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A ComprehensiveFunctional System Descriptionfor Mass Casualty Medical

and Health Incident Management

Joseph A. Barbera, M.D.Co-Director, The George Washington University,

Institute for Crisis, Disaster, and Risk Management

Anthony G. Macintyre, M.D.The George Washington University

Supported by The Alfred P. Sloan Foundation

Medical and Health Incident Management (MaHIM) System

Final Report - December 2002


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Medical and Health Incident Management (MaHIM) System: A ComprehensiveFunctional System Description for Mass Casualty Medical and Health Incident Management

Joseph A. Barbera, M.D.Co-Director, The George Washington University,Institute for Crisis, Disaster, and Risk Management

Anthony G. Macintyre, M.D.The George Washington University

This document may be referenced using the following:

Barbera J.A., Macintyre A.G. Medical and Health Incident Management (MaHIM) System: A Comprehensive FunctionalSystem Description for Mass Casualty Medical and Health Incident Management. Institute for Crisis, Disaster, and RiskManagement, The George Washington University. Washington, D.C., October 2002.Supported by a grant from the Alfred P. Sloan Foundation.

Copyright 2002, Institute for Crisis, Disaster, and Risk ManagementThe George Washington University

Graphic Design: Ann Kollegger Design • Proofreading: Marjorie Weber (TQM — Total Quality Management)


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Preface Preface

Chapter 1 Executive Summary

Chapter 2 Introduction and Background

Chapter 3 Project Methodology: Objectives, Assumptions,and Description of the Process

Chapter 4 MaHIM: Objectives and Assumptions

Chapter 5 MaHIM: Functional System Description Overview

Chapter 6 MaHIM: Medical and Health Incident Management Functional Area

Chapter 7 MaHIM: Medical and Health Operations Functional Area

Chapter 8 MaHIM: Medical and Health Support Functional Areas

Chapter 9 MaHIM: Concept of Operations

Chapter 10 Project Findings and Conclusions

Appendix A Document Research List

Appendix B Project Work Plan and Task Completion Schedule

Appendix C MaHIM Peer Review Group

Appendix D Acronyms

Table of Content


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Project Goal

This project was designed to develop a peer-reviewed, require-ments-based operational model for mass casualty response,

based upon medical, public health, and emergency managementscience. The model provides a single, comprehensive systemdescription of the functional components critical to effectiveresponse for any mass casualty incident. It describes the func-tions according to management system constructs, delineatingthe critical relationships between functions, both within the sys-tem and with important nonmedical emergency response func-tions such as law enforcement and fire services. It also describesthe system processes that coordinate these many componentfunctions to work toward a common goal: the limitation of mor-

bidity (injury or illness) and mortality (deaths) in a populationexposed to a major hazard. While the model is qualified as beingfor “mass casualties” it is intended to be interpreted into daily

operations.The development process for the model was based upon severalcore themes:

• An all-hazards approach (natural, technological, andhuman induced) that is applicable to planning for all masscasualty incidents.

• A peer-review methodology from a range of experts to promote multidisciplinary acceptance and application of themodel to diverse geographic regions.

• A focus on the central issues of incident managementorganization, information management, communicationconnectivity, medical surveillance, medical patient carecapacity, and patient specialty care. This is not an attemptto define the innumerable and rapidly evolving technical requirements (“how to do it”), but rather it describes the

functional requirements (“what needs to be done”) of acomprehensive system. The term “system” in this projectmeans a clearly described functional structure, includingdefined processes, that coordinates otherwise diverse partsto achieve a common goal.

For the purposes of this project, the term “mass casualties” isdefined using Secretary of HHS Tommy Thompson’s definitionof greater than 500 casualties.*

How To Use This Document

This document provides a broad overview of the breadth andcomplexity of mass casualty medical incident response. Thedocument moves through a description of the backgroundinformation and science upon which this project is based (the

“development process assumptions”) and provides a functional description of the model developed in the project:the Medical and Health Incident Management (MaHIM)System. Incident management and response components are

designated by the term “function.” A description of each of the functions and sub-functions and how they primarily relatewithin the MaHIM System is provided in Chapters 5-8. AConcept of Operations (Chapter 9) assists the reader in under-standing how management processes coordinate the functionsto operate as a comprehensive system.

It must be emphasized that this is not an “organizational”model. To use the model as a planning tool, readers shoulddetermine which organizations within their jurisdiction areresponsible for each of the described functions, sub-functions,and processes. Delineating these findings in the MaHIM layoutthen provides a customized organizational model for that indi-

vidual jurisdiction.The model is intended to be a primarily formative rather than anevaluative tool. In other words, this model is designed to assista region or jurisdiction in developing an optimally effective masscasualty capability. It is not intended to be used as a pass/failgrading method for current systems and personnel.

Because of the ever-increasing importance and prevalence of theMetropolitan Medical Response System (MMRS)** across theUnited States, this model has been designed to meet or exceed therequirements of the MMRS contracts. It may therefore be a use-ful tool for the communities involved with the MMRS program.

The authors are indebted to Greg Shaw, Lissa Westerman, andJohn R. Harrald, Ph.D., for their research, administrative, andediting support in this project. The authors would also like toexpress their appreciation to the experts who participated so fullyin the project review process (a list of participating reviewers isfound in Appendix C). Their comments and suggestions helpedgreatly to improve the accuracy and focus of this project and thefinal model.

1 - 1Joseph A. Barbera, M.D.

Anthony G. Macintyre, M.D.

Mass Casualty Medical and Health Incident ManagementThe Institute for Crisis, Disaster, and Risk Management

The George Washington University, FINAL REPORT 12/02

* 31 January 02 Letter from Secretary of Health and Human Services Tommy Thompson to state governors,copy distributed to the American Hospital Association, Enclosure 2: Critical Benchmarks for BioterrorismPreparedness Planning: “7. Develop a time line for implementation of regional hospital Plans that would accom-modate in an emergency at least 500 patients.” “Casualty” refers toany human accessing health or medicalservices, including mental health services and fatality care, as a result of a hazard impact.

**The Metropolitan Medical Response System is a program under the Office of Emergency Response of theU.S. Department of Health and Human Services that provides preparedness funds for communities to improvehealth and medical capabilities for mass casualty incidents. More information is available at:http://ndms.dhhs.gov/index.html.

Preface


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Introduction

The attacks of September 11th, followed shortly by theanthrax dissemination event in Florida, the National CapitalRegion (NCR), and the New York metropolitan area, haveconfirmed that the United States faces a true threat of inten-tional mass casualty* incidents caused by terrorism. These

events of 2001, coupled with the results of recent exercises(TOPOFF 2000, Dark Winter, and others), have also demon-strated that as a system, U.S. medical response is not adequate-ly prepared, resourced, or organized to deal with mass casual-ty incidents, particularly those resulting from bioterrorism.There are no mass casualty response standards that organizeall health and medical responses within a jurisdiction. Withfew exceptions, federal and state preparedness programs havenot placed visible priority on establishing comprehensivemedical and health emergency management systems, and nocomprehensive, published system model exists.Furthermore, the effects of this poor coordination are exacer-

bated by the negative impact of adverse medical economicand political decisions on the surge and specialty capabilitiesof individual medical assets.

Examination of medical response to mass casualty events inthe United States reveals several recurring concepts:

• The initial response to any event will be almostentirely based upon locally available health and medicalorganizations.

• The response to a mass casualty incident impacts an entirecommunity and involves numerous diverse medical and pub-lic health entities, including healthcare facilities, publichealth departments, emergency medical services, medicallaboratories, and individual healthcare practitioners.• Healthcare facilities have traditionally planned andresponded to emergencies as individual entities, not as part of a larger system.

• Public health departments are not traditionally integratedwith emergency response operations, including the acute caremedical and mental health communities.

