In baseball, you'd never even think of leaving the manager on the bench without assistance. But we do that in hospital incident management, expecting our leader to manage the World Series, so to speak, at a moment's notice - with only a few sandlot games and a job action sheet under his or her belt.
Hospitals don't run like fire departments, and hospital leadership doesn't use the Incident Command System (ICS).
Fire departments utilize the ICS on every call; it's their standard operating procedure, just as it is for emergency medical services (EMS). Hospitals, however, only use it during a disaster, which is a federal standard. But using it only during disaster scenarios leads to inconsistent and potentially weak command centers. Those in charge of hospital preparedness agree that an atmosphere of confusion surrounds hospital command centers in terms of job descriptions and position-specific roles of incident command, such as planning section chief and operations section chief.
When a facility looks at its response assets, it usually only looks internally. Being part of an overall health system, however, one facility has access to more assets than just its own inventory - but may not realize it. This leads us to the hospital incident management team concept: What if, like wild land firefighters, we could develop an incident management team that could deploy to an affected facility and assist in command center operations?
At Sanford Health in Sioux Falls, S.D., we've done just that.
Developing the Team
Sanford Health is a large health-care system that covers South Dakota, Minnesota, Iowa and Nebraska, and serves 24 hospitals, and more than 100 clinics and long-term care facilities. Most hospital facilities under our flag are Critical Access Hospitals, which are hospitals certified to receive cost-based reimbursement from Medicare. Most of them would suffer immediate staffing issues during a major incident.
About three years ago, the Center for Prehospital Care and Emergency Preparedness at Sanford Health began rolling out National Incident Management System (NIMS)-compliant incident command training. I traveled to each of the aforementioned Critical Access Hospital facilities to assess their capability to expand during an incident and maintain care over several days. The findings were simple: Although each facility could generate an adequate number of staff members to meet the initial needs of an incident, most couldn't maintain complex operations over numerous operational periods. This becomes even more challenging when you add an incident requiring decontamination, and is still more challenging when you look at incidents requiring a lot of resource management like a pandemic.
Every hospital has a few people who are active in regional committees regarding NIMS compliance issues, infection control, pandemic planning and local exercises. Many of these people have been active in these roles for several years and know the standards and requirements to meet each year's competencies for federal funding. At Sanford Health, it was these people who began the focus and led the hospital incident management team to what it is today. We brought training in for them in higher levels of incident command, hazardous material operations, chemical hazard recognition, etc.
We began developing, almost innocently, what we see today: a deployable team of emergency operations center managers and incident management specialists who can respond to any affected facility in our health system, and assist the incident commander and the incident management team to achieve its objectives. The team has 24 members, and there isn't a second string. Team members are trained to a particular level. We eventually plan to have at least three members at each hospital, which would triple the team number.
The Training Ladder
The team response hierarchy is broken down into four levels. Each level is associated with a team member name or role, has a set of requirements and builds on the previous level's requirements. In addition, as a team member moves up to the next level, he or she becomes a trainer for the previous level.
Using training previously developed and widely accepted by regulatory agencies, such as the Federal Emergency Management Agency (FEMA) and The Joint Commission on the Accreditation of Health Care Organizations, we can build a team using widely accepted concepts. It also ensures almost certain compliance with federal, state and local regulations.
The only acceptable online training is FEMA's Emergency Management Institute's Professional Development Series. All other classes, including ICS 100-200 and IS-700, are required in the classroom to ensure comprehensive understanding of the curricula.
Training is advertised through the team e-mail group and offered every other month - the most recent training opportunity was a Level 4 exercise design class delivered by the South Dakota Office of Emergency Management. The average participant can complete all levels of coursework within one year, though some take longer. Some of the monthly training sessions are three-day classes. Other course subjects include team activation, exercise planning, upcoming federal requirements and cross-state border issues.
Most, if not all, members look forward to the regularly scheduled meetings and training. The development of this team concept is a key element of its success. Members are there because they see the ultimate value of this project. They also know that they are the reason for its success and that their continued participation is what makes it a tangible asset.
When to Activate?
Powering up the system command center won't be necessary for every event across the health system. The assumption was that activation would be automatic for any event requiring decontamination support or that is expected to exceed a single operational period - a specific, predetermined amount of time used to complete objectives.
In a recent event, we ran into an awareness and training problem: Many staff members involved in the hypothetical incident - an ammonia leak at a local business resulting in about two dozen injuries, which involved two of our hospitals - either knew little about the process or thought about it but didn't activate the command center.
