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.
3.3.1 Incident Management Organization
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.
3.3.2 Proactive Incident Planning
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).
3.3.3 Information Sharing
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.
3.3.4 Medical Mutual Aid
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.
- Additional information on the key components of an incident action plan is provided in Appendix C.
- 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.
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