4: Toolkit Part 2: Emergency Management

INTRODUCTION

This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide emergency management decision making during a disaster. This tool focuses specifically on the role of emergency management in supporting the public health and medical sectors during an incident that impacts conventional levels of care (although a similar discussion process could be used to develop indicators and triggers to guide decision making for a broader range of emergency management responsibilities). Because integrated planning across the emergency response system is critical for a coordinated response, it is important to first read the introduction to the toolkit and materials relevant to the entire emergency response system in Chapter 3. Reviewing the toolkit chapters focused on other stakeholders also would be helpful.

Roles and Responsibilities

Emergency management serves as the lead incident coordinating entity and thus supports the public health and medical (Emergency Support Function-8, or ESF-8) sector during a major disaster or incident via

• Facilitation of incident management process (including planning and operational cycles) and development of jurisdictional incident action plans;

• Public information and risk communication coordination (Joint Information System)

• Situational awareness and maintenance of the Common Operating Picture (COP);

• Resource request, management, and delivery logistics;

• Transportation coordination or support;

• Communications support;

• Mass care and sheltering;

• Public works, including road access and utilities support, and incident-specific safety;

• Legal and regulatory mechanisms, including the ability to co-opt resources and space when required; and



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4: Toolkit Part 2: Emergency Management INTRODUCTION This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide emergency management decision making during a disaster. This tool focuses spe- cifically on the role of emergency management in supporting the public health and medical sectors during an incident that impacts conventional levels of care (although a similar discussion process could be used to develop indicators and triggers to guide decision making for a broader range of emergency management responsibilities). Because integrated planning across the emergency response system is critical for a coordi- nated response, it is important to first read the introduction to the toolkit and materials relevant to the entire emergency response system in Chapter 3. Reviewing the toolkit chapters focused on other stakeholders also would be helpful. Roles and Responsibilities Emergency management serves as the lead incident coordinating entity and thus supports the public health and medical (Emergency Support Function-8, or ESF-8) sector during a major disaster or incident via • Facilitation of incident management process (including planning and operational cycles) and devel- opment of jurisdictional incident action plans; • Public information and risk communication coordination ( Joint Information System) • Situational awareness and maintenance of the Common Operating Picture (COP); • Resource request, management, and delivery logistics; • Transportation coordination or support; • Communications support; • Mass care and sheltering; • Public works, including road access and utilities support, and incident-specific safety; • Legal and regulatory mechanisms, including the ability to co-opt resources and space when required; and 93