Rather than recognizing and addressing these recurring,large-scale issues, the current approach to mass casualtyincident preparedness is primarily focused upon individual

problems that were experienced during the events of 2001,or are anticipated in future mass casualty incidents. Diseasesurveillance, patient tracking, rapid laboratory diagnostics,and many other identified issues are being addressed indi-vidually in an effort to achieve adequate preparedness for future mass casualty events. Careful examination of theseissues suggests that they must be solved through processesthat involve many diverse organizations, and this can only

be accomplished through comprehensive management. Toaddress these deficiencies in a rapid, effective, and commu-nity-wide manner, a well-defined and developed masscasualty response systemmust first be established.

The MaHIM System project was undertaken to address thiscritical management deficiency. The goal is to reduce futuremorbidity and mortality in mass casualty incidents and other emergencies by providing a model system, adaptable to anyindividual community, that promotes optimal medical man-agement and response operations.

MaHIM describes an overarching systemfor organizing andmanaging the many diverse medical and public health enti-ties involved in mass casualty response. The product of thisstudy is a requirements-based, planning framework derivedfrom a functional analysis of mass casualty care.

The model provides a systematic approach for a communi-ty (defined as an individual jurisdiction) to use in develop-ing its own medical response capability. In a sense, it can

be viewed as a “tool-kit” that provides assistance witheverything from broad-based management strategies tomore discrete, actionable items such as the requirements for

processing unsolicited volunteers during a response.Though the entire system description may initially appear quite complex, the overriding management principles arestraightforward and relevant to all communities, from thesmallest to the largest and most diverse. Some portions of the project are stand-alone, in that a community can use



Mass Casualty Medical and Health Incident Management

The Institute for Crisis, Disaster, and Risk ManagementThe George Washington University, FINAL REPORT 12/02

Executive Summary

1

* “Casualty” refers toany human accessing health or medical services, including mental health services andfatality care, as a result of a hazard impact.


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these specific components to focus on the narrower man-agement challenges within a mass casualty emergency.MaHIM also provides a framework for interjurisdictional,regional cooperation during a large-scale response. Themodel is based upon established medical, public health, andemergency management science and best practice,including concepts from the Incident Command(Management) System.

It is worth noting that the Incident Command System (ICS) isa structured response framework (Figure 1-1) used by thenation’s fire and EMS agencies, by federal response organi-zations, and increasingly by law enforcement personnel asthe means of organizing their day-to-day operations as wellas major emergencies. A hierarchical approach establishesindividual responsibility, lines of authority, effective span of control of resources, and defined paths for information flow.

No similarly effective system description for health and med-ical assets has been demonstrated, in part because of the com-

plexity created by the wide range of organizations involved.Some entities are public, others are private, and all have dis-tinct organizational structures, agendas, and core missionsthat markedly differ from one another. The MaHIM Systemis designed to overcome these obstacles. It is therefore basedupon three core principles:

1. Medical and Health Management

MaHIM provides a single, comprehensive system for man-agement of medical and health assets in emergencies and dis-asters. Because of the inherent nature of health and medicalorganizations, control of these entities can only occur through“management” and not “command.” The authors of thisstudy have purposely chosen the terminology “IncidentManagement” for describing the model, rather than the morecommonly used vocabulary of “Incident Command.” Thisnomenclature emphasizes the reality that medical and healthassets in the United States are generally autonomous enti-ties, and not connected through any inherently defined

“command” structure. The management framework must be based upon authority generated by responsibility, and/or awillingness to participate, rather than by only statutory or regulatory power. The motivation for many of these organ-

izations to participate in an Incident Management Systemmust be promoted through the de facto competence of sys-tem managers, compensation for services (preparation,response, and recovery), access to information, opportunityto participate as respected partners, and assurance that par-ticipation will result in improved capacity/security for par-ticipants. Management methodology is carefully developedin MaHIM, incorporating concepts not currently evident inmost other medical mass casualty programs. For instance, adisciplined, analytical planning process is described. This

process, which incorporates a planning cycle, allows transi-tion to proactive management as an incident evolves, insteadof remaining in a purely reactive management posture. The

planning cycle defines processes for establishing objectivesand strategy based upon the medical characteristics of anincident; addressing current needs and projecting futurerequirements; and providing management guidance acrossthe system.

2. Information Management

Health and medical data generated during incident responseis only valuable when it is accumulated in the right places atthe right times during a response. MaHIM provides an infor-mation architecture, with a description of procedures to cap-ture, analyze, and appropriately disseminate essential infor-mation throughout the response system. Critical require-ments for individual system components are described, andextend beyond “communication” (an important but muchnarrower topic). The model does not provide a descriptionof technology, but it does provide a basis for defining essen-tial technological capability.

The sharing of information among all jurisdictions thatmake up a “region” is critical for effective regional man-agement coordination. Mutual trust and understanding of





Figure 1-2

Real-TimeInfo. Sharing

Real-TimeInfo. sharing

LocalInformation

Function

LocalData Collection,

Analysis &Information

Dissemination



Dissemination



Dissemination

RegionalInformation

Function

LocalInformation

Function

LocalInformation

Function

Figure 1-1

FinanceSector

Incident Command System

INCIDENTCOMMAND

OperationsSector

LogisticsSector

PlansSector

Real-Time Info.Integration

& Reporting

1 Executive Summary


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each other’s evolving impact, and response actions, are fos-tered through the existence of an information architecture that

provides for adequate information exchange between all par-ties (Figure 1-2).

3. Functional Description of Medical Response

Medical response to mass casualty incidents can be exceeding-ly complex, with many seemingly diverse tasks.Responsibilities for each of these actions vary significantlyamong organizations in different communities, yet all neces-sary functions must be adequately addressed for a successfulmass casualty response. MaHIM provides a description of every major function that may be required in the medicalresponse to a mass casualty and organizes them into a struc-tured framework that maximizes the effectiveness of an indi-vidual community’s resources. It is therefore adaptable to anycommunity and for all hazards (terrorism, natural hazard, tech-nological event, etc.).

It has become evident that, by clearly defining the purpose of each function, and by grouping seemingly disconnected activ-ities within those functions, processes and relationships can becreated to develop a more powerful health and medicalresponse capability. For example, “surveillance” has receivedmuch funding and attention in attempting to develop sensitive

processes for detecting the onset of bioterrorism effects.Patient tracking during the post-impact phase has also receivedmuch, similarly narrow, focus. The reality is that the systemsused for case surveillance (to identify an incident) and for

patient tracking (after an event has occurred) should be one andthe same, and applicable for all types of events. Systems thatcan detect an increase in fever, headache, and other flu-likesymptoms in patients presenting to health care facilities shouldalso be effective in rapidly determining the number, distribu-tion, and identifiers of patients presenting with shrapnel and

blast injuries after a high-explosive event. Moreover, deter-mining that “something is occurring” through a surveillancesystem is relatively useless to the medical response communi-ty without simultaneous capabilities for rapid epidemiologicalinvestigation and a determination of the size, scope, at-risk

population, and other vital incident characteristics. Criticaldiagnostic information may initially come from animal sur-veillance, environmental evaluation, or criminal investigationrather than patient examinations. All of these activities (manyaccomplished by nonmedical or nonhealth organizations) must

be coordinated and have predetermined pathways for exchangeof information. MaHIM groups these actions under the func-tion “Incident Epidemiological Profiling” and defines theinformation processing support required for these activities(provided through Planning/Information Functions). This cre-ates potent tools for rapidly defining an otherwise chaotic eventand, furthermore, may provide accurate measures of effective-ness as response actions are implemented.

System Description

For this project, the defined goal of medical consequencemanagement in an mass casualty incident is to maximally

limit morbidity (injury or illness) and mortality (deaths) inthe population exposed to a major hazard, and to return thecommunity to normalcy as soon as possible. The three pri-mary medical objectives to attain this goal are to:

1. Reduce hazard exposure.Avoid or minimize the hazard exposure to patients and the

population after hazard “release.”

2. Increase hazard resistance.Maximize patient and population resistance to the hazardimpact after exposure.

3. Promote/achieve healing from hazard

effects. Maximize the rate and degree of patient and population healing from the hazard impact.

MaHIM is organized according to the architecture ofsuccessful incident management (Figure 1-3).





1Executive Summary

ManagementFunctional Area

OperationsFunctional

Area

LogisticsFunctional

Area

PlanningFunctional

Area

Admin/FinanceFunctional

Area

SupportsMgmt. &

Operations

AccomplishesGoals/Objectives

Figure 1-3

Jurisdiction Incident ManagementSystem Description

DevelopsGoals/Objectives

Figure 1-4

COMMUNITY MEDICALINCIDENT MANAGEMENT

Functional Area

IncidentManagement

SystemsMonitoring

Liaison

PublicInformation

(media/public affairs

Media Message

Public InformationTracking

(Rumor Control, etc)

Safety

Community Medical and Health IncidentManagement Functional Area

COMMUNITY MEDICALAND HEALTH

INCIDENT MANAGEMENTFunctional Area


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1 Executive Summary

• Medical and Health Incident Management• Medical and Health Operations• Support to Medical and Health Operations and to

Management including:✓ Medical and Health Logistics✓ Medical and Health Planning and

Information Processing✓ Medical and Health Administration/Finance.

Medical & Health Management

The Management Function is responsible for the entire inci-dent response, and addresses all “strategic” incident issues

(Figure 1-4). It sets the overall goals and objectives for theincident response and defines the major incident manage-ment parameters. The management approach in this modelis best described as “management by objectives,” with theincident-specific objectives and priorities developed duringthe Planning Cycle (Figure 1-5).

Management responsibilities include:

• Liaison:This function is important for coordinating with major organ-izations outside the community’s medical and health response

system (e.g., federal law enforcement, the U.S. military, etc.).Medical and Health Management may also assign a liaison to political leaders, though senior management may elect to retainthis role and directly brief the political leadership.

• Incident Management Systems Monitoring:

This function provides management oversight of the overallMaHIM during the response. It monitors the adequacy andeffectiveness of the system itself, and its components (i.e., itassures that the response system is functioning as designed),and has the authority to address deficiencies in the system.

• Safety:

This is a critical management activity that provides oversightfor all issues related to responder safety during incidentresponse. This function manages very active processes,which execute overall strategic and administrative tasks aswell as individual field monitoring activities. The SafetyFunction develops and manages the Health and Safety Plan,a written message outlining response hazards and consistent

protective measures for all incident personnel.

• Public Information (Media/Public Affairs):

This function produces timely, structured information,





Figure 1-5

MaHIM Management Process

IncidentRecognized


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approved by management, for use in briefing the media and the public. The messages serve multiple purposes: they providegeneral incident information, guide public actions, reassure the

public, and prevent speculation and subsequent rumors.

Management is closely aligned with the community’s emer-gency operations center (EOC), which is expected to providehigh-level support to the MaHIM System (large-scalecontracts and financing, interface with the state and federalsupport agencies, etc.).

Medical and Health Operations

The Medical and Health Operations Function oversees andcoordinates all activities that are directly responsible for accomplishing the strategic goals and objectives set byManagement (Figure 1-6). Medical and Health Operationsestablishes the tactics (methods) necessary to achieve theincident objectives (i.e., tactics are the responsibility of theoperations managers).

Components of Medical and Health Operationsinclude:

• Incident Epidemiological Profiling:This encompasses all activities to identify, define, and track an incident from a medical and epidemiological perspective.

• Pre-Hospital Care:This function comprises all health and medical actions fromthe initial victim contact with first responders through patientarrival at a definitive care site. EMS and OperationalMedical assets (medical assets attached to rescue operationssuch as SWAT, urban search & rescue teams, andHAZMAT teams) must coordinate closely on-scene.Processes to promote this coordination are defined.

• Medical Care:This function encompasses the delivery of all organizeddefinitive medical interventions to meet the medical needs of the affected population. It includes coordination of acute care(through hospital and outpatient settings), post-acute medical

care, patient diagnostics, and medical evacuation/patientinter-facility transports. Strategies for providing surgecapacity are identified, as well as methods for addressingengineered (or “managed”) degradation of medical capabili-

ties if capacity is exceeded (to prevent catastrophic failure ofmedical services).

• Mental Health:

This covers mental health preventive care and counseling for injured or ill victims, for asymptomatic but possibly exposedindividuals, for affected families and the general public. Thisfunction coordinates closely with Public Information andwith Public Warning/Alerts & Public Education to providestrategic mental health preventive measures through targetedmessages to the at-risk populations. It should be noted thatindividuals requiring acute and chronic psychiatric interven-

tions are not addressed through this sub-function, but throughMedical Care operations.

• Hazard/Threat/Disease Containment:This consists of all activities that intervene to control, arrest, or minimize the threat of chemical, biological, radiation, andother hazards. It includes population-based public health inter-ventions (mass or targeted prophylaxis, patient isolation activ-ities, evacuation strategies, Public Warning/Alerts & PublicEducation, and mass victim decontamination) and environ-mental-based interventions. Some functions listed here (e.g.,hazardous scene containment or mass evacuation) may not bedirect responsibilities of the medical and health response sys-tem, but critical input into decisions and strategies must be pro-vided by the health and medical communities.

• Mass Fatality Care:This function addresses the complex requirements of pro-cessing fatalities (deceased victims) in a mass casualty inci-dent. Attention must be paid to such critical issues as defin-itive body and body fragment recovery, identification, anddisposition. Components include: cataloguing and protec-tion of personal items, chain of custody, body storage, pre-venting cross contamination from contaminated bodies, andrespect for the cultural traditions of affected groups.

Medical and Health Support Functional Areas

Support Functions are those that assist Management andOperations in accomplishing their goals and objectivesduring the incident response (Figure 1-3). They provide logis-tical support, planning and information support, andadministrative/ finance support to Management andOperations throughout the incident.

• Logistics:

This area encompasses all functions that support





1Executive Summary

Figure 1-6

MEDICAL OPERATIONSFUNCTIONAL AREA MedicalOperations

Staging

IncidentEpidemiological

ProfilingPre-Hospital Care Medical Care Mental Health

Hazard / ThreatDisease

Containment

Mass FatalityCare

Medical and Health OperationsFunctional Area

Medical andHealth Operations

Staging

MEDICAL ANDHEALTH OPERATIONS

FUNCTIONAL AREA


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Management and Operations in their use of personnel,equipment, and supplies, and includes supporting the main-tenance of facilities used by Operations (Figure 1-7).Critical support activities, such as receiving, managing, andtransporting pharmaceutical surge supplies (the NationalPharmaceutical Stockpile and other caches) are addressedthrough this functional area.

• Planning:Planning encompasses all activities that supportManagement and Operations in the processing of incidentinformation and in the development of plans for managingthe incident (Figure 1-8). The key information processingfunction, the Medical and Health Local InformationFunction (MH-LIF), resides within the Planning/Information Functional Area. The MH-LIF is responsible

for information collection and dissemination to and fromthe various response system elements (and is supported bythe Communications Function under Logistics). The sec-ond critical function, Plans Development and Assessment,supports all activities through the development and mainte-nance of a planning process. This includes a PlanningCycle (Figure 1-4), which provides a continuous, deliberatemethod of defining incident objectives, evaluating their effectiveness, reacting with revised and new objectives, andforecasting future needs or contingency plans.

• Administration/Finance:

This functional area encompasses all activities that supportManagement and Operations in incident administrativeissues and in the tracking and processing of incidentexpenses (Figure 1-9). Examples of issues that this sub-function is responsible for include:

• Licensure requirements.• Regulatory agency compliance issues.• Financial accounting during the incident.• Contracting services at levels below the EOC.

Through established MaHIM processes, individual responseentities (healthcare facilities, laboratories, medical clinics,

and others) may request assistance with administrative andfinance issues, which could otherwise compromise responsecapacities.

