HPP Capabilities Cover Image

The  Health Care Preparedness and Response Capabilities (HCPR Capabilities) outlines the high-level objectives that the nation’s health care delivery system, including Healthcare Coalitions (HCC) and individual health care organizations, should undertake to prepare for, respond to, and recover from emergencies.

ASPR recognizes that there is shared authority and accountability for the health care delivery system's readiness that rests with private organizations, government agencies, and Emergency Support Function-8 (ESF-8) lead agencies. Given the many public and private entities that must come together to ensure community preparedness, HCCs serve an important communication and coordination role within their respective jurisdiction(s). Hence HCCs are referenced over 350 times in the document.

The HCPR Capabilities replace the Preparedness Capabilities: National Guidance for Healthcare System Preparedness, published in 2012.

Remember!  The Healthcare Preparedness and Response Capabilities are guidance, not grant deliverables or a regulatory requirement. They only become a grant requirement if included as a deliverable within the healthcare coalition's sub-award (grant from state)
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four capabilities

Four HCPR Capabilities Image

capability 1

foundation for healthcare and medical readiness

The community’s health care organizations and other stakeholders—coordinated through a sustainable HCC—have strong relationships, identify hazards and risks, and prioritize and address gaps through planning, training, exercising, and managing resources.

ASPRHCPR Capabilities

The HCC should coordinate with their members to facilitate:

  • strategic planning Identification of gaps and mitigation strategies
  • operational planning and response
  • information sharing for improved situational awareness
  • resource coordination and management

HCCs serve as multiagency coordination groups that support and integrate with other ESF-8 activities. Coordination between the HCC and the ESF-8 lead agency can occur in a number of ways. Some HCCs serve as the ESF-8 lead agency for their jurisdiction(s). Others integrate with their ESF-8 lead agency through an identified designee at the jurisdiction’s Emergency Operations Center (EOC) who represents HCC issues and needs and provides timely, efficient, and bi-directional information flow to support situational awareness.


The HCC should define its boundaries based on daily health care delivery patterns—including those established by corporate health systems—and organizations within a defined geographic region, such as independent organizations and federal health care facilities.

Additionally, the HCC may consider boundaries based on defined catchment areas, such as regional EMS councils, trauma regions, accountable care organizations, emergency management regions, etc. Defined boundaries should encompass more than one of each member type (e.g., hospitals, EMS) to enable coordination and enhance the HCC’s ability to share the load during an emergency. HCC boundaries may span several jurisdictional or political boundaries, and the HCC should coordinate with all ESF-8 lead agencies within its defined boundaries.

The HCC should:

  • Include enough members to ensure adequate resources; however, at the same time, having too many members may make the HCC unmanageable
  • Consider existing regional service areas, as they define common and known health care delivery patterns and emergency response activities
  • Consider existing regional service areas, as they define common and known health care delivery patterns and emergency response activities
  • Engage the jurisdiction’s public health agency to ensure all health care facilities, including independent facilities, belong to an HCC and that there are no geographic gaps in HCC coverage

An HCC member is defined as an entity within the HCC’s defined boundaries that actively contributes to HCC strategic planning, identification of gaps and mitigation strategies, operational planning and response, information sharing, and resource coordination and management.

In cases where there are multiple entities of an HCC member type, there may be a subcommittee structure that establishes a lead entity to communicate common interests to the HCC (e.g., multiple dialysis centers forming a subcommittee). HCC membership does not begin or end with attending meetings.

The HCC should include a diverse membership to ensure a successful whole community response. If segments of the community are unprepared or not engaged, there is greater risk that the health care delivery system will be overwhelmed. As such, the HCC should liaise with the broader response community on a regular basis (see Introduction for a list of stakeholders). The list is recreated below, delineating core and additional HCC members.

Core HCC members should include, at a minimum, the following:

  • Hospitals
  • EMS (including inter-facility and other non-EMS patient transport systems)
  • Emergency management organizations
  • Public health agencies

Additional HCC members may include but are not limited to the following:

  • Behavioral health services and organizations
  • Dialysis centers and regional Centers for Medicare & Medicaid Services (CMS)-funded end-stage renal disease (ESRD) networks
  • Federal facilities (e.g., U.S. Department of Veterans Affairs (VA) Medical Centers, Indian Health Service facilities, military treatment facilities)
  • Home health agencies (including home and community-based services)
  • Infrastructure companies (e.g., utility and communication companies)
  • Jurisdictional partners, including cities, counties, and tribes
  • Local chapters of health care professional organizations (e.g., medical society, professional society, hospital association)
  • Local public safety agencies (e.g., law enforcement and fire services)
  • Medical and device manufacturers and distributors
  • Non-governmental organizations (e.g., American Red Cross, voluntary organizations active in disasters, amateur radio operators, etc.)
  • Outpatient health care delivery (e.g., ambulatory care, clinics, community and tribal health centers, Federally Qualified Health Centers (FQHCs), urgent care centers, freestanding emergency rooms, stand-alone surgery centers)
  • Primary care providers, including pediatric and women’s health care providers
  • Schools and universities, including academic medical centers
  • Skilled nursing, nursing, and long-term care facilities
  • Support service providers (e.g., clinical laboratories, pharmacies, radiology, blood banks, poison control centers)
  • Other (e.g., child care services, dental clinics, social work services, faith-based organizations)

Specialty patient referral centers (e.g., pediatric, burn, trauma, and psychiatric centers) should ideally be HCC members within their geographic boundaries. They may also serve as referral centers to other HCCs where that specialty care does not exist. In such cases, referral centers’ support of HCC planning, exercises, and response activities can be mutually beneficial.

Urban and rural HCCs may have different membership compositions based on population characteristics, geography, and types of hazards. For example, in rural and frontier areas—where the distance between hospitals may exceed 50 miles and where the next closest hospitals are also critical access hospitals with limited services—tribal health centers, referral centers, or support services may play a more prominent role in the HCC.

The HCC should define and implement a structure and processes to execute activities related to health care delivery system readiness and coordination. The elements of governance include organizational structures, roles and responsibilities, mechanisms to provide guidance and direction, and processes to ensure integration with the ESF-8 lead agency.

The HCC should document the following information related to its governance:

  • HCC membership
  • An organizational structure to support HCC activities, including executive and general committees, election or appointment processes, and any necessary administrative rules and operational functions (e.g., bylaws)
  • Member guidelines for participation and engagement that consider each member and region’s geography, resources, and other factors
  • Policies and procedures, including processes for making changes, orders of succession, and delegations of authority
  • HCC integration within existing state, local, and member-specific incident management structures and specified roles—such as a primary point of contact who serves as the liaison to the ESF-8 lead agency and EOCs during an emergency

The HCC should identify and plan for risks, in collaboration with the ESF-8 lead agency, by conducting assessments or using and modifying data from existing assessments for health care readiness purposes.

These assessments can determine resource needs and gaps, identify individuals who may require additional assistance before, during, and after an emergency, and highlight applicable regulatory and compliance issues. The HCC and its members may use the information about these risks and needs to inform training and exercises and prioritize strategies to address preparedness and response gaps in the region.


A hazard vulnerability analysis (HVA) is a systematic approach to identifying hazards or risks that are most likely to have an impact on the demand for health care services or the health care delivery system’s ability to provide these services. This assessment may also include estimates of potential injured or ill survivors, fatalities, and post-emergency community needs based on the identified risks.

General principles for the HVA process include but are not limited to the following:

  • HCC members should participate in the HVA process, using a variety of HVA tools
  • The HVA process should be coordinated with state and local emergency management organization assessments (e.g., Threat and Hazard Identification and Risk Assessment [THIRA]) and any public health hazard assessments (e.g., jurisdictional risk assessment). The intent is to ensure completion, share risk assessment results, and minimize duplication of effort
  • Health care facilities, EMS, and other health care organizations should provide input into the development of the regional HVA based on their facilities’ or organizations’ HVAs
  • The assessment components should include regional characteristics, such as risks for natural or man-made disasters, geography, and critical infrastructure
  • The assessment components should address population characteristics (including demographics), and consider those individuals who might require additional help in an emergency, such as children; pregnant women; seniors; individuals with access and functional needs, including people with disabilities; and others with unique needs
  • The HCC should regularly review and share the HVA with all members

HCC members should perform an assessment to identify the health care resources and services that are vital for continuity of health care delivery during and after an emergency.

The HCC should then use this information to identify resources that could be coordinated and shared. This information is critical to uncovering resource vulnerabilities relative to the HVA that could impede the delivery of medical care and health care services during an emergency. The resource assessment will be different for various HCC member types, but should address resources required to care for all populations during an emergency.

