Function 1. Assessment and Activation. The state EMS office should assume a lead role in collaboration with the state public health agency and state EMA regarding the response to a disaster. It is the responsibility of the state EMS office to assist local agencies in recognizing the magnitude of the incident and determining whether it is necessary to implement the state CSC plan. As the incident progresses, the state EMS office should confer with the SDMAC regarding medical care and policy issues and when to activate the CSC plan. It is essential for dispatch centers/call centers, EMS providers, and the state EMS office to recognize when to activate and authorize implementation of the CSC plan, including resources such as poison control centers, 211 centers, and nurse referral centers, based on the triggers identified in the plan.
Function 2. Alerts and Notifications. Each state EMS office should strive to develop and utilize a statewide integrated communications system to provide and receive timely alerts during a CSC incident. The state EMS office should be responsible for activating the CSC plan, in collaboration with the state health department and EMA, and for ensuring that notification of the plan’s implementation reaches all key stakeholders. The state EMS office may also need to provide information directly to the public or the news media, a role that should be managed in a timely manner and with prescripted messages, if possible. To ensure immediate notification, the system should be redundant and interoperable with the systems of all first-response agencies, including law enforcement, public health, EMS, and hospitals. The implementation of electronic incident management systems may assist in the notification process while also enabling monitoring of resources and patient destinations.
The regional infrastructure and local providers need to understand what actions to take when the state EMS office or lead ESF-8 agency sends notification of a crisis or potential crisis situation. They may also need to provide consistent messages and notifications to the public or the media. They should understand that communication with the state EMS office is essential for authorizing CSC strategies as additional resources will be scarce.
Dispatch and call centers also play a key role in the alert and notification process, and should understand when to send messages to stakeholders regarding the activation and termination of the CSC plan.
Function 3. Command. The state emergency management agency is responsible for implementing the ICS and will work with the state EMS office in activating appropriate emergency operations centers (EOCs) during a disaster. The state EMS office, along with regional and local EMS agencies, should utilize the ICS within affected jurisdictions. All staff should be trained and exercised in the use of CSC strategies, such as alternate destinations, transportation modes, and staffing configurations.
The state EMS office staff should be well trained in and understand incident action planning and how to incorporate appropriate technical experts into the planning process for long-term incidents. The state EMS office also should ensure that staff have the job aids needed to guide decisions to activate, implement, and terminate the CSC plan.
All stakeholders should understand the role of the ESF-8 lead agency in a CSC incident and how the chains of command of the state EOC and agency internal coordination center coordinate the development, communication, and implementation of new CSC strategies in response to incident-specific demands.
Function 4. Control. It is the ultimate responsibility of the state EMS office staff to understand how to request additional medical resources from the federal government. They also should know how to integrate and track the requested assets within jurisdictions, regional structures, and local emergency management and public health systems.
The state EMS office should ensure that EMS providers utilize triage, treatment, transport, and transfer protocols approved by the medical director within the response area as required during a CSC incident. Medical direction at the state and local levels is key to the successful implementation of CSC strategies. Local EMS providers need to be familiar with the CSC strategies and know when to implement them.
The regional EMS infrastructure and local EMS agencies should work in cooperation with local law enforcement and understand the EMS options for security and access control during a disaster. This consideration should be integrated into the planning process as well.
Function 5. Communications. The state EMS office, in coordination with the state joint information center (JIC), should have the staff and resources to ensure the real-time exchange of information among stakeholders necessary to assess the magnitude of the incident and evaluate ongoing resource needs and requests. This function is essential when federal resources may be needed and when the necessity of implementing the CSC plan must be determined.
The state EMS office also should ensure that policies and procedures are in place to provide and receive situational communications among staff, facilities, and agencies within the affected region. This means having the ability to use e-mail, text messaging, paging, telephone, amateur radio, satellite phone, and other devices. Communication with stakeholders and the public should be both transparent and timely. Other means of communicating with the public and the news media should be established, such as announcements, handouts, postings, traditional media, and web-based and social media.
