Pro and Con, Yea and Nay - Experts' Dialogue on the New HICS Guidebook

A new medical-systems guidebook published by the state of California has elicited both praise and criticism from the U.S. medical community – praise because of the wealth of useful information provided and the quality and readability of the guidebook’s contents, and criticism because of several significant omissions and the alleged lack of a common-sense perspective in the development of certain comments and recommendations included in the guidebook.

The HICS Guidebook, including the command-structure organization chart referenced below, is available at www.emsa.ca.gov/hics/hics.asp

Without taking sides, DomPrep Journal asked two highly respected medical authorities, Dr. Michael Allswede and Dr. Jerry Mothershead, who hold different but not diametrically opposed views about the guidebook’s usefulness, to provide a “Point/Counterpoint” discussion about the guidebook’s strengths and weaknesses. Dr. Allswede leads off the discussion with his comments just below.

The state of California has recently published a 117-page “guidebook” that, among other things, provides a methodology for organizing medical systems to respond to an all-hazards problem set that conforms closely to the National Incident Management System (NIMS). Also included in the officially titled Guidebook for Hospital Incident Command System Development are 256 additional pages of job action sheets and 56 pages of additional forms and instructions – in other words, a grand total of 429 pages of material describing the duties and responsibilities of a notional 25-person command structure.

The HICS Guidebook also provides an abundance of assorted training materials, and 28 training scenarios to digest. The command-system material is complete and well organized, and represents an admirable effort to conform medical system decision-making to the National Incident Command System – which makes it a particularly valuable resource for the U.S. Department of Homeland Security (DHS).

While this effort is laudable and there is a clear need for such a guidebook, there also are some concerns about this one, the first and most important of which is that the entirety of life-saving personnel resources is compressed into a single box in the command structure called “Medical/Technical Specialists” – an oversized umbrella term which may or may not reflect the operational reality at every U.S. hospital. In addition to the fact that nowhere in the plan is there specific guidance for medical care per se, and/or triage guidelines to use in a variety of scenarios, there are three basic problems with the HICS approach to hospital readiness:

1. The first is what might be called the “all things to all people” problem. Any plan designed to cover all contingencies in all circumstances may almost by definition be perhaps too large and too confusing to be truly useful in times of crisis without prior training – a lot of it.

2. The “lack of an audience” problem is next in line. The California plan seems to presume that the U.S. government’s National Incident Management System is applicable to normal hospital operations and that it simply will be “someone’s” job (the specific individual not identified) to provide training for and teach the material provided. The fact is, though, that most disaster training in the United States is today an unfunded responsibility assigned to most medical systems. Unless there is funding provided to train hospital personnel in accordance with the HICS guidelines, that training undoubtedly will be carried out piecemeal, not systematically.

3. The third problem is the complexity of the HICS approach. In times of crisis, personal relationships usually carry more weight than unfamiliar job titles and new and rather complicated organizational diagrams. Common sense suggests that reliance on an unfamiliar scheme with its multitude of responsibilities will fail and that the native system will dominate.

Going Back to Basics

Medical planning should begin with a clear explanation of what is needed to save lives, not on how to conform to some externally recommended structure. The HICS system does not in and of itself deliver care to victims and for that reason alone may not fit too well (if at all) with the variety of hospital administration structures present in American medicine. One of the most important problems in managing a chemical or biological incident, for example, or an infectious-disease emergency, is that a great deal of medical/technical expertise is needed – and that particular expertise is in scarce supply at most of the nation’s medical facilities.

As previously mentioned, just one organizational box on the command-structure chart – 1/25 of the overall leadership structure, in other words – is used to encompass all of the technical/medical expertise necessary for life-saving operations and medical treatment. That is probably the inverse of what an organizational diagram should look like for a typical American medical facility today.

All-hazards planning for hospitals can be simplified, though, into three basic types of response situations:

• Trauma Disaster Plan: In this response mode, the rapid delivery of large numbers of traumatic casualties is a large part of the problem, and the maximum development of caregivers and the delivery of life-saving treatment in the shortest amount of time are the keys to success.