The resource assessment should include but is not limited to the following:

  • Clinical services – inpatient hospitals, outpatient clinics, emergency departments, private practices, skilled nursing facilities, long-term care facilities, behavioral health services, and support services (see Capability 4 – Medical Surge)
  • Critical infrastructure supporting health care (e.g., utilities, water, power, fuel, information technology [IT] services, communications, transportation networks)
  • Caches (e.g., pharmaceuticals and durable medical equipment)
  • Hospital building integrity
  • Health care facility, EMS, corporate health system, and HCC information and communications systems and platforms (e.g., electronic health records [EHRs], bed and patient tracking systems) and communication modalities (e.g., telephone, 800 MHz radio, satellite telephone)
  • Alternate care sites
  • Home health agencies (including home and community-based services)
  • Health care workforce
  • Health care supply chain
  • Food supply
  • Medical and non-medical transportation system
  • Private sector assets that can support emergency operations

A comparison between available resources and current HVA(s) will identify gaps and help prioritize HCC and HCC member activities.

Gaps may include a lack of, or inadequate, plans or procedures, staff, equipment and supplies, skills and expertise, services, or any other resources required to respond to an emergency. Just as the resource assessment will be different for different member types, so will efforts to prioritize identified gaps. HCC members should prioritize gaps based on consensus and determine mitigation strategies based on the time, materials, and resources necessary to address and close gaps. Gaps may be addressed through coordination, planning, training, or resource acquisition. Ultimately, the HCC should focus its time and resource investments on closing those gaps that affect the care of acutely ill and injured patients.

Certain response activities may require external support or intervention, as emergencies may exceed the preparedness thresholds the HCC, its members, and the community have deemed reasonable. Thus, during the prioritization process, planning to access and integrate external partners and resources (i.e., federal, state, and/or local) is a key part of gap closure.

Certain individuals may require additional assistance before, during, and after an emergency. The HCC and its members should conduct inclusive planning for the whole community, including children; pregnant women; seniors; individuals with access and functional needs, such as people with disabilities; individuals with pre-existing, serious behavioral health conditions; and others with unique needs.

The HCC should:

  • Support public health agencies with situational awareness and IT tools already in use that can help children; pregnant women; seniors; and individuals with access and functional needs, including people with disabilities; and others with unique needs (e.g., the U.S. Department of health and Human Services emPOWER map, which provides information on Medicare beneficiaries who rely on electricity-dependent medical and assistive equipment, such as ventilators, at-home dialysis machines, and wheelchairs)
  • Support public health agencies in developing and augmenting existing response plans for these populations, including mechanisms for family reunification
  • Identify potential health care delivery system support for these populations (pre- and post-event) that can reduce stress on hospitals during an emergency
  • Assess needs and contribute to medical planning that may enable individuals to remain in their residences. When that is not possible, coordinate with the ESF-8 lead agency to support the ESF-6 (Mass Care, Emergency Assistance, Housing, and Human Services) lead agency with inclusion of medical care at shelter sites
  • Coordinate with the ESF-8 lead agency to assess medical transport needs for these populations
  • Assess specific treatment and access to care needs; incorporate how to address needs into individual HCC member Emergency Operations Plans (EOPs) and the HCC response plan (see Capability 2, Objective 1 – Develop and Coordinate Health Care Organization and Healthcare Response Plans)
  • Coordinate with the U.S. Department of Veterans Affairs (VA) Medical Center to identify veterans in the HCC's coverage area (if applicable)

The HCC, in collaboration with the ESF-8 lead agency and state authorities, should assess and identify regulatory compliance requirements that are applicable to day-to-day operations and may play a role in planning for, responding to, and recovering from emergencies.

The HCC should:

Understand federal statutory, regulatory, or national accreditation requirements that impact emergency medical care, including:

  • Centers for Medicare & Medicaid Services (CMS) conditions of participation, (including CMS-3178-F Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers)
  • Clinical Laboratory Improvement Amendments (CLIA)
  • Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule requirements and circumstances when covered entities can disclose protected health information (PHI) without individual authorization including to public health authorities and as directed by laws (e.g., state law)
  • Emergency Medical Treatment & Labor Act (EMTALA) requirements
  • Licensing and accrediting agencies for hospitals, clinics, laboratories, and blood banks (e.g., Joint Commission, DNV GL – Healthcare)
  • Federal disaster declaration processes and public health authorities
  • Available federal liability protections for responders (e.g., Public Readiness and Emergency Preparedness (PREP) Act)
  • Environmental Protection Agency (EPA) requirements
  • Occupational Safety and Health Administration (OSHA) requirements (e.g., general duty clause, blood-borne pathogen standard)

Understand state or local regulations or programs that impact emergency medical care, including:

  • Scope and breadth of emergency declarations
  • Regulations for health care practitioner licensure, practice standards, reciprocity, scope of practice limitations, and staff-to-patient ratios
  • Legal authorization to allocate personnel, resources, equipment, and supplies among health care organizations
  • Laws governing the conditions under which an individual can be isolated or quarantined
  • Available state liability protections for responders

Understand the process and information required to request necessary waivers and suspension of regulations, including:

  • Processes for emergency resource acquisition (this may require coordination with the federal, state, and/or local government)
  • Special waiver processes (e.g., section 1135 of the Social Security Act waivers) of key regulatory requirements pursuant to emergency declarations
  • Process and implications for Food and Drug Administration (FDA) issuance of emergency use authorizations for use of non-approved drugs or devices or use of approved drugs or devices for unapproved uses
  • Legal resources related to hospital legal preparedness, such as the deployment and use of volunteer health practitioners
  • Legal and regulatory issues related to alternate care sites and practices
  • Legal issues regarding population-based interventions, such as mass prophylaxis and vaccination
  • Processes for emergency decision making from state or local legislature

  • Support crisis standards of care planning, including the identification of appropriate legal authorities and protections necessary when crisis standards of care are implemented (see Capability 4 – Medical Surge)
  • Maintain awareness of standing contracts for resource support during emergencies
The HCC preparedness plan enhances preparedness and risk mitigation through cooperative activities based on common priorities and objectives.

 

In collaboration with the ESF-8 lead agency, the HCC should develop a preparedness plan that includes information collected on hazard vulnerabilities and risks, resources, gaps, needs, and legal and regulatory considerations (as collected in Capability 1, Objective 2, Activities 1-5 above). The HCC preparedness plan should emphasize strategies and tactics that promote communications, information sharing, resource coordination, and operational response planning with HCC members and other stakeholders. The HCC should develop its preparedness plan to include core HCC members and additional HCC members so that, at a minimum, hospitals, EMS, emergency management organizations, and public health agencies are represented. The plan can be presented in various formats (e.g., a subset of strategic documents, annexes, or a portion of the HCC’s concept of operations plans [CONOPS]).

The HCC preparedness plan should:

  • Incorporate the HCC’s and its members’ priorities for planning and coordination based on regional needs and gaps
  • Draw from and address gaps identified in HCC members’ existing preparedness plans as required by CMS-3178-F Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers
  • Outline strategic and operational objectives for the HCC as a whole and for each HCC member
  • Include short-term (e.g., within the year) and longer-term (e.g., three- to five-year) objectives
  • Include a recurring objective to develop and review the HCC response plan, which details the responsibilities and roles of the HCC and its members, including how they share information, coordinate activities and resources during an emergency, and plan for recovery (see Capability 2 – Health Care and Medical Response Coordination)
  • Include and inform training, exercise, and resource and supply management activities during the year
  • Include a checklist of each HCC member’s proposed activities, methods for members to report progress to the HCC, and processes to promote accountability and completion

HCC members should approve the initial plan and maintain involvement in regular reviews. Following reviews, the HCC should update the plan as necessary after exercises and real-world events. The review should include identifying gaps in the preparedness plan and working with HCC members to define strategies to address the gaps.

The HCC should also develop a complementary HCC response plan in collaboration with the ESF-8 lead agency (see Capability 2 – Health Care and Medical Response Coordination).

Training, drills, and exercises help identify and assess how well a health care delivery system or region is prepared to respond to an emergency.

 

These activities also develop the necessary knowledge, skills, and abilities of an HCC member’s workforce. Trainings can cover a wide range of topics including clinical subject matter, incident management, safety and protective equipment, workplace violence, psychological first aid, or planning workshops. The HCC should promote these activities and participate in training and exercises with its members, and in coordination with the ESF-8 lead agency, emphasizing consistency, engagement, and demonstration of regional coordination.


The HCC should assist its health care organization members and other HCC members with National Incident Management System (NIMS) implementation. The HCC should:

  • Ensure HCC leadership receives NIMS training
  • Promote NIMS implementation, including training and exercises, among HCC members to facilitate operational coordination with public safety and emergency management organizations during an emergency using an incident command system (ICS)
  • Assist HCC members with incorporating NIMS components into their EOPs
  • For those members not bound by NIMS implementation, the HCC should consider training on response planning techniques, organizational structure, and other incident management practices that will prepare members for their roles during a response

HCC members should support education and training to address health care preparedness and response gaps identified through strategic planning, development of the HCC preparedness and response plans, or other assessments. Whenever possible, training should be standardized at the HCC level to ensure efficiency and consistency. The HCC should:

  • Promote understanding of every HCC member’s specific roles and responsibilities in the health care delivery system’s emergency response
  • Base training on specific gaps and needs identified by HCC members
  • Promote and support training for health care providers, laboratorians, non-clinical staff, and ancillary workforce in clinical management for all populations, responder safety and health requirements, and management of patients in a resource-scarce environment
  • Ensure health care organization leadership is aware of and engaged in HCC activities (see Capability 1, Objective 5, Activity 2 – Engage Health Care Executives below)
  • Develop and implement training plans, including those that support appropriate health care providers and first responders. Training plans may include but are not limited to, initial education, continuing education, appropriate certifications, and just-in-time training
  • Employ a variety of modalities (e.g., online, classroom, etc.)

The HCC, in collaboration with its members, should plan and conduct coordinated exercises to assess the health care delivery system’s readiness.

The HCC should focus exercises on the outcomes of HVAs and other assessments that identify resource needs and gaps, identify individuals who may require additional assistance before, during, and after an emergency, and highlight applicable regulatory and compliance issues.

The HCC should:

  • Plan and conduct health care delivery system-wide exercises that incorporate hospitals, EMS, emergency management organizations, public health agencies, and additional HCC member participation
  • Base exercises on specific gaps and needs identified by HCC members, including emerging infectious diseases and CBRNE threats
  • Update an exercise schedule annually or in accordance with jurisdictional needs
  • Provide opportunities for clinical laboratory participation
  • Assess readiness to support emergencies involving children across the age and developmental trajectory; children represent nearly 25 percent of the population and have unique response needs during emergencies, including special medical equipment and treatment needs and family reunification considerations
  • Collect information about HCC member operating status and resource availability during exercises and disseminate the information to other members
  • Assess readiness to support other individuals who have special health needs and may require additional assistance before, during, and after an emergency (e.g., pregnant women, seniors, individuals who depend on electricity-dependent medical and assistive equipment, etc.)
  • Exercise Continuity of Operations (COOP) plans (see Capability 3, Objective 2, Activity 1 – Develop a Health Care Organization Continuity of Operations Plan and Capability 3, Objective 2, Activity 2 – Develop a Health Care Coalition Continuity of Operations Plan)
  • Exercise medical surge capacity and capability, including decisions leading to the implementation of crisis standards of care (see Capability 4 – Medical Surge); Assess the mobilization of beds, personnel, and key resources, including equipment, supplies, and pharmaceuticals
  • Coordinate exercises with other response organizations (e.g., Federal Emergency Management Agency [FEMA], National Guard, etc.)
  • When appropriate, include federal, state, and local response resources in exercises (e.g., National Disaster Medical System [NDMS] Disaster Medical Assistance Teams [DMAT], NDMS Federal Coordinating Centers [FCCs], Emergency System for Advance Registration of Volunteer Health Professionals [ESAR-VHP], state medical teams, MRC, and other federal, state, local, and tribal assets)
  • Develop an after-action report (AAR) and improvement plan (IP) that incorporates lessons learned from exercises and a follow-up process, including steps to overcome the identified gaps in the AAR/IP (see Capability 1, Objective 4, Activity 5 – Evaluate Exercises and Responses to Emergencies below)

The HCC should consider the following when developing and executing exercises:

  • Apply Homeland Security Exercise and Evaluation Program (HSEEP) fundamentals to both the exercise program and the execution of individual exercises
  • Integrate current health care accreditation requirements such as the Joint Commission Emergency Management Standards, and health care regulatory requirements such as CMS-3178-F Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers
  • Use a stepwise progression of exercise complexity for a variety of emergency response scenarios (e.g., workshop to tabletop to functional to full-scale exercises)

The HCC should coordinate with its members and other response organizations to complete an AAR and an IP after exercises and real-world events.

The same exercise or response may generate facility, member type, HCC, and community AAR/IPs – each with a somewhat different focus and level of detail. The AAR should document gaps in HCC member composition, planning, resources, or skills revealed during the exercise and response evaluation processes. The IP should detail a plan for addressing the identified gaps, including responsible entities and the required time and resources to address the gaps.

The IP should also recommend processes to retest the revised plans and capabilities. Facility and organization evaluations should follow a similar process. AARs may also reveal leading practices that can be shared with HCC members and other HCCs.

Successful HCC maturation depends on integrating AAR/IP findings into the next planning, training, exercise, and resource allocation cycle.

The HCC should coordinate with its members, government partners, and other HCCs to share leading practices and lessons learned. Sharing information between HCCs will improve cross-HCC coordination during an emergency and will help further improve coordination efforts.

The HCC should employ the following principles when sharing leading practices and lessons learned:

  • Ensure information is shared among HCCs after real-world events and exercises to identify gaps, leading practices, and lessons learned
  • Incorporate lessons learned from real-world events and exercises into HCC plans, training, and exercises
  • Utilize mechanisms to rapidly acquire and share new clinical knowledge for a wide range of hazards and threats during exercise scenarios and real-world events. Examples include:
  • Utilizing the Office of the Assistant Secretary for Preparedness and Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE)
  • Sharing hazardous material (HAZMAT) information from poison control centers
  • Using virtual telemedicine platforms (e.g., Project ECHO)
  • Obtaining information from federal alert systems (e.g., Centers for Disease Control and Prevention [CDC], FDA, FEMA)
  • Coordinating clinical treatment information on conference calls or webinars (e.g., CDC Clinician Outreach and Communication Activity [COCA])
Sustainability planning is a critical component to HCC development. Strong governance mechanisms, constant regional stakeholder engagement, and sound financial planning help form the foundation to continue HCC activities well into the future. Sustainability should emphasize HCC processes and activities that support member needs and regulatory requirements (e.g., exercises and evacuation planning).

The HCC, with support from its health care organization members, should be able to articulate its mission, including its role in community preparedness and how that provides benefit (both direct and indirect) to the region.

The HCC has a duty to plan for a full range of emergencies and both planned and unplanned events that could affect its community. It is essential that the HCC has leaders who can serve as primary points of contact to promote preparedness and response needs to community leaders. Additionally, members have a shared responsibility to ensure the HCC has visibility into their activities in the region.

The HCC should:

  • Develop materials that identify and articulate the benefits of HCC activities to its members and additional stakeholders
  • Engage champions among its members and other response organizations to promote HCC preparedness efforts to health care executives, clinicians, community leaders, and other key audiences
  • Consider existing regional service areas, as they define common and known health care delivery patterns and emergency response activities
  • Engage the jurisdiction’s public health agency to ensure all health care facilities, including independent facilities, belong to an HCC and that there are no geographic gaps in HCC coverage

The HCC should communicate the direct and indirect benefits of HCC membership to health care executives to advance their engagement in preparedness and response.

Executives can promote buy-in across all facility and organization types, clinical departments, and non-clinical support services. The benefits of HCC participation are not limited to emergency preparedness and response.

Day-to-day benefits may include:

  • Meeting regulatory and accreditation requirements
  • Enhancing purchasing power (e.g., bulk purchasing agreements)
  • Accessing clinical and non-clinical expertise
  • Networking among peers
  • Sharing leading practices
  • Developing interdependent relationships
  • Reducing risk
  • Addressing other community needs, including meeting requirements for tax exemption through community benefit

Health care executives should formally endorse their organization’s participation in an HCC. This can take the form of letters of support, memoranda of understanding, or other agreements. Health care executives should be engaged in their facilities’ response plans and provide input, acknowledgement, and approval regarding HCC strategic and operational planning.

The HCC should regularly inform health care executives of HCC activities and initiatives through reports and invitation to participate in meetings, training, and exercises. The HCC should engage health care executives in debriefs (“hotwashes”) related to exercises, planned events, and real-world events.

The HCC should engage health care delivery system clinical leaders to provide input, acknowledgement, and approval regarding strategic and operational planning.

Clinicians from a wide range of specialties should be included in HCC activities on a regular basis to validate medical surge plans and to provide subject matter expertise to ensure realistic training and exercises. Clinicians with relevant expertise should lead health care provider training for assessing and treating various types of illnesses and injuries. Clinicians should be engaged in strategic and operational planning, contribute to committees and advisory boards, and participate in training and education sessions. Additional engagement can include active participation in planning, exercise, and response activities.

Consistent with a whole community approach to preparedness, the HCC should actively work with and engage community leaders outside of its members.

