When disaster strikes suddenly, first responders gather their resources, move to the scene, and begin to execute a well-rehearsed response. Personnel, supplies, and equipment arrive at the scene and meet the requirements of the operation, and once completed they are refitted and resupplied for the next calamity. But what happens when the disaster evolves slowly over time and distance, involving many organizations across jurisdictional boundaries? Or when, given the prior scenario of a sudden-impact disaster, local resources become rapidly depleted? Victims of a disaster require a number of resources, and whether in the form of a warm bed or a hot meal these requirements may exceed the local capabilities.
Just as an individual who is baking a cake may need a cup of sugar from a neighbor, organizations responding to emergencies occasionally need the assistance of others. Mutual aid is one of the earliest and most organic forms of interagency cooperation and coordination in public safety and health services. Without prearranged mutual aid agreements, events that deplete or exhaust community resources jeopardize the health and safety of not only the victims directly affected by the disaster but also the rescuers and emergency management personnel themselves.
This chapter introduces a brief history of the federal plan to support disaster responses as it applies to working with state and local governments. The chapter also covers the basic concepts of developing mutual aid agreements, organizational examples (at the local, state, and federal levels for developing plans), pitfalls, and successful disaster responses that effectively used mutual aid.
The mutual aid concept
Response, Recovery, and Regional Capacity Building
Mutual aid can provide an organization with personnel, equipment, supplies, and pharmaceutical agents in an existing or anticipated emergency. Mutual aid agreements serve to regulate the sharing process, with the identification of what resources can be shared and under what circumstances. Agreements also address potential problems, such as the liability of sharing organizations and responders, reciprocity of credentialing and licensure, ability of the sharing organization to hold back resources to protect itself, and expectations regarding accounting and reimbursement. Logistics concerning mobilization and demobilization, transportation to and from the incident, food and shelter, and other pertinent functional aspects of the asset’s deployment are addressed. The most effective mutual aid agreements apply to all phases of the disaster response.
Mutual aid agreements tend to be made between like organizations: hospitals make them with hospitals, law enforcement agencies with other law enforcement agencies, and utility companies with utility companies. Even libraries and museums have mutual aid agreements for coping with disasters. , However, agreements also are made among jurisdictions, such as state-to-state or county-to-county mutual aid, covering a range of public safety, health, and public works organizations. Mutual aid for response and recovery has become part of the decision matrix for planners in many areas of the United States. As the technical base for response equipment and training expands, planners must make decisions about where to place specialized resources for the maximum sustainable value to the region.
As with the other realms of studying disaster preparedness, as a retrospective science, we will study mutual aid using multiple examples of systematic preparation and recovery. In West, Texas, a fertilizer plant explosion and fire in April 2013 displayed the well-established fire department mutual aid agreements. After Hurricane (Superstorm) Sandy in 2012 the $68 billion dollar cleanup and recovery process required and led to mutual aid policy coordination between insurance companies, interstate and intrastate governments, and private organizations. In this natural disaster New York City saw courageous and efficient mutual aid between hospitals: generators went down and ill patients were transferred between hospitals. From scenarios like these we are able to grow the process of mutual aid, fill in gaps where agreements lack, and enhance communication between cooperating groups.
Conceptual Planning Concerns
Many regions are not able to provide exactly equal resources in every area or in each facility; mutual aid as a planning tool can build overall capacity and capability. Good agreements allow planners to consider the capability of the entire mutual aid network when choosing how to allocate resources for overall preparedness. Historically, but not always, this type of planning has taken place on an informal level. Planners tend to know what other organizations in their area have available to share when open lines of communication exist. However, in immediacy of some disasters the use of mutual aid agreements can systematize the process and make it more accountable, minimizing the chances of gaps or misunderstandings.
Most conceptual planning concerns are ultimately problems of definition, management, or sustainability. When an organization, such as a hospital, realizes it is overwhelmed, it usually requests mutual aid when somebody, preferably within the hospital’s Incident Command, recognizes what “overwhelmed” means based on preset, defined parameters. Advance work to define what “almost overwhelmed” might look like in various scenarios goes a long way toward smoothing actual operations. Costly preparations are made to mitigate the effects of a hurricane only for the storm to change direction. Although most would argue that preparation is still the superior option over not preparing, this process can consume financial resources and manpower without deployment, making accurate prediction of when “overwhelmed” status will be reached essential. Organizations must also work to “type” their resources, categorizing assets they can share or expect to receive based on the disaster.