The after-action discussion resulted in the development of an activation checklist that's part of the disaster packet distributed to every facility. The checklist asks simple questions with "yes" or "no" answers. The affected hospital command center and call team leader is activated with any "yes" response. This will take the guesswork out of activation on the end-user level.
Activation doesn't call out the entire cavalry immediately; it sets up an instant consultation between the affected facility and one of two on-call, Level 4 team members. The activation algorithm explains the process
Once the decision is made to power up the System Command Center, the on-call team member who provided the initial consultation responds to the System Command Center and becomes the liaison. The second on-call team leader deploys to the affected facility and also notifies team members at the closest unaffected facilities. This begins to power up the "close support" concept. A team member, usually Level 3, is deployed from the closest unaffected facility to the affected facility to meet the team leader.
There are team members at each facility, which quickly puts no less than three incident management team members in the command center at an affected facility. One team member immediately takes the liaison position and ensures hard communication with the system command center. Communication is then extended to the city or county emergency manager to ensure that all resource needs can be met either locally or from a distance.
Having these team members in place at the Hospital Command Center (HCC) provides several major benefits, including:
· hard-wired liaisons for solid communications;
· an ICS coaching staff to assist the HCC in the incident action planning process;
· freedom to release some local facility leadership from the command center to the operational areas; and
· confidence, although this might be an underestimated asset. There is much to be said about a team that plans with confidence versus a team that plans with uncertainty.
The entire team concept is to provide a command center coaching staff. This supports leadership. I regularly use the phrase, "I can run a disaster, but I can't run your hospital." However, together, as a team, we can do anything.
Trial and Error
One of the biggest issues discovered outside the command center is the need for decontamination team support. Many of our communities have large amounts of hazardous materials, like anhydrous ammonia, and organophosphate- or carbamate-based pesticides. This, combined with the staffing available at our small facilities, leads to decontamination teams that can handle an initial surge, but need support to maintain operations. It's surprising how quickly you can run out of decontamination personnel on a hot day.
Today, hospitals are staffed with just enough personnel to handle the average daily patient load. In many cases, even a small-scale mass casualty incident could push a facility to a breaking point. This is even more apparent in Critical Access Hospitals.
It's even more surprising how quickly a health system can develop a large decontamination team if you look beyond the doors of the affected facility. With 24 hospitals in our system, decontamination training is an ongoing and continuous process. At any given time, we have approximately 160 personnel trained to the Occupational Safety and Health Administration (OSHA) 1910.120 (and .134) standards. OSHA 1910.120 is the hazardous waste operations standard for industrial facilities that dictates the standards that must be met by professional decontamination teams. The 134 level is the respiratory protection standard. Having one curriculum for training allows team members to easily integrate with one another, from one facility to another.
In addition, U.S. hospitals are working to achieve NIMS compliance. As the new NIMS five-year plan has been released, it is painfully clear that hospital leadership will have to participate in the higher-level - and drastically longer - incident command classes. Also, they will likely have to participate in the position-specific competencies being developed.
With that said, it's one thing to participate in a course, and another to practically apply - and eventually master - the skill sets delivered in these classes.
Another lesson came from a recent 10-facility ice storm exercise: Our command centers need to be more mobile.
South Dakota saw the value in that process and provided funding for command center technology that includes laptop computers with wireless cards and an electronic incident management tool called E-Sponder Express. The health system is deploying E-Sponder Express software across the intranet, which will be available to all system facilities.
E-Sponder Express contains electronic ICS forms, resource management tools and a powerful communication tool that will automate all call trees. With the addition of this software, team leaders can log into an incident from home over a secure Web connection and monitor an incident anywhere in the system.
Moving Forward
Make no mistake, the development and design of a team like this is no easy feat. It takes the support and backing of many people, including local emergency managers, regional and state health department representatives, and many others. Most importantly, it works only when the team believes in it.
This isn't only a hospital-based process; this same concept can be used by a rural fire service, EMS and emergency management, to name a few. Keep in mind that this concept was developed to manage wildfires with great success. It's not new; it's just underused in other arenas.
The next step is to expand the project outside our health system. There are numerous stand-alone hospitals all over our service areas that would require the same assistance as our affiliated facilities. Expanding this project outside the system and to other systems expands the support structure and opens the door to necessary resources.
Maybe one day there will be an expert response team for hospitals across the nation. Maybe it will have started in South Dakota.
