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Medical Surge Capacity and Capabilities (MSCC) Handbook

Why the MSCC Project?

In the aftermath of the 9/11 terrorist attacks and the dissemination of anthrax in 2001, the ability of the U.S. healthcare system to provide an effective and coordinated response to mass casualty or complex[5] incidents came under intense scrutiny. More recently, the devastation caused by Hurricane Katrina and the mass disruption of public health and medical services along the Gulf Coast spotlighted the need for cohesive strategies that focus on management systems for major public health and medical response. The critical question becomes:

What management structure will allow us to discuss, analyze, and describe complex medical and public health response under exceptional[6] circumstances as a single system?

Examinations of major public health and medical emergencies reveal exceptionally complex management scenarios. This is true for all hazard types (natural disasters, infectious diseases, terrorism, large-scale explosives, and etc.) and is apparent even in events without large numbers of physically injured or ill patients. Medical evaluation and treatment of incident victims require many complicated tasks that extend beyond hands-on medical care and are dispersed across a wide range of resources. Surprisingly, however, the management of such complex scenarios has received very little attention.

In addition to ensuring adequate patient care, critical management responsibilities in major medical and public health incidents include:

  • Medical system resiliency: The ability of healthcare organizations (HCOs) to survive a hazard and rapidly recover any compromised medical services is critical. This ensures that a reliable platform is available to address medical surge needs. It also provides the public with access to regular medical services, thus minimizing the risk of a "secondary surge" that can result when people with chronic health conditions decompensate because they lack access to their normal care.
  • Responder safety: The protection of healthcare personnel and other responders as they perform activities to minimize the hazard impact on an affected population is paramount. Personal protective equipment (PPE), vaccination, prophylactic medication, and other interventions may be necessary in the midst of a rapidly evolving emergency.
  • Information management: A large amount of complex information must be collected, analyzed, and managed to determine incident parameters and response needs. Information is needed to rapidly and accurately determine patient distribution and numbers, the range of injury and illness caused by the hazard, recommendations for evaluation and treatment, the post-impact condition of public health and medical assets, and other response considerations.
  • Coordinating diverse operating systems: The multiple disciplines involved in response to a major public health or medical event do not routinely work together. This complicates interaction when they engage under the stress of incident response.
  • Resolving intergovernmental issues: Major public health or medical incidents often involve initiatives across multiple levels of government. Usually, Federal and State Governments operate in support of the local response, though the reverse may occur. Management activities at each level will vary from incident to incident and must be well coordinated.
  • Medical asset support: For public health and medical response agencies to perform optimally, extensive logistical, financial, and administrative support is necessary. This may include ensuring prompt and reasonable financial compensation for extraordinary medical efforts, and temporarily waiving certain regulatory and compensatory requirements so medical assets may care for increase patient volume.
  • Addressing time constraints: Medical emergencies are time-sensitive and require rapid intervention by clinicians to address the urgent medical and surgical needs of victims. In addition, rapid public health and public safety interventions are necessary to limit the number and/or severity of casualties.
  • Incorporating public health and medical assets into public safety response: In many locales, public health and medicine are not recognized as traditional first responders. As a result, they may not receive equal treatment and prioritization for training and funding compared to public safety and other response assets.

Given the complexity of response to major public health and medical events described here and elsewhere, sustainable solutions to these multifaceted challenges have been elusive. The MSCC Management System proposed in this document outlines and recommends a systems-based approach[7] that focuses on the management solution for these complex tasks. It describes how to manage, within a single system, the diverse public health and medical entities involved in incident response, and it identifies mechanisms to integrate medical and public health assets with traditional response disciplines (e.g., public safety, emergency management).

The basis of the MSCC handbook is the Medical and Health Incident Management (MaHIM) System, the first published U.S. effort to conceptually address the complex health and medical issues that arise during major medical incidents.[8] The MaHIM model provides a comprehensive system description of the functional components critical to effective response for any mass casualty event. It further describes the processes that coordinate these functions to limit morbidity and mortality after exposure to a hazard. The MSCC Management System extracts key concepts from MaHIM to develop practical, operational guidance for medical and health emergency planners.

MSCC Project Goal

The goal of this project is to develop a management system (framework) that promotes public health and medical system resiliency and maximizes the ability to provide adequate public health and medical services during events that exceed the normal medical capacity and capability of an affected community.

MSCC Project Objectives

The primary objectives of this project are to:

  • Assist healthcare organizations, other acute-care medical assets, and local/regional emergency response entities in establishing and integrating effective management systems during emergencies and disasters.
  • Provide concrete operational direction without supplanting State and local authorities' responsibilities and initiatives. This guidance must be flexible and allow the integration of ongoing initiatives and programs, while maintaining consistent management architecture.
  • Integrate the use of established incident command principles.
  • Promote coordination between medical response management and the larger emergency response community.
  • Delineate information management and coordination processes that can be established at the local and regional levels to rapidly enhance surge capacity and capability.
  • Define a management system that is directly applicable to mitigation, preparedness, response, and recovery activities, and on which current and future training efforts may be based.
  • Promote adoption of systems that are consistent with NIMS.
  • Use a working group process to obtain a wide range of expert input through an open, valid peer review of concepts and products.

