CHAPTER 17. Emergency Preparedness
Kathy S. Robinson
Disasters—natural and manmade events that dramatically affect life and property to catastrophic proportions—are fortunately rare, largely unpredictable, and yet inevitable. Historic events such as the attack on the World Trade Center in 2001 and Hurricane Katrina in 2005 reinforce the need for a national coordinated emergency response. Emergency responders, including nurses, are compelled by a sense of duty as the magnitude of any disaster unfolds and graphic images of human suffering are replayed over various media outlets. However, responding to human need is not as simple as grabbing a few supplies and jumping on the next bus to help. In 1995 a nurse was killed by falling debris in Oklahoma City in the aftermath of the explosion at the Alfred P. Murrah Building, illustrating the need for protective equipment and proper training. Hundreds of rescue and medical personnel who showed up via public transportation and private vehicles had to be turned away in the Gulf Coast region following Hurricane Katrina. Although professional skills were needed in specific locations, local officials did not have the means to feed or shelter unexpected personnel, verify professional credentials, or spare the resources to identify and coordinate proper work assignments in the midst of the actual event. Stockpiles of unrequested, unused supplies still sit in southern warehouses today. One of the greatest lessons learned during such events is that advance planning and preparation about the roles, responsibilities, and resource management strategies are essential to matching personnel, equipment, and supplies with the people and communities that need them most. Many mistakenly view the federal government (and in particular, the Federal Emergency Management Agency [FEMA]) in a lead and primary role in this regard. In reality, local emergency managers make intrastate and interstate requests for assistance long before a federal disaster response is activated by the governor of an affected state. These activations typically occur when local and state resources are exhausted or insufficient to meet the demands of the incident. FEMA is just one of many federal departments or agencies that may be called upon to assist rescue and recovery efforts.
The Homeland Security Act of 2002 refers to domestic incident management from an “all-hazards” perspective, in other words, any potential hazard that threatens a jurisdiction within our country’s borders. The terms emergency preparedness and domestic preparedness are frequently used interchangeably. Under the initial U.S. Department of Homeland Security (DHS) reorganization in 2003, the Emergency Preparedness and Response Directorate contained most of the pre-DHS FEMA functions and staff, which were geared mostly toward natural disasters such as hurricanes and floods. The focus of this chapter addresses preparedness and response from an emergency management perspective, so the term emergency preparedness has been retained even though the more contemporary term is domestic preparedness.
Emergency nurses routinely plan, assess, adapt, and respond, and they can easily transition to unpredictable and chaotic environments while caring for patients. To serve as active participants in a disaster response, emergency nurses should gain additional skills and knowledge through an understanding of the Incident Command System (ICS) and of the various disciplines of emergency management—mitigation, preparedness, response, recovery, and communications5—before a disaster occurs.
EVOLUTION OF EMERGENCY MANAGEMENT
As a function of public health and safety, emergency management is an essential role of the government. During the Cold War era, the principal disaster risk in the United States was believed to be a nuclear attack by the Soviet Union. Individuals and communities were encouraged to build bomb shelters, and every community had a civil defense director (usually retired military personnel). Preceded by a string of natural disasters in the 1960s, a national focus on emergency management in the 1970s resulted in the formation of FEMA during the Carter administration. In the 1970s new categories of catastrophes also became evident—those caused by human error or malfeasance and involving chemicals or other toxic agents. 10 A new type of disaster without precedent was revealed in 1978 when toxic waste, buried in the Love Canal some 30 years earlier, was identified as the source of an alarming rate of cancer and birth defects in local residents. President Carter used emergency authority granted in disaster relief legislation to relocate families from the affected area. 2
Several federal legislative milestones have been identified over the last decade making federal assistance available at the local level (Table 17-1). One of the most significant pieces of emergency management legislation was enacted by Congress in 1988. The key provision of the Robert T. Stafford Disaster Relief and Emergency Assistance Act included authorization (statutory authority) for most federal disaster response activities. The Stafford Act also encouraged hazard mitigation measures to reduce losses from disasters, authorized creation of the Federal Response Plan, and required all states to prepare their own Emergency Operations Plans. The Federal Response Plan, a landmark federal document when it was released in 1992, identified and organized Emergency Support Functions (ESFs) as a mechanism for grouping activities most frequently used to provide federal support, both for declared disasters and emergencies under the Stafford Act and for non–Stafford Act incidents. ESF #8, the Public Health and Medical Services Annex, 3 was revised in 2007 and is categorized into the following core functional areas:
| Year | Milestone or Legislative Action | Key Elements |
|---|---|---|
| 1803 | Congressional Act | One of the first federal actions to provide local financial assistance (Portsmouth, NH, devastated by fire) |
| 1934 | Flood Control Act | Authorized U.S. Army Corps of Engineers to design and build flood control projects |
| 1950 | Civil Defense Act | Created shelter, evacuation, and training programs that state and local governments would implement |
| 1950s | Ad hoc legislation | Provided disaster assistance funds following a series of hurricanes |
| 1968 | National Flood Insurance Act | Created the National Flood Insurance Program (NFIP) |
| 1974 | Disaster Relief Act | Coordinated federal response and recovery efforts through the NFIP |
| 1979 | Executive order by President Carter | Federal Emergency Management Agency (FEMA) created |
| 1988 | Robert T. Stafford Disaster Relief and Emergency Assistance Act | Amended Disaster Relief Act—constituted statutory authority for most federal disaster response activities, encourages hazard mitigation measures to reduce losses from disasters, authorized creation of the Federal Response Plan, required all states to prepare their own Emergency Operations Plans |
| 1994 | Stafford Act amended | Incorporated most of the former Civil Defense Act of 1950 |
| 1995 | Nunn-Lugar Act | Core purpose was to reduce the nuclear threat to the United States domestically and abroad; it became the first federal legislation reflecting the government’s concern for domestic disaster management resulting from terrorism |
| 1996 | Emergency Management Assistance Compact | Provided form and structure to interstate mutual aid |
| 2001 | Patriot Act | Significantly increased the surveillance and investigative powers of law enforcement agencies in the United States |
| 2002 | Homeland Security Act | Established Department of Homeland Security and refocused the country on terrorism |
| 2002 | Public Health Security and Bioterrorism Preparedness and Response Act | Related to public health preparedness and improvements, controls on biologic agents, protecting food, drug, and drinking water supplies; created state bioterrorism preparedness block grant program |
| 2006 | Pandemic and All-Hazards Preparedness Act | Transferred the National Bioterrorism Hospital Preparedness Program (NBHPP) from the Health Resources and Services Administration (HRSA) to the assistant secretary for preparedness and response (ASPR); ASPR is the principal advisor to the secretary of health and human services on public health and medical preparedness and response |
• Assessment of public health/medical needs
• Health surveillance
• Medical care personnel
• Health/medical/veterinary equipment and supplies
• Patient evacuation
• Patient care
• Safety and security of drugs, biologics, and medical devices
• Safety of blood and blood products
• Food safety and security
• Agriculture safety and security
• Worker safety and health
• All-hazard public health and medical consultation
• Technical assistance and support
• Behavioral health care
• Public health and medical information
• Vector control
• Potable water/wastewater and solid waste disposal
• Fatality management
• Veterinary medical support
• Human services coordination
Before Hurricane Katrina in 2005, Hurricane Andrew, which ravaged the state of Florida in 1992, was the most expensive disaster in United States history. At the time, Florida was ill-prepared to handle a disaster the magnitude of Hurricane Andrew. The state was not capable of providing adequate assessments of its damage and was unprepared to make appropriate requests for assistance. As a result, the Southern Regional Emergency Management Assistance Compact (SREMAC) was created through the Southern Governors Association. This compact “allowed states to assist each other with some certainty of the expectations and responsibilities involved, which in turn increased the likelihood of their doing so at considerably reduced risk of suit or of great expense. It also allowed states to provide assistance to one another either in advance of FEMA aid where it was forthcoming, or in place of FEMA aid where it was not.”1 Using SREMAC as a model, the U.S. Congress ratified the Emergency Management Assistance Compact (EMAC) as Public Law 104-321 on October 19, 1996, and today 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands have enacted legislation to become members of EMAC.
In the months following the 2001 attack on the World Trade Center, President George W. Bush created the Homeland Security Council within the executive branch of the federal government and began issuing a series of executive orders commonly known as “Homeland Security Presidential Directives” or HSPDs, which record and communicate presidential decisions about the homeland security policies of the United States. Among them, in February 2003 President Bush issued Homeland Security Presidential Directive (HSPD)-5, Management of Domestic Incidents,6 which directs the secretary of homeland security to develop and administer a National Incident Management System (NIMS). The system is intended to provide a nationwide template to enable federal, state, local, and tribal governments to work effectively together to manage a range of domestic incidents. Under NIMS, the president leads the federal government’s response effort to ensure that the necessary coordinating structures, leadership, and resources are applied quickly and efficiently to large-scale catastrophic incidents. Under the NIMS structure, the secretary of homeland security is the principal federal official for domestic incident management. HSPD-5 requires all federal departments and agencies to adopt NIMS and to implement it across all programs. The directive also requires federal departments and agencies to mandate compliance with NIMS as a condition for federal preparedness assistance (i.e., grants, contracts, and other activities). As a result, NIMS became an essential component of the United States health care system through the National Bioterrorism Hospital Preparedness Program. Originally administered by the Health Resources and Services Administration (HRSA), the National Bioterrorism Hospital Preparedness program is now located in the United States Department of Health and Human Services (DHHS) under the assistant secretary for preparedness and response (ASPR). The focus of the program has become all-hazards preparedness and not solely bioterrorism. NIMS also identifies the basic principles of ICS.
Overview of ICS and NIIMS
According to FEMA, one of the most important “best practices” incorporated into NIMS is ICS, a standard, on-scene, all-hazards incident management system already in use by firefighters, hazardous materials teams, rescuers, and emergency medical teams. ICS has been established by NIMS as the standardized incident organizational structure for the management of all incidents.
The concept of ICS was developed more than 30 years ago, in the aftermath of a devastating wildfire in California. During 13 days in 1970, 16 people died, 700 structures were destroyed, and over one-half million acres burned. The cost and loss associated with these fires totaled $18 million per day. Although all of the responding agencies cooperated to the best of their ability, numerous problems with communication and coordination hampered their effectiveness. As a result, Congress mandated that the U.S. Forest Service design a system to effectively coordinate interagency actions and to allocate resources that would be applicable to multiple-fire situations. This system became known as Firefighting Resources of California Organized for Potential Emergencies (FIRESCOPE). FIRESCOPE ICS is primarily a command and control system delineating job responsibilities and organizational structure for the purpose of managing day-to-day operations for all types of emergency incidents.
By 1980, FIRESCOPE ICS training was under development. Recognizing that, in addition to the local users for whom it was designed, the FIRESCOPE training could satisfy the needs of other state and federal agencies, the National Wildfire Coordinating Group (NWCG) conducted an analysis of FIRESCOPE ICS for possible national application. Also during the 1970s the NWCG was chartered to coordinate fire management programs of the participating federal and state agencies.
By 1981, ICS was widely used throughout southern California by the major fire agencies. It was quickly recognized that ICS could help public safety responders provide effective and coordinated incident management for a wide range of situations: floods, hazardous materials incidents, earthquakes, and aircraft crashes. This system was flexible enough to manage catastrophic incidents involving thousands of emergency response and management personnel. By introducing relatively minor terminology and organizational and procedural modifications to FIRESCOPE ICS, ICS became adaptable to an all-hazards environment.
In 1982, all FIRESCOPE ICS documentation was revised and adopted as the National Interagency Incident Management System (NIIMS). In the years since FIRESCOPE and NIIMS were blended, the FIRESCOPE agencies and the NWCG have worked together to update and maintain the Incident Command System Operational System Description (ICS 120-1). This document would later serve as the basis for the NIMS ICS, created by HSPD-5 in 2003 and implemented by DHS in 2004. In December 2008, FEMA published a revision to NIMS, superseding the March 2004 version. It expands on the original version released in 2004 by clarifying existing NIMS concepts, better incorporating preparedness and planning, and improving the overall readability of the document. The revised document also differentiates between the purposes of NIMS and the National Response Framework (NRF) by identifying how NIMS provides the action template for the management of incidents, whereas the NRF provides the policy structure and mechanisms for national-level policy for incident management. The basic tenets of NIMS remain the same. There have been several improvements to the revised NIMS document that will aid in readability and usefulness of preparing, preventing, and responding to incidents, including a reordering of the key components to emphasize the role of preparedness and to mirror the progression of an incident. Additional information is available at http://www.fema.gov/emergency/nims/.
ICS Requirements for Hospitals and Practitioners
NIMS requires that all federal, state, local, tribal, private sector, and nongovernmental personnel with a direct role in emergency management and response must be NIMS and ICS trained. 4 This includes all emergency services–related disciplines such as emergency medical services (EMS), hospitals, public health, fire service, law enforcement, public works/utilities, skilled support personnel, and other emergency management response, support, and volunteer personnel. FEMA does not review or endorse commercial or proprietary courses. Currently the only approved training courses that meet NIMS competencies are provided through FEMA’s Emergency Management Institute (EMI) and through approved local and state providers. EMI serves as the national focal point for the development and delivery of emergency management training. Courses are available online, and registration is free. It is anticipated that emergency nurses who wish to participate in disaster response under NIMS will be required to have this training in the future. Additional information is available at http://www.training.fema.gov/EMIWeb/. Emergency nurse managers involved or interested in hospital preparedness are encouraged to consider FEMA Independent Study Courses IC 100 and 200 HC for hospitals and health care systems. The Hospital Incident Command System (HICS, formerly HEICS) is an important foundation for the more than 6,000 hospitals in the United States in their efforts to prepare for and respond to various types of disasters. All HICS materials posted at www.emsa.ca.gov/dms2/dms2.asp are NIMS compliant and meet the requirements for hospital training when attended through EMI or an approved local or state provider. All hospitals were required to be fully compliant with NIMS activities delineated by FEMA9 as of September 30, 2008, for hospitals to remain eligible for federal preparedness and response grants, contracts, or cooperative agreement funds.
Credentialing of Emergency Responders
Three principal efforts among FEMA’s HSPD-5 initiatives are directed at supporting NIMS’ policies to improve mutual aid processes. These include establishment of common performance standards for training emergency responders, use of common definitions for typical response resources (National Mutual Aid and Resource Management Initiative or “Resource Typing”), and implementing a national system for credentialing emergency responders that can be used to easily support mutual aid through the verification of the identity and qualifications of emergency response personnel. The credentialing system, currently referred to as the National Emergency Responder Credentialing System (NERCS) can help prevent unauthorized (i.e., self-dispatched or unqualified) personnel access to an incident site. Most homeland security experts agree that once the system is fully operational, access to a disaster scene will be restricted to those with a documented mission assignment and authorization to provide assistance through interstate mutual aid agreements.
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