The HCC should identify and engage community members, businesses, charitable organizations, and the media in health care preparedness planning and exercises to promote the resilience of the entire community. Community engagement creates greater awareness of the HCC’s role and emergency preparedness activities, promotes community resilience, and speeds the recovery process following emergencies.

There are a variety of ways to promote greater community effectiveness and organizational and financial sustainability.

Full investment in readiness includes in-kind donation of time, resources, support, and continued engagement with HCC members and the community. Financial strategies, including cost-sharing techniques and other funding options, enhance stability and sustainment.

The HCC should:

  • Offer HCC members technical assistance or consultative services in meeting CMS-3178-F Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers
  • Explore ways to meet individual member’s requirements for tax exemption through community benefit
  • Analyze critical functions to preserve, and identify financial opportunities beyond federal funding (e.g., foundation, and private funding, dues, and training fees) to support or expand HCC functions
  • Develop a financing structure, and document the funding models that support HCC activities
  • Determine ways to cost share (e.g., required exercises may be coordinated with public health agencies, emergency management organizations, and other organizations with similar requirements)
  • Incorporate leadership succession planning into the HCC governance and structure
  • Leverage group buying power to obtain consistent equipment across a region and allow for sharing or emergency allocation of equipment

HCC members should be aware of the HCC’s sustainability activities, including any requirements established by HCC leadership, so they can plan their future investments accordingly.

capability 2

healthcare and medical response coordination

Health care organizations, the HCC, their jurisdiction(s), and the ESF-8 lead agency plan and collaborate to share and analyze information, manage and share resources, and coordinate strategies to deliver medical care to all populations during emergencies and planned events.

ASPRHCPR Capabilities

Health care organizations respond to emergent patient care needs every day. During an emergency response, health care organizations and other HCC members contribute to the coordination of information exchange and resource sharing to ensure the best patient care outcomes possible.

HCCs and their members can best achieve enhanced coordination and improved situational awareness when there is active participation from hospitals, EMS, emergency management organizations, and public health agencies and by documenting roles, responsibilities, and authorities before, during, and immediately after an emergency.

Every individual health care organization must have an Emergency Operations Plan (EOP) per federal and state regulations and multiple accreditation standards. The HCC, in collaboration with the ESF-8 lead agency, should have a collective response plan that is informed by its members’ individual EOPs. In cases where the HCC serves as the ESF-8 lead agency, the HCC response plan may be the same as the ESF-8 response plan. The purpose of coordinating response plans is not to supplant existing ESF-8 structures, but to enhance effective response in accordance with the wide array of existing federal, state, and municipal legal authorities in which HCC members operate (e.g., Emergency Medical Treatment & Labor Act [EMTALA], communicable disease reporting, and the Health Insurance Portability and Accountability Act [HIPAA] Privacy Rule).

Each health care organization should have an EOP to address a wide range of emergencies.

The EOP should detail the use of incident management—including specific indicators for plan activation, alert, and notification processes, response procedures, and resource acquisition and sharing—and a process that delineates the thresholds to demobilize and begin the transition to recovery and the restoration of normal operations (see Capability 3, Objective 7 – Coordinate Health Care Delivery System Recovery). The plan should define the internal and external sources of information that will be necessary to assess the impact of the emergency on the health care organization. The plan should also address how the individual HCC member communicates this information to the HCC and to key health care organization leadership.

Critical elements of the health care organization’s EOP include:

  • Identification of triggers to activate the plan
  • Communications (internal and external)
  • Information management
  • Access to resources and supplies
  • Safety and security measures
  • Delineation of staff roles and responsibilities within the incident command system (ICS)
  • Utility readiness (e.g., back-up generator, water supplies)
  • Provision of clinical care
  • Support activities

The EOP should summarize the actions required to initiate and sustain a response to an emergency. Health care organizations’ departmental plans should provide specific information for each unit or area. Employees should have a clear understanding of their actions and how to communicate with the facility or organization’s EOC during a response. The EOP should include plans for caring for employees and their dependents during and after an emergency in an effort to promote their return to work (see Capability 3, Objective 5 – Protect Responders’ Safety and Health)...

The HCC, in collaboration with the ESF-8 lead agency, should have a collective response plan that is informed by its members’ individual plans.

In cases where the HCC serves as the ESF-8 lead agency, the HCC response plan may be the same as the ESF-8 response plan. Regardless of the HCC structure, the HCC response plan should describe HCC operations that support strategic planning, information sharing, and resource management. The plan should also describe the integration of these functions with the ESF-8 lead agency to ensure information is provided to local officials and to effectively communicate and address resource and other needs requiring ESF-8 assistance.

The HCC should develop a response plan that clearly outlines:

  • Individual HCC member organization and HCC contact information
  • Locations that may be used for multiagency coordination
  • Brief summary of each individual member’s resources and responsibilities
  • Integration with appropriate ESF-8 lead agencies
  • Emergency activation thresholds and processes
  • Alert and notification procedures
  • Essential Elements of Information (EEIs) agreed to be shared, including information format (e.g., bed reporting, resource requests and allocation, patient distribution and tracking procedures, processes for keeping track of unidentified [John Doe/Jane Doe] patients)
  • Communication and information technology (IT) platforms and redundancies for information sharing
  • Support and mutual aid agreements
  • Evacuation and relocation processes
  • Policies and processes for the allocation of scarce resources and crisis standards of care, including steps to prevent crisis standards of care without compromising quality of care (e.g., conserve supplies, substitute for available resources, adapt practices, etc.) (See Capability 4, Objective 1, Activity 1 – Incorporate Medical Surge into the HCC Response Plan)
  • Additional HCC roles and responsibilities as determined by state and/or local plans and agreements (e.g., staff sharing, alternate care site support, shelter support)

The HCC should coordinate the development of its response plan by involving core members and other HCC members so that, at a minimum, hospitals, EMS, emergency management organizations, and public health agencies are represented. While the interests of all members and stakeholders should be considered in the plan, those of hospitals and EMS are paramount given these entities’ roles in patient distribution across the HCC’s geographic area during an emergency...

Effective response coordination relies on information sharing to establish a common operating picture.

Information sharing is the ability to share real-time information related to the emergency, the current-state of the health care delivery system, and situational awareness across the various response organizations and levels of government (federal, state, local). The HCC’s development of information sharing procedures and use of interoperable and redundant platforms is critical to successful response.

Individual HCC members should be able to easily access and collect timely, relevant, and actionable information about their own organizations and share it with the HCC, other members, and additional stakeholders according to established procedures and predefined triggers and in accordance with applicable laws and regulations.

HCC information sharing procedures, as documented in the HCC response plan, should:

  • Define communication methods, frequency of information sharing, and the communication systems and platforms available to share information during an emergency response and steady state
  • Identify triggers that activate alert and notification processes
  • Define the EEIs that HCC members should report to the HCC, and coordinate with other HCC members and with federal, state, local, and tribal response partners during an emergency (e.g., number of patients, severity and types of illnesses or injuries, operating status, resource needs and requests, bed availability)
  • Identify the platform and format for sharing each EEI
  • Describe a process to validate health care organization status and requests during an emergency, including in situations where reports are received outside of HCC communications systems and platforms (e.g., media reports, no report when expected, rumors of distress, etc.)
  • Define processes for functioning without electronic health records (EHRs) and document issues related to interoperability

The HCC may coordinate with state and local authorities to identify information access and data protection procedures, including:

  • Access to public or private systems
  • Authorization to receive and share data
  • Types of information that can and will be shared (e.g., EEIs)
  • Data use and re-release parameters for sensitive information
  • Data protections
  • Legal, statutory, privacy, and intellectual property issues, as appropriate

The HCC should utilize existing primary and redundant communications systems and platforms—often provided by state government agencies—capable of sending EEIs to maintain situational awareness.

The HCC should:

  • Identify reliable, resilient, interoperable, and redundant information and communication systems and platforms (e.g., incident management software; bed and patient tracking systems and naming conventions; EMS information systems; municipal, hospital, and amateur radio systems; satellite telephones; etc.), and provide access to HCC members and other stakeholders
  • Use these systems to effectively coordinate information during emergencies and planned events, as well as on a regular basis to ensure familiarity with these tools
  • Maintain ability to communicate among all HCC members, health care organizations, and the public (e.g., among hospitals, EMS, public safety answering points , emergency managers, public health agencies, skilled nursing facilities, and long-term care facilities)
  • Restore emergency communications quickly during disruptions through alternate communications methods
  • Leverage communications abilities of health information exchanges (HIEs) and capabilities of EHR vendors where they exist

capability 3

••••••••••••••••••

Health care organizations, with support from the HCC and the ESF-8 lead agency, provide uninterrupted, optimal medical care to all populations in the face of damaged or disabled health care infrastructure. Health care workers are well-trained, well-educated, and well-equipped to care for patients during emergencies. Simultaneous response and recovery operations result in a return to normal or, ideally, improved operations.

