The jurisdictional (Tier 3) response to a major medical incident is guided by the same general ICS principles as the Tier 1 response (i.e., it is organized by functional areas—Command, Operations, Logistics, etc.). However, responsibility for the five primary functions may be distributed among multiple agencies at the Tier 3 level. In many cases, collaborative efforts between disciplines are necessary to ensure that these functions are adequately addressed (see example below). This is particularly true for the Command function. Distinguishing features of the jurisdictional (Tier 3) response, are unified command and Multiagency Coordination Systems (MACS). These form the basis for the remainder of the chapter.
Example of Multiagency Unified Command During Incident Operations:
After recognition that a biological agent has been intentionally released into the community, public health may be designated as the lead agency in incident management, with primary responsibility for protecting the health and safety of the community. Public safety agencies also play a critical role by providing assistance to public health through their familiarity and expertise in ICS. They also support public health and medical operations. For example, the Logistics Section may consist primarily of fire service and public works resources providing support to public health by assisting epidemiological investigations or delivering prophylaxis medications to distribution centers.
4.4.1 Unified Command
Because multiple disciplines may have significant management roles in incident response, implementing a unified command (UC) is an effective way to promote cohesion within the response system. The UC facilitates information sharing and allows each involved discipline to provide input directly into the development of incident objectives and priorities. Although each agency's resources are integrated into the jurisdictional (Tier 3) operation, each agency retains individual authority over its assets and responsibilities. The disciplines most important to incorporate into the UC are those that primarily manage response in the jurisdictional EOP, including fire/EMS, law enforcement, public health, public works, and human services.
4.4.1.1 How Unified Command Works
Although the UC approach provides a certain level of equality among participants, a lead agency must be designated as the final arbiter in decision-making. This lead agency authority (a "first among equals") is determined by the type of incident according to guidelines established during preparedness planning (see example below). The lead agency should be clearly established at the outset of the incident response and publicized throughout the system so there is no doubt where the final decision authority rests.
Example of Lead Agency Designation Guidelines:
- Crisis/pre-hazard impact = Police department
- Hostage/standoffs = Police department
- Fires/explosions = Fire service
- Flash floods = Fire service
- HAZMAT release = Fire service
- Infectious disease = Public health
- Food contamination with illness = Public health
- Water contamination, utility disruption = Public works
Because strategic concerns may change as an incident evolves, the lead authority may be temporarily deferred, via open dialogue between UC participants, to another agency. In some cases, incident parameters may change enough to require a transfer of lead authority to another discipline. In a well-run UC, the decision to transfer lead authority is made during a management meeting using processes established for incident planning; it is documented and disseminated to all responders. Processes for deferring or transferring lead authority should be outlined during preparedness planning.
The site where the UC operates, the Incident Command Post (ICP), must be rapidly established and communicated to all agencies at the outset of a response. In any large-scale or multi-scene event, several ICPs may be estab-lished during the early reactive phase of response, with multiple disciplines involved. Identifying where the primary incident command is occurring—and how it integrates with the other command, operations, support, and information centers—should be prioritized as a critical incident-planning task.
Responsibility for specific functions under UC should also be defined using guidelines established during preparedness planning. The conduct of Safety, Liaison, and Public Information functions may be considered as follows:
- Safety Officer oversees all actions taken to protect responders, including issues related to the health (e.g., vaccination/prophylaxis) and security safety of responders. It may be best managed with input from a multidisciplinary group (i.e., Safety team) composed of the jurisdiction's (Tier 3) public health, EMS, law enforcement, and/or medical assets. The Safety team provides high-level input directly to incident management and has the authority to interrupt activities that appear unduly hazardous to responders.
- Senior Liaisons are assigned to agencies outside the jurisdictional ICS, such as jurisdictions adjacent to an affected community, or Federal agencies operating independently in an area. UC designates liaisons based on the type of incident and the agencies involved. For example, during response to a terrorist act involving an infectious disease outbreak, a senior public health official might be assigned as a liaison to the Joint Field Office (JFO). Assignments may vary from one incident to the next, and as incident parameters change, but liaison staff should remain consistent during an incident to promote continuity of interactions.
- Public Information Officer (PIO) serves as the official spokesperson for the jurisdiction (Tier 3) response, talking specifically about the incident and providing official incident-related data. Moreover, the PIO monitors the media message and the public's reaction in an effort to detect rumors and correct misinformation. The PIO should not usurp the responsibility of the PIO from the jurisdiction's political authority or from the Emergency Operations Center (EOC). Thus, processes should be established during preparedness planning to ensure coordination among these entities in developing the media message. As with safety, multidisciplinary input to this task is generally preferred, with the lead PIO assigned according to the lead authority in the UC.
