in the jurisdictional ICS.

State Alpha's Governor and State health officer temporarily suspend, through emergency declarations, selected State health regulations. This action allows for:

• Relaxation of restrictions on hospital bed capacity in the most heavily affected jurisdictions so facilities that are still operational can "legally" care for more victims than their State license stipulates.
• Temporary changes to State licensing and certification regulations for healthcare professionals. The emergency regulations, developed during preparedness planning, permit HCOs to accept evidence of licensure from other States and allows medications to be dispensed by healthcare personnel other than physicians, nurses, or pharmacists.
• Establishment of several convenient locations where out-of-State healthcare personnel who want to volunteer in the response can report for screening, examination of their professional credentials, and granting of temporary credentials from State Alpha. This removes the credentialing burden from local jurisdictions and local HCOs.
  

One jurisdiction that was not fully evacuated has temporarily lost use of its primary outpatient and inpatient dialysis centers. Mutual aid is requested to provide dialysis services using resources from an unaffected jurisdiction elsewhere in the State. The State MAC Group (Agency Executive directors convened to address strategic and policy issues in the response) addresses the financial issues involved in meeting this request. The MACC (i.e., State EOC) implements the MAC Group decisions and addresses the issues that allow the dialysis mutual aid to be arranged and executed. Logistical issues involve transportation to move personnel and equipment, public works to arrange for a clean water source for the dialysis machines, and other details. The State also provides a financial guarantee to the assisting jurisdiction, as well as reporting guidelines so Federal reimbursement may be obtained.

The State facilitates coordination between affected local jurisdictions (Tier 3). Situation assessment and resource status reports are collected from affected jurisdictions and collated to provide summary health and medical information for the State. These aggregate data are included in the State IAP. State public health authorities provide case definitions for reporting storm-related injuries or illnesses. Included in this message is guidance for reporting gastrointestinal complaints. This becomes critical later to counter rumors about the outbreak of infectious disease.

Lastly, State Alpha coordinates with other nearby States (Tier 5) and with Federal agencies (Tier 6). Jurisdictional public health and medical needs that cannot be met through local resources or tactical mutual aid are reported to the State EOC. The State rapidly evaluates the requests and attempts to meet them using assets within State Alpha. For requests that cannot be met by the State, the MACC (i.e., State EOC) inquires from its regional partners (Tier 5) and/or forwards a request for assistance to Federal authorities. For example, when all three affected jurisdictions request medical teams to provide out-of-hospital patient evaluation and medical care, the State-sponsored DMAT can only fill one jurisdiction's request. Additional resources are requested from Federal agencies (Tier 6), but will take time to arrive. The appropriate assignment of the State DMAT may be determined by the MAC Group, or through the MACC using a pre-developed decision support tool for determining the best use of the DMAT asset.

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^55. This chapter does not examine specific components of the State EOP, since these will vary significantly from State to State. The focus instead is on the various roles States may have in catastrophic events.
^56. The State EMP may be accredited through the Emergency Management Accreditation Program (EMAP), a voluntary process to assess EMPs through collaboratively developed national standards.
^57. Mutual aid may be guided by "agreements," "memoranda of understanding," or other designations based on the degree of legal obligation desired by the mutual aid partners.
^58.Appendix C provides a more detailed description of incident action plans.
^59.Emergency Managers Mutual Aid (EMMA) Plan. California Office of Emergency Services, November 1997
^60. The NIMS definition of area command is provided in Appendix D.
^61.Because the role of senior political authorities varies from State to State, readers are advised to review their respective State laws and regulations for State-specific information
^62. Additional information on MSEHPA can be accessed at the Center for Law and the Public's Health at Georgetown and Johns Hopkins Universities
^63. If the State is serving as the primary incident command authority, then its ICS Planning Section would provide this service.
^64. Office of Emergency Services, California. Standardized Emergency Management System (SEMS) Guidelines for Special Districts (1999)
^65.Information on the MMRS program

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