Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Clinic Management/Command Structure
Incident management systems enable emergency responders to manage the coordinated response to mass casualty incidents and other emergency scenarios.74 A bioterrorism event or infectious disease outbreak may be a large-scale event (e.g., similar in size and scope to an earthquake or flood) requiring the activation of a community all-hazard response plan. However, the response to a large-scale bioterrorism event poses special challenges in that it may require use of local, State, and Federal medical stockpiles; coordination of multiple State and Federal agencies with non-overlapping fields of expertise (e.g., law enforcement and public health); and outreach to a large proportion (if not all) of the community for prophylaxis and treatment. As such, bioterrorism and epidemic outbreak response epitomizes the type of complex multi-jurisdictional operation for which the recently published National Incident Management System (NIMS) has been designed.74 The local implementation of a NIMS-based Command and Control function, described here, would need to integrate with regional, State, and Federal response plans.
Mass prophylaxis involves a number of multiply-coordinated activities (e.g., the Receipt, Store and Stage (RSS) centers for Strategic National Stockpile supplies, where Federal assets are transferred to State control), but dispensing operations using DVCs pose perhaps the greatest logistical challenge. As noted in Section One, DVC operations are the critical point of contact between public health/emergency preparedness activities and the wider public. The complexity and importance of DVC operations necessitate that DVCs have a clearly defined command structure that integrates seamlessly into the broader mass prophylaxis campaign command structure which, in turn, integrates into the existing local, regional, or State emergency management system. This nested command structure is illustrated in Figure 6.
The National Incident Management System exemplifies a national movement toward developing an all-hazards approach to natural disasters and terrorist events at the local level using the principals of incident command (IC).76 IC should also serve as the framework for management of each DVC, because it provides a standardized structure that can be easily integrated into larger campaign and all-hazards plans. Furthermore, the inherent flexibility of IC allows for easy expansion or contraction over time as the mass prophylaxis response demands.
Conceptually, the command system should be utilized in the planning, mobilization, operation, and demobilization of each DVC. As demanded by the characteristics of the response (e.g., population density), multiple DVCs can be organized in an expanded IC structure, easily integrated into the mass prophylaxis campaign management system and a community's Emergency Operations Plan (EOP), and ultimately placed under a multi-agency and multi-jurisdictional Unified Command (UC). Figure 6 has shown the relation of the DVC IC structure to other mass prophylaxis elements and the overall UC system. Figure 7 details the internal command structure of a sample DVC. The various components, explained in detail below, may be added or removed as required by the complexity and size of the DVC.
A. Core Functions
- Staff Positions
The Incident Command System (ICS) serves as the framework for all of the managerial support staff positions in the DVC. Standardized titles should be used whenever possible to minimize misunderstandings in terminology among different responding agencies. The core managerial units and staff are as follows:
- DVC Command and Control
The DVC Command and Control unit of the ICS functions as the highest direct managerial unit of all individual DVC procedures. Decisions regarding DVC procedures and control of information flow, both intra- and inter-DVC, are centralized in the DVC Command and Control unit. The DVC Command and Control unit is located in the DVC Incident Command Post (DVC ICP), which should be contained within the DVC yet free from direct patient traffic to ensure easy and immediate accessibility to various ICS managers. The DVC Command and Control unit comprises a single Site Commander (DVC SC) and a DVC Command Staff. In campaigns requiring more than one DVC, each DVC SC will report to a single Dispensing Operations Commander (DOC) who, in addition to overseeing all of the DVCs, will serve as the liaison to the community's Emergency Operations Center (EOC), the "nerve center" of the larger central Command and Control function.
- DVC Site Commander (SC) and Dispensing Operations Commander (DOC)
The SC is responsible for overall management of DVC operations and for the formation of the DVC Site Action Plan (SAP—see A.2) with collaboration from the Planning and Operations Sections (see A.1.b.i and A.1.b.ii). Optimally, the SC will be a public health or emergency management official. The SC has executive responsibility for directing all aspects of deployment, operation, and maintenance of the DVC.
Campaigns using multiple DVCs will require an SC for each DVC, who will report to a single DOC located within the community's Emergency Operations Center (EOC). This DOC should be a senior public health official who can coordinate the operating activities of all DVCs in the campaign. The DOC is responsible as well for communication between the EOC and the DVCs to ensure that DVC management and operations integrate into the mass prophylaxis campaign system and the larger central Command and Control function.