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• State emergency management working with state health (or public health, as applicable) for requests for federal public health and medical resources such as the Strategic National Stockpile, National Disaster Medical System, or declarations related to health emergencies. Key Issues for Emergency Management Emergency management provides a critical nexus on which a major public health and medical response depends for success. The specific relationship between the other ESFs and ESF-8 are described in the introductory text (Chapter 1) along with an expanded overview of emergency management’s importance to public health and medical incident response. A brief summary is included here to facilitate discussion and consideration during stakeholder meetings. Emergency management should play an active role in facilitating and maintaining multiagency coordi- nation with local public health, hospitals, emergency medical services (EMS), and other health care orga- nizations; otherwise, it is extremely likely that the response will be negatively impacted. Pre-event planning specific to the role emergency management will play and the responsibilities of public health, hospitals, health care coalitions, and EMS agencies in various scenarios is critical to successful response. Lead agency designation and who represents the interests of the key ESF-8 stakeholders at the jurisdictional emergency operations center (EOC) is also a key issue to address prior to an incident as well as to confirm during an incident, so that roles and responsibilities are clear. Emergency management will likely play a lead role in community infrastructure protection, logistical support, situational awareness and information gathering, and facilitation of public information and risk communication dissemination. Public health will have the lead role in community-based health interventions (with logistic support from emergency management), policy development, containment measures, health surety (food and water safety, etc.), and public message development. Ensuring that the emergency management/public health relationship is synergistic prior to an incident will enable each discipline to concentrate on their responsibilities, maximize their respective resources and talents, and avoid duplication. This should also avoid confusion and unrealistic assumptions about the powers and abilities of each agency. This can only occur through joint planning, exercising, and response, which can begin with the structured discussions outlined in this project. For the purpose of this toolkit, local and state public health will take the lead with their health care orga- nizations and health care coalitions on the implementation of crisis standards of care (CSC) when conditions require. In some states, the state EMS office may reside within the department of health and be included in the leadership role. Emergency management will have a critical supporting role. Additional discussion about roles and responsibilities in planning for and implementing CSC is available in the Institute of Medicine’s (IOM’s) 2012 report Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. This report also includes planning and implementation templates that outline core functions and tasks. DISCUSSION AND DECISION-SUPPORT TOOL Building on the scenarios and overarching key questions presented in Chapter 3, this tool contains addi- tional questions to help participants drill down on the key issues and details for emergency management. It also contains a chart that provides example emergency management indicators, triggers, and tactics, and 94 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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a blank chart for participants to complete. The scenarios, questions, and example chart are intended to provoke discussion that will help participants fill in the blank chart for their own agency.1 Participants may choose to complete a single, general blank chart, or one each for various scenarios from their jurisdictional Hazard Vulnerability Analysis. Discussion Participants Suggested participants and key stakeholders for a discussion focused on emergency management are listed below. Key discussion stakeholders: [suggested agency/jurisdiction primary participants] • Jurisdictional EMS entities (public and private), including key medical direction personnel for each discipline; • Jurisdictional fire/rescue; • Local public health;2 • Hospitals/health care coalition(s); • Local government legal counsel/authority; • Medical examiner/coroner; • 911 answering point(s)/public safety answering points (PSAPs); and • County commissioner/board. Secondary-level discussion stakeholders: [plans require integration with these partners] • State emergency management; • State public health; • State EMS authority; • State hospital and other associations; • Elected officials and executive officers; • State’s attorney office or state legal representative; • Law enforcement and corrections; • Funeral and mortuary services associations; • Faith-based and community volunteer agencies; • Representative(s) from utility service providers; and • Community stakeholders involved with management of large planned events. 1  The blank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards. 2  As discussed further in the public health toolkit (Chapter 5), in some states there are no local health departments, only a (centralized) state health department that acts as both state and local. Even in those states with both local and state health departments, the state health department needs to be involved in the discussions. As noted in the two previous IOM reports on crisis standards of care (CSC), the local health department will focus on local and regional issues related to CSC planning, while the state health department will help to coordinate the local/regional planning efforts to ensure intrastate coordination and consistency (IOM, 2009, 2012). The discussion participants and stakeholders listed here are provided as a suggestion; discussion organizers should develop a participant list that would be appropriate for the structures and organization of the particular jurisdiction. TOOLKIT PART 2: EMERGENCY MANAGEMENT 95

