Sign In
Search Icon
Menu Icon

Chapter 6: Interstate Regional Management Coordination (Tier 5)

Medical Surge Capacity and Capabilities (MSCC) Handbook

Tier 5 describes the processes by which States assist one another and coordinate management and response activities during times of crisis. It includes State-level agencies that oversee emergency management, public health, medical, and public safety emergency preparedness and response. 

Key Points of the Chapter

During a catastrophic event, interstate coordination is an effective and often necessary means to acquire adequate MSCC. Collaborative efforts between States promote system-wide consistency in response strategies and ensure optimal utilization of available public health and medical resources. An effective regional response must be rooted in an open exchange of information, incident management coordination, and mutual aid support, as described below:

  • Information sharing: Before addressing communications technology, States should establish what type of information is important to share, and to whom that information should be provided. These information "requirements" generally include the following:
    • Overarching management strategies and specific tactics
    • Situation assessments and resource updates
    • Safety information for responders and the public.
  • Management coordination: Incident action plans and support plans should be shared between incident managers while these plans are still in developmental stages. This will help identify potential areas of conflict in response strategy between States and allow for corrective action before such conflicts undermine the success of the overall response system.
  • Mutual aid: This describes the provision of emergency services and assets to provide MSCC when individual State resources are insufficient to meet surge demands. Strategic mutual aid guidelines provide the general framework for tactical mutual aid agreements between States. The latter specify operational processes for requesting, receiving, and managing emergency support assets.

The Emergency Management Assistance Compact (EMAC) provides a vehicle for regional coordination and mutual aid during a Governor-declared emergency or disaster. Public health and medical assistance is specifically noted in EMAC, and public health and medical emergency planners are encouraged to review EMAC and how it is being implemented in their State as part of their preparedness activities. In addition, they should work closely with the HHS Regional Emergency Coordinators (REC) in their region to coordinate planning for and execution of interstate regional public health and medical mutual aid assistance.[66]

6.1 The Role of Interstate Coordination in MSCC

Legal and political realities dictate that each State bears ultimate responsibility for the safety and welfare of its citizens. In times of crisis, however, it may be necessary for States to share information and resources with one another to support a coordinated response. The need for interstate coordination and mutual aid assistance is driven by several factors:

  • Few States, if any, possess the full range of resources necessary to respond to all types of emergencies (natural or man-made), or the capability to get resources to areas of greatest need.
  • Population growth near State borders has significantly increased the potential for hazard impacts to affect a population that extends across State boundaries.
  • An increasingly mobile workforce in the United States raises the probability that the onset of certain delayed hazards (e.g., biological, chemical, or radiological agents) may actually manifest more prominently in victims who live outside the area of immediate impact.
  • Omnipresent media coverage easily spotlights discrepancies in the response actions of affected jurisdictions or States. Reports of such discrepancies may erode public confidence and cause undue anxiety in the population.

The Implications of Interstate Incident Strategy Conflict:

A stark example of the problems with conflicting interstate response strategies was evident in the National Capital Area when West Nile Virus arrived in the summer of 2000. Montgomery County, Maryland, elected to spray for mosquitoes when the virus was detected in a mosquito pool on the border with the District of Columbia. In contrast, the District followed expert advice and elected not to spray. The conflicting policies and their rationale were not explained to the public until a media controversy erupted, causing significant public unrest that consumed public officials' time and attention.

Interstate coordination is an effective way to promote the optimal distribution of available medical and public health resources in support of overall MSCC. It enables affected States to share information, including incident goals (known as "control objectives" in NIMS) and operational period objectives defined by incident command, so that a consistent response strategy can be implemented across State borders.

To be effective, interstate coordination must entail the following:

  • Open and reciprocal information exchange regarding incident and response parameters
  • The ability to compare and discuss incident action plans (IAPs) for individual States, as they are developed
  • An understanding that creating consistency among State IAPs and proactively addressing apparent interstate discrepancies will enhance the overall response system
  • Effectively using the coordination platform to provide assistance, such as cross-border mutual aid.

6.2 Forms of Interstate Assistance

Three primary methods for interstate coordination during emergency or disaster response are information sharing, incident management coordination, and mutual aid. At a basic level, information sharing is critical because it allows States to stay up to date on how an incident is unfolding, how other States (Tier 4) or jurisdictions (Tier 3) are responding, and what resources have been committed or remain available. Incident management coordination builds consistency in regional strategies and promotes similarity in the development and application of operational tactics. Mutual aid maximizes MSCC by bringing materials, personnel, and/or services to areas where resources are insufficient to meet surge demands.

6.3 EMAC: A Model for Regional Coordination

The Emergency Management Assistance Compact (EMAC) is a congressionally ratified interstate mutual aid mechanism (Public Law 104-321) that is supported through legislation enacted by all 50 States, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. It provides a general framework (and legal basis) for interstate coordination and mutual aid during Governor-declared emergencies or disasters.[67] It also provides for interstate cooperation and resource sharing in emergency-related training, drills, and exercises. Important preparedness and response issues addressed in EMAC include the following:

  • Review of State emergency plans and hazard vulnerability analyses
  • Provisions for temporary suspension of any laws or ordinances
  • Licensure and permit waivers for medical and other professionals
  • Assumption of liability risk for donated personnel rendering aid
  • Reimbursement for assistance (e.g., personnel, equipment, and supplies)
  • Compensation for workers killed or injured while rendering aid
  • Interstate evacuation of the civilian population.

