An Overview of the Hospital Incident Command System (HICS)

The hospital incident command system (HICS) is an emergency response and preparedness system for hospitals. It enhances a hospital’s emergency capabilities both as an individual facility and as part of a broader response community. HICS also provides guidance for performing daily operations, pre-planned event and non-emergencies.

The Hospital Incident Command System began to be implemented during the late 1980s in the United States, and similar systems have also been implemented in other countries. The California Emergency Medical Services Authority (EMSA) publishes the HICS Guidebook for the United States.

As of this writing, it is currently in its fifth edition, which was published in 2014. This guidebook is intended to provide hospitals with the tools they need to improve their emergency response capabilities and preparedness, but it wasn’t written to be a definitive text on this subject. Furthermore, the HICS is a living document, meaning that it will evolve as additional best practices are adopted.

Principles

The Hospital Incident Command System (HICS) is based on the same principles as the National Incident Management System (NIMS), although they have been adapted for the healthcare environment. These principles apply to all mission areas of the HICS, including mitigation, prevention, protection, response, and recovery.

HICS principles include management by objectives, which consists of evaluating a problem, developing a plan to solve it, implementing the plan and allocating the necessary resources. The HICS must also be scalable, allowing it to address the planning and response needs of any hospital, regardless of its size. HICS components should use a modular approach to provide them with the adaptability needed to plan and manage a variety of incidents. Accountability of tasks is also a key function of HICS, which includes the prioritization of action checklists. A chain of command with a suggested span of control and effective interagency communication are additional principles of the HICS.

Planning

Planning is a key component for HICS and should be viewed as a continuing cycle rather than a linear process with a defined beginning and end. Major aspects of planning include assessing risks, evaluating capabilities and evaluating those capabilities through exercises. The planning phase of HICS should also include the engagement of stakeholders to ensure their representation and involvement in the planning process. A diverse planning team will be necessary to develop a realistic HICS, so it should also include representatives from various hospital departments, supporting facilities and community representatives.

The planners of a HICS implementation don’t need to anticipate every possible emergency scenario, as this approach would be impractical. However, the effects of those emergencies are much easier to predict, making common operational functions a better basis for planning. This approach to planning requires planners to identify tasks that would commonly need to be performed during an emergency and the individuals who would be required to accomplish them.

A HICS plan should also possess the flexibility to address incidents of varying scales, from a non-emergency event to a large-scale disaster. Exercises will be necessary to ensure that critical elements are able to handle these different scenarios. Operational personnel are also more likely to understand and execute a scalable plan.

Implementation

The successful implementation of HICS requires a designated individual or committee to review the HICS Guidebook and associated materials for their applicability to the hospital’s mission, risks and size as described in its annual Hazard Vulnerability Analysis (HVA). The Emergency Program Manager (EPM) will typically lead this effort, with the Emergency Management Committee (EMC) performing oversight.

The steps needed to integrate HICS into a hospital’s current operations include assigning an individual the task of implementing the HICS according to a plan. The hospital’s Chief Executive Officer (CEO) and other senior administrators will need to support the HICS if it’s to succeed. HICS activities will also require the allocation of adequate finance financial resources, including the training needed by emergency staff. Additional requirements of the HICS implementation include the integration of the HICS into the hospital’s existing community-based response.

Team Assembly and Use

The assembly of the Hospital Incident Management Team (HIMT) should be based on a HICS’s primary management components, which include Command, Finance, Logistics, Operations, and Planning. HIMT members with appropriate technical specialties should also be assigned according to the nature and scope of a particular emergency. The HICS describes specific positions for the HIMT, but these are only suggestions, as the optimal team is highly dependent on the particular hospital and incident.

The HICS must also include the procedures for transferring command efficiently between personnel. These procedures are particularly important during an emergency, where personnel are routinely relieved by someone with greater seniority or experience. Command transfer should generally involve a transition meeting in which the current commander briefs the replacement on the current situation, including response actions, resources and the role of external agencies.

Incident Response

Incident response begins with the recognition that an incident likely to disrupt a hospital’s normal operations has occurred or is about to occur. Hospitals may receive advance notification of some incidents from various sources, including law enforcement, emergency medical services (EMS), the local emergency management agency (EMA) and the local health department. These notices will generally be classified into three types, including advisories, alerts, and activations. An advisory indicates that no response is needed yet, although the potential for a response exists. An alert means a response is imminent, while activation indicates a response is required.

Many types of incidents provide little or no advance warning, however. Hospital staff members learn of these “no notice” incidents only after they’ve already occurred from sources such as media reports or victims arriving at the hospital’s emergency center. Information from these sources is often sporadic and erroneous, as it typically takes time to develop a more accurate picture of the incident.

Scenarios

Hospitals use documents such as an Incident Planning Guide (IPG) and Incident Response Guides (IRG) to plan and conduct incident scenarios. The purpose of these scenarios is to allow hospitals to evaluate their level of preparedness and identify ways of improving it. The HICS Guidebook classifies scenarios into internal and external types.

Internal scenarios occur within the hospital and include environmental accidents such as fire, flooding, and hazardous material spills. They also include manmade incidents such as hostage crises, child abductions, and patient overloads. External scenarios affect larger areas than just the hospital and include manmade attacks with nuclear, biological and chemical weapons. Natural epidemics of diseases such as influenza and plaque are also common types of external scenarios. Other examples include natural disasters such as earthquakes and hurricanes.

Incident Action Plans

An Incident Action Plan (IAP) is essential for a successful recovery from an incident. This document provides the goals, strategies, and tactics that HICS needs to facilitate the management by objectives principle. An IAP should also be scalable to be effective for both small and large-scale incidents. Hospitals often start with an IAP Quick Start, which they can later develop into a fully documented IAP.

An IAP reduces the omissions and duplication of effort in developing the HICS. It also provides a historical record of the incident, thus facilitating the dissemination of information. Additional benefits of the IAP include improved communications between departments, better use of available resources and reduced costs during an incident.

Customization

The HICS Toolkit provides a number of tools to assist administrations in customizing HICS for their hospital. Administrators should review these tools carefully with the understanding that the ICS model has proven successful across many disciplines. They can make minor modifications to fit a hospital’s particular mission and resources, but they should use caution when considering significant variations. The primary risk of a HICS implementation that differs significantly from the norm is that it won’t be recognized by the hospital’s response partners, which could impair the coordination needed during large-scale incidents.

Common examples of HICS customization include adding hospital-specific information to IPGs, IRGs and job action sheets. The pre-population of key forms is another way hospitals often customize HICS since it allows the forms to be completed more quickly during an emergency. Hospitals may also add communication instructions that aren’t specifically addressed in the HICS Guidebook.

Small Hospitals

Small hospitals and those in rural locations can use the same principles that make HICS beneficial for a large, urban hospital, although this may require some adaptations. This process often involves assigning multiple roles to the same individual that would normally be given to different people in a larger setting. Staff members at Critical Access Hospitals (CAHs) routinely fill multiple roles, especially those in rural settings that are more likely to be understaffed.

The right combination of roles is critical for the success of HICS in a small hospital. For example, the Incident Commander at these facilities will often fill additional roles such as Public Information Officer (PIO) and Liaison Officer. However, a safety officer shouldn’t be combined with other positions such as medical or technical specialists. The primary reason for this restriction is that a safety officer must be able to evaluate the actions of other roles, which can create a conflict of interest if the safety officer is also a medical or technical specialist involved in a safety incident.

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