Resource Typing Library Tool (RTLT) ( Figure 34-1 ) is an online catalogue of national resource typing definitions and job titles and position qualifications:
Supporting a common language for the mobilization of resources (equipment, teams, units, and personnel) prior to, during, and after major incidents
Providing users at all levels with access to an easily searchable database of typed definitions to identify resources for planning and incident operations, including mutual aid coordination
Resource typing definitions are provided for equipment, teams, and units. They are used to categorize, by capability, the resources requested, deployed, and used in incidents. Measurable standards identifying resource capabilities and performance levels serve as the basis for this categorization. Job titles and position qualifications are used in the inventorying and credentialing of personnel. Job titles for many personnel are cross-referenced and support the capabilities contained in resource typing definitions for teams and units. Credentialing ensures and validates the identity and attributes of individuals or members of emergency management teams through standards. There is no cost to use the RTLT, and a username or password is not required. On the World Wide Web, go to https://rtlt.ptaccenter.org. 7 Requests made under mutual aid agreements may be easier to fulfill when requestors ask for a specific capability rather than an organization. Resource Management Overview: Federal Emergency Management Agency, available at: http://www.fema.gov/resource-management
Plans to manage mutual aid must include how aid is dispatched, received, managed on scene, and demobilized. Appropriate dispatch depends on the organization being able to make a considered and coherent request for resources. With the advent of technology’s powerful databases, typing aid and up to the minute maintenance of surplus and need can be maintained. Tools, such as Mutual Aid Support System (MASS), are already available for Mission Ready Packaging and mutual aid sharing. The receiving organizations must also have protocols for receiving the aid and incorporating it into ongoing operations. Finally the receiving organization must understand how to demobilize human resources and return or dispose of material ones.
For many types of disasters, sustainability is a critical element of response and recovery; mutual aid can provide the resource “depth” for an organization or jurisdiction to sustain a response until state or national assistance is deployed. Problems can arise if resources are requested too quickly and are exhausted or if they are recalled before they can be useful in extending the duration of response. Some mutual aid planners now want their agreements to include discussions of response sustainability and to provide guidelines to help those on scene make sound judgments about response timeframes. Under incident management, it becomes the responsibility of the incident command structure to process assets arriving through mutual aid. The system depends on good operational guidelines to ensure that the only unpredictable element in the response is the evolving disaster itself.
Groups, such as the National Emergency Management Association and the American Hospital Association, have developed model agreements for organizations, localities, and states to use when developing their own mutual aid agreements. A well-known example of this standardization is the Emergency Management Assistance Compact (EMAC), a template plan for state-to-state mutual aid. , EMAC, described in more detail later in this chapter, is a national mutual aid system for states but allows some tailoring to meet local needs. For example, states in Federal Emergency Management Agency (FEMA) Region IX (HI, CA, AZ, NV, and Pacific Islands) have longer flight times with concentrated populations at larger distances, requiring mutual aid plans that would be different than others.
Various templates are available online for hospitals, fire departments, municipal governments, and other groups, allowing for standardization. Time and resources saved in creating the agreement can be used for implementation and training. Standardization can also help to ensure that agreements address operational concerns consistent with national plans, such as the National Response Plan and the National Incident Management System. Mutual aid training is as much if not more about maintaining open lines of communication between the two agreeing groups in times of well-being as it is about preparing for the actual disaster. Coordinating aid can be best accomplished when two groups understand each other beyond a list of needed typed assets. When disaster strikes, saving time maintaining databases with technology can afford opportunity for face-to-face networking empowering partners to work with established mutual respect. A mutual aid keystone is for familiarity among partners, not just organizations but the actual people assigned the tasks of asking and sending assets.
Although discussed in detail elsewhere in this textbook, a brief review of the national disaster response history may provide a perspective on how mutual aid agreements and processes at differing government levels have matured over time. Recent disaster response organizations in the United States at the federal level date to the early 1960s when the newly formed Federal Disaster Assistance Administration of the Department of Housing and Urban Development managed several massive disasters. For example, after the Alaska Earthquake of 1964, in which needs far exceeded available local resources, many questions arose as to the federal government’s capability to appropriately respond. Review of this disaster and others in subsequent years led to the establishment of a process for presidential disaster declarations through passage of the Disaster Relief Act in 1974. This act provided the legal processes under which state governors could formally request federal assistance after disasters for support that exceeded the state’s response capabilities. It was in essence the first state-federal government, disaster-specific mutual aid agreement.
