Introduction

Disasters, both natural and human-made, can occur at any time and have been increasing in frequency and number of victims. Planning and practicing for these events is a key factor for a favorable response. Since the 2001 terrorist attack on the World Trade Center, there has been an improvement in disaster preparedness and recognition of the importance of including public health and health care professionals in the planning process. There has also been an increase in government involvement at the Federal, State, and local levels. Disasters can take many forms and require healthcare leadership to take an all-hazards approach. Good planning produces effective emergency operations and improves overall preparedness.[1][2][3][4]

Issues of Concern

The basic structure for disaster planning includes the fours phases of comprehensive emergency management: mitigation, preparedness, response, and recovery. Mitigation involves preventive measures to reduce vulnerabilities. In healthcare, these include structural hardening and non-structural measures such as laws, guidelines, and surveillance. Preparedness builds capabilities to manage the impact of hazards and includes drills and exercises, education, and stockpiling supplies. A response is an action to reduce adverse actions during the disaster such as triage, treatment, and management of patient flow. Recovery involves actions to restore areas affected by the disaster to pre-disaster operations such as normal surgical schedules and billing procedures.

After September 11, 2001, the need to repair communication and coordination during a response was identified. President George W. Bush issued Homeland Security Presidential Directive-5, which tasked the Department of Homeland Security to develop a National Incident Management System (NIMS) and a National Response Plan (NRP). The NRP consolidated the plans of multiple agencies into a single document for an all-hazards response. It was superseded in 2008 with the National Response Framework (NRF). While the NRF is the plan, NIMS is the way to implement the plan and includes the creation of a Unified Command (UC) and an incident command system (ICS) – a method of command and control initially adopted by fire agencies. Healthcare uses the hospital incident command system (HICS) that establishes a standardized framework for command, communication, and coordination. Healthcare organizations are required to comply with ICS standards and participate in the national response system under NIMS and through accreditation by the Joint Commission.[5][6][7][8]

HICS uses the ICS framework and includes a command center established before or during a response and a flexible structure that can be scaled to a specific event. It uses ICS terminology to aid interaction with outside agencies improving coordination. The framework of HICS follows five basic management staff functions: command, planning, logistics, operations, and finance. 

• The command staff includes the incident commander, the overall leader in charge of the incident as well as additional staff that includes a public information officer who disseminates information to the media; a liaison officer who coordinates with external agencies; a safety officer who ensures safety of staff, patients, and visitors, and monitors hazards; and a medical/technical specialist who is a subject matter expert depending on the specific situation.
• The Planning staff is tasked to collect and organize information and resources and is responsible for creating the Incident Action Plan. 
• The Logistics staff supports the incident response with food, supplies, and transportation to meet objectives. 
• The Operations staff is in charge of tactical objectives and respond to the incident. 
• The Finance staff track expenditures and provide funds for costs and claims.  

Under each section, there are branch managers and unit leaders that are specific to HICS for carrying out specific functions within that section.

The Joint Commission standards require the establishment of an Emergency Management Program which includes four components: a hazards vulnerability analysis (HVA), an incident management system such as HICS, the establishment of an emergency operations plan (EOP), and an exercise program for the organization. The HVA identifies potential emergencies that might affect normal operations and drives the planning process. This includes internal and external incidents. The external incidents should be based on the geographic location of the facility. Some disasters may be combined, affecting internal operations and producing external casualties such as earthquakes and hurricanes. The HVA analyzes these threats and ranks them based on impact and probability of occurrence.

The Emergency Operations Plan (EOP) provides a framework for HICS and outlines the organization’s strategy to respond to emergencies. It includes a base plan as well as functional and incident specific annexes. The base plan covers roles and authorities and response to all hazards. It includes a HICS organizational chart and describes the concept of operations. This might include the steps: recognition of the event, activation, mobilization, incident operations, demobilization, and recovery. Functional annexes should include the concept of operations for each functional section including job action sheets and forms used by that section. Incident Specific annexes should address each of the hazards identified in the HVA and include contingency plans and standard operating procedures for each event. Additional information and policies are included in support annexes and appendices as needed.

Once a plan is developed, it must become a living document to be sure it applies to current threats, goals, and priorities. Training and exercises must be conducted as information is obtained and is then used to restart the planning cycle over again. Plans should evolve as new lessons are learned, information is obtained, and priorities are updated. Regular reviews of the plan should occur and updates made after organizational or resource changes, major exercises, events, activations, or if the external environment changes. Reviews should occur annually or at a minimum every 2 years.

Clinical Significance

The principles of disaster planning only have an impact when they are used for education and training. Frequent exercises and drills are necessary, and the plans need to be implemented during actual incidents. The importance of preparedness is emphasized after every major disaster, most recently after several mass casualty terrorist incidents. There is a need for more disaster research to validate or dispute assumptions that go into disaster plans. With the increased incidence of terrorist threats, the requirement to have plans to respond to chemical, biological, and radiological incidents including decontamination procedures must be developed and exercised. Scheduled large volume occasions such as concerts or sporting events can be used to exercise emergency plans to educate and familiarize staff. Frequent drills and exercises allow for evaluation and revision of plans before the disaster occurs.[9][10]