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
• 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 coordination with local public health, hospitals, emergency medical services (EMS), and other health care organizations; 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 organizations 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.
Building on the scenarios and overarching key questions presented in Chapter 3, this tool contains additional 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
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.
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.
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.
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
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 communications 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 potential 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 information 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 disseminated 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 Understanding 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.
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 functionally 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
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. Discussions about these tables should cover how such decisions would be made, even if the specifics cannot be included in a bulleted list in advance.
Example Emergency Management Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care
|Indicator Category||Contingency||Crisis||Return Toward Conventional|
|Surveillance data (Scenario 1: Slow-onset)||
• Health alert: Novel virus reported causing illness in United States
• Community epidemic
• Calls for additional resources and mutual aid increase from multiple local Emergency Support Function- (ESF-) 8 sector agencies
• Multiple jurisdictional and/or state emergency operations centers (EOCs) have been activated
• Activate incident planning process and communicate with key stakeholders
• Establish operational periods and communication expectations
• Communicate situation report to local EOC
• Begin developing Common Operating Picture (COP) process
• Novel virus causing epidemic affecting United States, and projected impact greatly exceeds available resources
• Declaration of a severe pandemic Crisis triggers
• None specified (surveillance data are not triggers for crisis care)
• Provide logistical support for ESF-8 planning/response driven by surveillance data—e.g., dispensing site or alternate care site security, volunteer staffing, transportation
• Determine the level of service the agency will be able to provide
• Coordinate information and response posture to state EOC
• Event has been stabilized by the facility and the impacted community
• Resources are returning to adequate levels based against the needs
• Stabilization or reduction in the number of activated jurisdictional and/or state EOCs to coordinate resources for the crisis
• None specified
• Create demobilization plan for operations and systems monitoring
• Provide support for documentation of surveillance data, their use, and archiving
|Surveillance data (Scenario 2: No-notice)||
• Media reports of incident
• National Weather Service (NWS) watches/warnings
• Hospitals on emergency medical services (EMS) diversion
• Media footage of earthquake impacting community
• Notify emergency management group
• Coordinate with stakeholder agencies to gain COP
• Determine need for declarations
• Develop initial risk communication/ public messages and publicize
• Media broadcasts of catastrophic event in progress
• NWS forecasts Category 4 hurricane landfall in 96 hours (or crest of flood that will inundate city center)
• Issue evacuation/shelter orders
• Determine likely impact
• Support hospital evacuations with transportation resources
• Risk communication to public about event impact
• Ensure health care providers can pass barriers to reach hospital
• NWS forecasts
• Damage assessments
• Flood crest receding
• Safe conditions exist in evacuated areas
• Establish plan to reopen areas to public
• Work with public health to protect returning citizens; e.g., communicate needs for water treatment, risk for infections/injury from cleanup, etc.
|Indicator Category||Contingency||Crisis||Return Toward Conventional|
|Communications and community infrastructure||
• Impact on community, including transportation and communications infrastructure
• Utilities monitoring information (grid monitoring)
• Loss of telecommunications capabilities to EOC or widespread community outages
• Widespread road damage and debris from tornado
• Use alternate communications strategies, such as mass media and text messages
• Public works clears roads to damaged areas to facilitate EMS/fire access
• Community-wide and likely prolonged impact on infrastructure affecting large number of homes, transportation, and communication
• Loss of potable water
• Long-term loss of electricity
• EMS unable to evacuate hospital and extended care patients due to flood waters
• Request National Guard high-clearance vehicles for transportation
• Mass care shelters open
• Open alternate care sites and shelters for patients with medical and functional needs in conjunction with public health consultation
• Restoration of services and transportation access
• Restored electrical service
• Increased supplies of potable water
• Decreasing sheltered population
• Scale back tactics or revert to conventional operations
• Transfer remaining patients with medical and functional needs to skilled nursing or other facilities
(Refer also to the worker functional capacity table in Toolkit Part 1 [Table 3-1])
• Increasing staff absenteeism
• School closures
• Community alternate care or vaccination sites required
• Provide appropriate protection for staff (and families where relevant) to maintain their health and safety
• Staff rosters should be referenced and calls to off-duty staff made for potential activation
• Mutual aid partners queried for additional staff if conditions persist or resources become increasingly scarce
• Coordinate personnel needs with ESF-8 partners and determine best source (local, regional, state, federal)
• Initiate just-in-time or cross-training educational programs and protocols for qualified or eligible personnel to fill staffing gaps
• Increasing number of alternate care patients, dispensing sites
• Insufficient staff available to provide usual health care
• Insufficient staff for dispensing sites/ alternate care sites
• EMS staff at risk of violence on scene due to disaster triage protocols
• Staff assigned to nontraditional roles
• Staff augmented from nontraditional sources
• Volunteer processing/vetting center initiated
• Law enforcement support for EMS responders
• Logistic support for any personnel brought into area through Emergency Management Assistance Compact
• Decreasing numbers of patients attending vaccination sites, alternate care sites
• Vaccination/alternate care needs can be met with more limited hours/sites/ resources
• Close specific sites and restrict hours of operation
• Augmented and contracted staff can be released
• Reduce staff hours and plan threshold for site closures
• Hospitals at capacity
• Community interventions planned (e.g., vaccination, home quarantine)
• Displacement of populations
• Morgue capacity exceeds usual space
• Shelter or space required for public health response
• Use emergency powers and mutual aid agreements to obtain appropriate space
• Provide transportation or communications support for individuals on home quarantine (assistance with meals, hotline)
• Hospitals over capacity
• EMS unable to answer volume of emergency calls
• Mass fatality event overwhelms morgue contingency capacity
• Alternate care spaces required for hospital patients—no remaining room on hospital campus to provide care
• Emergency repurposing or rededication of public space for patient care (gym, convention center)
• Emergency resources brought in to address infrastructure needs and 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
• Evacuated areas opening again
• Epidemic interventions winding down
• Space needs for patient care can be met at hospitals again
• Support transport of patients back to hospitals
• Facility space is returned to its pre-event purpose
• Rented or purchased emergency and auxiliary equipment is removed and taken out of service
• Vendor reports problem with supply/ delivery
• Supply consumption/use rates unsustainable
• Medication/vaccine supply limited
• Consumption rates of personal protective equipment unsustainable
• Vendor shortages impact ability to provide normal resources
• Requests for refrigerated trucks to expand temporary storage of decedents
• Supply levels are checked and estimates are made as to how long the current inventory will last
• Additional orders are readied in case demand exceeds supply
• Alternate vendors contacted
• Determine alternate strategies—e.g., conservation, substitution, adaptation
• Shortage of equipment and supplies
• Transportation resources unavailable
• Continued requests for mass fatality resources as capacity is exceeded
• Shortage of critical equipment and supplies
• Emergency powers considered to co-opt selected supplies
• Facilitate non-standard delivery (e.g., via boat, snowmobile, etc.) of materials
• Work with state emergency management and public health for identification and process to implement temporary internment
• Inventory needs become matched to inventory available
• Procurement and delivery systems have returned to pre-event status
• Supply needs can be met through usual channels/adequate supply available
• Return co-opted supplies
• Track return and invoicing of leased/ loaned supplies
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
• 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 implementation 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.
Scope and Event Type: _______________________________
|Indicator Category||Contingency||Crisis||Return Toward Conventional|
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 Academies Press. http://www.nap.edu/openbook.php?record_id=13351 (accessed April 3, 2013).