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Briefing-level participants: [plans require awareness-level knowledge by these entities] • Major local media; and • Representative(s) from all local chambers of commerce. Key Questions: Slow-Onset Scenario The questions below are focused on the slow-onset influenza pandemic scenario presented in Chapter 3:3 1. What ESF-8 system information can the EOC and/or emergency management access? Do these systems integrate into the state-level incident management system (WebEOC®, ETeam®, etc.)? 2. How are hospitals, public health, EMS, and the rest of the medical care sector (dialysis clinics, nursing homes, etc.) represented at the jurisdictional EOC? If they do not have an assigned “seat” in the EOC, who represents their interests, and how are coordination and two-way communica- tions maintained? 3. Is there a clearly delineated process by which these ESF-8 stakeholders advance resource requests to the local or state EOC? 4. What is the process by which the EOC communicates back to ESF-8 stakeholders about poten- tial resource shortages and other challenges in other organizations/sectors (security issues, travel restrictions, etc.) that will affect their ability to function? 5. What declarations or legal/regulatory relief can help support ESF-8 response strategies during a major disaster (e.g., suspension of ordinances requiring transport to hospital by EMS)? What agency (local, state, or federal) has the authority to waive such requirements? Based on what infor- mation and at what point is the decision made to pursue these declarations? 6. How is a COP maintained during a prolonged incident or event? 7. What process is in place to ensure that timely, accurate risk communication is available and dis- seminated to media outlets? 8. What information from ESF-8 systems or other sources would lead emergency management to begin rumor control and management during a health event, and how would this be handled? Are health public information officials integrated into Joint Information Systems? 9. What information is used to monitor whether resources (e.g., law enforcement) are becoming overtaxed? What adaptive strategies and/or personnel can be used? Are Memorandums of Under- standing in place to gain additional resources? 10. When does emergency management reach out to ESF-8 stakeholders to determine needs during a purely health-related event? At what point are virtual versus physical coordination locations used? 11. Does the jurisdiction have an active health care coalition that coordinates the medical aspects of incident response, and how can emergency management maximize these coordination resources? 3  These questions are provided to help start discussion; additional important questions may arise during the course of discussion. The questions are aimed at raising issues related to indicators and triggers, and are not comprehensive of all important questions related to disaster preparedness and response. 96 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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Key Questions: No-Notice Scenario The questions below are focused on the no-notice earthquake scenario presented in Chapter 3: 1. During a multi-jurisdictional incident or event, how are requests for resources prioritized when there are not enough resources to meet current requests? 2. How is utility outage and restoration information made available to the EOC and then to ESF-8 stakeholders (e.g., hospitals and their respective health care coalitions)? 3. What alternate transportation capabilities might be available to assist with evacuation in affected hospitals or health care organizations, such as skilled nursing facilities? Based on what information and at what point would the decision be made to implement these capabilities? What assistance is provided to health care organizations regarding decisions to evacuate or shelter in place? 4. What contingency plans are in place for regional staging areas and “automatic” regional mutual aid responses for public safety and EMS agencies after a catastrophic incident? Based on what information and at what point would the decision be made to implement these? Are additional contacts necessary with the state EMS and trauma office specific to the EMS role in response, and what information should be obtained prior to contact? 5. What process is followed when the traditional or legally authorized personnel and decision makers are unavailable to issue declarations? 6. How is situational awareness maintained with surrounding jurisdictions when widespread utility failures are possible? 7. How does emergency management support its staff (duty hours, sleeping areas, nutrition, etc.), reduce unnecessary workload, and provide family and staff with physical safety and support so that staff can make key decisions without impediments? 8. Do local and state emergency management have identified shelters, including those to meet the medical special needs clients in their jurisdictions? Decision-Support Tool: Example Table The indicators, triggers, and tactics shown in Table 4-1 are examples to help promote discussion and provide a sense of the level of detail and concreteness that is needed to develop useful indicators and triggers for a specific organization/agency/jurisdiction; they are not intended to be exhaustive or universally applicable. Prompted by discussion of the key questions above, discussion participants should fill out a blank table, focusing on key system indicators and triggers that will drive actions in their own organizations, agencies, and jurisdictions. As a reminder, indicators are measures or predictors of changes in demand and/or resource availability; triggers are decision points (refer back to the toolkit introduction [Chapter 3] for key definitions and concepts). The example triggers shown in the table mainly are ones in which a “bright line” distinguishes function- ally different levels of care (conventional, contingency, crisis). Because of the nature of this type of trigger, the examples can be described more concretely and can be included in a bulleted list. It is important to recognize, however, that expert analysis of one or more indicators may also trigger implementation of key TOOLKIT PART 2: EMERGENCY MANAGEMENT 97

