Planning Guide PDF

Standing Together
An Emergency Planning Guide for Americas Communities

Standing Together
An Emergency Planning Guide for Americas Communities
The Joint Commission is proud to acknowledge its partnership

with the following organizations
in developing this planning guide:
Illinois Department of Public Health
Maryland Institute of Emergency Medical Services Systems
National Center for Disaster Preparedness at Columbia University
Copyright 2005 by the Joint Commission on Accreditation of Healthcare Organizations.
All rights reserved. No part of this book may be reproduced in any form or by any means without written permission from the publisher.
Standing Together: An Emergency Planning Guide for Americas Communities
Table of Contents
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Emergency Management Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Essential Components of the Planning Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Section 1. Define the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 2. Identify and Establish the Emergency Management Preparedness
and Response Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Section 3. Determine the Risks and Hazards the Community Faces . . . . . . . . . . . . . 15
Section 4. Set Goals for Preparedness and Response Planning . . . . . . . . . . . . . . . . . 20
Section 5. Determine Current Capacities and Capabilities . . . . . . . . . . . . . . . . . . . . 31
Section 6. Develop the Integrated Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Section 7. Ensure Thorough Communication Planning . . . . . . . . . . . . . . . . . . . . . . . 53
Section 8. Ensure Thorough Mental Health Planning . . . . . . . . . . . . . . . . . . . . . . . . . 62
Section 9. Ensure Thorough Planning Related to Vulnerable Populations . . . . . . . . . 67
Section 10. Identify, Cultivate, and Sustain Funding Sources . . . . . . . . . . . . . . . . . . . 70
Section 11.Train, Exercise, and Drill Collaboratively . . . . . . . . . . . . . . . . . . . . . . . . . 72
Section 12. Critique and Improve the Integrated Community Plan . . . . . . . . . . . . . 80
Section 13. Sustain Collaboration, Communication, and Coordination . . . . . . . . . . . 84
Closing Comment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Acknowledgment of Roundtable Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Selected Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
iii
Executive Summary
Despite the passage of four full years since sized the challenges; and framed potential solu-
September 11, 2001, many small communities in tions. This document reflects the extensive input
the United States are struggling to meet the man- received from roundtable participants.
date for emergency preparedness and response
that would enable them to function on their own Although no one planning tool or template can
in the hours or days before help arrives from provide the breadth of guidance needed, this plan-
regional, state, and federal sources. Readiness bar- ning guide is offered as a multifunctional tool or
riers include lack of clarity about who is respon- template. It outlines 13 essential components of an
sible for preparedness and response planning, what effective community-based emergency manage-
elements of the planning and response processes ment planning process and provides multiple
are critical, how to coordinate with state and fed- planning strategies addressing each component.
eral emergency management programs, and how The components include the following:
to obtain and sustain funding.Whenever or what- 1. Define the community.
ever disaster or mass casualty event occurs, com- 2. Identify and establish the emergency manage-
munity and local response will be key to survival; ment preparedness and response team.
communities must look to themselves and adjoin- 3. Determine the risks and hazards the communi-
ing communities for answers. ty faces.
4. Set goals for preparedness and response plan-
ning.
This planning guide provides expert guidance on 5. Determine current capacities and capabilities.
the emergency management planning process that 6. Develop the integrated plan.
is applicable to small, rural, and suburban commu- 7. Ensure thorough communication planning.
nities. Its goal is to remove readiness barriers by 8. Ensure thorough mental health planning.
providing all communities with strategies, process- 9. Ensure thorough planning related to vulnerable
es, and tools for coordinated emergency manage- populations.
ment planning. The target audience is local lead- 10. Identify, cultivate, and sustain funding sources.
ersincluding elected or appointed officials, 11. Train, exercise, and drill collaboratively.
health care providers and practitioners, public 12. Critique and improve the integrated commu-
health leaders, and others who are responsible for nity plan.
13. Sustain collaboration, communication, and
initiating and coordinating the emergency man-
coordination.
agement planning effort in towns, suburbs, and
rural areas throughout the United States. Each of the 13 sections includes supporting tools
and provides links to Web sites that offer up-to-
To develop this planning guide, the Joint date information.The planning strategies are sum-
Commission partnered with the Illinois marized at the beginning of each component sec-
Department of Public Health, the Maryland tion for ready reference. Thus, this guide can be
Institute of Emergency Medical Services Systems, used in a modular fashion to address discrete areas
and the National Center for Emergency of interest to particular planning team members.
Preparedness at Columbia University and con- Or it can be read cover to cover as a comprehen-
vened two expert roundtable meetings in May sive guide to community emergency management
and October of 2004.These roundtables addressed planning.
the issue of emergency management planning in
small, rural, and suburban communities; synthe-
iv
This guide emphasizes two planning strategies the planning and response effort that will help
that are of particular significance to small, rural, individuals stay engaged over time, even during
and suburban communities. The first is to enable times of perceived low risk when apathy about
people to care for themselves, and the second is to preparedness can become pervasive.
build on existing relationships.
Highly organized community preparedness efforts
Enable people to care for themselves should also be supported. Communities whose
Planning that prepares the community to help residents have not yet experienced Community
itself can serve to reduce the potential surge in Emergency Response Teams (CERTs) may wish
demand for services experienced during an actu- to consider offering this program. CERTs are
al emergency. The emergency plan needs to funded by Congress through Citizen Corps pro-
include a well-defined risk communication plan gram grants, which are made available to local
that contains information on the guidance that communities.A key component of Citizen Corps,
