HOSPITAL INCIDENT

COMMAND SYSTEM
(HICS)
Reported by:
KAYE, Laqui
Marivic, miagar

HOSPITAL INCIDENT COMMAND SYSTEM (HICS)

Is a modification of the ICS that is used by

both hospitals and law enforcement agencies.

HICS incident commander is the hospital

emergency preparedness coordinator who

oversees and coordinates all efforts
surrounding the event.

Hospital Incident Command System

HICS incident management team charts depict the hospital command functions that

have been identified and represent how authority and responsibility are distributed
within the incident management team.
The activities at the Hospital Command Center (HCC) are directed by the Incident

Commander, who has overall responsibility for all activities within the HCC. The
Incident Commander may appoint other Command Staff personnel to assist.
Many incidents that likely will occur involve injured or ill patients. The Operations

Section will be responsible for managing the tactical objectives outlined by the
Incident Commander. Branches of this section include: Department Level,Patient
Care,Infrastructure, Business Continuity, Security, andHazMat.

The Planning Section will collect, evaluate, and disseminate incident

situation information and intelligence to Incident Command and

includes a Resources Unit, Situation Unit, DocumentationUnit,
andDemobilizationUnit. Support requirements will be coordinated by
the Logistics Section, and the Finance/Administration account for the
costs associated with the response.
Also, several additional incident command principles and practices

are covered in this section, including incident command staff

identification, building incident command staff depth, job action
sheets, and incident response guides.

Example HICS Structure:

Incident Commander Administrator-in-Charge, (may re-delegate

position, and provide control of the Command Center (CC)).

Public Information Officer provides official information to media.
Liaison Officer connects to external agencies in response efforts.
Safety Officer Identifies hospital threats and takes steps to ensure

continued safety of the facility, employees, and patients

Medical / Technical Specialist i.e. CDC Doctor.

 Operations Chief (Organize and direct essential activities given

by the CC and facilitate proper hospital staffing).
Staging Manager
Medical Care Branch Director
Infrastructure Branch Director
HAZMAT Branch Director
Security Branch Director
Business Continuity Branch Director

Planning Chief (Develops action plan for operations sustainment

in 4, 8, 24, and 48 hour increments after the disaster incident).
Resources Unit Leader
Situation Unit Leader
Documentation Unit Leader
Demobilization Unit Leader

 Logistics Chief (Direct maintenance and supply operations to

ensure patient care, supplies, equipment, and utilities for
essential hospital functions)
Service Branch Director
Support Branch Director

Finance Chief (Track expenditures for repayment and special

purchases)
Time Unit Leader
Procurement Unit Leader
Compensation/Claims Unit Leader
Cost Unit Leader

The Incident Commander:

Needs overall authority to carry out the mission
Often not the CEO for the initial response
Organizes and directs the EOC and all positions in HEICS structure
Gives overall direction to the operation
Authorizes hospital evacuationsMay require a change of command in the
early stages of response
Develops Incident Action Planfor the initial response period

The Medical Officer or Director:

Has the responsibility and authority to assure that the appropriate medical
care is delivered
Public Information Officer (PIO)
Provides concise and pertinent information to the media.
Provides scheduled briefings to the media and or public
Contact person for all media agencies
Works closely with PIOs from other agencies and hospitals


Liaison Officer
Functions as the incident contact person for other agencies
Communicates into and out-of the hospital

Safety / Security Function

Monitors the situation for safety related issues
Reinforces scene safety and makes reports on incidents
Establishes a security command area and works closely with I.C.

Responsible for maintaining the facility and procuring resources

Facilities Unit
Communications Unit
Transportation Unit
Materials Supply Unit
Nutritional Supply Unit

Logistics Mission-Provide a hospitable environment and materials to meet the overall

medical objectives

Planning Sector
Situation Status Unit
Labor Pool
Medical Staff Unit
Nursing Unit
Patient Tracking Officer
Patient Information
Planning Mission -determine and provide for the continuance of each medical objective;
Planning section personnel prompt and drive all HEICS officers to develop long and short
range plans.
Responsible for all financial activity and accounting;
Time Unit
Procurement Unit
Claims Unit
Cost Unit

Finance Mission -Provide funding for present medical objective and stress
organization-wide documentation to maximize financial recovery and
reduction of liability

Operations Section
Medical Care Director
Medical Staff Director
Ancillary Services Director
Human Services Director

Operations Mission -carry out the mission goals to the best of the
staffs abilities...by setting and assigning tactical strategies (objectives) to
meet the OVERALL STRATEGIC GOALS set by the IC and Section Chiefs.
Operations Mission -carry out the mission goals to the best of the staffs
abilities...by setting and assigning tactical strategies (objectives) to meet
the OVERALL STRATEGIC GOALS set by the IC and Section Chiefs.