Summary

The complete model provides a single, comprehensive, andadaptable system for Medical and Health Management inemergencies and disasters. It delineates required masscasualty incident response functions, critical relationships

between functions, and system processes that work towardthe common goal of reducing morbidity and mortality and





MEDICAL SUPPORTPLANNING FUNCTIONAL AREA

PlansDevelopment &

Assessment(Action Planning)

InformationProcessing(Med-LIF)

Information SystemsAdministration

Information SystemsDesign & Application

Information SystemsSupport

EventEpidemiological

Projection

MeasuringEffectiveness

Demobilization

Planning

Briefing Support

InformationCollection, Analysis,

Formatting &Reporting

Community HealthSurveillance

Data Processing

Patient Surveillance& Tracking (PSAT)Data Processing

Boundary FunctionInformationProcessing

Resource StatusTracking

Functional AreaReport Tracking

Hazard-RelatedExpert Information

Document Control& Archiving

Alternate & Long-Range Strategy

Planning

ContingencyPlanning

MEDICAL SUPPORTADMINISTRATION & FINANCE

FUNCTIONAL AREA

RegulatoryCompliance

FinancialSupport

HealthcareInfrastructure

BusinessContinuity

(Admin. & Finance)

Figure 1-9

1 Executive Summary

Medical and Health SupportPlanning Functional Area

Medical and Health SupportAdministration/Finance Functional Area

Figure 1-7

TechnicalSupport

MEDICAL SUPPORTLOGISTICS FUNCTIONAL AREA

PersonnelProcessing

Support

PersonnelSupport

Supplies andEquipment

Support

TransportationSupport

Medical and Health SupportLogistics Functional Area

Figure 1-8

MEDICAL AND HEALTHSUPPORT

LOGISTICS FUNCTIONAL AREA


PLANNING FUNCTIONAL AREA


ADMINISTRATION & FINANCEFUNCTIONAL AREA


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returning the community to normalcy. The model demon-strates methods for coordinating the many disparate healthand medical entities, and for maximizing general and spe-cialty care surge capacity. Coordination is based uponstrong management, developed through an effective infor-mation architecture and a clearly defined planning cycle.

In applying MaHIM within a specific community, jurisdic-tional organizations may be assigned functions within themodel framework according to their traditional responsibil-ities and capabilities. This creates an organizational struc-ture for the jurisdiction that closely matches mass casualtyfunctional requirements. It provides a method to delineateorganization responsibilities, interorganizational relation-ships, and critical coordination processes. The result is adefined architecture, with all elements incorporated into asingle, comprehensive medical and health emergencymanagement system for that jurisdiction. It is very likelythat organizations will find that they are sharing a functionwith other organizations, and relationships based uponeffective processes will need to be developed. It is also like-ly that new personnel positions will have to be created, withqualifications and operational checklists that will requirefurther training. This is expected to occur, in order to cover the many preparedness gaps that exist in almost every juris-diction. Further, application of the model to adjoining com-munities promotes regional management and response coor-dination. The model is structured so that implementation

provides both immediate improvement (by optimizing exist-

ing capability) and long-range benefits, as demonstrated inFigure 1-10.

MaHIM has application to the management of everydaymedical and public health problems as well, thus promoting

both cost-effectiveness and familiarity for the responsecommunity. The model may also be useful as a guidancetool when evaluating the potential effectiveness of productsoffered by contractors and vendors.

The unfortunate reality is that mass terrorism will be anenduring modern phenomenon. U.S. communities will con-tinually work towards adequate preparedness for the conse-quences of these horrific acts. MaHIM is intended to focusthis medical planning and preparedness, and maximize theeffectiveness of preparedness efforts. Response capabilitiesmust always be effectively ready, must be cost-effective,and must be as enduring and sustainable as the mass casual-ty threats are to America.

1 - 9

TimeSequence

ImmediateNeed

6 Months-1 Year

Follow-OnYears

DetermineRequirements &Responsibilities

OptimizeExisting

Capability

Build Capability & CapacityDevelop Required

Systems & SupportingTechnology

Achieve Adequate

Preparedness

Figure 1-10

Define &Prioritize Future

System &Resource

Improvements

Joseph A. Barbera, M.D.




1Executive Summary


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A mass casualty incident* is an event in which the availableorganizational and medical resources, or their managementsystems, are severely challenged or become insufficient toadequately meet the medical needs of the affected population.Deficiencies in management or response capability mayresult in increased morbidity and mortality. For almost 50years,** until the Murrah Building attack of 1995 and theevents of September 11, 2001, the United States experiencedrelatively few true mass casualty events, and none deliberate-ly created by terrorists. Accordingly, overall emergency man-agement response and recovery planning has focused on theother consequences of disasters, such as the provision of masssheltering and feeding, transportation infrastructure protec-tion and repair, restoration of utilities, hazardous materialscontainment and cleanup, and others. Medical preparationsfor mass casualty management have traditionally focused onthe scene and pre-hospital sectors. Comprehensive masscasualty care, from a health systems perspective, has receivedfar less attention and has evolved in a realm separate from the

rest of the emergency management and response communi-ties. The casualty load of September 11, 2001, the healthimpact of the subsequent anthrax dissemination event, andthe threat of future mass casualty terrorism have created animpetus to reevaluate this issue.

The range of probable etiologies for mass casualty scenarioshas widened markedly as the possibilities of chemical, bio-logical, radiological, nuclear, and (high) explosive (CBRNE)mass terrorism are acknowledged. Increasing technologicalhazards, the impacts of civil unrest, and the devastatingimpacts of natural hazards (witness the 2001 Houston Floods)have spotlighted the need for better preparedness for ALL

mass casualty events. The 2001 Houston Floods were also avivid example of how various incident factors can create seri-ous impacts on the actual ability to deliver health and medicalservices in a disaster.

A critical review of the mass casualty and disaster medicineliterature reveals deficiencies in widely accepted operational definitions of mass casualty care and inadequate descriptionsof system requirements for comprehensive mass casualtycare. Mass casualty care is often defined in relation to a

specific hazard. These hazards (earthquakes, tornadoes, hur-ricanes) cause primarily general trauma and not the widerange of biological, chemical, or radiation injuries. Masscasualty care is therefore narrowly described. Even descrip-tions of mass casualty care for large-scale explosives are lim-ited, since they are commonly based upon the military opera-tional medicine model. A common and problematic approachto special hazards (radiation, for instance) is the independentdevelopment of hazard-based plans by specialists who deal

primarily with their respective hazards, such as radiationresponse plans and biological response plans. The approachof developing multiple plans for a medical community risksduplication and gaps in capabilities between the multiple haz-ard-specific response plans. Additionally, it complicates edu-cation and training, and threatens cost-effectiveness, sustain-ability, and flexibility.

Neither the medical (partially due to economic factors) nor the public health (due to years of neglect) sectors are pre-

pared and organized to adequately deal with mass casualtyincidents, particularly incidents resulting from large- scalechemical or biological attacks on the civilian population. ThePrincipal Investigator and co-authors investigated the deficitsin medical and health preparedness for catastrophic terrorismin the recent past and reached the conclusion, “Without

prompt action, the nation carries the risk that victims of amass casualty-disaster might end up in ‘ambulances tonowhere’” (Barbera et al, 2001).

Medical care and public health resources are primarily local-ly managed assets, yet much of the current national focus has

been at a higher level of government or is being directed fromthat level. Most troubling is that progress in local and region-al planning for mass casualty care falls far short of that madein other areas of emergency management and disaster response in recent years. It can be suggested that one of theunderlying causes of this national deficiency is the lack of aconsensus for a conceptual framework of community andregional medical and health preparedness for response.Individual components and capabilities for medical andhealth response exist, but they are not comprehensivelyaddressed in an overall system. This has led to inefficiencies





* “Casualty” refers toany human accessing health or medical services, including mentalhealth services and fatality care, as a result of a hazard impact.