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response plans, actions, and tactics. This may be particularly true in a slow-onset scenario. In all cases, but particularly in the absence of bright lines, decisions may need to be made to anticipate upcoming problems and the implementation of tactics and to lean forward by implementing certain tactics before reaching the bright line or when no such line exists. These decision points vary according to the situation and are based on analysis of multiple inputs, recommendations, and, in certain circumstances, previous experience. Dis- cussions about these tables should cover how such decisions would be made, even if the specifics cannot be included in a bulleted list in advance. 98 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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TABLE 4-1 Example Emergency Management Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care Indicator Category Contingency Crisis Return Toward Conventional Surveillance Indicators: Indicators: Indicators: data (Scenario 1: • Health alert: Novel virus reported • Novel virus causing epidemic affecting • Event has been stabilized by the facility Slow-onset) causing illness in United States United States, and projected impact and the impacted community • Community epidemic greatly exceeds available resources • Resources are returning to adequate Triggers: • Declaration of a severe pandemic levels based against the needs • Calls for additional resources and Crisis triggers • Stabilization or reduction in the number of mutual aid increase from multiple local • None specified (surveillance data are activated jurisdictional and/or state EOCs Emergency Support Function- (ESF-) 8 not triggers for crisis care) to coordinate resources for the crisis sector agencies Tactics: Triggers: • Multiple jurisdictional and/or state • Provide logistical support for • None specified emergency operations centers (EOCs) ESF-8 planning/response driven by Tactics: have been activated surveillance data—e.g., dispensing site • Create demobilization plan for operations Tactics: or alternate care site security, volunteer and systems monitoring • Activate incident planning process and staffing, transportation • Provide support for documentation of communicate with key stakeholders • Determine the level of service the surveillance data, their use, and archiving • Establish operational periods and agency will be able to provide communication expectations • Coordinate information and response • Communicate situation report to local posture to state EOC EOC • Begin developing Common Operating Picture (COP) process Surveillance Indicators: Indicators: Indicators: data (Scenario 2: • Media reports of incident • Media broadcasts of catastrophic event • NWS forecasts No-notice) • National Weather Service (NWS) in progress • Damage assessments watches/warnings Crisis triggers: • Flood crest receding • Hospitals on emergency medical • NWS forecasts Category 4 hurricane Triggers: services (EMS) diversion landfall in 96 hours (or crest of flood • Safe conditions exist in evacuated areas Triggers: that will inundate city center) Tactics: • Media footage of earthquake impacting Tactics: • Establish plan to reopen areas to public community • Issue evacuation/shelter orders • Work with public health to protect Tactics: • Determine likely impact returning citizens; e.g., communicate • Notify emergency management group • Support hospital evacuations with needs for water treatment, risk for • Coordinate with stakeholder agencies transportation resources infections/injury from cleanup, etc. to gain COP • Risk communication to public about • Determine need for declarations event impact • Develop initial risk communication/ • Ensure health care providers can pass public messages and publicize barriers to reach hospital continued 99

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TABLE 4-1 100 Continued Indicator Category Contingency Crisis Return Toward Conventional Communications Indicators: Indicators: Indicators: and community • Impact on community, including • Community-wide and likely prolonged • Restoration of services and transportation infrastructure transportation and communications impact on infrastructure affecting large access infrastructure number of homes, transportation, and Triggers: • Utilities monitoring information (grid communication • Restored electrical service monitoring) • Loss of potable water • Increased supplies of potable water Triggers: Crisis triggers: • Decreasing sheltered population • Loss of telecommunications capabilities • Long-term loss of electricity Tactics: to EOC or widespread community • EMS unable to evacuate hospital and • Scale back tactics or revert to outages extended care patients due to flood conventional operations • Widespread road damage and debris waters • Transfer remaining patients with medical from tornado Tactics: and functional needs to skilled nursing or Tactics: • Request National Guard high-clearance other facilities • Use alternate communications vehicles for transportation strategies, such as mass media and text • Mass care shelters open messages • Open alternate care sites and shelters • Public works clears roads to damaged for patients with medical and functional areas to facilitate EMS/fire access needs in conjunction with public health consultation Staff Indicators: Indicators: Indicators: • Increasing staff absenteeism • Increasing number of alternate care • Decreasing numbers of patients attending (Refer also to the • School closures patients, dispensing sites vaccination sites, alternate care sites worker functional Triggers: Crisis triggers: Triggers: capacity table in • Community alternate care or • Insufficient staff available to provide • Vaccination/alternate care needs can Toolkit Part 1 [Table vaccination sites required usual health care be met with more limited hours/sites/ 3-1]) Tactics: • Insufficient staff for dispensing sites/ resources • Provide appropriate protection for alternate care sites Tactics: staff (and families where relevant) to • EMS staff at risk of violence on scene • Close specific sites and restrict hours of maintain their health and safety due to disaster triage protocols operation • Staff rosters should be referenced and Tactics: • Augmented and contracted staff can be calls to off-duty staff made for potential • Staff assigned to nontraditional roles released activation • Staff augmented from nontraditional • Reduce staff hours and plan threshold for • Mutual aid partners queried for sources site closures additional staff if conditions persist or • Volunteer processing/vetting center resources become increasingly scarce initiated • Coordinate personnel needs with ESF-8 • Law enforcement support for EMS partners and determine best source responders (local, regional, state, federal) • Logistic support for any personnel • Initiate just-in-time or cross-training brought into area through Emergency educational programs and protocols Management Assistance Compact for qualified or eligible personnel to fill staffing gaps

