How hospital could use ICS for pandemic flu incident

A pandemic incident brings number of unique challenges to standard ICS structure. Most obvious is that the day–to–day use of ICS is to handle incidents with specific geographical and chronological boundaries. Events occur in specific place at specific time where first responders converge on, contain and resolve the event. This author believes that there is even certain security for the first–responders and hospital staff in knowing that outside those boundaries, normal routines exist and are not impacted by the event pandemic – as with any serious public health emergency – does not occur in specific place or time. For most any community around the country, the pandemic will not be immediately identifiable, and then appear to be everywhere at once and recur in waves. The first responders and hospital staff will suddenly be in the pandemic with everyone else, and their security of being able to step out of the event is gone. \\\\nAs with all other businesses, absentee rates will be high and some predictions reach as high as 40%.< href=”http://robertory.com/wordpress/wp-admin/#_edn11″>[11] People may not show up to work because they fear the unknown, they are caring for family member or loved one, or have become incapacitated by the virus. Such high absentee rates mean that all critical functions and essential workers must have deep reserves to ensure that these functions continue.< href=”http://robertory.com/wordpress/wp-admin/#_edn12″>[12] There is good chance that the experienced leadership or even just sufficient numbers of workers will not be there. By the very nature of their work, healthcare providers will know that they will have higher and more sustained exposure rate then the general public putting them at higher risk The hospital may not be able to acquire necessary supplies due to production and transportation issues as the Federal government may be blocking what they decide are “non–essential movement of people, goods and services into and out of areas where an outbreak occurs.”< href=”http://robertory.com/wordpress/wp-admin/#_edn13″>[13] The Federal government will be “ensuring that all reasonable measures are taken to limit the spread of an outbreak within and beyond the community’s borders.” This may leave the hospital in the impacted community to its own on–hand resources.< href=”http://robertory.com/wordpress/wp-admin/#_edn14″>[14]\\

Understanding Pandemic Flu incident

\\nA pandemic flu is an event that is global by definition and can infect large percentages of the human population because it is novel virus that humans have little or no immunity to. It has the potential to kill more people in shorter time then any other public health threat if it has similar virulence to the flu virus of 1918.< href=”http://robertory.com/wordpress/wp-admin/#_edn1″>[] As with the seasonal flu, pandemic flu may have the greatest mortality rates on the very young, old, and immunocompromised. However there is also an immune system event that causes increased mortality rates in middle age people too called cytokine storm in which normally healthy bodies have an uncontrolled immune response where the body starts to attack itself.< href=”http://robertory.com/wordpress/wp-admin/#_edn2″>[] The end results is that this virus will have an impact on every demographic Unlike other types of major incidents, the start of the pandemic flu will not be know to many as it will start with simple sneeze or cough. It may actually take weeks to identify and confirm the start of pandemic The virus will spread rapidly throughout the world, attacking many areas of the United Stated near simultaneously. Additional resources and people will be scarce as the incident dramatically reduces the flow of goods from supplies to consumers due to transportation restrictions and worker shortages.< href=”http://robertory.com/wordpress/wp-admin/#_edn3″>[] This will cause large numbers of people to seek medical attention, which will overburden the healthcare system from the EMS first–responders to the hospitals and funeral homes. During this time, the healthcare system will experience shortages in supplies and people to meet the demand, fracturing an already stressed system During pandemic event, hospital will need to focus significant resources to meet the increased demand on its doorstep; even if it has nothing else to offer. This will force the hospital to adjust the daily working structure and reallocate resources into new duties. The Incident Command System (ICS) used by first–responders does offer basis where hospital’s management can start planning how they will operate. single organizational structure in hospital that identifies hierarchical lines of responsibility, authority, and information flow are traditional challenges to overcome.< href=”http://robertory.com/wordpress/wp-admin/#_edn4″>[]\\\\ \\