Components of HEICS

The basic components of HEICS are:

Organizational Chart
Job Action Sheets
Supporting Forms
Color Coded Vests
The Go Kitwhich contains the incident management tools identified above

Color Coded Vests

Vests are worn by the individuals filling the HEICS positions.
The vests are color coded for ease of identification of sections.
I.C./Support Group White/Black
Operations Red
Finance

Green

Planning Blue
Logistics Yellow

HEICS Tool Kits

Helps to keep materials organized
Important that staff know where these are located
Assure that the Tool kits are checked regularly for completeness and for other concerns such as battery
charging

Job Action Sheets

Job action sheets are provided for each HEICS position.
List specific objectives for each position
Provide direction and focus
Concise mission statement
Prioritize responsibilities into immediate, intermediate, and extended
Initiating an Incident Response
Open your Emergency Operations Center (EOC)
Gather your Command staff
Access your HEICS tools
Gather information about the incident
Begin to construct a plan to direct your organizations response to the incident

Emergency Operations Center (EOC)

Typically a meeting room away from the E.D. or the event
Staffed by the HEICS team

Establish Incident Objectives and Strategy

Strategic Goal Examples
Returning to normal operations hospital-wide
Returning ED to full functionality
Restoring water to Surgery

Tactical Objective Examples

Vertical evacuation of floor #2 to floor #1
Lockdown of the ED (all access and egress on floor #1)
Triage 45 patients on a bus in the lot
Assigning a 5 person team to perform a structural assessment
Documentation and Supporting Forms
Documentation is of key importance
Can aid in the financial recovery of the organization and may decrease liability
exposure
Two types of documents available:
Traditional FEMA ICS forms
HEICS supporting forms

Terminating the Incident

Develop a mechanism to determine when the facility cans
stand-down from its emergency response plan
Communicate this information to all parties
Assess facility
Account for all equipment
Assemble all key personnel
Gather incident documentation
Prepare a written after-action report
Gather financial documentation
Consider the need for Critical Incident Stress services
Do employees appear to be troubled by the event?
Are employees asking for help coping with their reactions to
the event?

Hospital Emergency Incident Command Structure:

1. Emergency Incident Command (in the Command Center/EOC)
a. All available information shall be evaluated and evacuation schedule
established in coordination with the Section Chiefs. This information
shall include:
Structural, non-structural, and utility evaluation from

Engineering/Damage Assessment & Control Officer.

Patient status reports from Planning Section Chief.
Evaluate manpower levels and authorize activation of staff call-in

plans, as needed.
b. Disaster evacuation schedule to:
Planning Section Chief
Liaison Officer
Safety and Security Officer
Logistics Chief
Operations Chief

2. Liaison Officer
a. Maintain contact with Public Safety Officials, Health Dept.
and Ambulance Agency.
b. Complete "Hospital Evacuation Worksheet"

3. Logistics Chief
a. Assign Transportation Officer to assemble evacuation
teams from Labor Pool.
b. Notify Planning Section Chief of plans.

4. Transportation Officer
a. Assemble evacuation teams from Labor Pool.
b. Ensure coordination of off-campus patient transportation
c. Confirm implementation of Transportation Action Plan.
d. If able, assign six people to each floor for evacuation manpower.
e. Brief team members on evacuation techniques, (attached)
f. Arrange transportation devices (wheelchairs, gurneys, etc. to be
delivered to assist in evacuation).
g. Report to floor being evacuated and supervise evacuation.
h. Report to Nurse Manager/Charge Nurse for order of patients
being evacuated and method of evacuation.

5. Nursing Service Officer

a. Designate holding areas for critical, semi-critical, and
ambulatory evacuated patients.
b. Organize efforts to meet medical care needs and
physicians staffing of Evacuation Holding areas.
c. Distribute evacuation schedule to Nurse Managers.
d. Verify Nurse Managers/Charge Nurses have initiated
evacuation procedure.
e. Request Medical Staff Officer to notify physicians of need
for transfer orders.
f. Assign Holding Area Coordinators, and adequate number
of nurses to holding areas.
g. Contact pre-established lists of hospitals, extended care
facilities, school, etc. to determine places to relocate
patients. Forward responses to Planning Section Chief.

h. Designate a safe exit after determining location of patients to

be evacuated.
i. Assign a person to record Evacuation Activity, including:
Time of evacuation
Method of evacuation
Name of patient
Evacuation status A B C
Evacuated from Rm. to (area)
j. Forward documentation of evacuation and patient disposition
to Patient Tracking Coordinator or Patient Info Manager.
6. Medical Staff Officer
a. Notify physicians of need for patient transfer orders.
b. Assist Nursing Service Officer as needed.