DVC Command Staff:
The DVC Public Information Officer (PIO) serves as the local liaison between the EOC Joint Information Center (JIC) and the local community. The PIO, under directives from the SC, DOC, and ultimately the EOC, coordinates the release of information to the general public prior to the initiation of the mass prophylaxis program (e.g., DVC location; description of process), the release of updated directives as necessary, and progress reports. While each community's central Command and Control function will have its own senior information officers, the presence of DVC-level PIOs (if permitted by staffing constraints) may help foster a community-DVC link that ensures that the public receives accurate, focused, and timely information to support operational goals such as efficient patient flow.
The DVC Liaison Officer serves as the DVC contact point for all involved responding agencies, including police, public health, emergency management, hospital, Federal, and other activated DVCs. The Liaison Office coordinates information and directives with representatives from all participating agencies to ensure focused and cooperative action.
The DVC Medical Director and Chiefs of the Operations and Logistics sections (go to A.1.b.ii and A.1.b.iii), assists the SC and DOC in determining the timing of restocking of supplies from the distribution center. Additionally, the DVC Medical Director coordinates use of clinical protocols (e.g., written decision trees) to guide triage, prophylaxis, and treatment of patients. Finally, the Medical Director serves as quality control manager regarding all clinical activities in the DVC.
The DVC Safety Officer is responsible for security at the DVC and directs activity of the security staff inside the DVC. In addition, this officer manages the health and safety of all DVC staff and ensures that operating conditions meet all Federal, State, and county health and safety regulations.
- DVC General Staff
The DVC General Staff is the organizational level comprising the major functional sections of the DVC and includes the following:
- DVC Planning Section
The DVC Planning Section collects, evaluates, and disseminates real-time information regarding DVC operations. The Planning Section also monitors and reports resource use and allocation and prepares Situation Reports (SitReps) to be incorporated in the development of the next SAP (go to A2).
- DVC Operations Section
The Operations Section directs and coordinates DVC operational activities and ensures proper implementation of the SAP. Section subgroups under DVC Operations may include a Medical Section (covering triage and medical evaluation), a Pharmacy Section (covering dispensing of prophylactic medicines and vaccines and treatment regimens used for seriously ill patients), a Mental Health Section, and a Transportation Section, as well as the DVC Security Unit.
- DVC Logistics Section
The Logistics Section responds to information generated from the Planning Section and coordinates the provision of required services and materials. Additionally, the Logistics Section will directly support the needs of the DVC staff (e.g., food, medical treatment).
- DVC Finance/Administration Section
The Finance/Administration Section is responsible for DVC costs and financial considerations. The Finance/Administration Section records staffing hours, procurement costs, and unused and returnable SNS inventories. Furthermore, the Finance/Administration Section monitors the patient flow entering and exiting the DVC, including the collection of patient information/forms upon DVC exit. Finally, the DVC Finance/Administration Section may oversee the Translators Unit that will vary in size as determined by the needs of the community.
- Development of the DVC Site Action Plan (SAP)
The DVC Site Action Plan (SAP) serves as a detailed operational guide to the deployment and operation of individual DVCs and should be an extension of the larger campaign goals of the Incident Action Plan (IAP) established by the campaign's central Command and Control function. The DVC SAP should address the following:
- Policies, priorities, and objectives determined by the DVC Command and Control, integrated into the larger Unified Command function.
- Organizational plans to meet these objectives developed by the DVC Planning and Operations Units.
- Support and service plans to accomplish the organizational plans developed by the DVC Logistics Unit (with input from the Security Officer).
- Financial and resource considerations compiled by the Financial/Administration Unit.
The DVC SAP should explicitly state the prophylaxis goals of the operational period (e.g., number of patients to prophylax over the next 24 hours) and detail all tactical actions (e.g., staffing levels at individual stations) and supporting information. This SAP should be updated prior to the initiation of the next operational period and reflect the developments of previous periods. It is important to note that SAP must be developed uniquely by each DVC to meet its specific needs as time unfolds; however, it should integrate into the larger campaign IAP (developed in the EOC of the community's central Command and Control function) and thus should be in accordance with the larger campaign goals.
- Job Action Sheets and Protocols
Each staffing position in the ICS should have a prioritized Job Action Sheet describing in detail the roles and responsibilities associated with that particular position. Job Action Sheets serve to standardize position duties and allow staff to move easily from one position to another as the response dictates. Clinical protocols are required to guide several of the core DVC functions (including triage, medical evaluation, and drug triage and dispensing). These protocols, which must be developed prior to any implementation of the DVC plan, are incorporated into Job Action Sheets as a prioritized item number (e.g., Item #2: triage arriving patients according Triage Protocol sheet). Optimally, each DVC will have an identical structure and thus Job Action sheets should be uniformly developed by the DOC under the direction of the community's EOC. However, due to such factors as size limitations or unique target population characteristics, a particular DVC may require a unique staffing structure and thus specialized Job Action Sheets.
B. Additional Functions
The ICS provides managerial structure for additional functions including staff room and board, receipt, storage, and staging of resources, and intra-DVC transportation for both staff and patients. Additionally, the modular flexibility (i.e., functional units) of the ICS allows incorporation of volunteer staff. For example, the DVC Reception/Greeting Unit can contain a Volunteer Team to handle appropriate duties. The DVC SAP should provide detailed procedures for utilizing volunteers in DVC operations.
C. Flexibility and Redundancy
The ICS provides a time- and experience-tested management structure that has been adopted by many State and local emergency response agencies. ICS combines clear delineation of roles and reporting channels with flexibility and adaptability to local requirements and resources. A mass prophylaxis program framed in the ICS structure can rapidly respond to changes in local DVC goals, resources, and personnel.
The size and scope of a mass prophylaxis campaign requires coordinated collaboration among different agencies that previously may not have undertaken joint large-scale community operations (e.g., public health and law enforcement, U.S. Postal Service and emergency management) and may have very different jurisdictional levels (e.g., county versus Federal). The ICS structure (and related Incident Management System [IMS]) allows for efficient interagency collaboration and communication. The ICS operates with "unity of command," whereby information flows from each organizational member to only one designated manager, creating an internal quality control system.
ICS also allows for the coordination of multiple DVCs with clear lines of communication. Each DVC has a single individual responsible for a defined functional area that is consistent across all DVCs. A mass prophylaxis program utilizing multiple DVCs linked to an overall Command and Control function framed in ICS permits the efficient gathering of community-wide data and the shifting of staff and resources between DVCs (e.g., from a demobilizing DVC to those DVCs receiving an accelerating patient flow rate).
In order to maintain appropriate staffing levels in a crisis situation, emergency management planning often calls for "3-deep" staffing whereby every position has 2 back-up personnel. However, given the potential size of staff required for a mass prophylaxis campaign, this ratio may be infeasible. An alternative would be to ensure each staff member's familiarity with the roles and responsibilities of 2 additional and related positions, creating in effect a reverse 1 to 3 ratio. For example, a medical evaluator could familiarize oneself with the triage and pharmacy protocols in case there was need for additional staff at these positions. A protocol-driven ICS structure allows for easy review of different staff duties. Additionally, an ICS structure creates an inherent layer of redundancy, as managers are familiar with the operational protocols guiding the members of the group.
The chief drawback of ICS is the need to adopt a new technical vocabulary and response structure for those unfamiliar with its roles and concepts. Consequently, time for education and training in ICS should be factored into DVC plans. This up-front training time may require significant buy-in in terms of staff time and resources from all of the agencies involved in planning for mass prophylaxis campaigns. However, simple Job Action Sheets, a clear, uniform command structure, and defined protocols allow for rapid training that, when necessary, can be done during the activation and/or escalation of a response.
D. Command and Control Integration
Operation of a DVC during an actual bioterrorism event would be a complex endeavor requiring dynamic management to ensure efficient operation and success of the overall prophylaxis campaign. Depending on the magnitude of the terrorist event, the size and location of the affected community, and the existing emergency response infrastructure, the Command and Control function may be too far removed from actual dispensing activities to effectively manage the minute-by-minute operational requirements of a functioning DVC. Employing a DVC-specific modified ICS structure as described in this section should improve the effectiveness of DVC operations and contribute to the success of the overall prophylaxis campaign provided that this DVC ICS functions as an extension of the community's central Command and Control function.
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