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Space/infrastructure Indicators: Indicators: Indicators: • Hospitals at capacity • Hospitals over capacity • Evacuated areas opening again • Community interventions planned (e.g., • EMS unable to answer volume of • Epidemic interventions winding down vaccination, home quarantine) emergency calls Triggers: • Displacement of populations Crisis triggers: • Space needs for patient care can be met • Morgue capacity exceeds usual space • Mass fatality event overwhelms morgue at hospitals again Triggers: contingency capacity Tactics: • Shelter or space required for public • Alternate care spaces required for • Support transport of patients back to health response hospital patients—no remaining room hospitals Tactics: on hospital campus to provide care • Facility space is returned to its pre-event • Use emergency powers and mutual Tactics: purpose aid agreements to obtain appropriate • Emergency repurposing or rededication • Rented or purchased emergency and space of public space for patient care (gym, auxiliary equipment is removed and taken • Provide transportation or convention center) out of service communications support for individuals • Emergency resources brought in to on home quarantine (assistance with address infrastructure needs and meals, hotline) shortages • Request the dispatch or activation of mobile hospitals from their agent/ agency of authority and provide any regulatory relief that they or traditional health care facilities may need • Provide regulatory relief for EMS to allow them to reconfigure crews and not respond to all calls according to emergency plans Supplies Indicators: Indicators: Indicators: • Vendor reports problem with supply/ • Shortage of equipment and supplies • Inventory needs become matched to delivery • Transportation resources unavailable inventory available • Supply consumption/use rates • Continued requests for mass fatality • Procurement and delivery systems have unsustainable resources as capacity is exceeded returned to pre-event status Triggers: Crisis triggers: Triggers: • Medication/vaccine supply limited • Shortage of critical equipment and • Supply needs can be met through usual • Consumption rates of personal supplies channels/adequate supply available protective equipment unsustainable Tactics: Tactics: • Vendor shortages impact ability to • Emergency powers considered to co- • Return co-opted supplies provide normal resources opt selected supplies • Track return and invoicing of leased/ • Requests for refrigerated trucks • Facilitate non-standard delivery (e.g., loaned supplies to expand temporary storage of via boat, snowmobile, etc.) of materials decedents • Work with state emergency Tactics: management and public health for • Supply levels are checked and identification and process to implement estimates are made as to how long the temporary internment current inventory will last • Additional orders are readied in case demand exceeds supply • Alternate vendors contacted • Determine alternate strategies—e.g., conservation, substitution, adaptation 101

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Decision-Support Tool: Blank Table to Be Completed Prompted by discussion of the key questions above, participants should fill out this blank table (or multiple tables for different scenarios) with key system indicators and triggers that will drive actions in their own organizations, agencies, and jurisdictions.4 Reminders: • Indicators are measures or predictors of changes in demand and/or resource availability; triggers are decision points. • The key questions were designed to facilitate discussion—customized for emergency management— about the following four steps to consider when developing indicators and triggers for a specific organization/agency/jurisdiction: (1) identify key response strategies and actions, (2) identify and examine potential indicators, (3) determine trigger points, (4) determine tactics. • Discussions about triggers should include (a) triggers for which a “bright line” can be described, and (b) how expert decisions to implement tactics would be made using one or more indicators for which no bright line exists. Discussions should consider the benefits of anticipating the implemen- tation of tactics, and of leaning forward to implement certain tactics in advance of a bright line or when no such line exists. • The example table may be consulted to promote discussion and to provide a sense of the level of detail and concreteness that is needed to develop useful indicators and triggers for a specific organization/agency/jurisdiction. • This table is intended to frame discussions and create awareness of information, policy sources, and issues at the agency level to share with other stakeholders. Areas of uncertainty should be noted and clarified with partners. • Refer back to the toolkit introduction (Chapter 3) for key definitions and concepts. 4  The blank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards. 102 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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Scope and Event Type: __________________________________ Indicator Category Contingency Crisis Return Toward Conventional Surveillance data Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Communications and Indicators: Indicators: Indicators: community infrastructure Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Staff Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Space/infrastructure Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Supplies Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Other categories Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: 103

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REFERENCES IOM (Institute of Medicine). 2009. Guidance for establishing crisis standards of care for use in disaster situations: A letter report. Washington, DC: The National Academies Press. http://www.nap.edu/catalog.php?record_id=12749 (accessed April 3, 2013). IOM. 2012. Crisis standards of care: A systems framework for catastrophic disaster response. Washington, DC: The National Acad- emies Press. http://www.nap.edu/openbook.php?record_id=13351 (accessed April 3, 2013). 104 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS