Lessons learned from extended incident command operations

By now, we are approximately nine months into a complex emergency event, arguably the most complex any of us have ever experienced. Although time seems to pass more quickly each day, it is worth a few minutes to pause and reflect on what has happened thus far and where we are headed. We must reconcile with the fact that this event is likely to persist for many months to come and any opportunity to improve our response and to adopt more effective, sustainable strategies should be explored. Scalable and mobile incident command tactics, as well as COVID-19 vaccine considerations, will be reviewed in this discussion.  

This time of year, it is also key to mention another prevalent respiratory illness — the seasonal flu — in the context of COVID-19. It is more important than ever to get your flu shot this year, due to the potential to be co-infected with both flu and COVID-19. The flu vaccine is the best way to protect yourself against that illness. And while COVID-19 and the flu have some similarities, there are important differences too. With the flu virus, a person will typically develop symptoms from one to four days after infection. For COVID-19, a person usually develops symptoms five days after being infected, but symptoms can appear anywhere from two to fourteen days after infection. COVID-19 also seems to cause more serious illness in some people, and people can experience different symptoms, such as a loss of taste and/or smell. It is also important to remember that, although the SARS-Cov2 virus has been around for several months, there are still many unknowns, and we learn more details about this novel illness as time progresses.

Demobilizing versus scaling back incident command

One of the first objectives when incident command is activated for any event is to assess when the team can be demobilized and return to normal operations. In a complex, months-long response like a pandemic, this is easier said than done. However, many teams may have completely demobilized response operations at times when facilities had low or no COVID-19 patients. But without definitive treatment and an approved vaccine that is widely available, the risk for increasing community COVID-19 rates or patient admissions in any area is a real one.

Additionally, just because a facility is fortunate to not have any COVID-19 patients at a given time does not mean that the attention can be turned away from the response. Treatment strategies change, community policies are updated, and other variables require teams to pay consistent active attention to the response. Rather than totally demobilizing incident command, consider scaling back staff resources dedicated to the event when possible. By taking this route, a small team can more readily stay on the pulse of the ever-changing COVID-19 world and will have more capacity to react faster to scenarios that require incident command to ramp back up to full staffing. Recall from the Federal Emergency Management Agency’s training course Incident Command System 100 that there is only one ICS position that needs to be activated for a response, the incident commander. Additionally, consider relevant financial elements (such as grant funds) and the ability to ensure surge locations remain operational that will require an activated incident command team and emergency operations plan be in place from a regulatory perspective.

Mobile incident command/emergency operations centers

When COVID-19 first began, it is likely that the incident command team met in person, in the designated environment of care to operationalize an initial response. Within a few weeks, following the new rules of physical distancing and minimizing in-person gathering sizes, large in-person meetings were no longer allowed so we could keep each other safe. In an ideal world, teams would be able to meet in person to discuss these complex situations face to face. As the last several months have shown us, this is a far from ideal situation.

In the dynamic world of health care, before COVID-19, mobile incident command strategies seemed inevitable. In a hospital emergency event, the normal operations of the facility do not pause to allow staff to completely step away from their primary role to support an incident response. Health care staff have to remain mobile, flexible and available for any issue pertaining to their role and expertise. This is key because, in a hospital, whatever the emergency happens to be it will eventually end up being integrated into the normal state of the facility.

For example, in a mass casualty incident, the patients are either admitted and become part of the general population or they are transferred to another facility. In a downtime event, patient care staff transition to alternate procedures to continue providing patient care. Hospital incident command staff have to have the adaptability and expertise to manage the overall house operations and the impacts of an unexpected event. A mobile incident command structure provides the framework to be effective in this realm. A mobile or remote incident command team is still an active, real incident command team. The good news is, there is a wealth of technology now at our fingertips to support this effort. This is the new normal for incident command during a pandemic. Key concepts to consider:

• Validate your agency's delegations of authority. Most facilities previously had these delegations outlined in their emergency operations plan, but confirm the authorities specific to ongoing COVID-19 operations. Perhaps names and duties have changed since the plan update or even since the pandemic began or perhaps the agency CEO has delegated COVID-19-related decisions to another administrator. Ensure the team collectively understands the decision-making authority at all levels and that decisions are made following the team's chain of command.
• Ensure the incident command communications plan is regularly updated. Share the information among the team, especially cell phone contacts.
• Create a structured meeting calendar and maintain agendas. Determine a regular cadence for large team briefings, incident command section meetings and other consistent forums. The more reliable the schedule, the better meeting attendance will be.
• Use your “out of office” email prompt. It is important to take a break, even if that seems impossible some days. This is a worn out phrase by now, but we have to remind ourselves that this is a marathon, not a sprint. Ensure your “out of office” email reply includes alternate points of contact and what to do in an emergency situation. Activate this auto-reply even if you are only out for a day.
• Be patient and forgiving. incident command is about teamwork and staff are trying their best to meet the demands of COVID-19. Meeting remotely means we often lose the value of body language, voice tone and other expressions that frame what people are saying. This is a tough situation and everyone will be frustrated and tired at some point. Assume the best intentions from all involved and don't focus on trivial items.

COVID-19 vaccine campaign

In the very near future, health care agencies will operationalize a COVID-19 vaccine campaign. As with nearly every other aspect of this event, the process for vaccinating our health care workers and eventually the public will be complex. Pre-planning will help provide the framework to ensure this process is as organized as possible. Incident command team leaders, including the logistics section, pharmacy and public information officers, will be key to managing the various components of the campaign.

• Vaccine distribution and storage. COVID-19 vaccine is expected to be managed by federal, state and local public health partners. Ensure your incident command team has a good connection with these agencies to stay up-to-date on the details of distribution and vaccine provider agreements. Some versions of the COVID-19 vaccine currently in development will require ultra-cold storage (such as a bone freezer, -60^oC to -80^oC). This capability does not exist in every hospital, so agencies should take this time to assess their storage capacity for this type of vaccine. If facilities do not have these types of freezers, consider potential alternatives to support temperature management, like dry ice vendors. If a new ultra-cold freezer is to be acquired, consideration on which branch of the essential electrical system it will be placed on should be risk assessed. The freezer could be installed on the equipment or critical branch depending on the criticality of the nature of what is being stored. It is not recommended to use the normal branch.
• High throughput vaccination strategies. Plans will need to consider the COVID-19 guidelines for physical distancing and minimizing large gatherings, while creating a forum to vaccinate a large number of people in a short amount of time. Mobile vaccinator carts, outside vaccination stations (even in less than ideal weather conditions), and appointment-based vaccination clinics are all options to consider in an effort to minimize the risk for disease transmission.
• Communications. Ensure the incident command public information officer(s) are involved early on in the vaccination effort, for both internal and external communications. When the vaccine is first available, there will be very limited supply, so priority groups will be identified. Ensuring both health care staff and the public understands this strategy and the process to improve access to the vaccine over time will be key. Another element to consider is that just because a vaccine is available, does not automatically mean an instantaneous change in behaviors or community-based policies. Masking, physical distancing and other guidelines will likely be in place for some time.

We are all learning about what it means to manage a complex health care emergency. It is through each other's shared experiences that together we will become more effective in our response strategies for the challenges ahead. For additional details on the topics reviewed here, please visit these links:

• CDC Similarities and Differences between Flu and COVID-19
• COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, published 10.29.20

Kathryn Quin Dudley, safety officer at Saint Alphonsus Health System.