MSCC Project Scope

As shown below, the MSCC handbook presents a system for management integration that ranges from the individual healthcare organization (HCO) through jurisdictional, State, and Federal Government levels.[9] Because of the local jurisdiction's central role in providing MSCC, the handbook's primary emphasis is on jurisdictional incident management and the coordination and support of HCOs. The handbook also highlights the functions and processes that promote integration of assets into an overall response system and coordination between assets.

Graphic shows the Public health and medical response management across the intergovernmental and public-private divides.  

What the MSCC Management System Is

The MSCC Management System is designed to promote the integration of existing programs for incident management used by hospitals, public health, and traditional response entities into an overarching management system for major public health and medical response. It defines the basic requirements for medical and public health asset participation in the overall response system. Rather than focus on narrow topics (e.g., communications or training), the MSCC Management System examines functional relationships across the range of response needs. In so doing, it provides a systematic approach to organize and coordinate available public health and medical resources so they perform optimally under the stress of an emergency or disaster.

The MSCC Management System seeks to enhance management integration and coordination by:

  • Defining a system that integrates the management of local, State, Tribal, and Federal medical response to provide optimal surge capacity and capability, while protecting healthcare staff, current patients, and healthcare system integrity.
  • Defining the management relationship between HCOs and providers, and the multiple levels of government response.
  • Establishing incident planning processes and information management to promote an integrated medical response that is timely and accurate.
  • Incorporating incident command system principles to facilitate medical system integration with non-medical incident management during response, and to establish acute care medicine as "first responders" in the emergency response community.
  • Providing a platform for effective training of medical incident management and response, from the local to the Federal response levels.

What the MSCC Management System Is Not

This handbook does not focus extensively on the internal management of individual public health and medical assets, nor is it specifically for hospital emergency preparedness. It does not attempt to redefine the operational methods of other entities (e.g., law enforcement, fire service, emergency management) that also have as primary missions the preservation of life and/or critical infrastructure. Though the handbook describes overall management processes and systems, it is not a compre-hensive, standalone description of MSCC. For example, it does not address the specific amounts of materials, personnel, and other resources required for specific numbers of patients. Moreover, it provides only a general description of Federal programs that currently exist, or those in development, to address quantitative adequacy in surge capacity.[10]

The National Response Plan and individual Federal health and medical programs should be accessed for specifics on these Federal capabilities.

How To Use This Document

The MSCC Management System is intended for all professionals in the U.S. who are involved in planning for, responding to, and recovering from domestic public health and medical emergencies or disasters. They include, but are not limited to, public health (State and local) and emergency management personnel, emergency planners, planners at hospitals or other community health and medical organizations, public safety personnel, healthcare executives, public health and medical providers, and political officials responsible for emergency preparedness and response. The handbook is meant to promote collaborative planning and discussion among these professionals.

Readers may apply the management processes detailed in the MSCC handbook to ongoing preparedness planning activities. Whether undergoing initial development or revision of existing plans, readers are encouraged to examine portions of the MSCC applicable to their specific situation. Incorporating the MSCC guidance may enhance their ability to interface with other response entities. Most importantly, the material presented is intended to promote cooperative planning and community integration of public health and medical assets into the overall response. The material is also relevant as an evaluative measure during after-action analyses, and in developing and implementing education, training, drills, and exercises.

The concepts are applicable to response across all hazards, from small incidents to the largest and most intense events. They are presented in a manner that demonstrates their consistency with NIMS, a requirement for Federal funding. In fact, the MSCC Management System was incorporated into the 2006 guidance for the Hospital Preparedness Program (HPP). This represented a major shift in the program's focus towards the development of management systems for emergency public health and medical response. HPP awardees should use the MSCC to promote more consistent terminology, processes, and interfaces between HCOs and the various disciplines and levels of government involved in emergency preparedness and response.

The management processes described in the MSCC may also be leveraged to integrate local capabilities developed through other Federal programs, such as the Metropolitan Medical Response System (MMRS). MMRS program guidance embodies the concepts of the MSCC Tier 3, requiring jurisdictions to develop linkages among first responders, medical treatment resources, public health, emergency management, volunteer organizations, the private sector, and other jurisdictional elements.[11] Finally, readers may apply MSCC management processes during exercises and small or low-intensity events (e.g., managing community healthcare issues in a snow emergency) to prepare for response under more severe incident stress.

5. In complex incidents, the victims have unusual medical needs or require medical care that is not readily available. These medical needs may be difficult to define or address without specialized expertise, even with only a few casualties.
6. Throughout this document, exceptional refers to unusual numbers or types of victims, affected medical care systems, or other adverse conditions.
7. The term system in this project means a clearly described functional structure, including defined processes, that coordinates otherwise diverse parts to achieve a common goal.
8. J. A. Barbera and A. G. Macintyre. Medical and Health Incident Management (MaHIM) System: A Comprehensive Functional System Description for Mass Casualty Medical and Health Incident Management. Institute for Crisis, Disaster, and Risk Management, The George Washington University. Washington, DC, October 2002. 
9. The MSCC handbook acknowledges the sovereignty of Tribal Nations and the responsibility of Tribes for preparedness and response planning in areas governed by Tribal authority. When incident circumstances warrant, management integration may include Tribal authority. In States where Tribal Nations are located, State and local emergency planning should consider Tribal health and medical resources that may be called on to augment State or local response efforts.
10. The National Response Plan and individual Federal health and medical programs should be accessed for specifics on these Federal capabilities.
11. Additional information on the MMRS program is available.

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