ASPRHCPR Capabilities

There are key health care functions (e.g., Mission Essential Functions [MEFs]) that should be continued after a disruption of normal activities and are a priority for restoration should any be compromised.

Health care organizations should first determine its key functions when planning for continuity of health care service delivery. The HCC may play an important role in assessing and supporting the maintenance of these functions.

These key health care functions include clinical services and infrastructure:

  • Pre-hospital care
  • Inpatient services
  • Outpatient care
  • Skilled nursing facilities and long-term care facilities
  • Home care
  • Laboratory
  • Radiology
  • Pharmacy
  • Supply chain management (leasing, purchasing, and delivery of critical equipment and supplies such as medical devices, blood products, personal protective equipment (PPE), and pharmaceuticals)
  • Facility infrastructure
  • Utilities (water, electricity, gas, sewer, and fuel)
  • Medical gases
  • Air handling systems (heating, ventilation, and air conditioning [HVAC])
  • Telecommunications and internet services
  • Information technology (e.g., software and hardware for EHRs and patient billing)
  • Central supply
  • Transportation services
  • Nutrition and dietary services
  • Security
  • Laundry
  • Human resources

Health care and administrative personnel are a critical component of continuity. More information is included in Capability 3, Objective 5 – Protect Responders’ Safety and Health.

The foundation for safe medical care delivery includes a robust, redundant infrastructure and availability of essential resources.

Health care organizations should determine their priorities for ensuring key functions are maintained during an emergency, including the provision of care to existing and new patients. Facilities should determine those services that are critical to patient care and those that could be suspended (e.g., closing a hospital’s outpatient clinics to preserve staff to manage an elevated inpatient census). In addition, the HCC should have a plan to maintain its own operations.

Continuity of Operations (COOP) planning ensures the ability to continue essential business operations, patient care services, and ancillary support functions across a wide range of potential emergencies. The health care organization’s COOP plan may be an annex to the organization’s Emergency Operations Plan (EOP) and during a response should be addressed under the incident command system (ICS).

Regardless of the format, the COOP plan should include the following:

  • Activation and response functions
  • Supervisor and managerial points of contact for each department
  • Orders of succession and delegations of authority
  • Immediate actions and assessments to be performed in case of disruptions
  • Safety assessment and resource inventory to determine whether the health care organization can continue to operate
  • Redundant, replacement, or supplemental resources
  • Strategies and priorities for addressing disruptions

Multiple employees from each HCC member organization should understand and have access to the HCC’s information sharing platforms to ensure the continuity of information flow and coordination activities. The HCC and governmental partners (including the ESF-8 lead agency) should be engaged when one or more health care organizations has lost capacity or ability to provide patient care or when a disruption to a health care organization requires evacuation.

The HCC and its members should incorporate COOP into their routine exercises (see Capability 1, Objective 4, Activity 3 – Plan and Conduct Coordinated Exercises with HCC Members and Other Response Organizations).

HCC COOP plans may be an annex to the HCC’s response plan or may take another form. In addition to the topics covered in Capability 3, Objective 2, Activity 1 – Develop a Health Care Organization Continuity of Operations Plan, the HCC COOP plan should include strategies for communications and leadership continuity.

The HCC, in coordination with the ESF-8 lead agency, should ensure that communication and coordination systems that are used for incident management are adequately secured, backed up, and have redundant power and server protections. In addition, redundant or backup systems should be identified in case the usual means of coordination (e.g., internet software platform) is unavailable. Backup plans for communications should be understood prior to an emergency and documented in the HCC response plan.

HCC leadership may not be available to assist with coordination during an emergency due to illness, injury, or commitments external to the HCC. The HCC COOP plan should detail orders of succession and delegations of authority, and a suitable number of personnel (ideally not from the same organization) should be trained to carry out HCC coordination activities.

Health care organizations and the HCC should maintain administrative and financial functions during and after an emergency even if these functions need to continue at an off-site location. This includes essential business processes used to maintain financial security (e.g., registration, billing, access to health records, payroll, and human resource systems).

The decision to shelter-in-place is based on the nature and timing of the emergency (e.g., tornado, flooding, active shooter, or improvised nuclear device detonation), the potential effects on patient care delivery, and the status of critical infrastructure in the surrounding community.

Health care organizations should consider the following when developing their shelter-in-place plans:

  • Decision-making criteria and authorities
  • Identification of patient and non-patient care locations to provide protection from the external environment
  • Operational procedures for shutting down HVAC, lock-down, and access control
  • Assessment of internal capabilities and needs
  • Acquisition of supplies, equipment, pharmaceuticals, and other necessary resources for sustainment (e.g., water and food), as well as materials that may be important for children and others during extended sheltering (e.g., books and games)
  • Internal and external communications plans, including plans for communicating with patients’ and workforce’s families
  • Triggers for lifting shelter-in-place orders
Critical equipment and supplies for all populations should be available to ensure the ongoing delivery of patient care services. HCC members should assess equipment and supply needs that will likely be in demand during an emergency and develop strategies to address potential shortfalls.

 

Each individual HCC member should examine its supply chain vulnerabilities by collaborating with manufacturers and distributors to determine access to critical supplies, amounts available in regional systems, and potential alternate delivery options in the case that access or infrastructure is compromised. The HCC should then collect and use this information to coordinate effectively within the region, in collaboration with the ESF-8 lead agency.

The supply chain integrity assessment should include the following:

  • Blood banks
  • Medical gas suppliers
  • Fuel suppliers
  • Nutritional suppliers and food vendors
  • Pharmaceutical vendors
  • Leasing entities for biomedical (monitors, ventilators, etc.) and other durable medical equipment and beds
  • Manufacturers and distributors for disposable supplies
  • Manufacturers and distributors for PPE
  • Hazardous waste removal services

The HCC should collaborate with health care organization members and other stakeholders to develop joint understanding and strategies to address supply chain vulnerabilities.

These vulnerabilities may be addressed at a health care organization and/or HCC level by decisions and mitigation strategies including but not limited to:

  • Accessing stockpile (or maintain and rotate higher stock levels)
  • Accessing vendor- and/or distributor-managed inventory/stockpile
  • Establishing secondary vendors
  • Developing ‘push’ or pre-event disaster supply procedures and triggers for activation
  • Identifying alternate modes of delivery
  • Using bulk purchasing to benefit from advantages in pricing and availability across HCC members

Health care organizations will need to determine whether additional new contracts or other agreements are needed prior to an emergency. In many cases, there is little redundancy in available vendors and little available inventory, which may contribute to rapid exhaustion of supplies in a major emergency. HCC agreements to share supplies may provide a critical resource during emergencies.

Pharmaceuticals and medical materiel are needed for both emergency treatment and to maintain the health of patients, health care providers, and first responders. Health care organizations should maintain awareness of critical medications and materiel they have on hand and how to obtain additional supplies through their established procurement processes, their HCC, and any state/local stockpiles.

Certain categories of pharmaceuticals and medical materiel are more likely to be required during a patient surge, such as:

Pharmaceuticals

  • Analgesia and sedation medications (including oral and injectable)
  • Anesthesia medications (e.g., paralytics)
  • Antibiotics (including oral and injectable)
  • Tetanus vaccine
  • Pressor medications
  • Antiemetics
  • Respiratory medications (e.g., albuterol)
  • Anticonvulsant drugs
  • Antidotes (e.g., atropine, hydroxocobalamin) – based on community risks and resources
  • Psychotropic medications

Medical supplies and equipment

  • Blood products
  • Intravenous fluids and infusion pumps
  • Ventilators
  • Bedside monitors
  • Airway suction for all populations, including children
  • Surgical equipment and supplies
  • Supplies needed to administer pharmaceuticals, blood products, and intravenous fluids (e.g., needles, syringes, etc.)

Health care organizations should ensure access to formulations appropriate for dosing all patient types, including children and other special populations.

For most health care organizations, small increases above baseline levels of common, inexpensive medications will provide a buffer, particularly when organizations can share resources with HCC members during an emergency. Decisions to stockpile medications are complex and rely on a risk assessment and resource commitments by health care organizations, the HCC, and other stakeholders. Acquisition, storage, rotation, activation, use, and disposal decisions should all be considered and documented.

All health care organizations and the HCC should understand the SNS distribution plan for their jurisdiction(s). Health care organizations and HCCs in jurisdictions participating in the CHEMPACK program, the Cities Readiness Initiative (CRI), and local and state-based plans that maintain treatment or prophylaxis caches should be engaged in the development, training, and exercising of those distribution plans.

Cyberattacks on health care organizations have had significant effects on every aspect of patient care and organizational continuity.