• HAZMAT Disaster Plan: In this response mode, the hospital has an ethical obligation to respond, simultaneously and effectively, to victims of a toxic exposure, ensure workplace safety for its own employees, and preserve a safe care environment for those already admitted to and resident within the medical facility. A rapid decontamination capability, decontamination surety determinations, and the rapid administration of potentially large quantities of unfamiliar antidotal medications are the keys to success.

• Infectious-Disease Disaster Plan: In this response mode, the hospital has an ethical obligation, once again, to respond to a potentially large number of victims over a potentially protracted period of time, while also ensuring workplace safety for its own employees and a safe-care environment for patients previously admitted but not infected. Here, the segregation of contagious patients from the general hospital population and staff, the management of waste materials, and specimen collection and handling are the keys.

Operational and Fiscal Realities

Each of the plans described above requires guidelines for the individual care needed, the ability to allocate scarce resources, and the procedures to be followed to facilitate and ameliorate the delay – or, in certain cases, denial – of care to victims who either are not salvageable or, more optimistically stated, are not lethally injured. Today, most care guidelines of this type are institution-specific and represent the key capabilities that the command structure must support.

It is important to understand that most of the nation’s medical systems also are “high-overhead” businesses – and, as such, must maintain a 95-100 percent bed-occupancy rate to remain financially solvent. That fiscal fact of life permits only a relatively small amount of surge capacity – which is what the HICS command structure is intended to govern. Even in a best-case (95 percent occupancy) scenario, therefore, to use but one example, a 500-bed facility serving a community of 40,000 people typically would have only 25 beds that would be available for use under the HICS command system.

It seems obvious that the current decision-making structure in most medical facilities today is probably sufficient for that task. The creation, therefore, of a NIMS-compliant 25-person command structure to decide the fate of a mere 25 beds – but provide little expertise on medical management per se – would probably not affect (i.e., improve) victim survivorship in any significant way. The medical surge capacity of 25 beds could be used for only 0.625 percent of the local population of 40,000 potential victims of a major disaster. What is clearly and much more urgently needed, it seems, is a methodology to delay, transfer, or – if necessary – deny care to victims of the stricken city.

Are Better Options Available?

Instead of developing and training an expansive (and expensive) command structure, perhaps a better and more useful endeavor would be to create training programs and allow working-level staff to gain familiarity with the equipment and medications they may be required to use in times of crisis. A hospital at work is much like a ship underway: Every member of the staff is either on the job already or off-duty – but ready to report for duty on a later shift.

Although disaster training is often described as a critical need for U.S. hospitals, the idea that a hospital drill actually “trains” the hospital – i.e., all personnel working at the hospital in different assignments and on different shifts – is probably flawed to begin with, because most disaster drills carried out at most U.S. hospitals today train only a single shift of the hospital’s personnel for only about one day per year.

The development of “downtime” training and/or incorporation of disaster-management training within the existing educational programming would seem to be a much more efficient way to train the highest percentage of staff personnel – but only if job action sheets and critical medical treatment guidelines are readily accessible for immediate use, not buried somewhere in a large all-encompassing document. An organizational diagram of properly trained and equipped medical providers is clearly needed at almost every medical facility imaginable.

Once the medical-care capability is developed, an adaptable command structure would be relatively easy to create to meet the needs of a trauma, HAZMAT, or infectious-disease emergency. Putting the development of life-saving capabilities ahead of the NIMS planning concept means that the DHS guidelines in this area would, and should, be written to conform to local medical leadership structures, not the other way around.  