However, disaster response at the federal level remained fragmented. More than 100 federal agencies could be called on to respond to disasters ranging from natural events to accidents involving the transportation of hazardous materials. , In 1979 President Carter issued Executive Order 12127, which merged many disaster-related responsibilities into FEMA. By 1989 with the fall of the Berlin Wall and the decline in the global threat of nuclear warfare, FEMA was funded and empowered to focus its efforts on nonnuclear disaster response as well. The current basis for federal disaster response stems from the Robert T. Stafford Disaster Relief and Emergency Assistance Act (most commonly known as the “Stafford Act”). This law gives the federal government operational guidelines and funding to execute disaster response. ,
This section describes many local, state, and federal assets or policies that can be used when an organization sets out to develop a mutual aid plan. The activity level and effectiveness of organizations and policies vary, and although each possibility described in this section may not have all the answers, each provides a place to start and is part of the overall context of mutual aid. Because disaster response and mutual aid begin on the local level, we will begin by discussing local aid agreements then move to larger geographic areas’ mutual aid agreements.
Local Community Assets
Community-level first responders typically serve on the front lines for disaster response, often placing their own personal safety in jeopardy in the process. Some disasters, such as biological terrorist events, may develop slowly over time and great distances, yet the first case is often identified by a local health care worker or rescuer who notes an unusual incident, such as the physician who diagnosed the incident case of anthrax in 2001. ,
Disaster or emergency planning in communities has historically been developed by fire departments, in part as a result of their personnel’s ongoing training and experience in managing day-to-day emergencies. In some municipal emergency operations plans (EOPs), town managers or mayors have overall responsibility; however, fire departments have typically served as both planner and operator. Close integration of the administrative lead and the fire department remains critical to the successful planning and execution of EOPs. In the West, Texas, fertilizer plant explosion in 2013, fire departments coordinated through the Texas Intrastate Fire Mutual Aid System (TIFMAS) provided manpower and resources to respond effectively in rural Texas. ,
Local Emergency Planning Committees
Although since 1986 communities, by law, have had to develop a Local Emergency Planning Committee (LEPC), the events of September 11, 2001, dramatically increased the emphasis placed on these organizations to expand their disaster-planning process. Planning now must occur not only across some jurisdictional boundaries, but it also must entail other entities beyond industry, fire, and law enforcement personnel. Specifically the federal government in 1986 mandated the formation of State Emergency Response Commissions (SERCs); these SERCs were tasked to develop emergency planning districts to “… facilitate preparation and implementation of emergency plans.” Within these districts, the state is to “… appoint members of a local emergency planning committee for each emergency planning district. Each committee shall include, at a minimum, representatives from each of the following groups or organizations: elected State and local officials; law enforcement, civil defense, firefighting, first aid, health, local environmental, hospital, and transportation personnel; broadcast and print media; community groups; and owners and operators of facilities subject to the requirements of this subchapter.” In areas where an LEPC is active, it can serve as the focal point in the community for information and discussions regarding all aspects of emergency planning as well as health and environmental risks.
U.S. Citizen Corps
The federal government created the USA Freedom Corps after September 11, 2001 in an effort to provide opportunities for citizens to serve their community and foster a culture of service, citizenship, and responsibility. Under the auspices of the Department of Homeland Security, components of the U.S. Citizen Corps are designed to be staffed by local volunteers and serve in local events. The Community Emergency Response Team (CERT) program helps to train individual volunteers to be better prepared to assist their community, serving as support to first responders, directly assisting victims, and organizing volunteers who arrive on scene. They also can assist in projects designed to enhance public safety. ,
The other major component of the U.S. Citizen Corps available for assistance at the local level is health care personnel who serve as part of the Medical Reserve Corps (MRC). “The MRC program coordinates the skills of practicing and retired physicians, nurses and other health professionals as well as other citizens interested in health issues, who are eager to volunteer to address their community’s ongoing public health needs and to help their community during large-scale emergency situations.” Office of the Surgeon General within the U.S. Department of Health and Human Services oversees the program, but its components, tasks, activation, utilization, etc., are governed locally and through state Citizen Corps Councils. Local community leaders develop MRCs and outline their roles and responsibilities in disaster response. MRCs may also play a role in day-to-day public health and safety campaigns or other volunteer efforts.
Other Government Agencies
A variety of other government organizations may play a prominent role in local disaster response. Search and rescue organizations may come from state fish and game agencies, private organizations, Civil Air Patrol, and others, although federal agencies, local military, Veterans Affairs, federal law enforcement agencies, etc., may serve as first responders for some communities and hence need to clearly predetermine their roles, responsibilities, and command relationships during disaster planning.