Incident Command System

\\nThe Incident Command System (ICS) has been long used by first–responders to handle major incidents. It is widely accepted that ICS was first developed and used by responders to wildland fires in the Western United States. The .. Department of Homeland Security picked up on ICS and integrated it into most recently the National Response Framework (NRF).< href=”http://robertory.com/wordpress/wp-admin/#_edn5″>[]\\\\nICS is based on specific principles to enable it to function supporting variety of different types of responses. The overarching principle is to manage by clearly stated and known objectives using the most experienced leadership in modular chain–of–command structure that can adapt as objective change.< href=”http://robertory.com/wordpress/wp-admin/#_edn6″>[] Under the incident commander, ICS divides into major functional areas or sections: Command, Operations, Planning, Logistics, and Finance/Administration.< href=”http://robertory.com/wordpress/wp-admin/#_edn7″>[] There may be an Intelligence section on some incidents but this concept is set aside for this review Command is responsible for developing the goals and objectives by which the incident will be resolved and is at the top of the organization structure. In smaller incidents, this can all be done by the incident commander. In larger incidents, this may be broken out into different command staff officers such as the public information officer, the liaison officer and the safety officer. The incident commander may receive authority from an agency executive; however, the agency executive is not directly involved in the incident.< href=”http://robertory.com/wordpress/wp-admin/#_edn8″>[]\\\\nOperations is responsible for accomplishing the goals and objectives set forth by Command. Operations will divide into smaller parts through divisions (by geography), groups (by function), and branches (for span of control).< href=”http://robertory.com/wordpress/wp-admin/#_edn9″>[] All direct and tactical commands originate from the Operations Section The next three sections – Planning, Logistics, and Finance/Administration – all support the Operation section. Planning will collect, consolidate and share information regarding the incident in the Incident Action Plan. Logistics will obtain all the “stuff” needed to supply and maintain operations, including people, equipment, food services and facilities. Finance/Administration handles all the behind–the–scenes paperwork such as contracts, accounting, compensation and claims.< href=”http://robertory.com/wordpress/wp-admin/#_edn10″>[10]\\
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Using ICS in Hospital