will be provided to the public and how that guid- the CERT program trains citizens to be better
ance will occur (for example, through distribution prepared to respond to emergency situations in
of fliers or other written material, or public ser- their communities. When emergencies occur,
vice announcements on local radio and television CERT members can give critical support to first
stations). Some types of emergencies can be man- responders, provide immediate assistance to vic-
aged in homes if proper information, such as how tims, and organize volunteers at a disaster site.
to prevent and treat influenza in low-risk individ-
uals during an outbreak in the community, is The CERT program is a 20-hour course, typical-
made available. For certain kinds of chemical ly delivered over a seven-week period by a local
exposure, the instruction to stay at home and take government agency, such as the emergency man-
a shower rather than go to the hospital to be agement agency or fire or police department.
decontaminated is appropriate. Other types of Training sessions cover disaster preparedness, dis-
emergencies will require mass evacuation, which aster fire suppression, basic disaster medical opera-
is best supported by ongoing public communications, light search and rescue, and team operations.
tion, education, testing, and drills. Hurricane plans The training also includes a disaster simulation in
in Florida provide an excellent example of proac- which participants practice skills that they learned
tive, multilingual, and pervasive preparedness; throughout the course.
evacuation signs are well recognized throughout
communities in Florida. Build on existing relationships
The time and resource requirements associated
Community awareness, education, and engage- with emergency management planning, response,
ment can be supported not only through formal and recovery are considerable. Communities
public health and public safety mechanisms and should carefully and creatively examine their cur-
the local media, but also at a grass roots level rent assets and expand upon them to best capital-
through a range of community groups, such as ize on their investment in preparedness. A key
civic organizations, religious groups, Boy/Girl asset is the relationships that already exist among
Scout troops, and high school sport teams, among potential planning partners in the community;
others. These groups provide not only informa- these relationships can serve as an important plat-
tion, but also social support for participation in form for building response capability.
v
Small communities located near military installa- largest retail pharmacy serving the community,
tions, nuclear power plants, hydroelectric dams, and the local postal service.They establish a
and other large-scale industrial entities are famil- preliminary plan for locating the vulnerable
iar with the extensive public education and col- disabled and elderly in the community and, on
laboration required to maintain general public the basis of this preliminary plan, are able to
pull in representatives from local police, the
safety. Periodic joint meetings involving the local
911 call facility, EMS, county mental health
utility company, telecommunications company, agency, and others to help refine the plan and
water bureau, public health department, hospital, address issues of service needs, communication
fire department, police, and emergency medical strategies, transport, and medical equipment
services (EMS) are not unusual in such communi- and supplies. Problem solving around this spe-
ties, but in other communities there are long- cific issue leads to collaboration on broader
standing walls that must be breached to facilitate issues of emergency management planning in
collaborative planning. In such situations, it may the community, and the integrated community
be advisable to begin with natural allies who can planning team builds from there.
quickly identify common ground. The following
examples illustrate how to call the first meeting Finding dual uses for existing or emerging capa-
over a focused issue, then expand the work group bilities is also particularly critical for resource-
into a broader, integrated community planning strapped small, rural, and suburban communities.A
team: reverse 911 call system established by a communi-
EMS leadership partners with the local hospital ty for law enforcement emergencies could also be
around first responder/first receiver communi- used to communicate information about other
cation issues, pulling in fire and police to initi- types of emergencies. Motels and college dormito-
ate discussions about potential improvements. ries can be utilized to provide additional bed
Further planning discussions expand the dialog capacity. Investments made by local public health
and include the risks associated with certain departments in upgrading laboratory services for
types of communicable disease outbreaks. For smallpox, sudden acute respiratory syndrome
additional expertise and operational informa- (SARS), anthrax, and other specialized testing can
tion, the local health department, state labora-
buttress routine laboratory services in the commu-
tories, and bureau of primary health care clinics
are brought to the table.The integrated com- nity. Boats or school buses can provide alternative
munity planning team builds from here to means of emergency transportation. Businesses
include broader areas of risk and response with call-center capabilities, such as telemarketing
expertise respecting potential issues facing the and airline operations, can support community
community. communication needs during a disaster.
A local municipality, in responding to the need
to establish special-needs shelters, hasthrough By creating an informed and empowered citizen-
its department of human services and local ry, and by bringing to the table the full range of
nursing homesidentified all the vulnerable assets within the community including planning
disabled and elderly residents in institutions but partners perhaps not previously considered, small,
has not identified all those living in the com-
rural, and suburban communities can deepen and
munity.The municipality establishes a work
group that includes representatives from human extend their capability to plan for and respond to
services, nursing homes, the largest home all types of natural and man-made disasters.
health agency serving the community, the
vi
Introduction
We cannot live for ourselves alone. Our lives are tural chemical facilities make chemical threats a
connected by a thousand invisible threads, and reality as well. Moreover, following a terrorist
along these sympathetic fibers, our actions run as event, residents fleeing large urban areas and in
causes and return to us as results. need of food, shelter, clothing, and health care
could very well land on the doorsteps of small
Herman Melville communities and overwhelm community
resources.
It would seem to take more than a village to
respond to the catastrophic events witnessed in Terrorists, of course, are not always the cause of
