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Hospital Incident Hospital Incident Management Management
SystemSystemDan Cass MD FRCPCDan Cass MD FRCPC
Chief, Emergency Chief, Emergency MedicineMedicine
St. Michael’s Hospital, St. Michael’s Hospital, TorontoToronto
ObjectivesObjectives• Outline the evolution of the Incident Outline the evolution of the Incident
Management System (IMS) modelManagement System (IMS) model• Provide an overview of the Provide an overview of the
principles of IMSprinciples of IMS• Illustrate how IMS can be used as a Illustrate how IMS can be used as a
framework for emergency response framework for emergency response for health care institutionsfor health care institutions
• Provide some practical applications Provide some practical applications of IMS in the hospital settingof IMS in the hospital setting
What is IMS?What is IMS?
• A way of creating (some!) order A way of creating (some!) order
out of chaosout of chaos
• A frameworkA framework
• A toolA tool
TerminologyTerminology• For our purposes, For our purposes, allall of these of these
terms are interchangeable:terms are interchangeable:– Incident Management System (IMS)Incident Management System (IMS)– Incident Command System (ICS)Incident Command System (ICS)– Hospital Emergency Incident Hospital Emergency Incident
Command System (HEICS)Command System (HEICS)
Where Does IMS Come Where Does IMS Come From?From?
Origins of IMSOrigins of IMS• California wildfires, 1980s – California wildfires, 1980s –
“FIRESCOPE”“FIRESCOPE”– Multiple fire agencies involvedMultiple fire agencies involved
• Local, regionalLocal, regional– Coordination of local / state / federal Coordination of local / state / federal
resourcesresources• Many challenges…Many challenges…
– Lack of common terminology / organizational Lack of common terminology / organizational structure / rolesstructure / roles
– Incompatible equipment (radios; Incompatible equipment (radios; firefighting)firefighting)
Origins of IMSOrigins of IMS• Fire protection agencies developed Fire protection agencies developed
common organizational and response common organizational and response structurestructure– Evolved into IMSEvolved into IMS
• Deployed across CaliforniaDeployed across California– Subsequently to much of USA and CanadaSubsequently to much of USA and Canada
• Began to expand to all pre-hospital Began to expand to all pre-hospital providers (fire / ambulance / police)providers (fire / ambulance / police)– Eventually into hospitalsEventually into hospitals
Origins of IMSOrigins of IMS• 1987: Hospital Council of 1987: Hospital Council of
Northern CaliforniaNorthern California– Adapted IMS into “Earthquake Adapted IMS into “Earthquake
Preparedness Guidelines for Preparedness Guidelines for Hospitals”Hospitals”
• 1991: Orange County EMS1991: Orange County EMS– Used IMS principles to develop Used IMS principles to develop
Hospital Emergency Incident Hospital Emergency Incident Command System (HEICS)Command System (HEICS)
Why Should We Care??Why Should We Care??• In day-to-day operations, hospitals In day-to-day operations, hospitals
often very insularoften very insular– ““Our” procedures don’t have to be same Our” procedures don’t have to be same
as “their” proceduresas “their” procedures– Applies Applies withinwithin as well as as well as betweenbetween
institutionsinstitutions• In mass casualty incident, we In mass casualty incident, we cannotcannot
operate in a vacuum!operate in a vacuum!– Need way to communicate / coordinate Need way to communicate / coordinate
effortsefforts
IMS - ComponentsIMS - Components1.1. Unified commandUnified command structurestructure2.2. Common terminologyCommon terminology3.3. Modular organizationModular organization4.4. Integrated communicationIntegrated communication5.5. Consolidated action plansConsolidated action plans6.6. Job Action SheetsJob Action Sheets7.7. Manageable & sensible span of Manageable & sensible span of
controlcontrol8.8. Designated facilitiesDesignated facilities9.9. Comprehensive resource managementComprehensive resource management
IMS - ComponentsIMS - Components1.1. Unified command structureUnified command structure2.2. Common terminologyCommon terminology3.3. Modular organizationModular organization4.4. Integrated communicationIntegrated communication5.5. Consolidated action plansConsolidated action plans6.6. Job Action SheetsJob Action Sheets7.7. Manageable & sensible span of Manageable & sensible span of
controlcontrol8.8. Designated facilitiesDesignated facilities9.9. Comprehensive resource managementComprehensive resource management
IMS StructureIMS Structure
Command
Operations Planning Logistics Finance / Administration
IMS StructureIMS Structure
Command
Operations Planning Logistics Finance / Administration
Doers Thinkers Getters Payers
Incident Incident CommandCommand
• Directs activities of personnel in Directs activities of personnel in Emergency Operations Centre (EOC)Emergency Operations Centre (EOC)
• Most senior trained responderMost senior trained responder– In hospital model, may In hospital model, may startstart as on-duty as on-duty
Emergency Physician or Charge NurseEmergency Physician or Charge Nurse• As response progresses, IC position may As response progresses, IC position may
be “handed off” to more senior personbe “handed off” to more senior person
Incident Commander
Operations Planning Logistics Finance
OperationsOperations
• Directs “front-line” response to eventDirects “front-line” response to event• Implements response activities as Implements response activities as
determined by Incident Commanderdetermined by Incident Commander• Maintains communication between Maintains communication between
EOC and siteEOC and site• Requests and assigns resources as Requests and assigns resources as
directeddirected
Incident Commander
Operations Planning Logistics Finance
PlanningPlanning
• ““What’s next?”What’s next?”• Control and flow of all informationControl and flow of all information• Data collection, analysis and Data collection, analysis and
forecastingforecasting• Development of Development of responseresponse and and
recoveryrecovery objectives and strategiesobjectives and strategies• Mutual Aid requests Mutual Aid requests
Incident Commander
Operations Planning Logistics Finance
LogisticsLogistics
• Support OperationsSupport Operations• Acquire and allocate resources Acquire and allocate resources
and provide all materials, and provide all materials, equipment, and personal requiredequipment, and personal required
• Application of additional Application of additional resources provided by Mutual Aidresources provided by Mutual Aid
Incident Commander
Operations Planning Logistics Finance
FinanceFinance
• Tracking of expensesTracking of expenses• FundingFunding• Government Financial Aid Government Financial Aid
requestsrequests• Financial Aid distributionFinancial Aid distribution
Incident Commander
Operations Planning Logistics Finance
IMS StructureIMS StructureCommand
Operations Planning Logistics Finance / Administration
ResponseTeam(s)
Safety Information
Liaison
IMS - ComponentsIMS - Components1.1. Unified commandUnified command structurestructure2.2. Common terminologyCommon terminology3.3. Modular organizationModular organization4.4. Integrated communicationIntegrated communication5.5. Consolidated action plansConsolidated action plans6.6. Job Action SheetsJob Action Sheets7.7. Manageable & sensible span of Manageable & sensible span of
controlcontrol8.8. Designated facilitiesDesignated facilities9.9. Comprehensive resource managementComprehensive resource management
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Fi na n ceS e ct io n
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In c id e n tC o m m a n d er
Provincial
Regional
Local Local Local
IMS - ComponentsIMS - Components1.1. Unified commandUnified command structurestructure2.2. Common terminologyCommon terminology3.3. Modular organizationModular organization4.4. Integrated communicationIntegrated communication5.5. Consolidated action plansConsolidated action plans6.6. Job Action SheetsJob Action Sheets7.7. Manageable & sensible span of Manageable & sensible span of
controlcontrol8.8. Designated facilitiesDesignated facilities9.9. Comprehensive resource managementComprehensive resource management
Modular OrganizationModular Organization• IMS model is IMS model is scaleablescaleable• Position = Position = rolerole
• One person may have several roles, One person may have several roles, especially in smaller-scale responseespecially in smaller-scale response
• Activate Activate onlyonly those positions you those positions you need for a given responseneed for a given response• HEICS - concept of “minimal HEICS - concept of “minimal
activation”activation”
IMS - ComponentsIMS - Components1.1. Unified commandUnified command structurestructure2.2. Common terminologyCommon terminology3.3. Modular organizationModular organization4.4. Integrated communicationIntegrated communication5.5. Consolidated action plansConsolidated action plans6.6. Job Action SheetsJob Action Sheets7.7. Manageable & sensible span of Manageable & sensible span of
controlcontrol8.8. Designated facilitiesDesignated facilities9.9. Comprehensive resource managementComprehensive resource management
Integrated Integrated CommunicationsCommunications
Who?Who?• Liaison Officer (in EOC)Liaison Officer (in EOC)
– Point of contact with external Point of contact with external agencies (EMS; other hospitals, etc.)agencies (EMS; other hospitals, etc.)
• Public Information Officer (in Public Information Officer (in EOC)EOC)– Deals with media / publicDeals with media / public
Integrated Integrated CommunicationsCommunications
How?How?• Ensure able to communicateEnsure able to communicate
– Established meansEstablished means• Dedicated linesDedicated lines
– Established frequenciesEstablished frequencies• Encryption!Encryption!
– BACKUP plan!BACKUP plan!
IMS - ComponentsIMS - Components1.1. Unified commandUnified command structurestructure2.2. Common terminologyCommon terminology3.3. Modular organizationModular organization4.4. Integrated communicationIntegrated communication5.5. Consolidated action plansConsolidated action plans6.6. Job Action SheetsJob Action Sheets7.7. Manageable & sensible span of Manageable & sensible span of
controlcontrol8.8. Designated facilitiesDesignated facilities9.9. Comprehensive resource managementComprehensive resource management
Incident Action PlanIncident Action Plan• Part of Incident Commander’s role = Part of Incident Commander’s role =
development of Incident Action Plan development of Incident Action Plan (IAP) (IAP) – AssessmentAssessment– ObjectivesObjectives– ResourcesResources– NeedsNeeds
• Constantly updated / revised based Constantly updated / revised based on new information and progress of on new information and progress of responseresponse
Incident Action PlanIncident Action Plan
• Each Section Chief (Operations, Each Section Chief (Operations,
Planning, Logistics, Finance) Planning, Logistics, Finance)
develops IAP for their areadevelops IAP for their area
– Immediate / Intermediate / ExtendedImmediate / Intermediate / Extended
• Integrates with overall IAPIntegrates with overall IAP
IMS - ComponentsIMS - Components1.1. Unified commandUnified command structurestructure2.2. Common terminologyCommon terminology3.3. Modular organizationModular organization4.4. Integrated communicationIntegrated communication5.5. Consolidated action plansConsolidated action plans6.6. Job Action SheetsJob Action Sheets7.7. Manageable & sensible span of Manageable & sensible span of
controlcontrol8.8. Designated facilitiesDesignated facilities9.9. Comprehensive resource managementComprehensive resource management
INCIDENT COMMANDER Job Action Sheet, Page 1 of 1
INCIDENT COMMANDER
Mission:
Organize and direct the Incident Command Center (ICC). Give overall direction for the incident response.
Immediate ____ Initiate the Incident Command System by assuming role of the Incident Commander. ____ Read this entire Job Action Sheet. ____ Appoint required Section Chiefs and distribute the: Job Action Sheets for each position Forms pertinent to Section & positions ____ Appoint Public Information Officer, Liaison Officer, and Safety and
Security Officer; distribute Job Action Sheets. ____ Conduct a size up. ____ Announce a status/action plan meeting of all Section Chiefs to be
held within 5 to 10 minutes. ____ Assign someone as Documentation Recorder/Aide. ____ Receive status report and discuss an initial action plan with
Section Chiefs. ____ Assure that contact and resource information has been
established with outside agencies through the Liaison Officer. Intermediate ____ Authorize resources as needed or requested by Section Chiefs. ____ Designate routine briefings with Section Chiefs to receive status
reports and update the incident action plan. ____ Communicate status to C.E.O of the Hospital or the designee. Extended ____ Approve media releases submitted by P.I.O. ____ Observe all staff, volunteers and patients for signs of stress and
inappropriate behavior. Provide for staff rest periods and relief. ____ Other concerns:
Job Action SheetJob Action Sheet• Role titleRole title• Reports toReports to• MissionMission• TasksTasks
– ImmediateImmediate– IntermediaIntermedia
tete– ExtendedExtended
IMS - ComponentsIMS - Components1.1. Unified commandUnified command structurestructure2.2. Common terminologyCommon terminology3.3. Modular organizationModular organization4.4. Integrated communicationIntegrated communication5.5. Consolidated action plansConsolidated action plans6.6. Job Action SheetsJob Action Sheets7.7. Manageable & sensible span of Manageable & sensible span of
controlcontrol8.8. Designated facilitiesDesignated facilities9.9. Comprehensive resource managementComprehensive resource management
Span of Control: Span of Control: The number of The number of subordinates that a superior can subordinates that a superior can manage manage effectivelyeffectively
• Each person responsible for a Each person responsible for a maximum of 3 to 7 subordinatesmaximum of 3 to 7 subordinates
–Ideal = Ideal = 1:51:5 command ratio command ratio•Each person reports up to Each person reports up to oneone supervisorsupervisor
IneffectivIneffectivee
Effective
IMS - ComponentsIMS - Components1.1. Unified commandUnified command structurestructure2.2. Common terminologyCommon terminology3.3. Modular organizationModular organization4.4. Integrated communicationIntegrated communication5.5. Consolidated action plansConsolidated action plans6.6. Job Action SheetsJob Action Sheets7.7. Manageable & sensible span of Manageable & sensible span of
controlcontrol8.8. Designated facilitiesDesignated facilities9.9. Comprehensive resource managementComprehensive resource management
IMS - ComponentsIMS - Components1.1. Unified commandUnified command structurestructure2.2. Common terminologyCommon terminology3.3. Modular organizationModular organization4.4. Integrated communicationIntegrated communication5.5. Consolidated action plansConsolidated action plans6.6. Job Action SheetsJob Action Sheets7.7. Manageable & sensible span of Manageable & sensible span of
controlcontrol8.8. Designated facilitiesDesignated facilities9.9. Comprehensive resource managementComprehensive resource management
How Does This Work in How Does This Work in Real Life?Real Life?
• Incident occursIncident occurs• NotificationNotification
– Official (eg – EMS to ED via amblance Official (eg – EMS to ED via amblance phone)phone)
– Unofficial (ie people start showing up…!)Unofficial (ie people start showing up…!)
• On-Scene Leader (Emerg Physician / On-Scene Leader (Emerg Physician / Nurse) becomes Incident CommanderNurse) becomes Incident Commander
Initial ResponseInitial Response
Emerg Doc or RN
Initial Response (cont’d)Initial Response (cont’d)• Priorities and objectives establishedPriorities and objectives established• On-site command developedOn-site command developed• Multi agency communication establishedMulti agency communication established• Resource needs and allocation identifiedResource needs and allocation identified
NEEDS EXCEED NEEDS EXCEED AVAILABLE AVAILABLE RESOURCESRESOURCES
The Incident The Incident Progresses…Progresses…
• Decision to initiate hospital disaster Decision to initiate hospital disaster planplan
• Fan-Out processFan-Out process– Clinical staffClinical staff– LeadershipLeadership
• Senior on-site leader assumes IC roleSenior on-site leader assumes IC role– Establishes EOC / Command Post**Establishes EOC / Command Post**– Begins to assign roles / responsibilitiesBegins to assign roles / responsibilities
• May be replaced by more senior staff May be replaced by more senior staff as they arriveas they arrive
EOC
Command Post
Hospital-Wide ResponseHospital-Wide Response• Incident Commander appoints key Incident Commander appoints key
personnelpersonnel– Four section ChiefsFour section Chiefs– Liaison / Information / SecurityLiaison / Information / Security
• Job Action Sheets distributed and Job Action Sheets distributed and checklists beginchecklists begin
• Priorities and objectives establishedPriorities and objectives established– Incident Action Plan(s) developedIncident Action Plan(s) developed
• Span(s) of control establishedSpan(s) of control established
Hospital-Wide Response Hospital-Wide Response (cont’d)(cont’d)
• Multi-agency communication Multi-agency communication establishedestablished
• Resource allocation identifiedResource allocation identified• Tracking, Evaluation, and cost recovery Tracking, Evaluation, and cost recovery
initiatedinitiated• Off-site command established (as Off-site command established (as
needed)needed)• Information released to media / publicInformation released to media / public
SummarySummary• IMS is a framework for emergency IMS is a framework for emergency
responseresponse– IdealIdeal for health care environment for health care environment
• Many advantages:Many advantages:– Scaleable to size of eventScaleable to size of event– Common terminology / organization of Common terminology / organization of
rolesroles– Manageable span of control Manageable span of control – Task-oriented approachTask-oriented approach
• Job action sheetsJob action sheets• Incident Action PlanIncident Action Plan