4.4.1.2 Medical Participation in Unified Command
During a large-scale event, especially one with a primarily medical focus, acute-care medicine should be involved in incident command decisions and defining the response objectives. UC, therefore, must allow for direct input from a jurisdiction's medical community.[1] This can be accomplished either by including medicine as a formal participant in the UC (with fire/EMS, human services, law enforcement, etc.), or by establishing a senior advisory role for medicine to the UC. Because most medical assets are privately owned (and therefore lack legal protection for public action during incident response), the senior advisory approach may be preferred.
Figure 4-1 (presented in section 4.3) illustrates the senior advisory concept and how it fits into the UC. The medical representatives who serve as advisors may come from the healthcare coalition (Tier 2) or be jointly selected by the jurisdiction's medical community. The role of these "trusted agents" must be clearly defined during preparedness planning. They should be chosen based, in part, on their ability to represent the collective interests and concerns of all health and medical organizations in the jurisdiction when presenting recommendations to incident command. In addition, the medical advisors should have operational medicine experience and be well versed in the principles of ICS.
The advisory group should be notified and available on request to provide advice throughout an incident; however, its input is most critical when incident circumstances require the medical community to significantly alter its normal operations (e.g., asking HCOs to adhere to unusual isolation procedures in a prolonged disease outbreak). Although medical advisors report incident information back to their constituents, they are not responsible for providing jurisdictional (Tier 3) management with updates on the status of HCOs. This should occur through a defined process within the Planning Section of the jurisdictional ICS.
4.4.2 ICS Functional Area Activities in a Tier 3 Response
Operations, Logistics, Planning, and Administration/Finance Sections will likely also require multiple disciplines to collaborate using a unified methodology. The managers of these sections, typically known as "Chiefs," make up the "general staff" of the jurisdictional (Tier 3) response. The Incident Commander (or lead authority in the UC team) appoints Section Chiefs at the outset of response from a pool of candidates identified and trained during preparedness planning. The Chiefs are usually senior members of the lead authority agency/organization who have significant experience in emergency or disaster response and demonstrated management expertise in ICS.
Specific activities of the four sections are as follows:
- Operations Section develops the tactics and assignments to accomplish operational period objectives set by the incident commander. In a jurisdictional (Tier 3) response, several "branches" within Operations may be necessary to organize assets responsible for public health and medical issues. For example, Operations branches that may be indicated during a major medical incident, are highlighted in Figure 4-2 below along with brief descriptions of the activities for which each branch is responsible.[2] The activation of Operations branches will depend on incident circumstances and, in fact, most incidents will not require all branches.
- Logistics Section manages activities that provide support through equipment and supplies, transportation, personnel, processing of volunteers, and technical activities to maintain the function of operational facilities. For example, Logistics would help in receiving, transporting, and protecting a cache from the Strategic National Stockpile (whereas Operations focuses on providing prophylactic medications to the at-risk population).
- Planning Section supports Command and Operations in processing incident information and developing incident action plans (IAPs) for the response. It is responsible for collecting, analyzing, and disseminating aggregate data, and maintaining up-to-date documentation of resource status. The Planning Section must specifically address:
- Support for incident command in carrying out planning meetings (e.g., set meeting schedule, develop an agenda, ensure that objectives are established, incorporate decisions into the IAP)
- Event projections (based on the known characteristics of the hazard and its historical impact, if there is one)
- Evaluation of response progress by monitoring valid measures of effectiveness.[3]
- Contingency and long-range planning
- Demobilization planning
- Support to complete each IAP (e.g., writing, printing).
- In addition, the Planning Section manages multiple types of information in a major health or medical response including:
- Situation status: Incident parameters (e.g., numbers of victims, locations, types of injury or illness)
- Resource status: Response asset parameters (e.g., tracking such resources as staffed beds available at local hospitals, quantities of a particular prophylaxis for distribution)
- Recommendations and directives (e.g., informing responders and the general public about evaluation and treatment protocols).
- Administration/Finance Section supports Command and Operations in administrative issues and in tracking and processing incident-related expenses. Examples of the issues that might be of concern for the public health and medical disciplines include:
- Practitioner licensure requirements
- Regulatory compliance issues, including the possible temporary suspension of certain regulations during the period of emergency (as indicated)
- Financial accounting during an incident
- Contracting for services and supplies directly available to incident managers.
Figure 4-2. Operations Branches for Medical and Public Health Assets
More information on individual Operations branches.
Adapted from 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. More information on individual Operations branches.
- Hospitals, integrated healthcare systems, clinics, alternative care facilities, nursing homes and other skilled nursing facilities, private practitioners' offices, and other assets constituting Tier 1 in the MSCC Management System represent the medical community.
- This example is adapted from the Medical and Health incident Management (MaHIM) System.
- Measures of effectiveness are observable criteria that management accepts as accurate and valid reflections that incident response is accomplishing its objectives. They should be defined in the planning process and used in the situation status reports.
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