Spearheading Transformation

By: Dan Gerard

EMS is faced with an incredible challenge; we are at the forefront of fantastic change in healthcare. An aging population, technology (both sustaining and disruptive), diversity, adaptive challenges and the healthcare environment are all drivers that will need to be addressed in a meaningful way.

Our challenge is having the capability to adapt. For nimble organizations, this is an easy prospect. For others, due to internal (e.g., approval from city council) and external (voter initiatives) constraints, the ability to advance to the next level has hurdles that need to be overcome. The big elephant in the room is community paramedicine.

Costs associated with providing healthcare have skyrocketed approximately 150% over the past four decades. The share of the gross domestic product devoted to healthcare has increased from 7.2% in 1970 to 17.9% in 2009 and 2010.1 EMS (exclusive of ED care) accounts for only a fraction of 1%* of the total GDP spent on healthcare in the United States. We have increased demand for service and very little that is coming our way to increase capabilities and capacities.

Those managers who think small and wait for someone else to lead them down the path will have to accept whatever they are offered. The true leaders in EMS will embrace change and transform their services, staying ahead of the curve. Those leaders who go big, the early adopters, the ones who partner creatively and collaboratively, those services will achieve greatness. Now is the time to look within yourself and your agency, to reach deep down inside and transform our organizations in meaningful ways.

Change is scary for many of us but we need to remember that complacency is the bigger enemy. There are a few things we can do that can be transformative to our organization.

There are organizations that are struggling with how to make the transgenerational shift to community paramedicine. For some of them it may not happen. Our goal is to provide quality for our patients, both as a system provider and as part of the greater continuum of healthcare. How we provide it should not matter as much as making sure our patients receive what they need.

Advancing to the Next Level

We need to look at our organizations in the context of a much larger picture. If we can connect the dots, we will have a whole host of new opportunities. We can create new openings to leverage current capabilities and capacities within our services without creating new layers of care. These openings have the potential to catapult us to the next level of success, to truly transform our organizations.

Standardize what makes sense in your organization. Look at what successful services do to improve the ability to decrease turn- around times at change of shift, patient turn-over at the ED, even the completion of the electronic patient care report (ePCR). What are the biggest problems in your service, and what can you do to improve them through standardization and simplification? Many organizations have an ePCR, the truly successful ones have developed templates for every patient category and a style manual.

Customize the processes and services in your organization that will facilitate and enhance all phases of your operations: patient care, service delivery, logistics, dispatch, etc. Each organization has a certain uniqueness that is derived from management/labor work rules, contracts for service, organizational bureaucracy and, of course, culture. Make it work for you, but the end game is always providing the best in patient care and service.

System Equilibrium

When we speak about EMS in terms of the larger healthcare community, we tend to forget that we are one of the smallest sectors of the healthcare economy. Inefficiently delivered care wastes $130 billion dollars a year, with another $55 billion dollars wasted in missed opportunities for prevention.3 There is a tremendous opportunity for us to capitalize, to be innovative and to improve the quality of care and service delivered in your community with the resources we already have in place.

Many departments are looking to expand into a mobile integrated healthcare (MIH) platform by developing community paramedics. The idea of community paramedicine as a locally designed, community- based, collaborative model of care is progressive and has potential to elevate the profession to a new level in healthcare delivery.

The challenge for these organizations is that they are waiting for curriculums to be developed or for enabling legislation to run their programs. They are still asking how they will finance these programs and struggling with the metrics and benchmarks to quantify their value. In addition, no one is addressing competence or maintaining competency for these new providers. Failure to maintain competence will end up costing money rather than saving it.

Your service may not need community paramedics! We can improve care, increase our operational footprint, provide a more well-rounded scope of services and impact patients in a meaningful way by identifying potential partners who already exist in our communities.

If a community paramedic program is not in your near future, it is still vitally important to complete a needs assessment in order to work with these partners to address the needs of your patients. You would be remiss if you failed to perform this step. If you are looking at participating in a MIH program at some point, this is a critical first step to identify the gaps in care. Visiting nurse programs, mobile health clinics (pediatric and adult), homeless outreach, ethnic health groups, mobile psychiatric care, hospice, social services (public and private), veterans outreach, tribal medical programs, public health clinics, adult and child protective services are just a partial list of services that exist in your region.

My questions to you as EMTs and paramedics, or chiefs, managers and administrators:

Do you have a matrix of all the health providers, public and private, that are out in your community every day? Who provides medical, social and psychiatric services in my community? What are the services that they provide? Are they mobile? Are they providing the full breadth of services your community requires? Are you currently working with these services? Have you had discussions on how you can serve your overlapping patient populations better? What can you do to share information and serve your patient community in a new and meaningful way? How can you make a referral to them? Do they have a liaison with EMS? Who is it?

If you cannot answer those basic questions then your objective is clear: you need to reach out, find out what they do, how you can work together, and make them part of your team. Brand this new initiative with a name that is inclusive that recognizes your partnership.

Collaborate & Innovate

Once you have reached out to these other groups, leverage the complete skill set and talents of these organizations. This is a two-way street and should not occur in a vacuum. Ask yourself:

What services can EMS provide as a service that we currently don’t? An example could be public education and prevention awareness. Are you currently providing these services? What can these other potential partners provide that our current patient mix requires? They may already have a mechanism in place to provide vital functions such as complex assessments, referrals and admissions to healthcare facilities. Why reinvent the wheel if there is someone who already provides the service, has established relationships and does it well?

Is there a particular need that you have that these other groups may assist to creatively solve? Many times, visiting nurse services and hospice care providers have vendors that they work with who may be able to address a problem that plagues your service or patient population.

In the United States, 5% of the patients accounted for 50% of the total cost of providing healthcare, and 90% of the costs for healthcare were spent on the top 20% of the patients.

The Patient Protection and Affordable Care Act has increased the number of insured people in the U.S. Unfortunately, it has not increased the number of providers to keep pace with the increasing demand for care. High frequency users from populations that do not have access or ease of access to primary care, coupled with the increasing patient population reaching old age, is the challenge today. These patients are placing increasing demands and constraints on an already fragile and vulnerable system of emergency care.

A program out of Highland Hospital and Alta Bates Summit Medical Center in Oakland, Calif., Project RESPECT, utilized a multi-disciplinary case management approach to address the issues plaguing their hospital EDs. They utilized the skillsets of social workers, physicians, EMS, hospital administrators and even attorneys to address the needs of patients, to reduce ED over-crowding and demand for service.

One of the critical issues identified and solved by Project RESPECT was housing. While housing in and of itself was not the silver bullet to solve all of their problems, it was one critical piece that involved addressing primary care and social service needs, and it was a need not traditionally addressed by EMS. Remember: If you want to be considered more than a transportation service in the eyes of Medicare, hospitals and physicians, the provision of EMS and healthcare must extend past our preconceived boundaries.

Advocate

We are at the forefront of a revolution in healthcare. We are attempting to stake our claim as being more than transportation, that we are equal to other healthcare providers. Recently I told some friends that we think EMS is about saving lives. Truth be told, our profession is charity; we deal in kindness. Every day, out of view of people with cellphone cameras and a YouTube account, unknown to the world at large, we make a difference in unique ways. It is those acts of the heart that makes us distinct.

Our future, the future of our patients and the future of our profession lie at a point we cannot see, but that does not mean they are outside of our control. Our destiny is determined by what we shape with our own hands, not fate. We think with our minds and need to hold onto the principles of right and wrong in order to correct what is in front of us.

Changes in the healthcare system will have the potential to leave the most fragile and vulnerable segments of society behind. As an organization, what can you do or what are you currently doing to advocate for the elderly? Children? Abused women? The poor? Society has an expectation that we will have the courage to do what is morally and ethically correct. Stand up, do what is right.

Empower Your Staff

The best solutions for your problems come from inside your own organization. Let your staff lead work groups to find creative solutions to your biggest issues, then give them the tools and information they need to be successful.

PCR compliance, patient satisfaction, quality improvement, policy development, protocol development—these are all hotbeds of contention, with many land-mines. I was the EMS chief for an organization and worked with the local union to develop policies and procedures. Once we had something down on paper we rarely had an issue with compliance. Why? The union and its members had first crack in developing it. They had already thought through the problems and helped find a creative solution.

I would draw the starting line (for example, "We need a policy on getting signatures to verify patient transport"); then I wrote out the boundaries for the race ("We need to comply with this new regulation from CMS"); then I identified the finish: the final policy. We brought in the billing company to act as the "referee" and when the clock started, they had three weeks until the buzzer. I stood back and let them go to work. When all was said and done, we had a rock-solid policy and 100% compliance on getting signatures. It never would have happened if I stood in their way.

Foster a Positive Environment

A complex organization where individuals come together on a daily basis to make life-and-death decisions is the perfect situation for something to go terribly wrong. We are in the business of providing high quality patient care with a highly trained and educated staff. We take care of people, both inside our organization and out. Create happiness—a place where people want to come to work. It has been shown that a positive and supportive environment results in having staff who show up ready for work, support new initiatives, take fewer sick days, have fewer accidents and are engaged in a meaningful way.

Have you created opportunities within and outside your organization to relieve stress and foster social interaction? Bowling, picnics, night at the ball-park, barbecues and holiday parties are just a few examples. Don’t look for excuses, but create opportunities. You should also designate social activities to include outside organizations such as ED staff, police, fire and flight teams. Those non-stressful social situations help build bonds and reduce tensions between organizations during times of high stress and critical activity. If you spent a Saturday on a fishing trip with new friends from the police department, there is less likelihood for confrontation when they want you to move your ambulance on the scene of an MVC on the highway in the middle of the night.

Enhancing creativity within your organization is another way for staff members at all levels to participate in improving the service. But there are some myths to creativity that need to be dispelled:

Myth #1: Creativity resides in the artistic or, for lack of a better term, the crazy ones. Nothing could be further from the truth. Creativity resides inside all of us, for some it requires encouragement and a framework in order to access it.

Myth #2: Removing barriers is all that is needed to facilitate creativity. It isn’t that easy to just make the walls tumble down and all of a sudden the magic happens. Believe it or not, you can provide a structure to facilitate any employee to leverage their creative side.

Myth #3: You cannot teach creativity. This is another fallacy. You can create opportunities for employee participation and allow them to develop creative skills in a supportive environment.

Tools for stimulating creativity within an organization are taught at business schools across the country. An excellent one that I use frequently is called SCAMPER: Substitute, Combine, Adapt, Modify/Magnify, Put to other uses, Eliminate (or minimize), Rearrange. I hand out the words of the mnemonic on separate pieces of paper with the following questions for each heading underneath:

Substitute

What can be substituted? Who else? What else? Other place? Other people? Other materials?

Combine

What ideas can be combined?
Can we combine purposes? Units? Talents? Materials? How about an assortment?

Adapt

What else is this like?
What other idea does this suggest? What could I copy? Emulate? What else could be adapted?

Modify

How can this be altered for the better? What can be modified?
Is there a new twist?

Magnify

What can be made larger or extended? What can be exaggerated or overstated?
What can be added? More time? Stronger? Higher? Longer? What can be duplicated?

Put to Other Uses

What else can this be used for? Are there new ways to use as is? Other uses if modified?
Other extensions? Other markets?

Eliminate or Minimize

What if this were smaller? What should I omit?
Should I divide it up? Split it up? Subtract? Delete?
What's not necessary?

Rearrange

What other arrangements might be better? Interchange components?
Other pattern? Layout?
Other sequence? Change the order? Change pace? Change schedule?

We apply the questions to a problem and everyone answers each one on their own. It gets interesting when we read the answers aloud and we begin the discussion. Frequently people will hear another person’s response, and you can see the moment on their face when they have a new realization. They re-imagine the problem and the solution in a new way and develop novel and unique solutions to the issue we face. It is a true "wow" moment when you see it happen.

Conclusion

This is an exciting time in healthcare, especially for EMS. Think about your service in the context of the healthcare continuum: It is an intricate tapestry with many rich and interesting fabrics. Everyone is looking for new ways to collaborate and partner to provide high quality patient care. Good leaders will capitalize on this opportunity for their community. Look inside and outside your organization to recognize what you are doing well and improve upon what you could do better.

Build teams within the context of the larger healthcare system. Empower your staff and improve the work environment. Leverage the incredible talent that you have and show them they are appreciated. Foster creativity by using tools that allow everyone to unleash their inner genius.

References

Centers for Medicare & Medicaid Services. (Dec. 3, 2015) National Health Expenditure Data. Retrieved June 10, 2016, from https://www.cms.gov/research-statistics-data-and-systems/statistics- trends-and- reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html.

World Health Organization. (June 8, 2016) Global Health Expenditures Database. Retrieved on June 10, 2016, from http://apps.who.int/nha/database.

Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press, 2013. doi:10.17226/13444.

Cohen S, Yu W. (Jan. 2012) Statistical Brief #354: The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the U.S. Population, 2008–2009. Agency for Healthcare Research and Quality Medical Expenditure Panel Survey. Retrieved June 10, 2016, from http://meps.ahrq.gov/mepsweb/data_files/publications/st354/stat354.pdf.

Additional Resources

Pan American Health Organization. (Dec. 2003) Emergency Medical Services Systems Development. Lessons Learned from the United States of America for Developing Countries. Retrieved June 10, 2016, from http://publications.paho.org/product.php?productid=738.

Centers for Disease Control and Prevention. (n.d.) Ambulatory Health Care Data. National Center for Health Statistics. Retrieved June 10, 2016, from http://www.cdc.gov/nchs/ahcd/index.htm.

* Note: There are no concrete numbers for utilization and cost relevant to the GDP in the United States regarding emergency medical services. The estimate of a fraction of a percentage is determined based on the current GDP for healthcare in the United States ($2.9 trillion dollars) and utilizing the CDC’s National Ambulatory Medical Care Survey (NAMCS) survey tool. There were 136,000,000 emergency department visits in the United States in 2014, 15% arrived via EMS. Using 20.4 million (15% of 136,000,000) as a baseline number and multiplying that via the CMS fee schedule for an ALS1 response yields $6.6 billion dollars in revenue. The ALS1 rate was chosen because while the overwhelming majority of patients are transported utilizing basic life support, this figure does not account for mileage or those patients treated at the higher ALS2 rate (using CMS data approximately 3.6%).

This figure does not take into account patients who were treated/examined and left at the scene, nor does it account for the confounding variable in cost for volunteer versus career (paid) services.

Patient Care ?

By: Scott Cormier

Recently, I had the opportunity to respond to some EMS calls with my local volunteer fire department, that bring to question how we are defining and providing patient care. Our department is a small volunteer department, covering 10 square miles, surrounded by two paid departments and a paid county EMS agency. We have an ALS first response engine, and a dedicated group of volunteers. The first call was for a “suicide attempt with major bleeding from the wrists.” It was a patient that had a history with our service, and upon arrival, found she had fled the scene. After a short search by our department and the police, we found her in the woods a few hundred yards away from her house. It was nighttime, and the ground was moist, and she was shivering, barefoot and wearing only a thin top and jeans. The bleeding from the wrists were no more than scratches which were not actively bleeding. After a quick assessment, the crew was ready to walk her out to the street to meet the ambulance. I protested, concerned she would hurt herself with her bare feet on the rough ground and the cold weather. One of the responders replied “she got herself into this”, and stared at me as if I were crazy. Fortunately, someone radioed for the ambulance to come and pick up the patient. As the ambulance pulled up, I met the crew and asked for a blanket for the patient. The crew didn’t have any. We used two sheets to bundle her up, and placed her on the stretcher. The second call was for an elderly woman with chest pain. It appeared to be cardiac, so our team administered oxygen, aspirin, nitroglycerine, and performed an EKG. The nitro reduced her pain from a 9 to a 6. When the transporting crew arrived, they placed the stretcher in the hallway since the bedroom was cramped, and asked the woman to stand up and walk to the stretcher. I again protested, and asked to carry her to the stretcher. I was ignored, and the woman was walked.

My venture in EMS started in 1979, after watching too many episodes of ‘Emergency.” As an adventurous 16 year old, I found a volunteer EMS service that would accept a teenager, and began my lifelong career in EMS. Shortly after, I enrolled in a basic EMT program, and then a paramedic program. One of my mentors in those early days was a woman named Ginny Bakas, one of the few certified EMT’s at our service. While I was interested in the science of EMS, Ginny made sure I understood the social aspect of EMS. She would evaluate me on how I spoke to the patient, if I were able to carry on a conversation during the entire ambulance ride to the hospital, interaction with family members, as well as the medicine of emergency medical care. She reminded me that the social interaction is a part of our medical interactions.

I went on to work for the City of Pittsburgh, a high volume urban EMS system, and certainly had my share of cynical moments. The frequent flyers, the BS runs, people in “chronic” pain. I was losing my compassion. I moved on to become an EMS and rescue supervisor with a progressive suburban agency, but my bad habits didn’t change. I guess my awaking moment was when my mother was diagnosed with cancer. I began to see the social side of this disease, and it reminded me of the lessons taught to me by Ginny. A cancer patient in pain was no longer a frequent flyer or BS call, but rather an opportunity to provide a meaningful intervention. I felt like an idiot for all of the times I ignored those lessons on compassion and social interaction. Paramedic students today receive so much more training than the measly 150 hours required for my certification. But something that appears to be lacking are those wise lessons taught to me as a teenager. Patient care is about the patient. Whether you like them or not, sympathize with them or not, or are upset that they called you at 2am because they couldn’t pee, or weigh 400lbs and climbed upstairs before calling 911, our treatment needs to be much more than IV’s and splints. And it’s not something that you can learn from a textbook. It needs to come from our instructors, preceptors, and co-workers. Maybe we should take a lesson from Ginny Bakas, and evaluate our EMS students not just for the number of runs, splints, blood pressures, or intubations they perform, but were they able to carry on a conversation with the patient during the ride to the hospital, or how they interacted with the family.

Thank you Ginny, for giving me such an important lesson in emergency medical care.

Active Shooter Planning and Response in a Healthcare Facility

Planning for response to an active shooter event, from both a victim and public safety perspective, began in earnest after the tragedy of Columbine High School in 1999. In 2008, the Department of Homeland Security issued the guidance of Evacuate, Hide Out, and Take Action, which eventually became Run, Hide, Fight. However, the guidance of what to do when the active shooter was engaged in a hospital, nursing home, or other healthcare setting did not exist. Run, Hide, Fight was thought to be too harsh, especially with a vulnerable patient population, and worries of abandonment, ethics, and possible criminal charges confused the matter. Some healthcare facilities ignored it; others made policy requiring staff to stay with patients. Others allowed staff to decide if they wanted to stay or leave. None of it, however, was evidence based, or included experts to help design a solution.

To design an active shooter response plan, you first need to define what an active shooter is. An active shooter event, as defined by the FBI, is one or more individuals engaged in killing or attempting to kill people in a populated area. Between 2000 and 2013, there were four active shooter incidents in healthcare facilities, resulting in 10 killed and 10 wounded.

Active shooter is a unique event, and is not a suspicious person, hostage situation, a brawl, a murder, suicide, or knife attack. The distinction is important, because the response is unique. For example, during an event with a knife, barricading may be more feasible than during a firearm attack. For a hostage event, cordoning the area and evacuating nearby people may be a plan of action. During a murder or murder suicide, there may be no further threat. During an active shooter, everyone is at risk while the shooter or shooters are engaged.

In early 2013, the Healthcare and Public Health Sector Coordinating Council, a part of the Critical Infrastructure Partnership Advisory Council, formed a multidisciplinary team to look at active shooter response in healthcare. The team was comprised of federal, state, and private sector partners including clinicians, law enforcement, civil rights, attorneys, emergency planners, responders, fire and EMS, leaders from law enforcement active shooter training programs. The team discovered that not only was there confusion in how to prevent, respond, and recover from an event in a healthcare setting, but there was a lack of knowledge by law enforcement of the hazards in a healthcare facility, such as MRI machines, medical gases, and hazardous materials.

The team published their consensus recommendation guide "Active Shooter Planning and Response in a Healthcare Setting” in the summer of 2013, and later that fall, the federal government released “Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations.” In 2015, the team released an updated version of the Planning and Response Guide, which is available on the FBI active shooter website. The updated guidance includes a section for law enforcement responders, including tactics, crime scene operations, and interoperability, as well as a section on behavioral health support. The team has committed to reviewing and updating the guidance annually, and is currently meeting now, with an anticipated release this fall. The new guide will include staff and administrative tools, unified command issues and answers, recovery, and behavioral health assessment teams.

So how do you respond to an active shooter event inside a healthcare facility, and how do you address ethical issues such as abandonment? There is one fundamental point in an active shooter incident: the less people in the hot zone, the less number of targets and potential victims. Getting people out of the immediate areas of the shooter is the first priority. Hiding may not be adequate. Run, Hide, Fight are the recommendation for the immediate areas where the shooter is located. This may mean leaving patients behind, some of which may not be able to evacuate themselves. It’s a life and death decision, and that is why it’s important to discuss these options with staff before an incident occurs. It’s also important to remember that run, hide, fight are three options, and you may use more than one of them in the course of the event. For the rest of the healthcare facility (outside of the shooters location), then locking down the unit is imperative, and not an easy thing to do. Knowing how to barricade doors without locks takes practice and planning. Those units should also monitor the situation and prepare to run if the shooter enters their immediate area.

What about ambulatory patients, visitors, and contractors? The guidance recommends using plain language (and when appropriate, multi-lingual messaging) to announce what is happening and what to do. While some would argue that could cause panic, decades of research on emergency communication have consistently showed that during an emergency, people do not panic from messaging, but rather don’t respond appropriately because of the lack of guidance. Making sure the message is easy to understand and giving specific instructions can help save lives, such as “There is an armed intruder on 6 East. Everyone on 6 east should evacuate to another floor, and follow the instructions of staff. All others should stay away from 6E and follow staff instructions.”

The EMS response to a healthcare active shooter event is unique, as clinicians, medical supplies, and equipment may be available on the scene. Understanding how to utilize these assets must be preplanned, and questions of if the victims will be treated at the facility or transported elsewhere should be pre-planned. While EMS providers are now being introduced to warm zone operations, medical staff are not, but they could be a welcome asset during an active shooter event. It’s also important to understand the layout of the building or campus, hazards, and command center locations.

EMS and healthcare providers must also remember that during a large scale attack, prehospital agencies from outside the service are may respond. Those agencies must also be a part of the planning and training process, and they should have copies of plans, contact information, maps, communication, and access information.

Finally, behavioral health response needs to be planned before the incident, and needs to start as soon as the shooting has stopped. Mental health recovery can be a long term process for EMS and healthcare providers, and having a coordinated response can assure our caregivers have the necessary resources to continue to do the great work we do.

Scott Cormier, NRP, CHEP, serves as Vice-President of Emergency Management, Environment of Care, and Safety for Medxcel Facilities Management, and is a member of the Board of Directors of the International Association of EMS Chiefs.

EMERGENCY MANAGEMENT PRIMER FOR EMS

Published on: 08/11/2016
By Peter Dworsky, MPH, EMT-P

Since hurricanes Katrina and Sandy, emergency management has become more of a known entity to the emergency services sector and to the general public with programs such as Ready.gov. But what do emergency managers really do and how does it affect EMS?

Like police, fire and EMS, emergency management is an essential role of government. The Constitution tasks states with responsibility for public health and safety―hence, they are responsible for public risks—while the federal government’s ultimate obligation is to help when state, local or individual entities are overwhelmed.

The overarching goals of emergency management at all levels are:

  • First, to reduce the loss of life;
  • Then, to minimize property loss and damage to the environment;
  • And finally, to protect the jurisdiction from all threats and hazards.

Brief History
Emergency management is not a new field. In December 1802, fire engulfed the city of Portsmouth, N.H. This disaster exceeded local capabilities and had a severe impact on commerce for the entire nation. Congress quickly passed the Congressional Relief Act of 1803, which enabled the federal government to be involved in local disasters. This act is commonly regarded as the first piece of national disaster legislation.
The Federal Civil Defense Act of 1950 established a nationwide system of civil defense agencies and programs, such as air raid warning and emergency shelter systems, to protect the civilian population. Duck-and-cover drills became routine in schools, government agencies and other organizations. This was the first recognized face of modern emergency management. In 1952, President Truman ordered that federal disaster assistance was intended to supplement, not supplant, the resources of state, local, tribal and private-sector organizations. Today’s emergency management system supports the notion that all disasters are local and should be managed at the lowest level until response capabilities are exceeded.
During the 1960s and 1970s, the U.S. experienced many devastating natural disasters, including the Alaskan earthquake and hurricanes Betsy and Camille, which identified a need for a well-coordinated federal response and recovery operations during major events. Congress passed several disaster relief acts, which ultimately established the process for presidential disaster declarations.
In 1979, President Carter’s executive order merged many of the separate disaster-related responsibilities into a new Federal Emergency Management Agency, or FEMA.
Jumping ahead into the 21st century, emergency management saw dramatic changes at the federal level. FEMA was merged into the Department of Homeland Security and saw a shift in priorities, moving away from disaster preparedness and toward an emphasis on national security. However, we are still subject to natural disasters, such as hurricanes Katrina and Sandy, which continue to direct the scope of emergency management at the state and federal levels. One of the most important pieces of legislation for emergency management procedures is the Stafford Disaster Relief and Emergency Assistance Act, which created the system in place today through which a presidential disaster declaration triggers financial and physical assistance through FEMA. The Stafford Act covers all human intentional hazards (terrorism), and unintentional and natural disasters.

Key Components
As with EMS, emergency managers use terms that we should have a clear understanding of. A hazard is a potentially damaging physical event, phenomenon or human activity that may cause the loss of life or injury, property damage, social and economic disruption or environmental degradation. A threat is the presence of a hazard and an exposure pathway. The hazard must have accessibility to an individual, community or entity for a threat to exist. For example, there is currently no threat to Montana from an active volcano. The susceptibility of life, property or the environment to damage and destruction if a hazard occurs is called vulnerability. For our purposes, vulnerability is the absence of resiliency, which is the ability to absorb stress and maintain certain basic functions or recover after a hazard has been realized. Risk is defined as the possibility of suffering harm from a hazard. The mere presence of a hazard is not sufficient to establish that a risk exists.

There are four main phases to emergency management:

Prevention focuses on preventing human hazards, primarily from potential natural disasters or terrorist attacks (both physical and biological). The risk of loss can be limited with plans, training and design standards.

Mitigation activities are those necessary to reduce or eliminate risk to people, property or lessen the effects of an incident. This may include building resilient systems, communities and infrastructure to reduce vulnerability to incidents. This may also involve hardening or fortifying our communications centers, ensuring redundant power sources and supply chains.

Preparedness includes a range of deliberate, critical tasks and activities necessary to build, sustain and improve the operational capability to prevent, protect against, mitigate, respond to and recover from incidents. It is a continuous process to identify threats, determine vulnerabilities, determine impacts on capabilities and identify required resources.

Response is the reaction to the occurrence of a catastrophic disaster or emergency. It is comprised of the coordination and management of resources (including personnel, equipment and supplies) utilizing the incident command system in an all-hazards approach; and actions to save lives and minimize damage in a disaster or emergency situation. This phase includes:

  • Providing transportation for response priorities, including evacuation of people and animals, and delivery of response resources.
  • Providing fatality management services.
  • Minimizing health and safety threats.
  • Providing life-sustaining services with a focus on hydration, food, shelter, and reunifying families.
  • Delivering search and rescue services.
  • Ensuring a safe and secure environment for affected communities.
  • Ensuring timely communications.
  • Providing essential services including emergency power, fuel, access to community staples, and fire and first response services.
  • Providing lifesaving and medical treatment.

Recovery consists of those activities, which the agency must perform that continue beyond the emergency period to restore critical functions and initiate stabilization efforts. The goal of the recovery phase is to return our organization to normal operations.

Do you know how your EMS system fits into these four phases? Do you know who your local emergency manager is and how to contact them 24/7?

Each community is required to have an emergency operations plan (EOP). This document establishes the overall authority, roles and functions performed during incidents, and assigns responsibility to organizations and individuals. Do you know what is expected of your organization? Typically, the EOP will address several functional areas that impact EMS, including mass care, public health and medical services.

EMS is often written into these plans with no input from the EMS agencies themselves, resulting in unrealized expectations. For example, many plans call for EMS to provide services whenever an emergency shelter or relocation center is opened. The plan may also call for EMS to perform support functions at hazmat incidents or rehab at search-and-rescue functions. If you are not aware of what is written in the EOP, you may find yourself in a difficult situation. The plan may also be outdated, and your organization has since made changes in communications, equipment and staffing that may not be properly reflected.

Preparing for the Real Deal
The EOP needs to be tested to ensure the validity of the assumptions that exist. There is a specific formula that needs to be followed and it should involve all stakeholders. There are several ways of testing the plan, grouped into discussion-based and operations-based exercises.

Discussion-based exercises include seminars, workshops, tabletop exercises (TTXs) and games. These types of exercises can be used to familiarize players with current plans, policies, agreements and procedures, or to develop new plans, policies, agreements and procedures. Discussion-based exercises focus on strategic, policy-oriented issues. TTXs are aimed at facilitating conceptual understanding, identifying strengths and areas for improvement, and/or achieving changes in perceptions.

Operations-based exercises are more complex and include drills, functional exercises (FEs) and full-scale exercises (FSEs). These exercises are used to validate plans, policies, agreements and procedures; clarify roles and responsibilities; and identify resource gaps. Operations-based exercises are characterized by actual implementation of response activities in reaction to an exercise scenario.

FEs are traditionally used to evaluate coordination of command and control functions and focus on exercising plans, policies, procedures and staff members involved in management, direction, command and control of the various ICS branches or multiagency coordination centers. There is no actual deployment of assets.

FSEs are the most complex and resource-intensive type of exercise. They are conducted in a real-time, stressful environment intended to mirror a real incident where many activities occur simultaneously throughout the duration of the exercise. Assets are deployed and kept within strict timetables.

Continuing 'Business' Ops
For the sector of emergency management, there are valuable lessons to be learned from the field of business crisis and continuity management. We may not always view our agencies as a business, but think about how we keep units in service during a disaster. What does our manpower pool look like? How resilient is our supply chain? Do we have a back-up communications plan? How long can we keep the wheels turning if we do not have fuel, people, supplies and the ability to respond?

A top document for all emergency responders to obtain is a copy of the NFPA 1600: Standard on Disaster/Emergency Management and Business Continuity/Continuity of Operations Programs. This document addresses methodologies for defining and identifying risks and vulnerabilities, and provides planning guidelines that address stabilization of your physical infrastructure and protecting the health and safety of your personnel. It also provides guidance on crisis communications procedures and discusses strategies for both short-term recovery and ongoing long-term continuity of operations.

It has been said before, but it bears repeating: During a disaster is not the time to introduce yourself for the first time.

Peter Dworsky, MPH, EMT-P is President-Elect of the International Association of EMS Chiefs (www.IAEMSC.org), Corporate Director of MONOC EMS in New Jersey, and a Deputy OEM-EMS Coordinator for Monmouth County (N.J.) Sherriff’s Office.

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