EMAC was designed to apply only to the sharing of State resources and personnel. Therefore, coverage for such issues as professional licensure and liability risk applies only to State employees. Specific legislative or regulatory actions must be taken to address coverage of local government or private sector public health and medical personnel deployed to another State. For example, some States have enacted legislation allowing local government and private sector personnel to deploy as temporary State employees via EMAC during emergencies.

EMAC was a key mechanism used by States to deploy public health and medical personnel and resources following Hurricane Katrina. This was, in fact, the largest ever deployment through EMAC with an estimated 66,000 personnel (civilian and National Guard) deployed across all disciplines.[68] One of the key lessons learned from Hurricane Katrina was the need for specificity in requesting resources via EMAC (e.g., clearly delineating specific qualifications or training for personnel or teams). Healthcare resource typing as a national initiative is underway but incomplete. Thus, it is important to carefully describe the type of assistance being requested.

Public health and medical planners should work closely with their State's EMAC coordinator to understand how EMAC is being implemented in their State. They should also be directly involved in establishing processes to ensure coordination of public health and medical assets obtained/deployed via EMAC in support of MSCC. 

6.4 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

  • A large chemical factory that produces plastics resides in the far eastern corner of State Alpha. State Beta is adjacent to State Alpha and is "downwind" of State Alpha.
  • An explosion occurs at the factory, starting a fire that is difficult to control. Victims are coughing and complaining of breathing difficulties.
  • Large clouds of smoke, possibly containing combustion products, such as phosgene and other pulmonary irritants, are released into the atmosphere and carried downwind toward State Beta. The local fire service and a hazardous materials (HAZMAT) team respond to the scene.

Incident recognition at the State level occurs for State Alpha (where the explosion occurred) when the responding jurisdiction reports the findings of an initial HAZMAT scene survey to the State's Environmental Protection Agency (EPA) HAZMAT reporting center. State Alpha begins staffing its State EOC and notifies participating agencies that the State EOP is activated. The initial HAZMAT report forms the basis of State Alpha's notification of EOP activation.

For State Beta, incident recognition occurs when State Alpha's HAZMAT responders notify the fire service/HAZMAT team in the adjoining jurisdiction of State Beta using tactical channels established in preparedness planning. They decide that unified command should be set up to coordinate the evacuation of the at-risk population.

Notification/activation of the interstate response occurs through the aforementioned tactical coordination between local fire/HAZMAT units from State Alpha and State Beta. In addition, State Alpha directly notifies State Beta's Emergency Communications Center (ECC), which serves as the pre-event baseline operating entity for State Beta emergency management. State Beta immediately activates its State EOC and notifies participating agencies in its State EOP.

Mobilization of the interstate response occurs as State Alpha and State Beta activate and ramp up staffing at their respective State EOCs, and activate their State-level unified command teams.

Incident operations are characterized by initial reports from the affected jurisdiction in State Alpha of large numbers of respiratory injuries that have overwhelmed the local healthcare organization (HCO). Fortunately, this HCO is upwind of the area of concern and does not need to evacuate or consider sheltering in place. The HCO has activated its EOP and requested and received assistance from community medical providers, as well as from its mutual aid agreement with a hospital located ten miles away. The local MMRS plan is also activated and used to coordinate the metropolitan healthcare response.

State Alpha provides regular updates to State Beta's EOC regarding firefighters' progress in suppressing the fire and smoke, in determining the exact contents of the noxious smoke, and in plotting plume models as wind conditions at the scene change. In addition, State Alpha provides information to State Beta on the conditions of patients presenting at State Alpha hospitals, including symptoms correlated with positions where the victims were exposed. When State Beta requests to send its HAZMAT experts to the scene, State Alpha's EOC arranges for an escort from the fire marshal's office in State Alpha to facilitate scene evaluation by State Beta experts.

The heavily affected jurisdictions in State Alpha and State Beta decide to continue with a unified area command[69] to tactically manage joint issues caused by the smoke. State Alpha supports this initiative by supplying a command vehicle and medium-range communications equipment for use in the affected areas. This is closely coordinated with command staff in State Beta's EOC. Strategies and tactics, such as decisions to evacuate or shelter-in-place, are also coordinated between State Alpha and State Beta to avoid conflicting recommendations. Any differences are explained to the public in simple terms to prevent confusion. Similarly, medical evaluation and treatment protocols for victims are coordinated with input from both States' public health agencies. As the situation improves, recommendations for repopulating evacuated areas or ending shelter-in-place are consistently developed and applied across State boundaries.

State Alpha requires additional assistance for the local hospital that is caring for the majority of incident victims. It is determined that healthcare assets in State Beta can actually provide the necessary help faster than assets that could be obtained through intrastate mutual aid. Therefore, State Alpha's EOC asks for assistance from State Beta for critical care personnel and ventilators. This is accomplished using protocols and procedures developed during preparedness planning (through MMRS and other initiatives) and based on EMAC authorities.

State Beta notifies its Medical Reserve Corps and hospitals near its border with State Alpha. The requested resources are located and dispatched. The strategic mutual aid agreement between State Alpha and State Beta provides for:

  • Waiver of licensure and certification requirements in State Alpha for State Beta responders who are appropriately credentialed in State Beta
  • Extension of liability coverage by State Alpha to State Beta for workers as long as they operate within their defined scope of practice
  • Extension of worker compensation coverage by State Alpha to healthcare workers who respond from State Beta.

66. Tier 6 discusses the roles and responsibilities of HHS RECs in greater detail.
67. Additional information on EMAC.
68.EMAC Executive Briefing, August 16, 2006.
69.The definition of an Area Command (Unified Area Command) is provided in Appendix D.

<< ​Back                                                                                                                                                                 Next ​>>