** The 1947 Texas City, TX, ammonium nitrate fertilizer explosion killed or injured more than 3,500 people.

Introduction and Background

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and confusion, risking organizational failure in a truly masscasualty incident. The potential for health care organizationsto fail was demonstrated during the TOPOFF exercises of 2001, where disjointed and ineffective mass casualty

response reflected the lack of a coordinated systems approachto management (Inglesby, 2000, and this project’s authors’

personal observations as members of the TOPOFF exercisecontrol team). These organizational failures were again evi-dent during the National Capital Region anthrax incidents(October - November 2001). Added to these concerns are thedaily system stressors, including emergency departmentovercrowding, ambulance rerouting, and nursing shortages.

Systems engineering research in emergency response demon-strates that if organizational and technological systems do notmatch the local reality created by an actual event, complete

systems failure may occur, causing needless societal impacts.In 1989, the National Contingency Plan for Oil andHazardous Substances failed as a coordination mechanismduring the Exxon Valdez Response (“We Were Always Re-organizing…” Harrald, et al., 1992). Three years later, thenew Federal Response Plan met a similar fate during theresponse to Hurricane Andrew (Carley and Harrald, 1992).In both cases, the national plans had defined relationships atthe national level but failed to create a local response organi-zational system that worked. These failures were costly, withexcessive environmental damage in Alaska and human suf-fering in Florida. In a mass casualty incident, especially ter-rorism that specifically targets humans, the penalty for a sim-ilar failure could be thousands of needless deaths, public con-fusion, societal disruption, and possibly civil unrest.

It is critical to realize that technology is not the primary solu-tion to these problems. The proper application of technology

should follow from, and not determine, the operational requirements. Determining and defining requirements firstwill drive the development of effective systems (information,incident management, and response), which will then definethe systems’ resource and technology needs. For example,technology-based patient surveillance systems have beendeveloped and piloted for detection of a surreptitious biolog-ical agent release. Though technologically advanced, a sys-

tems approach to these technology applications has been neg-lected, and the surveillance systems’integration into the med-ical settings that must report data was not a major considera-tion. Consequently, many surveillance tools have been large-ly ineffective, underutilized even during high-risk, definedevents, as users have found them cumbersome, confusing,and lacking de facto usefulness.

The broad concepts of mass casualty care, and preventing thehazard impact from causing population illness (including

mental health), are generally well recognized and accepted.It is the effective execution of actions that accomplish theseconcepts that has not yet been well defined for community

preparedness. Researchers for this project could find no pub-lished description of an effective, comprehensive coordina-tion capability that has been developed and implemented in amajor U.S. civilian jurisdiction.

Defining a mechanism to achieve effective action is the focusof this project.The general objectives for a medical and health model of mass casualty care are described in Figure 2-1. The strategy to implement these objectives requires closecoordination of many diverse and only loosely connectedhealth and medical entities.

Preparedness for all-hazard mass casualty response is a complex undertaking, in part because medical infrastructureresides predominantly in the private sector, in many disparateresources. It is further complicated because adequate surgecapacity and specialized resources may not be organizedlocally to achieve maximum effectiveness. In most commu-nities, surge capacity exists to some extent but is under-lever-aged. Full community preparedness must involve the coordi-nation of health and medical assets across both jurisdictionaland public-private boundaries. Adequate mass casualty man-agement and response require systems * that achieve rapid,efficient expansion of capacity through local and regional coordination. Realistic planning must be focused at both thelocal and regional levels.

Besides being “all-hazards” and systems oriented, masscasualty planning must carefully address operational realitiesthat are obvious only in large-scale events (and therefore arevery infrequent). Examples of specific operational problemsfrom recent mass casualty incidents include the following:





Figure 2-1

Medical and Health Objectives

1. Reduce Hazard Exposure. Avoid or minimize the hazardexposure to patients and the population after hazard “release.”

2. Increase Hazard Resistance. Maximize patient andpopulation resistance to the hazard impact after exposure.

3. Promote/Achieve Healing from Hazard Effects.Maximize the rate and degree of patient and populationhealing from the hazard impact.

* The term “system” in t his project means a clearly described functional structure, with defined processes, thatcoordinates disparate parts to accomplish a common goal.

Mass Casualty Incident Response

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• Patient distribution among healthcare facilities: MurrahBuilding bombing in Oklahoma City, 1995. There are 16acute care facilities in reasonable proximity to the MurrahBuilding in Oklahoma City. After the bombing, three facili-ties carried the burden of caring for most of the patients, withthe nearest hospital receiving both high numbers of patientsand the most severely injured. While Emergency MedicalServices (EMS) organized rapidly and implemented a trans-

port function for patient distribution, the majority of patientsself-referred or reached medical care facilities through assis-tance outside the formal EMS system. Many EMS transportswere taken to facilities that were already severely taxed bythe volume of “walk-in” patients and by other non-EMStransported patients from the incident (Hogan, 1999). Evenwell-trained EMS personnel described transport to the near-est hospitals in the desperate early minutes/hours of the inci-

dent, while recognizing those hospitals were overburdened(personal communication from EMS providers to JAB, April1996).

• Patient tracking among numerous healthcare facilities:World Trade Center Attack in New York City, 2001. After the collapse of the World Trade Center, mass confusion exist-ed about the location of victims and the status of missing

persons. Particularly in the initial 24-48 hours, lower Manhattan hospitals were burdened by an overwhelmingnumber of families trying to locate loved ones. Though somehospitals were later able to share lists of patients being caredfor, patient information gaps led many distraught families to

multiple visits and desperate calls to many hospitals (Frank 2001, SoRelle 2001), adding to the psychological impact of the disaster.

• Coordination & information sharing among hospitals,public health, and private practitioners in adjoining

jurisdic tions: anthrax dissemination event in theNational Capital Region (NCR), 2001. No formal infor-mation management system was developed and implement-ed between the hospitals, practitioners, and local publichealth authorities during the NCR incident. Other than dailyconference calls (moderated by this project’s PI) betweenhospitals, medical practitioners, and public health authori-

ties, no detailed data was collected, analyzed, and returned to practitioners to define the size and scope of the patientencounters or the profiles of the exposed patient populationand infected victims. Standardization of the evaluation andtreatment protocols occurred only late in the incident. Theresponse to the anthrax dissemination event in the NationalCapital Region was further complicated by inadequate infor-mation coordination between the four jurisdictions (DC,MD, VA, and the U.S. Capitol). At one point, the improba-

ble situation existed in which the four public health depart-ments were prepared to issue conflicting public

recommendations for completing medical prophylaxis.Detailed communication between public health and the med-ical care disciplines was less than optimal: daily updates thatchanged the profile of at-risk patients were, for the most part,obtained by practitioners through media events conducted by

public health authorities, rather than directly from publichealth in regular, formal communication.

It is not enough to research problems to merely understandthem and describe a theoretical systems approach to solu-tions. Staff and resources must be dedicated by local emer-gency management, public health and public safety agenciesin a nonpartisan fashion to ensure development of capabilitiesand coordination across the health and medical spectrum of the community and the region. Important considerationsinclude regular interface between system components (infor-mal discussions, interagency planning meetings) and exercis-es (frequent inter-hospital communications tests also involv-ing public agencies, regular mass casualty drills using theestablished systems, etc.).

Unless an above-described systems approach is accomplished, the mass casualty preparedness process will continuealong a fragmented, technology-influenced course that iswasteful and ineffective.

This conceptual approach is not meant to suggest that alengthy process is required before significant managementand response improvement occurs. The strategy of definingsystem requirements and responsibilities is important for rap-idly optimizing existing capabilities as well as for determin-ing resource requirements, including technology, to be devel-oped along an extended time line (Figure 1-10).

The goal of this project is to define one comprehensive sys-tem model that incorporates the requirements and functionalresponsibilities for adequate mass casualty medical incidentmanagement. Mitigation (including prevention and decreas-ing vulnerability), preparedness, and response efforts must

be sustainable, must always be effectively ready, and must becost-effective.