State, regional, and local EMS agencies, as well as PSAPs (dispatch or call centers), should utilize interoperable and redundant systems to communicate with each other. The system should be able to access EOCs, hospitals, and law enforcement and public health entities.
To facilitate better communications among organizations, the state EMS office, regional and local EMS agencies, and medical directors need to understand the roles and functions of the SDMAC, state EMS medical director, state health officer/commissioner, regional medical coordination centers, regional call centers, regional EMS or trauma advisory committees, and local agencies and resources, and how information is received from or communicated to these bodies.
Function 6. Coordination. The state EMS office should understand how to request interstate assets through the EMAC process, as well as how to request medical and other assets through the federal coordinating center for the ASPR/National Disaster Medical System (NDMS). Through the planning process and in cooperation with the state EMA and state health department, the state EMS office should know how to integrate these outside assets with existing resources. The ability to utilize an electronic incident management system may be beneficial in tracking assets and patients. All stakeholders should be familiar with the incident management system, using it daily and exercising its capacity to manage assets and patients during a disaster. Therefore, it is essential for state and local EMS agencies to understand the authority, scope, and jurisdiction for all response organizations within a region and how they interface within the ICS during a CSC incident.
Function 7. Public Information. All EMS system providers and stakeholders need to be proactive in communications to the public (see Chapter 9). The state EMS office and local EMS agencies, utilizing the ICS, should ensure risk communication and consistent messaging to the public via the media. The public may need to receive instructions, coordinated through the state, on how to care for patients at home, where to seek alternate care, how to call a referral center, and what limitations may be set on EMS response.
With the implementation of the ICS, all stakeholders within the emergency health care system should coordinate information with other response organizations through the joint information system (JIS) and JIC to ensure accuracy and consistency of messaging.
Function 8. Operations. As discussed at the beginning of this chapter (and in greater detail in Chapter 2), there are three levels of emergency care: conventional, contingency, and crisis. Medical direction for determining which level of care to provide is essential for EMS personnel. Each level of care requires that stakeholders understand their roles and what strategies to implement and protocols to follow.
With conventional care, it is important for the state EMS office, regional infrastructure, and local EMS providers to understand their roles and authority in providing routine care through medically approved triage, treatment, and transport protocols and the use of normal modes of transportation, staffing, and equipment, including mutual-aid resources.
When contingency care is necessary, local EMS providers deploy and engage mutual-aid agreements/ operations and response plans to substitute, conserve, and adapt staffing, transportation, patient triage, and destinations while still providing medical care that is functionally equivalent to conventional care.
When crisis care is required, EMS providers activate mass casualty and surge capacity plans/strategies that include reuse and reallocation of supplies, alternate modes of transportation (buses), sheltering in place and transport to alternate care sites, modification of the ambulance staffing configuration (one medical person and a driver), use of medically approved protocols for patient care based on established triggers in the CSC plan, dispatch screening protocols, regional call centers to assist with coordination of assets and patient destinations, treatment and release of patients under specific guidelines, and 211, 311, and other call centers (e.g., nurse call centers). Under CSC, the state EMS office and local EMS providers should understand and know how to declare and operate under emergency orders to facilitate the provision of sufficient care. As with conventional and contingency care, it is critically important during CSC to coordinate with regional health care coalitions to ensure a common operating picture and coordinated care delivery strategies.
Within the medical branch of the ICS, the state EMS office should understand when to shift from contingency to crisis care based on the assessment and recommendation of the SDMAC and should know how to identify specific needs of response organizations and resources at risk. This includes understanding the process for requesting resources and coordinating these resources with federal partners and regional and local response organizations.
The state EMA may activate the state EOC and the crisis care annex of the emergency operations plan. The state EMS office and state health department should understand their roles and how to utilize the expertise of the SDMAC. Agency responsibilities may include waivers of regulatory standards for transportation and staffing modes, activation guidelines and triggers, medical records, and triage decisions.