7. Nurse Managers or Charge Nurses

a. Determine patient status. Patients will be evacuated according to status.
b. Communicate status with large sticker on patient's chart according to the
following criteria:
non-critical/Ambulatory
non-critical/Non-ambulatory
critical/requires ventilation or special equipment

c. Report patient status to Nursing Service Officer.

d. Assign specific nurses to maintain patient care.
e. Assign two nurses to prepare patients for evacuation.
Place personal belongings in a bag labeled "BELONGINGS" with name

Patient No. with medications,prosthetics, and special Patient need items

the sinside bag.
Place KARDEX and addressograph in Patient's chart secured with tape,

which is to remain with the patient.

f. Designate a safe exit after determining location of patients to be

evacuated.
g. Assign a person to record Evacuation Activity, including:
Time of evacuation
Method of evacuation
Name of patient
Evacuation status A B C
Evacuated from Rm. to (area)
h. Forward documentation of evacuation and patient disposition to

Patient Tracking Coordinator or Patient Info Manager.

8. Patient Information Manager

a. Compile patient info on Inquiry Sheets.

9. Cardiopulmonary Services Manager

a. Assign staff members to perform ventilation
on required patients.
b. Assess number of positive pressure breathing
devices/bag-valve-masks available

10. Safety and Security Officer

a. If able, assign a security person to each area being evacuated for traffic
control/safety.
b. Turn off oxygen, lights, etc. as situation demands.
c. Check the complete evacuation has taken place and that no patients/staff
remain.
d. Place "Evacuated at " (date/time) sign up at main area exit/entrance of
evacuated area after evacuation is complete.

11. Facilities Operation Officer

a. Obtain equipment/supplies needed for structural safety during evacuation.
b. Obtain portable toilets and privacy screens for use in areas where
evacuated patients are relocated, if necessary.

12. Labor Pool Officer

a. All available Engineering, Housekeeping, Security staff, etc. not previously
assigned to incident will assist in the movement of patients.

Hospital Emergency Preparedness Plans

Health Care facilities is required by the Joint Commission on Accreditation of

Healthcare Organizations (JCAHO) to create a plan for emergency preparedness

and to practice this plan twice a year.
Generally these plans are developed under the Environment of Care Committee

or Safety Committee and are overseen by an administrative liaison. Before the

basic emergency operations plan (EOP) can be developed, the planning
committee of the facility first evaluates the community to anticipate the types
of natural and manmade disasters that might occur.
This is not a difficult task and should be a responsibility of the local facility,

safety committee, safety officer, or emergency department (ED) manager.

This information can be gathered by questioning local law enforcement and fire

departments and assessing the amount of air or train traffic, automobile traffic,
and flood, earthquake, tornado, or hurricane activity. Consideration is given to
special situations such as proximity to chemical plants, nuclear facilities, or
military bases that may enhance the communitys potential for
manmade disasters.

The planning committee must have a realistic

understanding of its resources. It must

determine, for example, whether the facility
has a pharmaceutical stockpile available to
treat specific chemical or biological agents.

COMPONENTS OF EMERGENCY OPERATIONS PLAN

Once the initial assessment is complete, the facility develops the EOP. Essential
components of the plan are as follows:
An activation response: The EOP activation response of a health care facility
should define where, how, and when the response is initiated.
An internal/external communication plan: Communication is critical for all parties
involved, including communication to and from the prehospital arena.
A plan for coordinated patient care: A response is planned for coordinated patient
care into and out of the facility, including transfers to other facilities. The site of the
disaster can determine where the greater number of patients may self-refer.

 Security plans: A coordinated security plan involving facility and

community agencies is key to the control of an otherwise chaotic situation.
Identification of external resources: External resources are identified,
including local, state, and federal resources and information about how to
activate these resources.
A plan for people management and traffic flow: People management
includes strategies to manage the patients, the public, the media, and
personnel. Specific areas are assigned, and a designated person is delegated
to manage each of these areas.
A data management strategy: A data management plan for every aspect of
the disaster will save time at every step. A backup system for charting,
tracking, and staffing is developed if the facility has a computer system.