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Process Goal

This project was designed to use a peer review process, and base the model upon medical, public health, and emergencymanagement science.

Process Objectives

• Complete the project in a rapid time frame (total 7 months)due to urgency of national planning and preparedness for mass terrorism consequence management.

• Describe the concepts in language understood by the user community, particularly the emergency management, publichealth, and medical communities.

• Incorporate peer review input from medical and health professionals who represent the spectrum of incident man-agement and medical response.

• Describe an exceptionally complex subject as simply as possible, to both comprehend and to use, without creatinginaccuracies from oversimplification.

Background to the Development Process

This project was designed to use a structured approach for analyzing and describing systems requirements for regionalmass casualty care: it employs Systems Engineering methodswhile maintaining a base of sound medical scientific andoperational principles. Using Systems Engineering theory





Requirements Analysis• Analyze missions & environments• Identify functional requirements• Define/refine performance &

design constraint requirements

Functional Analysis/Allocation• Decompose to lower-level functions• Allocate performance & other limiting

requirements to all functional levels• Define/refine functional interfaces

(internal/external)• Define/refine/integrate functional architecture

Synthesis• Transform architecture (functional to physical)• Define alternative system concepts, configurationitems & system elements• Define/refine physical interfaces (internal/external)• Select preferred product & process solutions

System analysis& control(balance)

Process Input• Customer needs/objectives/requirements

•• Missions•• Measures of effectiveness•• Environments•• Constraints

• Technology base• Outputs from prior phase• Program decision

requirements• Requirements applied

through specifications andstandards

Process Output• Phase dependent

•• Decision support data•• System architecture•• Specification & baselines

• Trade-off studies• Effectiveness analyses• Risk management• Configuration

management• Interface management• Data management• Performance based

progress measurement•• SEMS•• TPM•• Technical reviews

Adapted from Systems Engineering, Military Standard 499B (1971).Washington, D.C.: U.S. Department of Defense

Figure 3-1

Project Methodology:Objectives, Assumptions, and Description of the Process

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and practice (Eisner), and the extensive medical and healthexperience of the investigators and the project reviewer con-sultants (Appendix C), the project is a comprehensive analy-sis of actual and theoretical components of mass casualtyincident management and response needs. All types of poten-tial hazards, including terrorism, were considered.

Systems Engineering

Dr. Howard Eisner, Distinguished Research Professor andProfessor of Engineering Management and SystemsEngineering at The George Washington University, definesthe discipline of Systems Engineering as an “iterative processof top down synthesis, development and operation of a realworld system that satisfies, in a near optimal manner, the fullrange of requirements for the system.” Figure 3-1 providesa description of Systems Engineering as implemented by theU.S. Department of Defense (MilStandard 499B). Theinputs to such a process are external and include such thingsas the overall mission needs, requirements, measures of effectiveness, and context (environment, constraints, avail-able technology).

This project focused on the requirements loop of theSystems Engineering process described in blocks 1 and 2 inFigure 3-1. The requirements analysis (top block), providesthe initial functional descriptions. The functional analysis

provides a decomposition of functions to lower-level func-tions and processes and defines/refines interfaces. Note thatthis iterative requirements loop is a prerequisite to thedesign loop in which organizational and physical systemoutputs are defined.

Using this methodology, a function is defined as a group of activities that together support one aspect of furthering themission of the enterprise. Functions can be grouped intofunctional areas that refer to major areas of activity. Afunctional decomposition is the breakdown of the activitiesof an enterprise into progressively increasing detail.Functions decompose into sub-functions , and then intoprocesses , which are low-level activities that have a defin-

able beginning, end, and output (Martin, 1990).

Stepwise functional decomposition of an enterprise can beviewed as a “top-down” approach to problem solving(Defense Systems Management College, 1990). This sys-tematic, disciplined approach can be particularly appropriatefor the current analysis of consequence management in order to avoid the potential of organizational “turf battles” over who should have responsibility, how missions should beexecuted, and which hardware and equipment should beacquired. As stated by Eisner (p. 197), “by maintaining a

focus on function, rather than the manner in which the func-tion is to be executed in hardware, software, and humancomponents, we allow the system engineer to consider a host of alternative ways of implementing a given function. Weexplicitly separate the ‘what’ is to be done from the ‘how’ it

should be done. We consciously want to avoid leaping to a premature conclusion regarding a specific way to implement a given function.”

This approach contrasts with the common approach for developing mass casualty and terrorism response capabili-ties, which is done by identifying the organizations that aretraditionally in charge of various functions, and havingthem define an organizational system. The contrasting ratio-nales (“traditional” versus “systems engineering”) aresummarized in Figure 3-2.





Figure 3-2

Systems engineering decomposition process(summarized)

“Old” logicbased on

organizations

Standard“Old”

organizationaldescription

“New” logicbased onfunction

Neworganizational

description

Functional decomposition

Commonly attempted approach

/ /

GOAL

Figure 3-3

Equivalency of Terms

IMSManagement

Management Staff General Staff

SectionBranches (geographic or functional)

Divisions(geographic) orGroups (functional)

UnitsTeams, TFs,

& single resources

Systems EngineeringManagementManagement Staff Functional Area Leadership Staff Functional AreaFunctionsSub-functions

““

======

==

Regional Planning for Mass Casualty Care

IMS & Systems Engineering

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For the purpose of analysis, mass casualty incident manage-ment and response were successively decomposed into func-tional areas, functions, sub-functions, and processes.Requirements were then delineated for these components.

Subsequently, these components were reassembled into afunctionally defined incident management system withdefined processes for management, coordination, and infor-mation sharing.

Description of tasks and procedures (which are the specificmethods used to execute processes and fulfill functions) isspecifically avoided, since it is imperative that they bedefined by the jurisdiction or entity according to their organi-zational structure, traditional methodologies, budgetary prior-ities, and other community specific factors.

Incident Management Systems

Most emergencies and disasters in the United States are nowmanaged using the Incident Command (ICS) or IncidentManagement System (IMS)*. For instance, federal healthand medical assistance in disasters, as described by theFederal Response Plan, are applied through an incident man-agement framework. Because of this widespread acceptanceof IMS concepts and practice, and the demonstrated effec-tiveness of IMS across a wide spectrum of incidents, IMS

became the logical model for the functional description of acomprehensive mass casualty response system.

The components of the functional analysis described above

were reconstructed into a comprehensive mass casualty careframework using the IMS template. The authors of thisstudy have purposely chosen the terminology “IncidentManagement,” not the more commonly used “IncidentCommand,” in recognition of the reality that medical andhealth assets in the United States are generally disparate enti-ties that are not connected through any inherently defined“command” structure.

The project describes a framework of coordination basedupon authority generated by responsibility rather than exclu-sively upon statutory or regulatory power. Many past plan-ning efforts have begun with the question “who’s in charge?”and the efforts have commonly stalled on this question or reached compromise that provided an ineffective basis for further planning.

By using the concepts of IMS, who is actually “in charge”depends very much upon the circumstances of the incident.It becomes apparent that for successful incident manage-

ment, it may in fact be more important to define each criticaloperational function and who is responsible for it than toknow who exactly will be in charge . In other words, ambi-

guity of authority is less troublesome than ambiguity of

responsibility . Responsibility for each critical functionthrough the four phases of emergency management (mitiga-tion, preparedness, response, and recovery), though, must bedetermined during any system implementation (i.e., who isaccountable for developing, implementing, and maintainingeach critical function).

Many versions of ICS and IMS have been promulgated over the past two decades. The authors chose the StandardizedEmergency Management System (SEMS) version of IMS asthe specific model for this planning framework. In additionto having demonstrated effectiveness in major emergencies,SEMS establishes terminology consistent with the “manage-ment” orientation of this project. The VeteransAdministration’s Strategic Healthcare Group has alsosuccessfully utilized SEMS as a template for theirrecommended Hospital Emergency Management Programsfor Veterans Administration Medical Centers. This projectuses the SEMS Incident Management System as a templatein considering functional positions and organizationalrelationships.