recent years. Terrorists, tsunamis, tornadoes, and events that overwhelm local resources. Every
other threats affect whole cities, countries, and community is vulnerable to an influenza pan-
continents. Yet most disasters and mass casualty demican event considered by most infectious
events are experienced locally; in this country, disease specialists to be long overdue. According
incidents are generally handled at the lowest pos- to a recent report from the Institute of Medicine,
sible jurisdictional level.1 When significant events experts believe that the world stands on the
occur, the intrusive reality is that small, rural, verge3(p. 1) of such a pandemic.4,5 Its estimated
and suburban communities in the United States impact in the United States is 89,000 to 207,000
may be on their own for 24 to 72 hours before deaths, 300,000 to 700,000 hospitalizations, and
help arrives from regional, state, and federal 18 million to 42 million individuals requiring
sources. Community and local response will be outpatient care. Every community must face the
key to survival; communities must look to them- possibility of responding to influenza with mini-
selves and adjoining communities for answers. mal or no external resources or support.3 Many
The invisible threads that connect individuals, as small communities with already seriously bur-
described by Melville, must be pulled together to dened and limited health facilities simply will not
create a surviving community fabric. be able to care for the surge of patients.
The goal of and need for this publication Despite the passage of four full years since
The goal of this publication is to provide small September 11, 2001, many small communities are
communities with strategies, processes, and tools struggling to meet the mandate for preparedness
for coordinated emergency management plan- and response that would return the desired
ning.To be fully effective, such information must results, as described by Melville. Challenges
stimulate and sustain linkages among the individ- abound (Sidebar 1), but perhaps the most threat-
uals and agencies composing a small communitys ening of these challenges is complacency. The
fabric. Rural areas may be particularly vulnerable feeling of relative safety brought on by the belief
to terrorist threats and they also may be least pre- that rural areas are at a lower risk for terrorism
pared to respond. Because nuclear power plants, may reduce rural communities sense of urgency
uranium and plutonium storage facilities, and all and limit preparation and responsiveness, notes
U.S. Air Force missile launch facilities are located one government report.2(p. 4) Studies published in
in rural areas, these communities represent poten- 2002 and 2003 indicate that public health emer-
tial terrorist targets.2 In addition, the interstate gency preparedness at the local level may be
transit of hazardous materials through small com- improving, but that gaps persist even in larger
munities nationwide and the location of agricul- communities.68 In reality, many of Americas
1
small communities are still waiting for someone care practitioners and providers, public health
to call the meeting.9(p. 11) Readiness barriers leaders, and others who are responsible for initi-
include lack of clarity about who is responsible ating and coordinating the emergency manage-
for preparedness and response planning, what element planning effort in small towns, suburbs, and
ments of the planning and response processes are rural areas throughout the United States. These
critical, how to coordinate with state and federal leaders bear responsibility for creating the inter-
emergency management programs, and how to connectedness that will help ensure the safety and
obtain and sustain funding. well-being of individuals in their communities.
SIDEBAR 1. COMMON EMERGENCY PREPAREDNESS This publication builds on a white paper pub-
CHALLENGES IN RURAL AREAS lished by the Joint Commission in May 2003
A limited public health infrastructure entitled Health Care at the Crossroads: Strategies for
A short supply of health providers Creating and Sustaining Community-wide Emergency
Lack of hospital bed surge capacity Preparedness Systems.9 That white paper framed the
Seasonal surge capacity and surge capacity from issues that must be addressed in developing com-
nearby urban areas munitywide preparedness and noted that public-
Mostly volunteer first responders private sector partnerships offer the best overall
Limited mental health services
prospect for research on and development of rel-
Limited access to hazardous materials units,
evant, scalable models that will meet local com-
recognition capability and decontamination train-
ing munity needs in a variety of urban, suburban, and
Lower Medicare payments to health care organi- sparsely populated settings. There is considerable
zations than to urban counterparts for equivalent urgency to move this work forward.
services
Difficult access to needed emergency services due No community is exactly like another. Structures,
to geography; residents may face greater trans- governance, resources, and capabilities vary wide-
portation difficulties reaching needed services ly. Development of a one-size-fits-all emergency
Complacency based on the belief that rural areas plan thus is neither doable nor desirable. The
are at a lower risk for terrorism than urban areas model or template offered in this planning guide
is a community-based planning process that con-
Sources: Robert M. Gougelet, M.D.; National Rural
Health Association: Whats different about rural health tains 13 components essential to the development
care? http://www.nrharural.org; U.S. Dept. of Health and and implementation of effective emergency pre-
Human Services, Office of Rural Health Policy (HHS): paredness and response. Strategies, tools, case
Rural Communities and Emergency Preparedness. Washington, studies, and how-to material provide local lead-
DC: HHS. Apr. 2002.
ers with ways to make this planning process hap-
pen. Tools or templates can guide operational
The audience planning in organizations, agencies, and commu-
This planning document seeks to help remove nities and can outline functional relationships
these barriers by providing expert guidance on across such entities and within a state or region.
the emergency management planning process By their very nature, tools and templates can help
that is applicable to small, rural, and suburban community leaders overcome resistance to
communities.The target audience is local leaders, change and political barriers by maintaining focus
including elected or appointed officials, health on shared goals rather than narrow agendas. Over
2
time, by fostering focus, perseverance, and trust, (DHS) in March and December 2004, respective-
planning templates and tools can facilitate change ly.The examples, tools, strategies, and other infor-
within the community and can help to sustain mation provided in this document cannot by
linkages with mission-critical partners in other their very nature be comprehensive, but rather are
