The Role of Hospital Medicine in Emergency Preparedness: A Framework for Hospitalist Leadership in Disaster Preparedness, Response, and Recovery

Effective participation in disaster response and planning requires a basic understanding of the organizational structures for incident management.^18,19 Overall disaster response within the United States is guided by the National Response Framework, a national-level strategy that directs coordination between military and civilian response efforts, the latter of which are structured by the National Incident Management System (NIMS).²⁰ NIMS organizes emergency management across all government levels (federal, state, and local) and the private sector under a common operational language and command structure. Both systems grew out of analyses of the September 11, 2001 attacks and Hurricane Katrina, indicating the need for a wider systemic organization to response efforts.¹ State-level efforts are designed to mobilize resources to assist in community-level operations. Incident management always falls to the local authorities. At this local level, discrete hospitals often take part in healthcare coalitions that act in conjunction with other health entities, local public health departments, and emergency medical services, forming a multiagency coordination system.⁵ This healthcare coalition (emergency support function #8 health and medical), in support of emergency managers of city and county governments, forms the core of the medical response. One commonality to all emergency management is the concept of an “all-hazards” approach, which aims to develop a broad and flexible strategy for efficient management of nearly any type of incident. This “all-hazards” approach allows effective management through each of the four phases of incident management: preparation, response, recovery, and ongoing mitigation.

Direct supervision over incident management is achieved through an Incident Command System (ICS), a hierarchical organization of positions involved in response. The top supervisory structure of ICS (Incident Command and General Staff) is the same regardless of the locale in which it operates, allowing coherent interoperability with other agencies. Incidents of any size are managed with a scalable approach; subordinate ICS positions, which are tailored according to specific needs, can be activated as needed. Healthcare implementation of the ICS structure led to the development of the Hospital Incident Command System (HICS), which now serves as the national standard for hospital-based incident management and facilitates the capacity of individual hospitals to coordinate with other resources regionally and is a part of NIMS for emergency response (Figure 1).²¹ The success of HICS-led regulatory agencies (namely the Centers for Medicare and Medicaid Services and the Joint Commission) to require ICS/HICS in-hospital incident response plans.²² The most recent HICS (Version V) excludes physician involvement in the overall management chart. However, we demonstrate how the inherent flexibility in ICS can adapt to involve hospitalists. Although HICS serves as a backbone that requires institutionally specific modifications, other institutions, such as ours, commonly have entire branches or positions renamed, reapportioned, or created to fill their specific needs. Specialized training in ICS, NIMS, and other aspects of hospital emergency response is beyond the scope of this article but is available for free through the Department of Homeland Security and FEMA.²³

Perhaps, the defining feature of ICS/HICS is its expandability, allowing the response efforts to be scaled and tailored in size, scope, and complexity of that of the incident.²⁴ At the same time, the principles of span of control and unity of command promote efficient command structure by mandating each participant within the disaster response process to report to only one superior, whereas these superiors are limited to a manageable number of subordinates. For example, in Figure 2, all Strike Team Leaders report to the Hospitalist Unit Leader. Each strike team itself is comprised of approximately five similar assets (such as two physicians, two residents, and an advance practice provider).