Voluntary Organizations and Volunteers
The American Red Cross (ARC) plays an active role in the health and safety in most communities, and although it is not a government entity it has a federal mandate to assist in disasters. It is a lead primary agency for Emergency Support Function #6 (Mass Care) in the National Response Plan. Staffed by both professionals and volunteers, disaster relief of the ARC is designed to meet the immediate, disaster-related needs of victims as well as emergency workers. It provides shelter, food, and health and mental health services to address basic human needs during the event and later provides services to help disaster victims and emergency workers return to some form of normalcy. Its special shelters may also be called on to assist in the care and management of hospitalized patients who are discharged because of low acuity or evacuated because of disruption of the hospital facility. The ARC normally provides care to all victims who arrive at one of its shelters for support, but pre-event mutual aid agreements and discussions can help coordinate disaster health services within a given community. ,
Other relief agencies appear at disasters and play a role in supporting both victims and rescue workers. At the Pentagon disaster on September 11, 2001, the first agency to arrive was the Salvation Army (J. Geiling, personal observation). The Salvation Army is a Christian-based, international organization whose mission includes “To provide support, training and resources to respond to the needs of those affected by emergencies without discrimination.” Additional religious or other cause-related organizations serve in part to assist their community in times of need.
Individual volunteers also tend to flock to disaster scenes, in part to assist with the rescue effort. This “convergent volunteerism” can be defined as “The arrival of unexpected or uninvited personnel wishing to render aid at the scene of a large-scale emergency incident [and who often] engage in freelancing, [that is,] operating at an emergency incident without knowledge of or direction by the on-scene command authority.” These volunteers are not limited to medical personnel but also can include fire and law enforcement representatives and others. Sometimes these volunteers, such as those brave civilians whose anecdotes we heard after the 2013 Boston Marathon Bombing, are on scene before emergency services. Multiple marathoners and spectators stepped in to provide immediate support after witnessing the finish line bombings. In other situations they migrate to the scene, in part as a result of misinformed requests for help often by well-intended media reporters, politicians, or professionals from their specific organizations. Due to the popularity and pervasiveness of social media, one of the new tasks of emergency personnel is to monitor the information about a disaster on social media by providing quick and accurate information about the event. Incident Command may choose to use social media as an outlet to monitor the need for mutual aid as well as gather volunteers.
Challenges facing these volunteers and those tasked to oversee the response effort include volunteer safety, interference with the operations, security (especially at a crime scene), and qualifications as responders. In the immediacy of a disaster, with limited technology, active and valid certifications and licenses of responders to participate are likely to not be available to cross reference. For example, incident managers often need to deal with firefighters who self-dispatch to a scene—they may be helpful with their specific skill sets but are unproven and unknown and may pose safety hazards on scene. They may lack specific gear and equipment, and their needs may burden the overall response. Development of a National Fire Service Responder Credentialing System could help to alleviate these questions by uniformly assessing the qualifications and capabilities of fire service personnel. , Finally for large-scale disasters, sustained operations will require the expertise of professionals working later shifts in their normal place of employment; organizations’ effectiveness will be depleted if their personnel report to the disaster scene as unsolicited volunteers.
Volunteers will likely continue to converge on disasters because of two reasons: (1) volunteers, especially first responders, are genuinely altruistic and want to help, and (2) they often are unsure as to the exact need, so assuming any help is better than none, they migrate to the scene. People who are used to going to disasters will likely continue in their quest to provide aid. However, rapidly obtaining a needs assessment and disseminating such information may prevent unnecessary aid; this communication depends on a functioning, well-tested, interorganizational, mutual aid, redundant, two-way communication system. Internet and cell phone services may still be widely available, in which case intraorganizational email and mass texts can be used effectively per the organization’s EOP. Social media outlets, such as Facebook, Twitter, and Instagram, can be used to disperse and obtain information quickly and efficiently through official EOPs to provide valid information. Key responders to disaster areas should proactively determine such roles and responsibilities, especially in scenarios that typically involve multiple organizations or jurisdictions. Convergence behavior is often not limited to the movement of personnel. Unnecessary donations of equipment, clothing, and supplies (including blood products that require significant logistical and administrative support) can also appear at a disaster scene. The management of unsolicited volunteers and this cache of supplies can, unfortunately, use critical assets otherwise needed to manage the disaster itself. Public relations officers who understand the functions of social media can coordinate mutual aid public donations of material and personnel: should more aid be needed, these outlets can quickly rally public support and provide details about donation receiving sites and regulations about what can be used; should supplies or personnel be in excess, these outlets can help to curb volunteers or direct them toward a more effective service.