communities. offered as representative of the many excellent
planning efforts under way in various domains.
Developmental process
Since 2000, the Joint Commission has expanded References
its traditional disaster preparedness requirements 1. U.S. Department of Homeland Security (DHS):
National Response Plan.Washington, DC: DHS, Dec.
for health care organizations into a community- 2004.
based emergency management framework. 2. U.S. Department of Health and Human Services,
Health care provider organizations are now Office of Rural Health Policy (HHS/ORHP): Rural
expected to be at the community planning table. Communities and Emergency Preparedness.Washington,
However, they cannot possibly manage alone a DC: HHS/ORHP, Apr. 2002.
3. Institute of Medicine: The Threat of Pandemic
mass casualty event of the proportions proved Influenza: Are We Ready? A Workshop Summary.
possible by 9/11; it takes a whole community to Washington, DC: National Academies Press, 2004.
do so. 4. World Health Organization: WHO Consultation on
Priority Public Health Interventions Before and During an
To develop this planning guide, the Joint Influenza Pandemic.Apr. 27, 2004. http://www.who.int/
csr/disease/avian_influenza/consultation/en/
Commission partnered with the Illinois (accessed Aug. 10, 2005).
Department of Public Health, the Maryland 5. Chen H., et al.: The evolution of H5N1 influenza
Institute of Emergency Medical Services Systems, viruses in ducks in southern China. PNAS 101(28):
and the National Center for Emergency 10452-10457.
Preparedness at Columbia University and con- 6. U.S. General Accounting Office (GAO): Bioterrorism:
Preparedness Varied Across State and Local Jurisdictions.
vened two expert roundtables in May and Washington, DC: GAO, Apr. 2002.
October 2004. These roundtables addressed the 7. National Association of City and County Health
issue of emergency management planning in Officials (NACCHO): Local Public Health Agencies
small, rural, and suburban communities; synthe- Better Equipped to Handle Bioterrorist Attacks.
sized the challenges; and framed potential solu- Washington, DC: NACCHO, Jan. 2003.
8. U.S. General Accounting Office (GAO): Hospital
tions. Preparedness: Most Urban Hospitals Have Emergency
Plans but Lack Capacities for Bioterrorism Response.
This document reflects the extensive input Washington, DC: GAO, Aug. 2003.
received from roundtable participants (page 90). 9. Joint Commission on Accreditation of Healthcare
It also incorporates selected emergency prepared- Organizations (JCAHO): Health Care at the
Crossroads: Strategies for Creating and Sustaining
ness lessons learned and recommendations Community-wide Emergency Preparedness Systems.
appearing in seminal publications. These include Oakbrook Terrace, IL: JCAHO, 2003.
the final report of the National Commission on 10. National Commission on Terrorist Attacks Upon the
Terrorist Attacks Upon the United StatesThe United States: The 9/11 Commission Report. New
9/11 Commission Reportpublished in July York:W.W. Norton, 2004.
11. U.S. Department of Homeland Security (DHS):
200410 and the National Incident Management National Incident Management System. Washington,
System11 and National Response Plan1 published by DC: DHS, Mar. 1, 2004.
the U.S. Department of Homeland Security
3
Emergency Management Leadership
Local jurisdictions of all sizes, including towns, coordinator, or administrator of the county health
cities, counties, and tribal governments, are department or health system (through the efforts
responsible for saving lives, protecting property, of emergency department physicians, local hospi-
protecting the economic base of the community, tal associations, and so forth) initiate and coordi-
and preserving the environment.1 Most emergen- nate the planning effort.This planning guide uses
cy incidents are managed locally, yet because the term local planner to refer to the individual
small communities are structured and governed who initiates the emergency management plan-
differently, incident managementthe ning process for the community, and uses the
response to a major event or emergencymay be term planning team to refer to the group of indi-
coordinated by individuals with many differing viduals that conduct emergency management
roles. Some communities have a mayor; others preparedness and response planning, as described
have a city or county manager. The chief leader in Section 2. Sidebar 3 describes three emergen-
may be elected or appointed, may have direct cy management planning roles often assumed by
control over public safety and health, or may local elected officials.
work through a council or manager. SIDEBAR 2. RESPONSIBILITIES OF THE LOCAL CHIEF
EXECUTIVE
This planning guide uses the term chief executive
Coordinates local resources to address the full
to indicate the elected or appointed leader of the spectrum of actions to prevent, prepare for,
small, rural, suburban, or tribal (when a tribal respond to, and recover from incidents involving
nation exists in the area) community who is held all hazards, including terrorism, natural disasters,
accountable for the safety and well-being of the accidents, and other contingencies.
population and community.To fulfill this role, the When necessary, uses the extraordinary powers of
chief executive typically works closely with lead- the position (depending on state and local law) to
ers of fire, law enforcement, emergency medical establish a curfew, direct evacuations, and/or, in
services (EMS), public works, public health, coordination with the local health authority, to
health care organizations, and other agencies and order a quarantine.
Provides leadership and plays a key role in com-
groups. Coordinated emergency management
municating to the public, and in helping people,
planning and decision making requires the chief
businesses, and organizations cope with the con-
executive to assume a leadership role in some cir- sequences of any type of domestic incident with-
cumstances (for example, within his or her own in the jurisdiction.
community) and yield the leadership role, assum- Negotiates and enters into mutual aid agreements
ing a team-player role, in other circumstances (for with other jurisdictions to facilitate resource shar-
example, when participating in multicommunity ing.
or regional planning efforts). Sidebar 2 outlines Requests state and, if necessary, federal assistance
the responsibilities of the local chief executive, as through the governor of the state when the juris-
defined by the U.S. Department of Homeland dictions capabilities have been exceeded or
Security (DHS). exhausted.
Tribal chief executives can elect to deal directly with
Responsibility for the development and coordi- the federal government (although a state governor
nation of emergency management planning is must request a presidential disaster declaration).
often assumed by the chief executive. However, in Source: U.S. Dept. of Homeland Security (DHS): National
some communities, a fire chief, police chief, EMS Response Plan. Washington, DC: DHS, Dec. 2004.
4
SIDEBAR 3. POSSIBLE ROLES OF LOCAL ELECTED Reference

1. U.S. Department of Homeland Security (DHS):
OFFICIALS IN LOCAL EMERGENCY PLANNING
National Response Plan. Washington, DC: DHS, Dec.
Coordinator: A local elected official serving in this 2004.
role coordinates critical local services such as law
enforcement, emergency medical services, and social
services. As the community prepares and tests its
emergency plan, the official can make a point of
clarifying and defining the roles of each local agen-
cy and each agency head to prevent gaps or overlaps
of function. During an emergency event, the local
elected official will meet regularly with agency
heads so that he or she can continuously monitor
the work of the agencies and adjust functions and
responsibilities, as necessary.
Liaison: Local elected officials will also find them-

selves in the role of liaison among various federal
and state agencies, community agencies, the business
community, and the public. To perform this role
effectively, local officials must maintain regular con-
tact with state and federal entities, such as the state
police and the regional FBI office. The liaison must
understand the roles of these state and federal agen-
cies, as well as their needs in an emergency situation,
and must communicate these roles and needs to
local agencies. Similarly, local elected officials act as a
link to local government for both the business com-
munity and the public, working to ensure that needs
and concerns are met.
Representative: Local officials act as representatives of

their communities in the wider regional emergency
planning effort. Most regions and metropolitan
areas, regardless of size, have some kind of regional
coordination effort in place, such as mutual aid
agreements or transportation plans. If no regional
entity exists, local officials can work to convene one.
Source: Adapted from National League of Cities (NLC):

Homeland Security: Practical Tools for Local Governments.
Washington, DC: NLC, Nov. 2002.
5
Essential Components of the Planning Process
The 13 essential components of an effective community-based emergency management planning process

are outlined here and provide the structure for the rest of the planning guide. These components can be
considered steps, with the caveat that the sequence of the activities may need to be varied or repeated based
on the communitys unique needs.The components are as follows:
1. Define the community.

2. Identify and establish the emergency management preparedness and response team.
3. Determine the risks and hazards the community faces.
4. Set goals for preparedness and response planning.
5. Determine current capacities and capabilities.
6. Develop the integrated plan.
7. Ensure thorough communication planning.
8. Ensure thorough mental health planning.
9. Ensure thorough planning related to vulnerable populations.
10. Identify, cultivate, and sustain funding sources.
11. Train, exercise, and drill collaboratively.
12. Critique and improve the integrated community plan.
13. Sustain collaboration, communication, and coordination.
These components are similar to those described in the Joint Commissions March 2003 white paper.
However, the strategies and examples that follow here for each component are geared specifically to small,
rural, and suburban communities, rather than the nation as a whole.
6
1. Define the Community unit for emergencies.4 As the chief executive will be
accountable for the safety and well-being of the
Recommended Planning Strategies: population during a disaster, his or her first task is
Identify key stakeholders in defining to collaborate with key stakeholder groups in the
the community. community to define the community for the pur-
Consider geopolitical and other defi- poses of emergency management planning.
nitional factors. Collaboration ensures that the scope of services
Consider impact of federal definitions. provided and the populations served by each enti-
ty are well understood early in the planning pro-
Websters, which provides a starting point, defines cess. Integrated, comprehensive planning reflects
community as follows: A social group of any size associations between the stakeholders who are pro-
whose members reside in a specific locality, share viding basic societal functions based on identified
government, and often have a common cultural
and historical heritage.1 This definition embraces SIDEBAR 4. KEY STAKEHOLDERS IN DEFINING THE
both the functional and structural realm of communi- COMMUNITY
ty as described by sociologists2: Public safety and security (fire, law enforcement,
A functional community can be defined as the emergency medical services)
associations that are required by groups of peo- Public works (roads, bridges, dams, transportation,
ple living together within a specific geographical sanitation, post office)
area. Public health (immunizations, food safety, animal
A structural community can be defined as the safety, epidemiology/disease surveillance, labora-
types of interconnectedness that individuals tory services)
choose to make with one another, such as Schools, colleges, and universities
through social organizations.3 Housing agencies
Utilities (energy, water, communications)
This planning guide focuses on functional commu- Health care providers (including, among others,
nity while recognizing the critical importance of hospitals, skilled nursing facilities, ambulatory and
structural community to the emergency prepared- rural health clinics, rehabilitation centers, mental
health facilities, and home care agencies)
ness and response process. Strategies to help achieve
Private industry (for example, chamber of com-
an accurate definition of the community follow. merce, local industries, corporations)
Service (for example, Scouts, Lions Club) and
Identify key stakeholders in defining the religious organizations (for example, churches,
community. synagogues)
The effectiveness of planning is dependent on the Federally funded local response initiatives (for
ability of communities nationwide to determine example, Metropolitan Medical Response
System, Medical Reserve Corps, and Community
the appropriate functional planning and response
Emergency Response Teams)
The effectiveness of planning is dependent on the ability of communities nationwide to deter-

mine the appropriate functional planning and response unit for emergencies.
7
roles and responsibilities. Sidebar 4 lists the stake- and assemble planning partners who can address
holders that provide key services in most com- certain types of emergencies across various bound-
munities. aries. In many states, there are multiple prepared-
ness regions for different functions. Law enforce-
Consider geopolitical and other ment regions may not be contiguous with EMS
definitional factors. regions or hospital catchment areas, which in turn,
Small, rural, and suburban communities will be able may not line up with emergency management
to define themselves as distinct geopolitical units planning regions. Political jurisdictions may no
(village, town, county, parish) under the leadership longer have much to do with population patterns.
of a mayor, manager, council, or other governing Each community must be able to assess its capacity
entity. Other definitional elements that can be con- as part of many different functional regions, notes
sidered include the following: one regions planning white paper.4
Specific aspects of the geography (for example,
mountains, valleys, flatland, rivers or other bodies Consider impact of federal definitions.
of water) The federal government has many different meth-
Residential patterns ods for defining urban and rural or metropolitan and
Highways and other infrastructure nonmetropolitan America, largely for purposes of
Employment type (farming, industry, corporate) administering federal programs.5 These definitions
Culture and language are not likely to provide local chief executives with
Climate
much help in defining the community, except in
the area of funding resources.
Geography is a significant factor in access to essen-
tial services during and following a disaster, but
For example, the Census Bureaus new classification
essential services such as health care providers, fire,
system, released with an update of the Census 2000
law enforcement, emergency medical services
data, indicates that rural includes open country and
(EMS), public health planning districts, schools,
small settlements of fewer than 2,500 persons. Small
utilities, and water supplies do not necessarily con-
towns and cities that have adjoining towns or sub-
form to the same geopolitical boundaries. For
urbs and collectively exceed 2,500 persons, regard-
example, health care providers may draw patients
less of political boundaries, are considered urban. A
from several towns across one or two counties; pub-
small town of 2,000 people with an adjacent dense-
lic health services may not be under the jurisdiction
ly settled suburb of 800 people would be designat-
of a mayor.
ed as an urban cluster with a population of 2,800.6
The Census Bureaus definition notwithstanding,
In addition, because disasters occur across geo-
such an urban community is one addressed in this
graphic and political boundaries, the chief execu-
planning guide.
tive may need to consider legal jurisdictional lines
Because disasters occur across geographic and political boundaries, the chief executive may
need to consider legal jurisdictional lines and assemble planning partners who can address
certain types of emergencies across various boundaries.
8
2. Identify and Establish the Emergency Management Preparedness

and Response Team
emergency response frequently revolves around
Recommended Planning Strategies:
Build on existing relationships.
neighbors helping neighbors.
Identify appropriate planning partners.
Consider start-up logistics.
Strategies to help ensure the best-possible emer-
gency management preparation and response team
The process of identifying who must be at the follow.
table for successful and sustained community-
based emergency management, which includes Build on existing relationships.
four phases (prevent, prepare, respond, and recov- Rather than beginning a planning process from a
er), is a critical one. A team approach brings blank page, the chief executive or local planner, as
increased creativity, knowledge, and experience appropriate and available, can build on effective
to each phase of emergency management plan- existing relationships and patterns of communica-
ning. A team-developed plan, which includes tion between community stakeholders as a founda-
multiple viewpoints and reflects shared goals, is tion for emergency management planning. Natural
more likely to be successfully implemented in the pre-existing relationships and mutual aid agree-
community. Closer professional and personal rela- mentsfor example, between the police depart-
tionships among the team members should trans- ment and the mayors office, local pediatricians and
late into better coordination and teamwork in the public health department, and EMS and the
emergencies.7 county hospitalare found in virtually every com-
munity. Many communities view their fire depart-
In small communities, the team identification pro- ment and EMS (and its link to area hospitals) as the
cess is often about bringing together neighbors backbone of emergency response. Thus, linkages
who work and live together routinely.These indi- between fire departments, EMS, hospitals, and var-
viduals assume that their communities need to be ious other community constituents may already be
self-sufficient and frequently do not expect the state well established.
or federal government to provide resources quick-
ly in the event of a large-scale disaster. However, Example: Following 9/11, a small community of
they do expect that representatives of local govern- 5,500 in Ohio formed an auxiliary force modeled on
ment and emergency response providers will be the former civil defense system for the community.The
goal was to meet community needs during the first 72
there for them immediately following a major
hours after a disaster.The force, which now includes 31
event. In addition, they often expect to be involved individuals, is working with the county in order to
in the response themselves. In small communities, dovetail with county efforts and obtain needed funding.8
A team-developed plan, which includes multiple viewpoints and reflects shared goals, is more
likely to be successfully implemented in the community.
9
Efficient and effective processes also may be in Example: In Texas, hospital leaders across the state
place to handle local emergencies (for example, brought together emergency management, law
dam overflows, chemical spills from a train derail- enforcement, and other community stakeholders to
ment). Some communities have citizens watch conduct emergency preparedness planning at the local
groups; others have formed or are forming level.9
Community Emergency Response Teams
Leaders and participants can emerge from many
(CERTs), a program sponsored by the Federal
different places, as described in the following
Emergency Management Agency (FEMA) (see
planning strategy.
page v.). These existing relationships can provide
the foundation of the emergency management
planning team. In addition, the Metropolitan Identify appropriate planning partners.
Medical Response System (MMRS) was created Sidebar 5 lists key areas from which to draw par-
in 1997 to build a system that enhances the local ticipants to the planning table. The emergency
communitys ability to respond. Although support functions as defined by the U.S.
MMRS is primarily based in urban areas, the Department of Homeland Security (DHS)
Northern New England MMRS, formed in (Sidebar 6) can provide another means to identi-
2003, has a rural base and multistate jurisdiction. fy appropriate representatives. Individuals who
live in the community may already serve in coun-
Most communities have some form of emergen- tywide or regional emergency management ini-
cy preparedness planning group, so reinventing tiatives and might be willing to play a dual role.
the wheel may not be necessary. It is important This is particularly true with health care
to review the groups constituents to ensure that providers who often have full-time health care
all key players are at the table. jobs and also volunteer with the local EMS or are
members of state national guard units. If not
Example: An emergency department physician in available in the community, representatives from
the major hospital in a small community in the nearby communities or counties can be invited to
Midwest built relationships and connections critical join the team. In addition, to expand the com-
to integrated emergency management planning. munitys capability to respond to and recover
Working first with infection control nurses in his from a disaster, partners and resources outside the
own hospital, he linked to the county health depart- community will be essential. These partners
ments communicable disease specialist and health should be brought to the table so that collabora-
director, and subsequently to the emergency services tive planning can occur and mutual aid relation-
directors.These individuals now exist as a ships can be defined.
medical/public health subcommittee within a region-
al emergency planning team established under the
authority of the council of governments. Representation from each area identified in
Sidebar 5, as available in the community or sur-
Where no relationships seem to exist, or where rounding communities, is important, but several
relationships are not functioning effectively, the warrant further explanation, as follows.
chief executive or local emergency management
planner will need to solicit interested parties to cre- Hospitals and other health care organizations are crit-
ate a working group to begin the planning process. ical to a communitys ability to prepare for and
respond to an emergency and must be at the
10
SIDEBAR 5. PARTICIPANTS AT THE PLANNING TABLE

