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U.S. Department of Health and Human Services

Integration With Other Tiers

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

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

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

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

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

2.4.1 Incident Command

There must be a clearly defined and tested command structure in place within an HCO in order for the facility to coordinate externally with other response entities. As an incident unfolds and details begin to emerge, the HCO incident management team should quickly transition from reactive to proactive management; this is best accomplished by establishing HCO control and operational period objectives for the response. These objectives should be defined and documented through incident planning—a process in which the incident management team outlines a response strategy and specific actions for the HCO. The result is often a formal IAP for the facility.[10]

The IAP should be shared with HCO staff so that they understand the "larger picture" of what is happening and how their facility is responding. The IAP should also be shared externally with other local HCOs and with jurisdictional authorities (Tier 3) to enhance their understanding of the event, the response parameters, and the status of the HCO. Because some facilities may be reluctant to share their IAPs due to concerns about proprietary information, critical components (e.g., updated situation reports, resource status reports, safety and communication plans) can be isolated from internal, more sensitive material. The latter may be designated as an internal support plan and not distributed externally.

Within the Command element of ICS are multiple subfunctions that help integrate individual HCOs with other responders:

  • Safety Officer: Recommendations for staff safety during emergency response should be standardized, if possible, across the healthcare coalition (Tier 2) and the jurisdiction (Tier 3). They should also carry the affirmation of the jurisdiction's public health authority. This includes traditional workplace safety (e.g., everyday precautions), preventive medical/health safety (e.g., vaccination prophylaxis), and security safety. Guidance should allow for variations among HCOs based on incident circumstances; however, any differences among HCOs should be identified and explained to patients and staff.
  • Senior Liaison Officer: The senior liaison officer shares information and knowledge with other response leaders outside the HCO to determine the best available strategy, set priorities, and identify major actions for the HCO incident management team. Ideally, this is accomplished through Tier 2 activities (e.g., conference calls or disseminated written materials) where information is shared among all HCOs. The liaison officer should participate in HCO management decisions to ensure that objectives from outside the HCO are considered. This position should be distinguished from operational-level liaisons that focus on tactical issues (e.g., the liaison between the emergency department and EMS units).
  • Senior Advisor: The senior advisor provides expert input to the HCO incident management team on medical issues that are directly relevant to strategic decision-making (e.g., provides knowledge about the stages of treatment for burn casualties so management staff may anticipate what resources will be needed at each stage). This helps the incident management team determine support needs that might have to be requested through mutual aid. The role of the senior advisor differs from that of the technical specialist, who advises the general staff on tactical issues related to patient care (e.g., specific medical and nursing procedures, medications, and other interventions).
  • Public Information Officer: This position promotes an accurate and consistent message across tiers by coordinating any information transmitted to the public and the media with the message developed at the jurisdiction level (Tier 3). Information released by the HCO should focus specifically on the situation at the HCO and its operations, training, and preparedness. It should not conflict with Tier 3 public messages, nor should it speculate on strategy beyond the HCO.

2.4.2 Planning Section

The Planning Section plays a critical role because of its involvement in processing information and developing IAPs for the HCO. When shared with other local HCOs (through Tier 2) and jurisdictional (Tier 3) authorities, the HCO IAP provides strategic information to help coordinate response efforts, and may give advance warning if mutual aid support will be necessary. For example, a strategy outlined in an HCO IAP to vaccinate staff enables other organizations to decide whether they want to proceed similarly. Even if uniform measures are not adopted across a jurisdiction, this knowledge allows HCOs to reassure their staff and the public as to why they elected a particular course of action. In addition, HCOs use long-range planning to predict extended resource needs (e.g., supplies, personnel), and contingency planning to identify alternative response actions should incident parameters change. Both long-range and contingency planning will necessarily involve close integration with organizations external to the HCO.

Information from other local health and medical assets will be critical to allow optimal coordination and operation of internal HCO divisions. By operating a well-established information management function at baseline, HCOs can receive the earliest reports of an event and immediately begin processing and distributing information within the facility and externally. Similarly, data generated by an HCO (e.g., number of emergency department visits) may provide first warning of an impending crisis and can be quickly sent to other HCOs, jurisdictional emergency managers, and public health officials to establish incident parameters.

Information on the numbers of patients seeking care in the emergency department for potential exposure to anthrax can be important to the HCO for both internal and external reasons. HCO managers could use this information to determine if objectives are being accomplished, to anticipate staffing needs for the next operational period, and to determine the need for external assistance. The data might also be analyzed for operational relevance (e.g., did patient concerns about potential exposure arise from a lack of information from jurisdictional incident management?). Similarly, it is important to transmit this information (through the HCO's senior liaison) to jurisdictional (Tier 3) incident management. Both the absolute numbers and the analysis that patients presented because of a lack of jurisdiction information would be important for Tier 3 in analyzing the effectiveness of their strategy and tactics.

An important part of information management is deciding who does not need specific information. In this example, regular inpatient units may not require detailed information about emergency department operations (though this information would be available to them, as requested, through an adequately disseminated HCO IAP). Instead, a brief status report indicating the number of patients evaluated and discharged in the emergency department may give inpatient staff an adequate sense of what is occurring without providing overly detailed information.

Provided below are several mechanisms to promote HCO integration with other tiers through an adequate information management function:

  • Establish regular reporting intervals that synchronize with the operational periods of Tier 2 (preferable) or Tier 3.
  • Determine early in response where, how, and in what format to transmit situation reports, resource status updates, IAPs, and other information for further aggregation and analysis.
  • Regularly provide situation reports and resource status updates for the HCO to appropriate external response entities. This can be easily accomplished by sharing the HCO IAP along with a list of incident- generated patients.
  • Obtain from public health authorities recommendations on prophylaxis or evaluation of potentially exposed individuals, or other pertinent information (e.g., global situation status reports from Tier 3).
  • Ensure that reliable and redundant systems are in place to accurately track, account for, and report on incident victims. Beyond just tracking patients in the HCO, the system must also reliably determine that a missing person is definitely not under the HCO's care.
  • Maintain an information function that is always operational, even at a minimum baseline during periods of non-response. This allows for a rapid, smoother ramp-up in operations during the initial phases of an event. It also enables information that is important for EMP activities to be relayed during times of non-response (e.g., jurisdictional exercise information, upcoming event announcements).


  1. A more detailed description of incident action plans, including an example of a hospital IAP, is provided in Appendix C.

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  • This page last reviewed: February 14, 2012