With increasing reliance on information systems, including EHRs, administrative and payment systems, mobile technology, communication systems, and networked medical devices, there is a potential risk to their integrity and safety. To combat these risks, health care organizations should implement cybersecurity leading practices and conduct robust planning and exercising for cyber incident response and consequence management. As the number of cyberattacks on the health care sector increases, health care practitioners, executives, IT professionals, legal and risk management professionals, and emergency managers should remain current on the ever-changing nature and type of threats to their organizations, systems, patients, and staff.

Health care organizations, assisted by the HCC, should explore industry cybersecurity standards, guidelines, and leading practices necessary to protect these systems (e.g., National Institute of Standards and Technology Cybersecurity Framework - Framework for Improving Critical Infrastructure Cybersecurity), and have a plan in place for response and recovery should they be compromised.

Some industry-recognized leading practices for protecting health care information systems and networks include but are not limited to:

  • Conducting a computer network assessment to obtain the information necessary to develop a cybersecurity plan to reduce cyberattacks and reduce breaches
  • Encrypting all computers and mobile devices
  • Pre-approving the use of any devices not issued by the organization
  • Implementing role-based access to any systems to ensure employees only have access to programs and applications necessary to perform functions of their jobs
  • Configuring any EHR system or database to require specific access permissions to each user; inquiring with the EHR vendor to determine how they provide updates and technical support
  • Developing security policies for the use of virtual private network (VPN) or private connections
  • Implementing staff cybersecurity training and enforcement policies
  • Including cybersecurity and continuity of information systems considerations in the organization's hazard vulnerability analysis (HVA)
  • Including appropriate IT personnel and considerations in EOPs, training, and exercises
  • Engaging outside partners (e.g., law enforcement, regulatory agencies, and IT securityproviders/vendors) for assistance with cybersecurity incidents
  • Becoming a member in information sharing and analysis organizations (ISAOs) or other means

The safety and health of clinical and non-clinical personnel are high priorities for preparedness and continuity as effective care cannot be delivered without available staff. Health care organizations, in coordination with the HCC, should develop processes to protect responders’ safety and health and align with various requirements, certifications, and standards (e.g., Occupational Safety and Health Administration [OSHA], Joint Commission, etc.).

Those processes should be implemented to equip, train, and provide resources necessary to protect responders, employees, and their families from hazards during response and recovery operations. PPE, medical countermeasures (MCMs), workplace violence training, psychological first aid training, and other interventions specific to an emergency are all necessary to protect health care workers from illness or injury and should be readily available to the health care workforce. This section addresses selected aspects of workforce safety and protection relevant to emergencies, but does not include the much broader spectrum of health care worker safety during routine operations.

It is important to keep patients, responders, employees, and their families safe during emergencies. The health care organization should be prepared to distribute MCMs, using a closed point of dispensing (POD) or other model, when there is potential or confirmed exposure to any chemical, biological, radiological, nuclear, and explosives (CBRNE) hazard for which MCMs exist. Access to such MCMs should be coordinated and planned for with the local public health department. This approach allows for organized and timely MCM distribution.

In addition, PPE (e.g., respirators, protective clothing, gloves, face shields, etc.) should be available to response personnel across varying job functions to offer protection from a wide range of threats such as infectious diseases, radiation, chemical exposure, and various physical hazards. In certain situations, staff exposures may warrant pharmaceutical prophylaxis, which should be managed according to the health care organization’s infection control policies. Exposures may result from PPE failure, emerging infectious disease outbreaks, industrial accidents, natural disasters, or terrorist attacks. Providing access to food and sleeping arrangements is also key to protecting responders’ safety and health, increasing their ability and willingness to work during an emergency.

The HCC should promote regional PPE procurement that could offer significant advantages in pricing and consistency for staff, especially when PPE is shared across health care organizations in an emergency. In circumstances where HCC members are part of a larger corporate health system, a balance between corporate procurement and regional procurement could be considered (see Capability 3, Objective 3, Activity 1 – Assess Supply Chain Integrity).

Training, drills, and exercises develop the knowledge, skills, and abilities of an HCC members’ workforce to effectively respond to emergencies (see Capability 1, Objective 4 – Train and Prepare the Health Care and Medical Workforce).

Health care organizations, in collaboration with other HCC members, should:

  • Integrate responder safety and health policy development, training, and program implementation with existing occupational health and infection control programs (e.g., PPE including respiratory protection, MCMs, workplace violence, psychological first aid)
  • Plan for pre-hospital decontamination, and ensure coordination among fire, emergency medical services (EMS), and other health care organizations
  • Create hazardous material (HAZMAT) plans that include appropriate staff training requirements and PPE to perform decontamination per OSHA guidance for first receivers (see Capability 4 – Medical Surge for more information on HAZMAT response)
  • Provide training for health care providers, laboratorians, and support staff for contact, droplet, airborne infectious diseases, including those that may be classified as highly pathogenic and transmissible
  • Work with human resources departments and health care unions, as applicable, to develop policies and procedures to ensure health care worker readiness and safety associated with caring for patients
  • Maintain PPE in a state of readiness, and ensure inventory is updated and adequate for staffing demands and needs

A resilient workforce is critical to successful emergency response and recovery. The HCC and its members should consider the following:

  • Pre-emergency resilience building, such as encouraging healthy lifestyles; developing family emergency plans; conducting staff training for active shooter events and psychological first aid; and instituting workplace violence reduction strategies
  • Emergency resilience support, such as rotating staff to limit fatigue; providing support to staff and families (e.g., child care); providing accurate and timely updates during an emergency; providing opportunities for interacting with health care organization leadership; and providing just-in-time training relative to the emergency
  • Post-emergency support, such as providing psychological first aid; distributing information on expected stress responses; conducting self- and peer-assessment and monitoring activities; providing access to employee assistance programs, including professional behavioral health services; and modifying duty assignments. Post-emergency activities may continue for months and even years beyond the emergency
  • Ongoing health and safety monitoring activities, such as determining which groups of responders should be included in a health care or disease registry program to monitor their long-term physical and behavioral health; establishing and implementing long-term tracking of responder health, and where appropriate, community health; and providing technical assistance to help determine the appropriate duration and content of long-term health tracking

The HCC can disseminate information and promote these programs and initiatives to all HCC members.

Health care organizations should evacuate or relocate when continuity planning efforts cannot sustain a safe working environment or when a government entity orders a health care organization to evacuate.

The HCC should ensure all members and other stakeholders are included in evacuation and relocation planning including but not limited to, skilled nursing facilities and long-term care facilities. The HCC plays a critical role in coordinating the various elements of patient evacuation and relocation.

The HCC and its members should prepare for evacuation or relocation with little or no warning. Evacuation and relocation plans assist health care organizations with the safe and effective care of patients, use of equipment, and utilization of staff when relocating to another part of the facility or when evacuating patients to another facility. Health care organizations may rely on the HCC and their affiliated corporate health systems to assist in planning, evacuation, and relocation processes. The HCC and its members, in coordination with the ESF-8 lead agency, should consider the following when planning and coordinating patient evacuation and relocation:


Planning considerations:

  • Establish authorities for decision-making processes, including triggers for evacuation
  • Ensure internal and external communications
  • Identify appropriate relocation and evacuation staging areas within the facility
  • Integrate health care organization evacuation planning with local and regional patient movement plans
  • Identify situations for early discharge
  • Identify available destination facilities and their ability to expand existing services to receive patients from evacuating facilities
  • Establish processes for when patients cannot be moved (see Capability 3, Objective 2, Activity 4 – Plan for Health Care Organization Sheltering-in-Place)
  • Establish procedures for facility closure

Evacuation and relocation considerations:

  • Prioritize the order and category of patients chosen for evacuation and relocation Obtain section 1135 of the Social Security Act waivers; these waivers can be obtained retroactively in certain emergency situations
  • Match patient needs with available transport resources (including non-EMS transportation assets)
  • Move and track patients and their belongings, staff, and medical records; ensure vital patient medications and equipment (e.g., mechanical ventilators, monitors, intravenous [IV] poles, etc.) are brought with the patient during patient transport and are returned to the facility of origin
  • Notify families, and initiate reunification

Planning, training, and exercising these activities are critical to the success of evacuation and relocation. High risk patients should be given special consideration during evacuation and relocation. These patients include adults, children, and neonates in critical care units, current operative cases, psychiatric (including memory/dementia care) patients, and other patients who may need specialized care during evacuation and relocation

The HCC and its members, in collaboration with the ESF-8 lead agency, should develop and implement transportation plans for evacuating patients from one health care facility to another.