\\nAutomatically adding ICS in hospital is not guarantee that things will go smoothly. However, it can formalize the organizational structure of the hospital into focused effort to achieve the goals that are in the best interest of the hospital and not any particular department. Defining single goal as over–arching all other goals and objectives will establish context and boundaries for any tasks that need to be done during an emergency. In Emergency Management Principles and Practices for Healthcare Systems, the authors recommend goal such as:\\\\“Providing the best possible care to victims of the incident while maintaining safety for healthcare system personnel, integrity of the healthcare facility, and the ability to perform the regular medical mission in the community.”< href=”http://robertory.com/wordpress/wp-admin/#_edn15″>[15]\\\\nThis goal covers the need to tend to the victims, balanced with the safety of the staff and facility, and then it goes one step beyond that to recognize that the everyday medical emergencies will still occur that need attention. In pandemic situation, people will still break bones, get in vehicle accidents and have heart attacks; all requiring the specialized medical procedures expected at any hospital. When the hospital administration (or designee) activates the hospital’s emergency operations procedures, these goals and plans already need to be known by the staff. Starting an emergency in one structure only to find that it does not work well and needs to be changed will waste scarce resources and time. It is this author’s experience that good start can make the difference between being in front of the demand or always chasing to catch up — and this rings true for any emergency situation key to success is the ability of the hospital to design structure in cooperation with other hospitals, and local and state emergency operations centers (EOCs). Working together, the hospital should be able to more quickly identify best practices and learn from each other. This structure needs to be tested regularly and the lessons learned of each test rolled back into the plan to improve it.< href=”http://robertory.com/wordpress/wp-admin/#_edn16″>[16] While each hospital doesn’t need to have the exact same structure to function well together, being similar helps in the event that staff is shared between the hospitals Certain top positions in ICS will remain the same. The Incident Commander (IC) would still be the top position of ICS. In hospital setting, the IC would be given authority by the executive in charge of the hospital as the IC is usually not the top most executive in the organization but instead someone with the knowledge and experience to run this type of event The IC would have command staff of officers for Public Information, Safety and Liaison. These three positions would function very similar to the current position in traditional ICS. Public information would share information and try to correct rumors. Safety would ensure that tasks being performed are following safety standards, and make recommendations to prevent injuries and illnesses. Liaison will be the connection from the hospital to outside agencies including the EOCs and other hospitals The Hospital Incident Command System also recommends command staff position for Medical/Technical Specialist officer who can provide the IC advice based on their specialized experience in medicine related to the event.< href=”http://robertory.com/wordpress/wp-admin/#_edn17″>[17] For pandemic flu event, this might be an expert in infectious respiratory diseases. This person could serve as the incident’s expert when guidance is needed to understand, communicate and educate about the pandemic flu. single point to verify information for consistency. Without this position, there would be gap in ICS because of the assumption that the IC has the knowledge and experience to effectively manage the event is also an expert in the specifics of the pandemic flu. The Emergency Management Principles and Practices for Healthcare Systems recommends another command staff position for Legal Counsel given the nature of the event and the importance of protecting the hospital.< href=”http://robertory.com/wordpress/wp-admin/#_edn18″>[18]\\\\nThe general staff that reports to the IC would also look familiar to traditional ICS broken out as the four sections Operations, Planning, Logistics, and Finance/Administration. Although, inside the Operations section of hospital ICS, the structure will take dramatically different look. The other three sections will look very similar to traditional ICS. \\\\nThe Operation section needs to reflect the tactical stance of the hospital to react to the expected surge of people requesting medical services. The branches can be reflective of the overall goal of the organization as mentioned earlier, giving one branch to handle all the medical care, one branch to keep the facility functional, one branch to provide security, and another to ensure business continuity.< href=”http://robertory.com/wordpress/wp-admin/#_edn19″>[19] Traditional ICS instruction does not include how to setup for hospital event, therefore this gap is covered by specialized ICS training. There are few open access (unrestricted) documents and template available to help hospital make the leap from ICS to their specific situation relative to the availability of ICS materials for first–responders. FEMA’s independent study course IS-100.HC is common starting point for healthcare facilities The medical care branch would be the most visible and interactive to patients as this branch would handle all care. The branch could be organized in variety of ways. Based on the research, one common way is to have unit triage and register all incoming patients. They would sort the patients into the other units as appropriate. Outpatient treatment could be handled by unit, inpatient by another unit, and fatalities by third. There would be another unit for people who are there fore non–pandemic related reasons. Each of these units could be broken down even more granular by having strike teams and task forces targeting specific tasks. \\\\nThe facility care branch would be responsible for keeping the facility and environment operating, and would probably exist of the everyday facilities management and staff. This branch can be broken down into the technical skills necessary to maintain the electrical systems, heating/ventilation/air conditioning (HVAC) systems, medical gases, and so on The security branch could be run by the everyday hospital security staff. Their duties would expand to prepare for large numbers of people who are worried, scared and otherwise emotional which may cause people to react in unusual ways.< href=”http://robertory.com/wordpress/wp-admin/#_edn20″>[20] If additional security resources are brought into provide additional coverage, the current security staff may take team leader position since they have knowledge of the facility and how to get around in it The business continuity branch would use the EOP to ensure that regular operations transition smoothly to the ICS structure. As the situation evolves, they would evaluate the operations to determine any places in the process flow that can be improved or made more accessible to the patients in order to enhance operation. Conversely, as the system becomes overloaded, they would be responsible for using the EOP to determine what non–essential services could be reduced or cut off to enable essential services to continue.< href=”http://robertory.com/wordpress/wp-admin/#_edn21″>[21]\\\\nThe Planning section will exist the same in hospital environment as it would in more traditional ICS environment. However, in hospital environment, the documentation unit will become critical component to having the supporting logs to justify the numbers of people assisted for insurance claims while still meeting Health Insurance Portability and Accountability Act (HIPAA) standards. \\\\nThe situation unit will keep handle all the patient tracking and maintaining current list of resources, such as available beds. This information will be important to the Liaison officer to communicate resource shortages or availability when working with other hospitals and EOCs in planning where to direct people who need certain type of medical assistance.< href=”http://robertory.com/wordpress/wp-admin/#_edn22″>[22]\\\\nThe Logistics section will function in the same way as it does in traditional ICS. The supply unit will need to be more resourceful in acquiring additional supplies as nearly all hospitals in the country will be making the same demands on the same suppliers.< href=”http://robertory.com/wordpress/wp-admin/#_edn23″>[23] The staff health and wellbeing unit and family care unit may need to be bolstered during this event as workers may bring their family members to the hospital to either attempt to get them faster access to medical care, or to place them in “protected” part of the hospital away from where they may get infected The Finance and Administrative section will need to work closely with the other sections to ensure that all costs are accounted for and documented correctly. This will be critical to being able to get reimbursed by insurance companies, and possibly local, state and Federal governments depending on what assistance becomes available. Where on traditional ICS operations, this section may be staffed with small number of people; the administrative burden of the health care system, federal regulations and insurance companies will necessitate the increase in staff for this section.\\