Mental health care under CSC will require specific competencies of mental health, social services, and health care staff (discussed in the mental health section of Chapter 4). Efforts also will be required to enhance community resilience through “neighbor-to-neighbor, family-to-family” support systems (such as certain psychological first aid models created specifically for use by community members). The resilience of the health care workforce, including those in EMS, is paramount to the success of the CSC strategy.
One-shot, one-size-fits-all approaches, such as some stress debriefing once common in EMS, are no longer recommended and may result in exacerbating the mental health problems of those most affected by a disaster (Bisson et al., 1997, 2007; IASC, 2007; McNally et al., 2003; NIMH, 2002). The replacement for those outmoded approaches is more integrated efforts to enhance the resilience of the workforce specifically with respect to mass casualty events, including CSC, as part of CSC preparedness (Schreiber and Shields, 2012).
EMS incident command operations need to encompass integrated mental health care as part of overall ICS/EOC and medical/health operations. Recent models developed for Los Angeles County, Seattle/King County, the American Red Cross’s National Operations Center/Disaster Mental Health, and a new national prototype specifically for children utilize real-time situational awareness of triage/ mental health risk in patients/disaster victims and responders (including health care workers, EMS workers, and their families) across varied disaster systems of care (e.g., hospitals, schools, shelters, public health settings) to guide actual mental health operations within the ICS (Schreiber et al., in press). Other recommended features include a common operating picture of
population-level mental health risks (traumatic loss, multiple traumatic losses) using a common rapid mental health triage system across disaster systems of care, including EMS;
mental health risk among EMS and health care workers; and
mental health resources, including emerging national models of Internet-based intervention (Ruggiero et al., 2006).
Addressing the social and psychological challenges of CSC requires a triage-driven mental health incident management system and community resilience efforts through community engagement (see Chapter 9). Also required are basic “neighbor-to-neighbor, family-to-family” psychological first aid competencies that leverage the community, responders, and family members as the first line of psychosocial support (see the American Red Cross’s “Coping in Times of Crises” and the “Listen, Protect and Connect” psychological first aid models).
The state and local CSC response should encompass palliative care. The state EMS office, with medical direction, should define the role of EMS personnel in providing symptomatic management for patients needing palliative care and should provide the necessary training and resources for EMS personnel (San Francisco Emergency Medical Services Agency, 2011). State and local medical directors should address palliative care in the CSC annex of the emergency operations plan, including triage tools and any agency-specific protocols or policies (which should be approved by medical directors at the state agency level).
Function 9. Logistics. At the state, regional, and local levels, it is important to know about the available staffing resources within jurisdictions and to utilize established processes for requesting and allocating the workforce (Medical Reserve Corps [MRC]; Emergency System for Advance Registration of Volunteer Health Professionals [ESAR-VHP]; state strike teams; NDMS teams; military/National Guard personnel, including ambulances). The state EMS office and local EMS providers should have the capability to assess the number of staff available for large-scale incidents, possibly through personnel rosters, licensing/certification databases, or personnel registries.
Local EMS agencies, through regional and state infrastructures, should utilize a resource monitoring system to track staffing resources and understand when to activate mutual-aid agreements or alternate staffing patterns. Ambulance supervisors must be able to ensure that call-back criteria and policies are in place, including maintenance of current and accurate employee contact information. This is a function for state EMS office response staff as well.
Finally, state EMS offices and regional and local EMS providers should ensure that their staff receive personal preparedness training to assist with family needs and are prepared for on-site accommodation of staff and family members, as appropriate.
The management of transportation resources, such as ambulances, and essential equipment is a key logistical element of the EMS response to a CSC incident. Therefore, the state EMS office should conduct an assessment of the types and locations of EMS transportation and equipment resources available within the state and know how to request resources from other jurisdictions (through EMAC, the federal ambulance contract, the NDMS, medication caches, all public and private ambulance providers, equipment trailers). The state EMS office, regional EMS infrastructure, and local EMS agencies should utilize a resource tracking or deployment system to monitor the availability of ambulances and understand when to engage other modes of patient transportation. The state EMS office and local EMS agencies, with medical direction, should work together to identify strategies for appropriate substitution, conservation, adaptation, reuse, and reallocation of scarce equipment and supplies.
In a CSC response, space for treating patients in hospitals will become extremely limited. EMS providers play a key role in triaging patients and can reduce the burden placed on hospitals during a disaster. Therefore, and consistent with alternate care site planning under way through the Hospital Preparedness Program, the state EMS office and local EMS providers need to understand when to initiate plans to transport patients to alternate care sites and the processes for requesting and allocating such space. They need to be able to recognize when to activate alternate call centers to provide information to the public (such as 211 or nurse triage centers); implement treat-and-release protocols; and identify regional staging areas for use when major mutual aid will be required but specific assignments are not yet available, and understand support requirements for those sites.
The state EMS office should also assist with dispatcher training and certification and establish standards for medical priority dispatch systems that can be modified for use during a disaster. Dispatch centers should not only be capable of using prearrival instructions on a daily basis but also be prepared to utilize CSC dispatch protocols and alter resource assignments.
Finally, the state EMS office and local EMS providers, through state and regional advisory committees/councils and medical directors, should identify special populations—patient groups requiring special consideration with respect to transportation, treatment, equipment, and supplies. EMS personnel must be trained in managing children, the elderly, burn patients, special-needs patients, and non-English-speaking patients. Not only should EMS personnel be trained in and exercise these skills, but equipment and supplies should be readily available to support the needs of these at-risk populations. This work should be coordinated with local health departments and emergency management.
Function 10. Planning. The state EMS office may be assisting the state health department as the lead ESF-8 agency. It is important for the state EMS office’s ICS to understand how to interface with unified ICS, in particular the planning section and planning cycle, as well as how to work with the SDMAC, as technical experts, in activating the CSC plan and other strategies. Local EMS agencies should be familiar with the SDMAC and its role in determining the activation of the CSC plan. Additional technical specialists and state, regional, and local medical directors should understand how to interface with the ICS and planning section.
In collaboration with existing regional structures, state and local EMS agencies should establish policies and procedures to integrate external staffing resources (MRC, ESAR-VHP, state strike teams, disaster medical assistance team [DMAT]) during a disaster based on mutual-aid agreements, EMAC, the NDMS plan, the emergency operations plan, and appropriate annexes. To this end, they should develop an educational program and materials to orient external staffing resources on local, regional, and state triage and treatment policies and applicable elements of the state CSC plan.
Through established state and regional advisory committees, state and local EMS providers should develop policies for personnel management, such as altered staffing configurations, shift lengths, and staff roles, and address any collective bargaining issues that may arise prior to an incident. This phase of planning provides an opportunity to address issues related to workforce unions and private EMS providers. In addition, the need for nonmedical assistance for families, volunteers, and external staffing resources within the state should be addressed in regional and local emergency operations plans.
Function 11. Jurisdiction, Scope, Authority, and Legal/Regulatory Issues. Since most state EMS offices have the scope, jurisdiction, and authority to support disaster planning and to coordinate a medical response to a disaster, it is essential for the state EMS office and public EMS providers to examine the scope and delegation of authority to incident commanders during a disaster and make any necessary changes to ensure that CSC decisions are supported (i.e., that the incident commander is acting with the authority of the agency/jurisdiction). Similarly, it is important that state public health and EMS officials understand the impact of state and local laws and regulations on the ability of EMS providers to implement CSC and identify solutions to likely obstacles. During a crisis, policy makers may require additional communications and coordination with the incident commander, and the structure of the ICS will most likely be a unified command.