Following is the Counterpoint argument provided by Dr. Jerry Mothershead

Although Dr. Allswede presents a cogent argument on the challenges inherent in changing organizational constructs during times of disasters, some of his assumptions beg to be challenged, including:

• The assumption that healthcare operations are unique: Very few U.S. corporations or concerns are organized for crisis management on a routine basis. Even fire and police departments are administratively organized at odds with those spelled out in the National Incident Management System. The key difference is that entities that frequently respond to crises have a vested interest in rapidly transitioning to whatever organizational structure is most conducive to executing the tasks required for crisis response. Moreover, Dr. Allswede implies that other organizations that train for and practice incident-management operations do not have other duties and missions, whereas those involved with healthcare are “too busy saving lives” to be bothered with training that may be rarely if ever used. Of course, training and exercises are required.

• The assumption that task management is synonymous with task execution: The HICS guidelines were neither intended nor designed to dictate triage or treatment protocols. Although triage and treatment may indeed be the “point of the spear” of healthcare operations, there is an abundance of ancillary and support requirements necessary for the spear to hit its target. In a large-scale disaster (the type that HICS was designed for), resource management and logistics may well play more important roles in the final results. Moreover, task management does not necessarily have to be manpower-intensive. One of the more important aspects of the incident-command concept is its inherent expandability. In a small hospital, for example, several if not all of the HICS elements could be combined under one authority – in which case, instead of a 25-person command structure, a 10-person command structure might well suffice, with many or most of those ten persons carrying out their assigned tasks or oversight responsibilities under routine operational guidelines.

• The assumption that HICS is not a relatively simple concept: Anyone who has been assigned major administrative responsibilities within a corporation or other major organization – whether its principal product line is healthcare or facial cream – understands that the corporate world is anything but simple. The HICS guidebook’s notional command structure is neither more nor less complicated than any other healthcare operations management system – but it is admittedly different (both conceptually and operationally). One of the benefits of training in this system, if it is to be used, is that it affords those in leadership roles (the principal targets of the HICS concept) the opportunity to work together under a different organizational model – and, not incidentally, develop effective working relationships with one another through the training exercises recommended or mandated. That training does not have to be exhaustive, or all-inclusive, for all staff personnel at the healthcare facility. A radiology technician’s tasks, for example, will probably not change much in a disaster. A clinician’s tasks might change somewhat. The head of a department may be required to make new and different decisions in times of crisis, and may be constrained in his or her decision-making because of actions, or limitations, in other healthcare operations sectors with which he or she has little routine interaction.

Cost/Benefit Ratios and Other Considerations

Nonetheless, there are some important problems associated with the HICS organizational structure in its present form, including a few not specifically addressed by Dr. Allswede. It should be kept in mind, for example, that most hospitals are not government entities. Their existence is dependent on pro t margins – as he does point out. Education, training, and exercises are both labor-intensive and expensive, and allocating limited resources on these evolutions, which not only are targeted on low-probability events but also are carried out without remuneration from the federal government, simply does not make good business sense. It is true that some funding has been provided to the healthcare sector in recent years – in most cases on a per-hospital basis – but in virtually all cases the funding provided was insufficient to even add one full- time staff member for emergency operations, much less train the entire hospital staff.

Another socio-economic fact of life that should be kept in mind is that hospitals are not islands. Although there are many American communities that, in theory, are serviced by only one hospital, there are very few if any that are serviced by only one healthcare facility – a more generic term that also includes physicians’ offices, clinics, and other medical (but non-hospital) facilities. Moreover, in almost all American communities the healthcare facilities themselves rely on an outside medical infrastructure, including freestanding pharmacies, medical supply distribution centers, and even local public health departments. For this reason, the HICS focus would perhaps be better directed toward a “community health” incident command system in which these disparate and sometimes competing components of the public health, healthcare operations, and ancillary/support services could be more cohesively organized to respond to the large-scale disasters that HICS was designed to address.

Controversy undoubtedly will continue–at least within the nation’s health industries–about the utility of such command re-organizations as that offered by the HICS Guidebook. Such controversy is not only reasonable and to be expected, it also is desirable as well. It is obvious at this point that all sides want the same thing – namely, the most good for the most people. What specific system will, or will not, work best remains to be seen.