Integration of Systems Engineering andIncident Management Systems

Because the theoretical bases for Systems Engineering andIMS are so similar, it becomes easy to move from theSystems Engineering decomposition findings to a functional-ly defined Incident Management System structure. Figure3-3 provides a comparison between classic ICS termsand those used in this system’s engineering functionaldecomposition.

Functional areas are organized on the concepts underlyingSEMS and listed below with explanations of how they areused in this project:

Regional Unified ManagementCoordination(SEMS addresses regions as adjoining geographicareas within the state of California). The termregional is used in this project to describe adjoin-ing geographic areas within a state or the far morecomplex phenomenon of adjoining interstate

jurisdictions.





*The Incident Command System is a very widely accepted management system for emergency response, usedby the fire service and by FEMA, and state and local emergency management agencies. Unfortunately, it is notwidely understood or used by public health, creating clear management deficits as noted in the recent anthraxmail dissemination. Additional information on Incident Command may be found at http://www.fema.gov/emi/is195lst.htm.

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ManagementUsed in this project to mean the functions related todirecting and coordinating resources while establishingoverall response objectives. Typically, objectives aredefined in a manner so that they are measurable andachievable within a defined period of time.

Operations -Used in a traditional manner in this project to denote thefunctions that develop and implement tactics (i.e.,methods) to achieve the objectives established byManagement.

LogisticsUsed in this project to denote the functions necessary to

support overall incident response with personnel,equipment and supplies, or specialized services for

Operations.PlanningSEMS uses the term “Planning/Intelligence” for thisfunctional area. “Planning” is used in this project todenote the functions necessary to support Managementand Operations in Action Planning and in InformationManagement, including collection and analysis ofdata, transforming it into relevant information, andformatting and disseminating the informationappropriately.

Administration/Finance

Used in this project to denote the functions that support Management and Operations in addressing financial andadministrative (including regulatory) issues encoun-tered during response.

This reconstruction of functional systems incorporates other principles of effective IMS such as: formal Action Planning;maintaining reasonable “span of control” in each functionalarea; basing authority upon responsibility.

Terminology

Because this project is a “hybridization” of the scientific dis-ciplines of emergency operations, acute care medicine, and

public health, terminology had to be adapted to be consistentacross the system. As much as possible, “usual” terms wereretained. In places where varying terms or meanings of termswere conflicted between the disciplines, selection was deter-mined according to the following strategy:

• Incident Management terms were retained if theconcepts being described are emergency operations.Terms were, however, adapted to emphasize “management,”and not “command” (for reasons noted above) and to reflectthe regional coordination concepts defined in this project.

• Medical terms were used when addressing primarilymedical concepts.

• Public health terms were selected when addressing

primarily public health issues.• When conflict arose between terminologies, decisionson the appropriate selection were made based upon thetenet that this project’s primary emphasis is on amedical and health model.

Project Process Funding and Management

Funding for this project was provided by the Alfred P. SloanFoundation to the Institute for Crisis, Disaster, and Risk Management (ICDRM) at The George WashingtonUniversity. Joseph A. Barbera, M.D., was the PrincipalInvestigator, and Anthony G. Macintyre, served as a co-author. An extensive research effort formed the basis for this

project model (Appendix A). ICDRM personnel coordinatedthis work with expert colleagues within The GeorgeWashington University and with a multidisciplinary groupfrom the National Capital Region and elsewhere (AppendixC). The document development process therefore drew uponthe operational and management knowledge of personnelexperienced in the emergency operations of public health,medicine, and emergency response. Daylong meetingsdevoted specifically to formal review and comment on thework products were a critical part of the process. SeeAppendix B for the Project Work Plan and Task Completion

Schedule.

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Joseph A. Barbera, M.D. Anthony G. Macintyre, M.D.



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The goal of this project was to develop a peer-reviewed,requirements-based operational model for mass casualtyresponse, based upon medical, public health, and emergencymanagement science. The Medical and Health IncidentManagement model was intended to be a single, comprehen-sive system description of the functional components criticalto effective response for any mass casualty incident. Thisincludes delineating the critical relationships between func-tions, both within the system and with important nonmedicalemergency response functions, such as law enforcement andfire services, and the system processes that coordinate thesemany component functions to work toward a common goal:the limitation of morbidity (injury or illness) and mortality(deaths) in a population exposed to a major hazard. The ini-tial intent was to develop a primarily regional model. Duringthe research and analysis phase of the project, it becameapparent that regional management coordination is criticallydependent upon a well-defined and implemented medicalincident management system in each jurisdiction within the

region. The model therefore focuses at that level, while pro-viding the framework and concept of operations for regionalmanagement cooperation.

Model Objectives

The model is intended to provide:

• A conceptual systems framework that allows a specificcommunity to develop organizational roles andresponsibilities, and to define the relationships betweenorganizational elements.

• An approach to maximize available capabilities throughthe integration and coordination of current health,medical, and emergency response assets, thereby

providing immediate benefit within the existing resource base.

• A description of the critical information needs ofeach organizational and functional element, the systemlinkages that provide this information, and the overallinformation management system requirements.

• A tool of reference, which allows a jurisdiction toevaluate proposed initiatives that would require anysignificant resource commitments or major changes in

policy.

• A dynamic model that can evolve after evaluation offuture responses to mass casualty events or exercises,

such that new knowledge can be efficiently incorporatedand organizational learning is therefore promoted.

• A basis for defining measures of operationaleffectiveness for the overall system as well as systemcomponents.

MaHIM is not intended to be an all-encompassing, “bank- buster” guide that promotes individual, stand-alone capacityfor mass casualties. In contrast, principles of cost-effective-ness, sustainability, flexibility, and adherence to multiuseand “daily routine” capability were used as guides in devel-oping the conceptual requirements for responding to a mass

casualty event.

Model Assumptions

In order to fully understand the rationale behind the MaHIMmodel, the assumptions upon which the model is based aredelineated. An extensive research effort and experience-

based knowledge were used in developing these assumptions.

Incident and Response Assumptions

Review of recent mass casualty incidents in the United States

and other medically developed countries reveals importantrecurring phenomena:

•Any incident resulting in mass casualties has the potential to produce a broad range of medical issues (aswell as additional nonmedical emergency issues that arenot addressed here). The delivery of adequate incidentmedical care (while maintaining normal routine medicalcapacity), reducing risk for potential victims (through

population action, prophylaxis, and other health

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4 MaHIM: Objectives and Assumptionsinterventions), providing a mass fatality response, andaddressing psychological needs all must be consideredfor effective response systems.

• Mass casualty incidents may have a sudden onset withextraordinary medical needs or may begin insidiously,requiring adequate surveillance systems for timelydetermination of size and scope.

• The event itself has the potential to directly impactmedical and health capabilities themselves, includingmanagement and response facilities, personnel,equipment, infrastructure support, and communications.This could compromise the delivery of even routinemedical and health services and severely affect medicalsurge capacity. For example, acute-care patients(including critical care cases) and long-term-care

patients in the hospital before the onset of the incidentmay need immediate relocation from those facilities dueto the hazard impact.

• Prolonged incident response (days to weeks) in and ofitself has the potential to impact the responders as wellas the victims. Issues related to responder fatigue, victimrelocation, mass sheltering, vector control, fooddistribution, provision of potable water, and wastewater/solid waste management all become critical.

•Hazard impacts that create mass casualties, particularly biological and other forms of mass terrorism, have the

potential to create a large population of concerned, potentially exposed persons. Significant medical andhealth resources must be devoted to evaluating these

patients. Mass casualties may require specializedmedical and health capabilities ranging from proactive,mental health interventions to unusual treatmentcapacities for such entities as chemical burns,respiratory failure, eye injury, radiation syndromes, ormass medication needs.

• Scene control in a mass casualty incident may benonexistent or bypassed during the early post-impact

phase, when patients are moving in large numberstoward healthcare facilities. Even with excellentemergency medical services (EMS) systems and timelyresponse, 75%-80% of mass casualty victimsconsistently reach hospitals (and other healthcare

providers, even private physicians’ offices) throughavenues other than organized EMS: Tokyo sarin attack,Oklahoma City bombing, World Trade Center (WTC)9-11 attack. Victims may therefore arrive at hospitalsrapidly, with little or no prior notification to thereceiving facilities, and without being matched with themost appropriate hospital capability (trauma center, burncenter, pediatric center, etc.).

• Based on prior experience, the majority of victimsmay not require hospitalization after initial care.Historically, approximately 10%-15% of mass casualtyincident victims evaluated at healthcare facilitiesactually require hospitalization for their injuries/illnesses (Nairobi embassy bombing, Oklahoma City

bombing, WTC, and Pentagon 9-11 attack). While thiscould drastically change in a very unusual CBRNEincident, it has been a relatively consistent finding acrossa wide range of mass casualty incidents and must beincorporated as a planning assumption for this project.

• In U.S. mass casualty incidents, the problem is rarelyoverwhelming for an entire community’s or region’smedical care capabilities but rather a temporary (anddangerous) mismatch between the specific locations ofunmet patient need and the available medical resources.Coordination of medical resources to move toward thesite of need must be considered, rather than dependingsolely on an expensive increase in individual stand-aloneresource capacities to address this phenomenon.

• Medical economics and public health fundingstrategies over the past decade have created the reality ofminimal medical and public health surge capacity at thelevel of individual institutions and agencies. A majormass casualty event will overwhelm this capacity. At aregional level, however, a significant but widelydispersed medical and health surge capacity continues toexist in the aggregate . Well-established coordination isrequired to effectively address patient needs during amajor mass casualty incident, especially if the victim

population extends across jurisdictional boundaries. Inmany situations, it may be more effective to move healthand medical personnel and supplies to the proximity of

patient need, rather than moving patients to relativelydistant medical facilities.

• Many disparate and very loosely connected medicalentities are required to function in a coordinated fashionin order to rapidly and effectively address mass casualtyneeds. These medical and health entities cannot bedirected through a traditional “command” structure

but rather must be managed through the incentives ofinformation management, adequate financial compensa-tion, and other measures to enhance preparednessand response.

• Standardization of response parameters (vocabulary,equipment, communications), political support, andregular interagency interactions promotes improved

preparedness.

• Hospitals have demonstrated a willingness to

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The Institute for Crisis, Disaster, and Risk ManagementThe George Washington University, FINAL REPORT 12/024 - 3

collaborate among themselves during mass casualtyincidents (Oklahoma City bombing, Washington, D.C.,anthrax incident, WTC and Pentagon 9-11 attacks, andothers). In some instances, hospitals have alsodemonstrated willingness and a capability tosuccessfully implement formal mutual aid arrangementsand common radio systems, shared protocols, and jointequipment purchases (D.C. Hospital Associationand Northern Virginia Emergency Response Coalitionexperience).

• Volunteerism and donations will be encounteredduring mass casualty incidents. These phenomena must

be addressed during the preparedness phase in order forthem to be a positive impact on the incident outcome(as opposed to a response distraction).

• Profiteering by medical and health assets is notexpected but has occurred in the past after certaintragedies. Pre-existent, exercised response systems must

be prepared to respond to this potential phenomenon.

• Systems that perform the best during a crisis areones that are used or practiced every day. This has beena stated reason for the use of IMS during day-to-dayoperations in the fire service, regardless of the scope ofthe event, and serves as a good model for mass casualtymedical incident management.

• Response capabilities will evolve over the course of

an extended event and may become exceptionallydifficult to manage without effective systems.

Emergency Management Assumptions

• Mass casualty incidents are commonly large andcomplex and often geographically spread out. Effectivemanagement requires a formal management structurewith defined functional components.

• As medical preparedness for mass casualties becomesincreasingly recognized as both a public safety functionand responsibility, the need for a fully integrated

emergency management system that includes medicalmanagers is becoming more recognized at the localgovernment level.

• Mass casualty care response is rarely isolated to the med-ical and health sector — it takes place in thecontext of a broader regional emergency response.Planning should therefore address management in thislarger context. A community’s emergency managementand public safety incident management must be intertwinedwith the medical and health planning. Medical and healthsupport needs (security, transportation, etc.)

should be identified and assured through existing localand regional emergency constructs (Logistics Functionof an emergency management agency, security/

protection by local law enforcement, etc.) rather thanthrough health systems trying to develop independent,stand-alone capabilities for each support function. Thisis the conceptual basis for current Federal Response Plan(FRP) and state level emergency response planning, anda similar approach should be incorporated in communitymedical mass casualty planning.

• Emergency management has developed to address alltypes of emergencies and disasters (as opposed to civildefense, which was focused primarily on protection ofcivilian populations against attack). The past twodecades have therefore witnessed the evolution into an“all-hazards approach,” which also encompassesincidents with mass casualties. The all-hazards approachof emergency management primarily denotes the use ofa single set of management and response systems for allhazards (the same systems for communication,notification, management methods, etc.). This projectemploys the philosophy of all-hazards preparedness bydefining systems for managing and responding to masscasualties from natural hazards (seismic, wind,infectious, incendiary, etc.), technological hazards(chemical, utility loss, etc.), and civil disturbance(terrorism, criminal, riots, war, and others). Approachesdiffer for only a few hazard-unique requirements.

• A fully integrated emergency management system formass casualty care includes both IMS and the effectiveuse of the emergency operations center (EOC) supportoperations. The two entities (IMS and EOC) should bemaintained as discrete functions, even if the EOC

provides some direct IMS services during a response(such as using its information management personneland equipment to assist the IMS Planning functionalelement and its information systems).

• Tactical mutual aid is commonly used to develop surgeand specialized capacity in EMS and other traditional

public safety disciplines. It is much less common inmedical, public health and health-related services. Thismust be addressed, since mutual aid is the single mostavailable and cost-effective way to obtain surge capacityafter maximizing the output of individual assets.Because mass casualty injury profiles commonly includea significant number of patients with medical conditionswhere time-to-adequate-medical-treatment is of theessence, mutual aid strategy should first emphasize alocal sharing of assets. Subsequently, regionally basedcapabilities are emphasized, and then finally a national

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mutual aid capacity for management of the trulycatastrophic event. The concept is based upon “mutual

self-interest ,” assuring that the sum of the local andregional assets creates a stronger capability for each

individual jurisdiction. Tactical sharing between jurisdictions should be guided by strategic mutual aidarrangement between interjurisdictional functions thatare consonant with the strategic regional action planning.

• The Emergency Management Assistance Compact(EMAC)* provides a basis for constructing interstatemutual aid arrangements.

Incident Management Assumptions

• Response functions can only be effective whenmanagement responsibility is constructed to maintain

effective “span of control” over response processesand tasks.

• Common terminology is essential to prevent confusionand potential harm when coordinating the efforts ofdifferent organizational entities.

• Clear-cut, well-delineated organizational roles andresponsibilities that follow the functional responsibilitiesmust be developed and exercised to promote efficientresponse.

• Incident Management System provides commonterminology, span of control, and a well-definedmanagement framework. IMS structure and concepts ofoperation have evolved beyond theory: through extensiveemergency operations experience, effectiveness has beenconclusively demonstrated when IMS is properly applied.

• The authors recognize the lack of comprehensiveunderstanding of IMS in the traditional medical and

public health response communities. The lack of aneffectively functioning, commonly defined,well-understood management system across thespectrum of disparate med/health resources has been amajor impediment in past large-scale events. Even theHospital Emergency Incident Command System(HEICS)** model, now being adopted by hospitals

across the country, contains primarily an organizationaldescription. There is less emphasis on critical processessuch as Information Management and Action Planning.

• In a sudden onset, unanticipated incident, the initial phase of response and management is best described asreactive , with management and response ass

Documents

MaHIM V2 Final Report Sec 2