The plans should:

  • Articulate the HCC’s role in coordinating EMS assistance
  • Include a process to appoint a transport manager or similar position under the ICS operations section
  • Identify a coordinating entity for public and private EMS agencies, including both ground and airmedical services
  • Identify transportation assets including non-medical transportation partners, such as commercial bus companies
  • Identify processes to access specialized transportation assets through emergency management organizations (e.g., National Guard [State Active Duty], tractors, boats)
  • Consider age- and size-related transportation equipment needs
  • Develop processes to track patients and staff during transport
  • Establish processes for transport partners to communicate with sending and receiving facilities
  • Establish processes to communicate with patients’ families when transferring patients to the next health care provider
Effective recovery and reconstitution of the health care delivery system includes pre-incident planning and implementation of recovery processes that begin at the outset of a response.

 

The HCC can play an important role in monitoring and facilitating the recovery processes of the health care delivery system disrupted by an emergency. These efforts are intended to promote an effective and efficient return to normal or, ideally, improved operations for the provision of and access to health care in the community.

Recovery processes can be integrated into existing plans (e.g., annex to EOPs) or be developed as a separate stand-alone plan. The HCC and its members should participate in state and local pre-emergency recovery planning activities as described in the National Disaster Recovery Framework in order to leverage existing recovery resources, programs, projects, and activities.

Response, continuity operations, and recovery are overlapping, interdependent, and often conducted concurrently. Therefore, identifying connected functions, tasks, or activities in the post-emergency environment will facilitate a coordinated transition from response to recovery.

Key considerations to recovery planning include:

  • Goals and strategic priorities for the continued delivery of essential health care services, including behavioral health, and opportunities for improvement after an emergency
  • Flexible operational objectives and tactics to accommodate different recovery approaches
  • Integration with pre-incident assessments and plans (e.g., community health needs assessments, community health improvement plans, organizational capital improvement plans)
  • Critical infrastructure dependencies (e.g., public utilities, IT, transportation, etc.)
  • Workforce retention issues essential to operations (e.g., access to child or adult dependent care)

The HCC may assist its members’ assessment of emergency-related structural, functional, and operational impacts.

The HCC can assist its members with the following activities:

  • Data collection and analysis to identify priorities in the reconstitution and delivery of community health care services at the outset of an emergency
  • Collaboration with federal infrastructure assessment teams to enhance knowledge of disaster impacts on physical infrastructure and inform future risk mitigation strategies
  • Implementation of emergency management organizations’ disaster impact assessments to assess post-disaster community health concerns

The HCC, in coordination with its government partners, supports its members in the post-emergency recovery process by facilitating patient repatriation and system operations restoration.

The HCC should:

  • Assist HCC members with government processes for reimbursement, reconstitution, and resupply in concert with its emergency management organizations and ESF partners
  • Convene a platform to identify long-term health care and community health recovery gaps, and develop potential strategies to address them
  • Develop and communicate short- and long-term priorities to the jurisdiction’s government and emergency management functions (e.g., ESF-6 [Mass Care, Emergency Assistance, Housing, and Human Services], ESF-8, and the Health and Social Services Recovery Support Function)
  • Collaborate with emergency management organizations and government officials to identify opportunities for future mitigation strategies or initiatives to enhance the resilience of the physical health care infrastructure

Health care organizations should ensure that their ICS prepares for a return to normal operations by:

  • Identifying and preparing documentation necessary for government assistance
  • Assessing damaged infrastructure and impacted patient care services to restore functionality
  • Supporting the physical and behavioral health needs of affected patients, staff, and families
  • Connecting patients and staff with case management and financial services
  • Planning the after-action learning and improvement processes

Successful reconstitution and recovery should be guided by efforts to build back better.

capability 4

medical surge

Health care organizations—including hospitals, EMS, and out-of-hospital providers—deliver timely and efficient care to their patients even when the demand for health care services exceeds available supply. The HCC, in collaboration with the ESF-8 lead agency, coordinates information and available resources for its members to maintain conventional surge response. When an emergency overwhelms the HCC’s collective resources, the HCC supports the health care delivery system’s transition to contingency and crisis surge response and promotes a timely return to conventional standards of care as soon as possible.

ASPRHCPR Capabilities

An emergency event will require the HCC and its members to share information, attain and maintain situational awareness, and manage and share resources, at a minimum. The HCC may help facilitate patient and resource distribution (or re-distribution) during a surge emergency. The health care organization’s Emergency Operations Plan (EOP) will help inform these efforts.

The health care organization EOP should summarize the actions to initiate a response to a medical surge. The EOP should include individual departmental sections that provide specific surge strategies for each unit or service line. Further, employees should clearly know how to communicate with the organization’s Emergency Operations Center (EOC). The EOP should include a process for the health care organization to request waivers and emergency use authorizations. As the response evolves and situational awareness is enhanced, the health care organization can refine its response strategies according to the scope of the emergency.

EMS organizations, the HCC, and its members support each other during medical surge. The EMS EOP should incorporate information on dispatch, response, pre-hospital triage and treatment, transportation, supplies, and equipment. Like the health care organization EOP, the EMS EOP will help inform the overarching HCC response.

The EMS EOP should detail the implementation of a stepwise approach to medical surge, including the use of conventional, contingency, and crisis care strategies, as well as state (e.g., request for National Guard) and interstate (e.g., Emergency Management Assistance Compact [EMAC]) resources to address potential shortfalls. Ultimately, EMS organizations should strive to return to normal operations as quickly as possible. EMS providers should develop and consistently implement common strategies within the HCC. EMS medical directors and managers should develop and activate surge procedures appropriate for the emergency that enable their employees to make informed decisions in the field so they can provide the best care possible, given limited resources and staff. Table 1 below outlines key elements to incorporate into an EMS EOP.

Table 1 Medical Surge Elements to Incorporate into an EMS Emergency Operations Plan

Category Elements to incorporate into an EMS EOP
Dispatch Identify procedures to:
  • Alert hospitals of an emergency
  • Communicate hospital capacity and capability to EMS providers
  • Track patient distribution (or redistribution)
  • Change emergency dispatch processes (e.g., not dispatching EMS to motor vehicle crashes until police or fire report significant injuries)
  • Assign low priority calls to other resources or alternative forms of transport
Response
  • Match appropriate specialized providers and equipment with the nature of the emergency (e.g., hazardous materials [HAZMAT] trained crews during a chemical spill)
  • Consider surge strategies such as changing shift lengths or crew configurations, using alternate vehicles, using community paramedicine, or other non-ambulance responses in coordination with dispatch priorities
Pre-hospital triage and treatment
  • Implement disaster triage procedures and other standard operating procedures (e.g., eliminate requirement for verbal orders)
  • Consider processes that allow for expanded scope of practice
  • Plan for specialty responses, such as HAZMAT, highly infectious disease, mass burn, mass trauma, and mass pediatric emergencies
Transportation
  • Identify procedures to surge the numbers of patients transported per vehicle or aircraft
  • Identify procedures for changing preferred destination facilities (e.g., trauma center, pediatric hospital) or not using the closest hospital
  • Identify procedures for type and level of pre-hospital care delivery and mode of transport (ground and air medical)
  • Develop and implement EMS patient distribution strategies to avoid overloading any single hospital
  • Identify procedures for transporting patients to alternate care sites
Supplies and Equipment
  • Utilize physical resources including supplies, equipment, and cached materials to support a medical surge 

The HCC response plan as described in Capability 2 – Health Care and Medical Response Coordination should detail the activation and notification processes for initiating medical surge response coordination among HCC members, including ESF-8 partners. The HCC response plan should include the following elements related to medical surge:

  • Strategies to implement if the emergency overwhelms regional capacity or specialty care (e.g., trauma, burn, pediatric) capability, including the execution of crisis standards of care plans; plans should also address steps to prevent crisis standards of care without compromising quality of care (e.g., conserve supplies, substitute for available resources, adapt practices, etc.)
  • Strategies for patient tracking, including a process for keeping track of unidentified (John Doe/Jane Doe) patients
  • Strategies for initial patient distribution (or re-distribution) in the event a facility becomes overwhelmed (e.g., across proximal geographic region among local hospitals)
  • Strategies for definitive patient movement out of the affected region coordinated with U.S. Department of Defense (DoD) or U.S. Department of Veterans Affairs (VA) Federal Coordinating Centers (FCCs), including the establishment of aerial ports of embarkation and debarkation for patient movement (e.g., deployable U.S. Department of Health and Human Services [HHS] response teams, definitive medical care in National Disaster Medical System [NDMS] civilian hospitals)
  • Processes for joint decision making and engagement among the HCC, HCC members, and the ESF-8 lead agency to avoid crisis conditions based on proactive decisions about resource utilization

Hospitals should activate their EOP to rapidly develop a medical surge response proportionate to the emergency. While the goal of immediate bed availability (IBA) is to create capacity within hospitals, other health care organization partners (e.g., home care, skilled nursing facilities, long-term care facilities, clinics, and community and tribal health centers) can meet the needs of patients who are discharged early as part of the surge response.