Conclusion

\\nThe Incident Command System (ICS) by nature is very flexible way of operating that can expand and shrink as needed to meet operational needs. This review of ICS as it would apply in hospital setting has identified few gaps in the traditional ICS structure that may cause problems. None of these problems were insurmountable nor would prevent ICS from working in hospital setting given the right leadership and planning for pandemic flu event. \\\\nThe optimal leader in this situation would be someone who has hospital administration background that participates as first–responder to gain experience in how ICS looks and feels in real–world situations. Taking an experienced first–responder leader who understands ICS but lacks knowledge of hospital administration, and having them run an incident at hospital could cause issues because of the assumptions that first–responders make in how ICS sections should be setup because “that’s the way it’s always been done.” It is more likely to get hospital person trained in ICS given the number of first–responder incidents that occur daily, then get first–responder trained in hospital culture, process and procedures \\\\

Bibliography

\\nAgency for Healthcare Research and Quality. (February 2007). Mass Medical Care with Scarce Resources: Community Planning Guide. (AHRQ Publication No. 07-0001.) Rockville, MD: Agency for Healthcare Research and Quality 2007 California Emergency Medical Services Authority. (August 2006). Hospital Incident Command System Guidebook. Available at < href=”http://www.emsa.ca.gov/hics/hics.asp”>http://www.emsa.ca.gov/hics/hics.asp, accessed February 15, 2008 Centers for Disease Control and Prevention. (June 2007). Hospital Pandemic Influenza Planning Checklist. Available at < href=”http://www.pandemicflu.gov/plan/healthcare/hospitalchecklist.pdf”>http://www.pandemicflu.gov/plan/healthcare/hospitalchecklist.pdf, accessed February 20, 2008 CNA Corporation. (August 2004). Medical Surge Capacity and Capability: Management System for Integrating Medical and Health Resources During Large-Scale Emergencies. Alexandria, VA: The CNA Corporation Cytokine Storm. (May 2007). Retrieved from Flu Wiki at http://www.fluwikie.com/pmwiki.php?=Science.PrimerCytokineStorm Emergency Management Principles and Practices for Healthcare Systems. The Institute for Crisis, Disaster, and Risk Management (ICDRM) at the George Washington University (GWU); for the Veterans Health Administration (VHA)/US Department of Veterans Affairs (VA). Washington, .., June 2006. Available at http://www1.va.gov/emshg/ .. Department of Health and Human Services. (November 2005). HHS Pandemic Influenza Plan. Washington, ..: US DHHS .. Department of Homeland Security. (September 2005). ICS–100: Introduction to ICS – Student Manual. (FEMA Independent Study ICS–100) Washington, ..: FEMA .. Department of Homeland Security. (February 2007). ICS–100: Introduction to ICS – Student Manual. (FEMA Independent Study ICS–100.HC). Washington, ..: FEMA .. Department of Homeland Security. (January 2008). National Response Framework. (FEMA Publication 08011-). Washington, ..: FEMA .. Department of Homeland Security. (March, 2008). NIMS Basic: The Incident Command System. (FEMA Publication 501–). Washington, ..: FEMA .. Department of Homeland Security. (September 2006). Pandemic Influenza; Preparedness, Response and Recovery Guide for Critical Infrastructure and Key Resources. Washington, ..: US DHS .. Department of Transportation. (May 2007). EMS Pandemic Influenza Guidelines for Statewide Adoption; Task ..13.. (DOT HS 810 776). Washington, ..: DOT .. White House, Homeland Security Council. (November 2005). National Strategy for Pandemic Influenza. Washington, ..: White House \\\\\\\\

List of Citations

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