planning table. Hospitals can work collaborative-
ly with all community health care organizations
Representatives from the following areas should be to plan for and respond to a surge in patients or a
brought together as planning partners: facility-disabling disaster that could overwhelm
Local government (mayor, village manager, or
any single health care organization. Home health
other elected official)
Fire
agencies can supplement a communitys surge
Law enforcement capacity by providing trained health care person-
EMS nel and medical equipment and supplies. Long-
Search/rescue agency term care facilities have the bed capacity, supplies,
Transportation and skilled staff to care for non-acutely ill or
Public health injured disaster victims. Ambulatory care clinics
Public schools and surgical centers can provide trained person-
Housing agency nel and equipment and can triage disaster victims
Utilities (gas, water, electric, telecommunications) so that hospitals receive only the most severely ill
Local or regional FBI office
or injured patients.
Health care (ambulatory care, rural health clinic,
hospital, long term care, rehabilitative, mental
health, home care, laboratories)
Local colleges and universities are an important ele-
Private industry (e.g., chamber of commerce, ment of the infrastructure in many communities.
local industries, corporations) They can often offer a variety of critical
Special needs populations (children, elderly, non- resources, such as facilities appropriate to emer-
English-speaking, disabled) gency needs; pharmacy, nursing, and medical stu-
CERT dents who have some health-related training; staff
Citizen Corps/Medical Reserve Corps with expertise in various areas of interest to
Colleges and universities emergency preparedness and response; and medi-
American Red Cross cal and transportation vehicles. Numerous aca-
Media and communications (print, radio,TV)
demic institutions are attracting funding, generat-
Mutual aid partners outside the community
ing valuable research, and developing innovative
Civilians
processes related to emergency preparedness.
SIDEBAR 6. EMERGENCY SUPPORT FUNCTIONS
ESF #1.Transportation Federal and civil transportation support

Transportation safety
Restoration/recovery of transportation infrastructure
Movement restrictions
Damage and impact assessment
ESF #2. Communications Coordination with telecommunications industry
Restoration/repair of telecommunications infrastructure
Protection, restoration, and sustainment of national cyber and information technology resources
ESF #3. Public Works and Infrastructure protection and emergency repair
Engineering Infrastructure restoration
Engineering services, construction management
Critical infrastructure liaison
continued
11
SIDEBAR 6. EMERGENCY SUPPORT FUNCTIONS (CONTINUED)
ESF #4. Firefighting Firefighting activities on Federal lands

Resource support to rural and urban firefighting operations
ESF #5. Emergency Coordination of incident management efforts

Management Issuance of mission assignments
Resource and human capital
Incident action planning
Financial management
ESF #6. Mass Care, Mass care

Housing, and Human Disaster housing
Services Human services
ESF #7. Resource Support Resource support (facility space, office equipment and supplies, contracting services, etc.)
ESF #8. Public Health and Public health
Medical Services Medical
Mental health services
Mortuary services
ESF #9. Urban Search and Life-saving assistance

Rescue Urban search and rescue
ESF #10. Oil and Materials Response

Hazardous Materials Oil and hazardous materials (chemical, biological, radiological, etc.) response
Environmental safety and short- and long-term cleanup
ESF #11. Agriculture and Nutrition assistance

Natural Resources Animal and plant disease/pest response
Food safety and security
Natural and cultural resources and historic properties protection and restoration
ESF #12. Energy Energy infrastructure assessment, repair, and restoration

Energy industry utilities coordination
Energy forecast
ESF #13. Public Safety and Facility and resource security

Security Security planning and technical and resource assistance
Public safety/security support
Support to access, traffic, and crowd control
ESF #14. Long-Term Social and economic community impact assessment