 Deactivation response: Deactivation of the response is as important as

activation; resources should not be overused. The person who decides

when the facility is able to go from the disaster response back to daily
activities is clearly identified. Any possible residual effects of a disaster
must be considered before this decision is made.
A post-incident response: Often facilities see increased volumes of

patients up to 3 months after an incident. Post-incident response must

include a critique and a debriefing for all parties involved, immediately
and again at a later date.
A plan for practice drills: Practice drills that include community

participation allow for troubleshooting any issues before a real-life

incident occurs.
Anticipated resources: Food and water must be available for staff,

families, and others who may be at the facility for an extended period
Mass casualty incident planning: MCI planning includes such issues as

mass fatality and morgue readiness.

An educational plan for all of the above: A strong educational plan for

all personnel regarding each step of the plan allows for improved
readiness and additional input for fine-tuning of the EOP.

INITIATING THE EMERGENCY OPERATIONS PLAN

Notification of a disaster situation to a facility varies with

each situation. Generally, the notification to the facility

comes from outside sources unless the initial incident
occurred at the facility.
The disaster activation plan should clearly state how the

EOP is to be initiated.
If communication is functioning, field incident command

will give notice of the approximate number of arriving

patients, although the number of self-referring patients will
not be known.

Identifying Patients and Documenting Patient Information

Patient tracking is a critical component of casualty management.
Disaster tags, which are numbered and include triage priority, name,

address, age, location and description of injuries, and treatments or

medications given, are used to communicate patient information.
The tag should be securely placed on the patient and remain with the

patient at all times.

The tag number and the patients name are recorded in a disaster

log. The log is used by the command center to track patients, assign
beds, and provide families with information.

Triage of Disaster Victims

Triage is the sorting of casualties to determine priority of health care

needs and the proper site for treatment.

In nondisaster situations, health care workers assign a high priority and

allocate the most resources to those who are the most critically ill.
For example, a young man who has a chest injury and is in full cardiac

arrest would receive advanced cardiopulmonary resuscitation, including

medications, chest tubes, intravenous fluids, blood, possibly even
emergency surgery in an effort to restore life.
In a disaster, however, when health care providers are faced with a

large number of casualties, the fundamental principle guiding resource

allocation is to do the greatest good for the greatest number of people.
Decisions are based on the likelihood of survival and consumption of

available resources. Therefore, this same patient, and others with

conditions associated with a high mortality rate, would be assigned a
low triage priority in a disaster situation, even if the person is conscious.

Although this may sound uncaring, from an ethical standpoint the expenditure of

limited resources on individuals with a low chance of survival, and denial of those
resources to others with serious but treatable conditions, cannot be justified.
The triage officer rapidly assesses those injured at the disaster scene. Victims are

immediately tagged and transported or given life-saving interventions.

One person performs the initial triage while other emergency services personnel

perform life-saving measures (eg, intubation) and transport patients.

Although emergency medical services personnel carry out initial field triage,

secondary and continuous triage at all subsequent levels of care is essential.

Staff should control all entrances to the acute care facility so that incoming

patients are directed to the triage area first. The triage area may be outside the
entry or just at the door of the ED.
This allows all patients, including those arriving by medical transport and those

who walk in, to be triaged. Some patients already seen in the field will be
reclassified in the triage area, based on their current presentation.

Managing Internal Problems

Each facility must determine its supply lists based on its own

needs assessment. The Red Cross has developed a basic

survival/ shelter resource kit.
The EOP committee should determine the top 10 critical

medications used during normal day-to-day operations and then

anticipate which other medications may be required in a
disaster or an MCI.
For example, the hospital might plan to have available a

stockpile of cyanide kits or antibiotics used in treating biological

agents.
Information should be available about local resources for

stocking or restocking any of the basic and special supplies,

how those supplies are requested, and the time required to
receive those supplies.

Communicating With the Media and Family

Communication is a key component of disaster management.

Communication within the vast team of disaster responders is

paramount; however, effective, informative communication with the
media and worried family members is also crucial.
MANAGING MEDIA REQUESTS FOR INFORMATION
Although the media have an obligation to report the news and can play

a significant positive role in communication, the number of reporters,

newscasters, and their support teams can be overwhelming, possibly
compromising operations and patient confidentiality.
A clearly defined process for managing the media, which includes a

designated spokesperson, a site for the dissemination of information

(away from patient care areas), and a regular schedule for providing
updates should be part of the disaster plan. Such a plan helps to
prevent the release of contradictory or inaccurate information.
Initial statements should focus on current efforts and what is being

done to better understand the scope and impact of the situation.