DoD military treatment facilities and VA Medical Centers should be included in surge planning and response. Hospitals should engage HCC members with the end goal of returning to normal operations as quickly as possible by either acquiring additional resources or sharing the patient load. Hospitals should develop medical surge capacity and capability for all populations across a number of areas (as described in Table 2 below).

Table 2 Areas to Develop Emergency Department and Inpatient Medical Surge Capacity and Capability

Area Description
Emergency Department
  • Make beds and surge spaces rapidly available for initial triage and stabilization, and obtain additional staff, equipment, and supplies
General medical, general surgical, and monitored beds
  • Ensure IBA (at least 20 percent additional acute hospital inpatient capacity within the first four hours following an emergency) by rapidly prioritizing patients for discharge, maximizing the use of staffed beds, and using non-traditional spaces (e.g., observation areas)
Critical care
  • Rapidly expand capacity (for those facilities that provide it) by adapting procedural, pre- and post-operative, and other areas for critical care
  • Assess staff, equipment, and supply needs for these spaces to facilitate requests
Surgical intervention
  • Secure resources, such as operating rooms, surgeons, anesthesiologists, operating room nurses, and surgical equipment and supplies to provide time-sensitive, immediate surgical interventions to patients with life threatening injuries
Clinical laboratory and radiology
  • Rapidly expand basic laboratory services (e.g., hematology, chemistries, Gram stain, blood cultures), including mechanisms for staff augmentation and rapid reporting
  • Consider use of point-of-care testing
  • Rapidly expand radiology services (e.g., diagnostic radiology, ultrasound, computed tomography [CT]), including mechanisms for staff augmentation and rapid reporting
Staffing
  • Call back clinical and non-clinical staff; utilize staff in non-traditional roles
  • Adjust staffing ratios and shifts as required, and implement HCC member staff sharing plans
Health care volunteer management
  • Identify situations that would necessitate the need for volunteers in hospitals
  • Identify processes to assist with volunteer coordination
  • Estimate the anticipated number of volunteers and health professional roles based on identified situations and resource needs of the facility
  • Identify and address volunteer liability issues, scope of practice issues, and third party reimbursement issues that may deter volunteer use
  • Leverage existing government and non-governmental volunteer registration programs (e.g., Emergency System for Advance Registration of Volunteer Health Professional [ESAR-VHP] and Medical Reserve Corps [MRC])
  • Develop rapid credential verification processes to facilitate emergency response

Patient care settings outside of hospitals may be impacted during an emergency. For example, structural impacts from natural disasters or increased demand during epidemics may compromise an outpatient clinic’s ability to provide care. If not adequately addressed, the demand for out-of-hospital care will usually fall on hospitals and EMS, further overloading an already burdened system.

Safe, continued operations of a community’s out-of-hospital care resources are critical to an effective medical surge response. Therefore, HCC out-of-hospital members should share staff and resources and fully integrate with the region’s surge response activities. Out-of-hospital members include but are not limited to, ambulatory care (including primary care providers), Federally Qualified Health Centers (FQHCs), community and tribal health centers, stand-alone surgical and specialty centers, skilled nursing facilities, long-term care facilities, clinics, private practitioners, and home care.

An alternate care system—the utilization of non-traditional settings and modalities for health care delivery—may be required when demand overwhelms a region or the nation’s health care delivery system for a prolonged period, or an emergency has significantly damaged infrastructure and limited access to health care.

In these situations, the ESF-8 lead agency, in collaboration with health care organizations and the HCC, should work together to meet patient care needs. Public health agencies and emergency management organizations have leadership roles in selecting, establishing, and operating the sites, though the health care delivery system may provide support, including personnel and supplies.

Initial efforts for staffing an alternate care system should not disrupt health care delivery services (see Capability 3 – Continuity of Health Care Service Delivery). Communities should utilize MRCs and other staffing augmentation efforts (e.g., nursing and medical students) to staff an alternate care system whenever possible. When these resources are no longer available, request for additional assistance (e.g., federal and state assistance, etc.) may be required. Table 3 below outlines key elements to consider when developing an alternate care system.

Table 3 Key Considerations to Develop an Alternate Care System

Category Key Considerations
Telemedicine/virtual medicine
  • Use telephone, internet, telemedicine consultations, or other virtual platforms to provide consultation between providers
  • Provide access to specialty care expertise where it does not exist within the HCC to allow for remote triage and initial patient stabilization
  • Establish call centers to offer scripted patient support
Screening/early treatment
  • Ensure that a section 1135 of the Social Security Act waiver is in place if required
  • Establish assessment and screening centers that allow the health care delivery system to respond to increased demand for screening and early treatment (e.g., during a pandemic)
  • Preferentially manage patients with minor symptoms and those who might require limited medical intervention as these patients might otherwise overwhelm emergency departments
Medical care at shelters
  • Provide medical care support at community-established shelters (may involve ESAR-VHP, MRC, state disaster medical teams, nursing home staff, or a variety of ambulatory care providers)
Disaster alternate care facilities selection and operation
  • Be able to provide non-ambulatory care for patients when hospital beds are not available
  • Select sites for out-of-hospital patient care management based on recommended guidance
  • Identify the process to assist with multiagency volunteer coordination to organize, assemble, dispatch, and properly out-process volunteers (e.g., Volunteer Reception Center)
  • Integrate with Federal Medical Stations (FMS)

All hospitals should be prepared to receive, stabilize, and manage pediatric patients. However, given the limited number of pediatric specialty hospitals, an emergency affecting large numbers of children may require HCC and ESF-8 lead agency involvement to ensure those children who can most benefit from pediatric specialty services receive priority for transfer.

Additionally, pediatric practitioners may be able to help identify patients who are appropriate for transfer to non-pediatric facilities. EMS resources, including providers with appropriate training and equipment, should be prepared to transport pediatric patients.

The HCC should promote its members’ planning for pediatric medical emergencies and foster relationships and initiatives with emergency departments that are able to stabilize and/or manage pediatric medical emergencies.

Communities should be prepared to manage exposed or potentially exposed patients during a chemical or radiation emergency. During such events, individuals may go to various health care facilities, police and fire stations, and other locations for assistance.

To ensure successful surge management, HCC members should be prepared to do the following:

  • Provide wet and dry decontamination by personnel trained and equipped according to the Occupational Safety and Health Administration (OSHA) guidance for first receivers and the Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities
  • Ensure involvement and coordination with regional HAZMAT resources (where available), including EMS, fire service, health care organizations, and public health agencies (for public messaging)
  • Distribute and administer available antidotes, including mobilization of CHEMPACKs when necessary
  • Screen to differentiate exposed from unexposed patients, especially in radiation emergency events
  • Develop a process for radiation triage, treatment, and transport (RTR response)
  • Manage behavioral health consequences for these types of emergency events (see Capability 4, Objective 2, Activity 8 – Respond to Behavioral Health Needs during a Medical Surge Response below)

All hospitals should be prepared to receive, stabilize, and manage burn patients. However, given the limited number of burn specialty hospitals, an emergency resulting in large numbers of burn patients may require HCC and ESF-8 lead agency involvement to ensure those patients who can most benefit from burn specialty services receive priority for transfer. Additionally, burn surgeons may be able to help identify patients who do not require burn center care and who are appropriate for transfer to other health care facilities.

The HCC and its members should coordinate a response to large-scale trauma emergencies with all trauma system partners. All hospitals should be prepared to receive, stabilize, and manage trauma patients. However, given the limited number of trauma centers, an emergency resulting in large numbers of trauma patients may require HCC and ESF-8 lead agency involvement to ensure those patients who can most benefit from trauma services receive priority for transfer. Health care facilities should ensure sufficient availability of operating rooms, surgeons, anesthesiologists, operating room nurses, and surgical equipment and supplies to provide immediate surgical interventions to patients with life threatening injuries.

Emergencies may have severe emotional impact on survivors, their families, and responders and also cause substantial destabilization of patients with existing behavioral health issues. Hospitals and outpatient care providers, including behavioral health professionals, should identify a regional approach to assess and address the needs of the community. Behavioral health organizations are valuable HCC members and can provide needed support to survivors, responders, and people with pre-existing behavioral health concerns.

HCC members should promote a robust behavioral health response that include the following elements:

  • A proportional behavioral health response, addressing the unique behavioral health needs of children, implemented according to the impact of emergencies on the community
  • The development and use of behavioral health support and strike teams to support the affected population
  • Ongoing support for inpatient and outpatient care of psychiatric patients
  • Widespread information dissemination to help providers, patients, family, and the community understand the symptoms and signs of acute stress responses and when and where to seek treatment
  • Behavioral health professionals increasing contact with clients
  • Provision of psychological first aid to those impacted (including health care workers)