Local Emergency Management Plans and Mutual Aid
A review of the agencies and personnel available as well as thought given to who else may show up at a disaster are important aspects of the planning or mitigation phases of disaster response. Formalizing this information into a plan and developing mutual aid agreements optimize the chances for successful disaster relief operations. Developing a plan at the local level can be a daunting job for the individual(s) tasked (or who volunteer) to complete it. The National Response Plan outlines the basic components for a roadmap, but often state governments provide their towns with a template. For example, the 1996 state of Vermont’s “Model Town Emergency Operations Plan” guides communities through purpose statements, hazard vulnerability analysis, operations, support resources, exercise and training, and other components needed to complete a town plan. Details on specific Emergency Support Functions can be found in its 13 annexes. The current Appendix D offers the Mutual Aid Guideline for Police Departments and the Vermont Memorandum of Understanding (MOU) template. ,
Other locations, typically large cities, may present more complicated situations—multiple agencies from a variety of jurisdictions and levels of government not only interact for daily operations but also for emergencies and disasters. The metropolitan Washington, DC, area has established a 22-member Council of Governments (COG) to help in a coordination effort for the region. Collectively with input from the state of Maryland, the Commonwealth of Virginia, the federal government, public agencies, the private sector, volunteer organizations, and local schools and universities, the COG has established a Regional Emergency Coordination Plan (RECP) to provide a vehicle for collaboration in planning, communication, information sharing, and coordination activities before, during, or after a regional emergency. The plan describes the purpose and scope, as well as the roles, responsibilities, communication, and coordination relationships among member organizations. In a manner similar to the Vermont plan, the RECP delineates its Emergency Support Functions into 16 areas, or Regional Emergency Support Functions (R-ESFs), which “identify organizations with resources and capabilities that align with a particular type of assistance or requirement frequently needed in a large-scale emergency or disaster.” The 16th R-ESF added since the first edition of this textbook is the necessary Volunteer and Donations Management. The R-ESFs are supported by 11 Annexes including the third, “Credentialing.”
Mission Ready Packages are specific response and recovery capabilities that are organized, developed, trained, and exercised before an emergency or disaster. They are based on National Incident Management System (NIMS) resource typing but take the concept one step further by considering the mission limitations that might impact the mission, required support, the footprint of the space needed to stage and complete the mission, personnel assigned to the mission, and the estimated cost. Mission Ready Package templates can be developed using a blank template that can be imported into the EMAC Operations System and models for Mission Ready Packages. The conditions of these arrangements may be to provide reciprocal services or to receive direct financial reimbursement for labor, supplies, or equipment. Ideally the arrangements are codified in writing before an event, although they may be based on unwritten mutual understanding and may even occur after an event has taken place. FEMA’s Mutual Aid Agreements for Public Assistance (Recovery Division Policy Number 9523.6) specifies criteria by which FEMA recognizes the eligibility for reimbursement of costs under the Public Assistance Program incurred by such mutual aid agreements. ,
Finally even though well-defined, codified mutual aid agreements serve all parties who participate in disaster response, it is the process by which disaster planning and mutual aid arrangements develop that is most crucial to a successful disaster response. It is through the planning process that relationships among emergency response organizations, both inside and outside of the planners’ jurisdiction, develop. Exchanging business cards, rehearsing plans through exercise drills, refining communications plans, and other activities during disaster preparedness all foster a sense of trust among the participating organizations, thereby improving overall interorganizational and intraorganizational communications in a disaster. It is incumbent on the agencies to maintain these relationships through personnel changes, due to staff leaving the organization, realignments, or reassignments.
Hospital disaster preparation and incident planning have had a dramatic surge in importance since September 11, 2001. Legislation delegating hospitals as first responders also makes them eligible for funding to support the planning process, an often-quoted impediment to their preparation. Individual hospital preparation and response to an incident have been reviewed in detail elsewhere. , However, outside organizations and agencies continue to expand their expectations for hospitals to be adequately prepared. Unfortunately, though, hospitals often tend to conduct their disaster preparations and training in isolation, which impairs their ability to interact with these groups when disaster strikes. As previously outlined, LEPC guidelines recommend that local hospitals participate in the community’s emergency preparation. In addition to routine agreements on patient receiving and treatment, these preparations now call for expensive and underfunded capabilities, such as planning for the reception of contaminated chemical casualties. Hospitals’ primary credentialing oversight comes from the Joint Commission (JC, formerly JCAHO). This body also mandates a variety of emergency preparations that, again, require additional expensive preparations. If hospitals do not receive adequate financial support and therefore are not prepared, victims of mass casualty incidents may end up riding “ambulances to nowhere.” ,
The JC, however, continues to refine its requirements; EM 02.02.03 preparedness activities include written agreements, MOUs, and other arrangements that are set up in advance so that resource commitments and working relationships are established before disaster strikes. Another valuable reference is the 2011 Centers for Disease Control and Prevention Public Health Preparedness Capabilities: the National Standards for State and Local Planning document, which sets a priority for health care facilities (HCFs) and their strategic partners to work in conjunction with local emergency management to develop written plans and MOUs that clearly define the processes and indications to transition into and out of conventional, contingency, and crisis standards of care.