Information about casualties should not be released. Security staff
should not allow media personnel access to patient care areas.

CARING FOR FAMILIES

Friends and family members converging on the scene

must be cared for by the facility.

They may be feeling intense anxiety, shock, or grief

and should be provided with information and updates

about their loved ones as soon as possible and
regularly thereafter.
They should not be in the triage or treatment areas,

but in a designated area staffed by available social

service workers, counselors, therapists, or clergy.
Access to this area should be controlled to prevent
families from being disturbed.

The Role of Nursing in Disaster Response Plans

The role of the nurse during a disaster varies. The nurse may be asked to

perform outside his or her area of expertise and may take on responsibilities
normally held by physicians or advanced practice nurses.
For example, a critical care nurse may intubate a patient or even insert chest

tubes. Wound dbridement or suturing may be performed by staff registered

nurses. A nurse may serve as the triage officer.
Although the exact role of a nurse in disaster management depends on the

specific needs of the facility at the time, it should be clear which nurse or
physician is in charge of a given patient care area and which procedures each
individual nurse may or may not perform.
Assistance can be obtained through the incident command center, and

nonmedical personnel can provide services where possible.

For example, family members can provide nonskilled interventions for their

loved ones. Nurses should remember that nursing care in a disaster focuses on
essential care from a perspective of what is best for all patients.

New settings and atypical roles for nurses arise during a

disaster: the nurse may provide shelter care in a

temporary housing area, or bereavement support and
assistance with identification of deceased loved ones.
Individuals may require crisis intervention, or the nurse

may participate in counseling other staff members and

in critical incident stress management (CISM). At-risk
populations may also require special considerations
during a disaster.

CONSIDERING ETHICAL CONFLICTS

Disasters represent a disparity between the resources of the health care agency and

the needs of the victims. This generates ethical dilemmas for the nurses and other
providers of care. Issues include conflicts related to
Rationing care
Futile therapy
Consent
Duty
Confidentiality
Resuscitation
Assisted suicide
Nurses may find it difficult to not provide medical care to the dying, or to withhold

information to avoid spreading fear and panic. Clinical scenarios that are
unimaginable in normal circumstances, confront the nurse in extreme instances.
Other ethical dilemmas may arise out of health care providers instinct for self-

protection and protection of their families. For example, what should a pregnant nurse
do when incoming disaster victims have been exposed to radiation, yet too few nurses
are available?
Nurses can plan for the ethical dilemmas they will face during disasters by

establishing a framework for evaluating ethical questions before they arise and by
identifying and exploring possible responses to difficult clinical situations.
They can consider how the fundamental ethical principles of utilitarianism,

beneficence, and justice will influence their decisions and care in disaster response.

MANAGING BEHAVIORAL ISSUES

Although most people pull together and function during a disaster,
both individuals and communities suffer immediate and sometimes longterm psychological trauma. Common responses to disaster include
Depression
Anxiety
Somatization (fatigue, general malaise, headaches, gastrointestinal
disturbances, skin rashes)
Posttraumatic stress disorder
Substance abuse
Interpersonal conflicts
Impaired performance
Factors that influence an individuals response to disaster include the
degree and nature of the exposure to the disaster, loss of friends and
loved ones, existing coping strategies, available resources and support,
and the personal meaning attached to the event.
Other factors, such as loss of home and valued possessions,
extended exposure to danger, and exposure to toxic contamination, also
influence response and increase the risk of adjustment problems.

Those exposed to the dead and injured, eyewitnesses and those

endangered by the event, the elderly, children, emergency firstresponders, and medical personnel caring for victims are
considered to be at higher risk for emotional sequelae.
Nurses can assist disaster victims by providing active listening

and emotional support, giving information, and referring

patients to a therapist or social worker.
Health care workers must refer individuals to mental health

care services, because experience has shown that few disaster

victims seek these services and early intervention minimizes
psychological consequences.
Nurses can also discourage victims from subjecting themselves

to repeated exposure to the event through media replays and

news articles, and encourage them to return to normal activities
and social roles when appropriate.

REFERENCES:
Brunner & Suddarths Medical-Surgical Nursing 12th
edition
http://en.wikipedia.org/wiki/Hospital_incident_comm
and_system
Basic HEICS Final.pdf