Hospitals affected by disasters often become inundated with victims seeking care, who in reality need minimal medical attention. Individuals who may simply need observation during the latency period of a potential biological hazard may also overwhelm a hospital’s requirements to treat the more seriously ill or injured. To prevent this increased burden, hospitals should explore mutual aid agreements with special shelters, such as those managed by the ARC or other volunteer organizations, as previously discussed. Urgent care centers, individual physician or health care worker clinics, mental health clinics, surgicenters, nursing homes, etc., may all be additional locations to provide care for low-acuity cases as well. These facilities and others may also help individuals seeking care who really only need shelter. In combination, hospitals may be able to work with these organizations to accommodate much needed surge capacity, a topic covered in detail elsewhere in this textbook.
Volunteers present a significant challenge to those planning for and managing a response. As previously discussed, well-intending volunteers tend to converge at a disaster to provide their assistance. This sense of duty also applies to health care providers who arrive at an overwhelmed or damaged hospital to assist in needed patient care activities. During disaster planning, the facility needs to decide whether volunteers will be used or in what roles they will be used, if nurse or physician volunteers will be used, and if so, how the credentials of volunteers will be verified. The American College of Emergency Physicians recommends that all hospitals have a detailed process in place to allow for the emergency privileging of additional physician staff who arrive at a facility to support response efforts to a declared hospital disaster. So-called “disaster physician privileging” should ideally be completed before an event and mirror the credentials of the providers at their “home hospitals.” , In the event of a disaster, immediate credentials can then be granted with proper identification. Hospitals providing these disaster credentials must also be prepared to provide professional liability coverage for physicians who provide care during a disaster in their institution and be prepared to address issues of compensation for injured workers. , The provision of disaster credentials must follow the medical staff guidelines outlined by the JC under EM 02.02.13 for Licensed Independent Practitioners (LIPs) and EM 02.02.15 for those who are not LIPs. Two standards have to be met: first there has to be a disaster that triggers the EOP and second that the supply of practitioners does not meet the immediate needs of existing patients, typical future patients, and those expected to be affected by the disaster. The elements of performance for this standard include identifying the individual(s) responsible for granting such privileges, a mechanism to manage those with these credentials, and the development of a priority pathway to verify credentials within 72 hours after an event. MOUs can be established with local, county, or state professional organizations’ non-HCF-affiliated LIPs to precredential for a declared disaster.
Identification and credentialing are topics that can be included in mutual aid agreements to the benefit of the entire community or state. As responders and volunteers appear on scene, it is critical that security personnel are able to determine who is allowed to work and in what capacities, often without the benefit of a sophisticated understanding of licensure and credentialing. Coordinated standards for identification can increase the speed and accuracy of this process. Some national initiatives are under way, such as the fire service credentialing proposal previously described. Another initiative is the Health Resources and Services Administration (HRSA) funding for the Emergency System for the Advance Registration of Volunteer Health Professionals (ESAR-VHP) program, which is an attempt to provide standardized credentialing and identification protocols. (The basis for the ESAR-VHP initiative is U.S. Public Law 107-188, the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 [section 107, Emergency system for advance registration of health professions volunteers].) (PL 107-188 is available at: http://thomas.loc.gov/ .) The 2005 HRSA guidelines require awardees to develop ESAR-VHP activities in their regions. However, HCFs should seek out local initiatives and actively participate to ensure that their needs are addressed and that they are aware of the systems that are developed in their communities.
Like other community-based organizations, hospitals must share resources and plans with other entities in the community. Mutual aid agreements or MOUs formalize and delineate each other’s roles and responsibilities. Agreements need to include not only representatives from public safety and community industry but also those from other nearby HCFs. Developing a detailed yet functional mutual aid agreement between medical facilities can be a challenging task. Much coordination, inspection, discussion, legal review, etc., must occur before most signatories will agree to such arrangements. Fortunately several templates exist to aid the process. These models include information, such as the purpose of the MOU, timing and method of communicating requests, documentation standards, guidance on patient transport, hospital supervision, financial and legal liabilities, and notification of next of kin and the patient’s physician. It is also important that these topics be discussed not only in general principles of medical operations, but also as they apply to the evacuation of patients and the transfer of personnel, pharmaceuticals, supplies, or equipment.
When disaster strikes a community, local, community-level assets typically respond first. The majority of organizations in the first responder community attempt to establish command and control of the scene using principles of the Incident Command System (ICS). Discussed in detail elsewhere in this textbook, the ICS establishes a proven organizational template that can be expanded or contracted in a modular fashion to meet the demands of the event. The emergency medical services (EMS) branch of the operations section is supposed to manage medical support to the operation. Under the NIMS, which is discussed in detail elsewhere in this textbook, a medical unit is also established under the logistics section to provide medical support to the emergency responders themselves. If the incident is primarily a mass casualty event involving essentially all medical assets, then the operations section chief, or even the incident commander, may be from the health sector. ,
This organizational paradigm is often not followed by hospitals in their response to either an internal or external disaster; they tend to rely on their own organizational structure that has evolved to support their day-to-day operations. However, when disaster strikes, hospitals need to move toward an emergency management structure to ensure institutional and personnel safety and security, optimize patient care, and efficiently use scarce resources. As previously mentioned, the JC mandates an emergency management system that easily integrates into that of the community.
The Hospital Emergency Incident Command System (HEICS) is the standard for health care systems’ disaster response originating in Orange County California in 1991. The organization of HEICS mirrors that of ICS, with five functional areas: command, operations, planning, logistics, and finance and administration. Job action sheets provide checklist tools for providers in each position to prioritize and categorize their efforts into immediate, intermediate, and extended tasks. HEICS is not a turnkey system; rather it is a process that must be adapted to each event and is supported by specific emergency management policies and procedures. , The HEICS structure focuses on management of internal disasters. As previously discussed, coordination with external agencies becomes necessary for the facility to effectively integrate itself into any community disaster response. HEICS can begin to facilitate that process by ensuring that outside groups and leaders that follow ICS principles can (ideally) find their hospital-based counterpart in the ICS structure to better coordinate the HCF disaster response.
State and federal assets that arrive on scene will similarly fall in line with their own form of an ICS, although a major event may result in the establishment of multiple incident command posts (ICPs) and agency emergency operations centers (EOCs). To manage the entire event, representative agencies may meet to form a Joint Operations Command (JOC), usually off-site to effectively provide a strategic, unified command.
As previously discussed, most disasters begin as local events and are managed with local, community-level assets. State and federal agencies located in the vicinity may also serve as first responders without full escalation of the response outside of the community. When community resources become overwhelmed or other characteristics of the disaster mandate state or federal involvement (such as in multijurisdictional fire response or events related to terrorism), individual state emergency management organizations respond.
Many state assets can be called on to support a state-managed disaster response. Integrating them into the state emergency management plan naturally requires detailed planning. One organization that is often overlooked, in part because of its perceived complexity, is the National Guard. At the disposal of the governor, National Guard units serve the public interest in their state in time of disaster unless they are called on for federal service. A specific asset is one of the 55 National Guard Weapons of Mass Destruction Civil Support Teams (WMD CSTs). These teams, under the operational control of the adjutant general and ultimately the governor of each state, are designed to mobilize within 2 hours to augment local and regional terrorism response, principally for events known or suspected to involve weapons of mass destruction, including nuclear, chemical, or biological agents. When deployed to an event these teams report to the incident commander and provide assessment capabilities, advice, and assistance to the response effort. In essence, they supplement other fire and hazardous materials teams that may be on location, serving as a bridge until other state or federal assets arrive. ,
State Emergency Response Commission
Each state develops its own disaster organizational system. However, the previously described legislation that mandated the establishment of LEPCs, also directed the establishment of SERCs. The Emergency Planning and Community Right-to-Know Act of 1986 (EPCRA) does not require a specific number of participants of the SERC nor their qualifications; thus each state and tribal land SERC varies, depending on the appointments by each governor and tribal chief executive officer. The SERC establishes local emergency planning districts, which may be a county or multiple counties of a metropolitan area. The four main duties of the SERC are to appoint, supervise, coordinate LEPC activities, to fulfill the requirements of EPCRA regarding specific reports and notifications, to make these reports and notifications available to the public, and annually review the LEPC local emergency plans.
Emergency Management Assistance Compact
Disasters that cross state boundaries may be managed at the state level, without necessarily invoking the need for a federal response, under the auspices of the EMAC. Legislated in 1996 as Public Law 104-321, EMAC is a mutual aid agreement and partnership between states that exists because of the common threat from a variety of disasters; it is a legal mechanism and not an organization. Out-of-state aid organized through EMAC helps ease the movement of personnel and equipment across state borders. Requests for EMAC assistance are legally binding contracts, obligating the requesting state to reimburse all out-of-state costs and liability complaints for out-of-state personnel. Finally, EMAC permits states to both ask for assistance and to provide available resources with a minimal amount of “bureaucratic wrangling.” ,
Model Intrastate Mutual Aid Legislation
Produced by the National Emergency Management Association, in concert with the Department of Homeland Security, FEMA, and other emergency responders, the Model Intrastate Mutual Aid Legislation provides a robust template to expand on the mutual aid agreement legislated under EMAC. A multidisciplinary group of subject matter experts gathered in January 2004 to review a variety of mutual aid agreements from all levels of government, and on thorough review and evaluation of “best practices” developed this template. Covering 11 basic articles, “The model is meant to be a tool and resource for states and jurisdictions to utilize in developing or refining statewide mutual aid agreements. States and jurisdictions have modified the model to conform to their own state laws and authorities, or to address unique needs and circumstances. Further, the proposed articles and provisions in the model are complementary to the recommended minimum elements to be included in mutual aid agreements that are a part of the draft National Incident Management System Plan.” , ,
Private Sector Resources
In 2013 the National Emergency Management Association (NEMA) recognized that a state lacked the mechanism to activate what has proven to be the majority of assets available to the state, nongovernmental, private sector, or tribal resources to fill requests for assistance through EMAC. Based on the successful deployment of these types of assets by the state of Minnesota to the North Dakota Floods (2009), Hurricane Irene (2011), and Hurricane Sandy (2012), NEMA developed the “Intergovernmental Agreement (IGA) Nongovernmental Organizational Agreement (NGOA) Tribal Agreement (TA).” The introduction explains the premise of the EMAC with fill-in-the-blank lines for the requesting state, sending state, and the reason for the EMAC request. Clearly stated are expectations about work conditions and shift hours and that the responders should be prepared to be self-sustained for several days. Terms and conditions, employee status, liability, logistics, equipment, reimbursement, and other stipulations are in the contract. The development of these types of contracts is one example of how the stream of private sector trucks headed from one state to another to repair downed power and telephone lines after an ice or other storm, tornado, or other disaster, is accomplished within hours of the event.
Once the disaster response exceeds the capabilities of local, state, or interstate capabilities or the disaster results from a recognized act of terrorism, federal resources mobilize to assist the community. A large number of diverse organizations with many differing capabilities can be called on to assist; many of these are discussed in detail elsewhere in this textbook. Both in metropolitan areas and in rural areas adjacent to federal facilities these assets may appear immediately on scene, serving in a first responder capacity. However, outside of this example, federal assets mobilize in a specified manner, according to federal policy.
The 2013 edition of the National Response Framework (NRF) with 14 core capabilities provides the information for the whole community to engage to achieve the National Preparedness Goal. Critical improvements over the 2008 NRF include the formal recognition of the Emergency Support Functions as coordinating structures. There are five frameworks intended to be strategic documents with tactical planning covering the preparedness missions: Prevention, Protection, Mitigation, Response, and Recovery.
The Disaster Declaration Process and Federal Disaster Assistance
When disaster strikes, individual communities, states, and other organizations cooperating through mutual aid agreements respond to assist the afflicted area and its victims. As noted some federal assets may be on hand, and depending on the scenario (e.g., a terrorist event) others may preemptively deploy to the scene. Outside of these settings, the federal disaster declaration process to request federal assistance follows the guidelines outlined in the 1988 Robert T. Stafford Disaster Relief and Emergency Assistance Act. This Stafford Act requires that “all requests for declaration by the President that a major disaster exists shall be made by the Governor of the affected State.”
The governor’s request is processed through the regional FEMA office. The first step is a preliminary damage assessment (PDA) conducted by state and federal officials. This assessment, in concert with the governor’s request, must demonstrate a need beyond the capabilities of the local and state governments. The PDA normally precedes the governor’s request, although it may follow for obviously catastrophic events. Pending the approval of federal assets, the governor must initiate the state’s emergency plan, documenting the resources used for the state’s response. Also required is an impact estimate, which is a projection of the financial cost to the public and private sectors. Finally the governor must provide a needs assessment on the assistance required. Based on this information and with the governor’s appeal, the president decides on the validity of the request; declaration of the event as a federal disaster activates a broad scope of federal programs and services to assist in the response, rescue, and recovery operations. Figure 34-2 presents a mutual aid flow chart.