Community Recovery and Long-term community recovery assistance to states, local governments, and the private sector
Mitigation Mitigation analysis and program implementation
ESF #15. External Affairs Emergency public information and protective action guidance
Media and community relations
Congressional and international affairs
Tribal and insular affairs
Source: U.S. Dept. of Homeland Security (DHS): National Response Plan.Washington, DC: DHS, Dec. 2004, p. 12.
12
Regional academic medical centers can identify sector, and other community stakeholders to help
best practices in the current medical literature make communities safer, stronger, and better pre-
and be valuable planning and response partners pared to address the threat of disasters of all
(for example, by providing resources such as diag- kinds.10 It works through a national network of
nostics capabilities, personnel, equipment, and state, local, and tribal Citizen Corps councils.
supplies).
The American Red Cross plays an integral role in
Local private industry represents key elements of a the federal emergency response plan and has
communitys infrastructure and resources, and available nursing and mental health resources,
disruption of their business operations may have and, as such, a local or regional representative
major community or regional impact. For exam- should be at the table for local planning as well.
ple, utility and telecommunications companies This humanitarian organization, led by volun-
have a vested interest in interoperability and teers and guided by a Congressional charter, pro-
emergency preparedness and therefore can be vides relief to victims of disasters and helps peo-
particularly helpful at the planning table. ple prevent, prepare for, and respond to emergen-
cies. It functions independently of the govern-
The federal government is encouraging the private ment but works closely with government agen-
sector to create emergency response plans and cies, such as FEMA, during times of major crises.
information-sharing processes and protocols that The American National Red Cross (as distinct
are tailored to their needs but that also map to from the International Red Cross) is one of a
regional, state, and local emergency preparedness very few national disaster relief agencies specifi-
plans and information-sharing networks.10 cally cited in the Robert T. Stafford Disaster
Participation at the community-based planning Relief and Emergency Assistance Act of 2000.
table is one way to ensure congruence between
community-based and industry-based plans and to Civilian representation at the planning table is
help obtain needed resources when disasters occur. critical. One of the key lessons learned from the
World Trade Center attacks of 9/11 was that the
Example: Caterpillar, one of the largest industries in first first responders during an emergency typ-
the Peoria, Illinois, area, was invited to the region- ically are private-sector civilians. Because 85
wide planning table. Caterpillar participated exten- percent of our nations critical infrastructure is
sively in plan development and offered specific controlled not by government but by the private
response help in the form of heavy construction sector, private-sector civilians are likely to be the
equipment that might be needed in the event of a
first responders in any future catastrophes, noted
disaster. In a collaborative spirit, the areas public
works office indicated that its staff members would the National Commission.11(p. 317) Civilians that
assume responsibility for driving the equipment. could address special needs populations should
also be considered; recommendations from state
Where they are active, Citizen Corps representa- task forces could assist in identifying knowledge-
tives should be at the local planning table. The able planning partners. For example, Missouri has
U.S. Citizen Corps brings together leaders from a state Special Needs Population Task Force that
law enforcement, fire, emergency medical and has brought together more than 17 organizations,
other emergency management services, volunteer agencies, and consumers to address this area.
organizations, local elected officials, the private
13
In considering media and communications, it is Throughout the start-up and ongoing process,
vital to identify someone in the community who the chief executive or local planner will want to
is well recognized, respected, and trusted to serve be conscious of the need to build a common lan-
in the role of communicating with the public guage among planning participants. Different
before, during, and following a major event. The types of professionals speak different languages,
chief executive or local planner might also wish which may require explanation. For example, the
to consider an individual who could engage the term surveillance, commonly used by public health
public and professionals as volunteers; this person officials and health care professionals, may not be
may be involved with the Citizen Corps/Medical known or may come across negatively in the
Reserve Corps, a CERT, the American Red business community, or it may mean something
Cross, or other organizations. entirely different to law enforcement agents.12
Professional terminology can be defined or
Consider start-up logistics. explained during meetings and in key docu-
Start-up logistics can be complex and include ments.
such mundane but essential tasks as who should
send the invitational letters for the first meeting,
where and when meetings are to be held, and so
forth. When the chief elected official or another
community leader calls the meeting, it may be
helpful to have someone such as the state com-
missioner of public health generate the invitation
letters.
Initial decisions will need to be made regarding the

leadership structure of the team and how commu-
nication will take place. The local planner who
calls the first meeting is not necessarily the lead-
er who coordinates the ongoing emergency man-
agement processes after they have been established.
In many communities, this leader is the mayor or
another chief elected official, hospital administrator,
city manager, public health director, emergency
management director, fire chief, or police chief.
Means to ensure effective collaboration across
political and organizational barriers will need to be
negotiated and implemented.
The local planner who calls the first meeting is not necessarily the leader who coordinates
the ongoing emergency management processes after they have been established.
14
3. Determine the Risks and Hazards the Community Faces

Recommended Planning Strategies: the community to construct, implement, and ana-
Use an all-hazards approach. lyze. The process of performing an HVA requires
Acknowledge the potential for a commitment to accuracy and thoroughness and
catastrophic event. continuing expertise and motivation.
Compile a list of potential hazards.
Recognize the problems inherent in Communities can perform an HVA in many
hazard lists. ways; there is no right or wrong way. Any
Assess and prioritize the listed hazards. methodology or approach that works effectively
Fine-tune the list by conducting a should be used and referenced in the emergency
gap analysis. management plan. Some systems use a quantita-
tive scoring method to rank the potential emer-
When the team is in place, the emergency man-
gencies, but this is not essential. The key is that
agement planning teams first task is to conduct a
each communitys emergency management plan-
hazard vulnerability analysis (HVA). An HVA
ning team identifies the events for which prepa-
identifies potential threats, risks, and emergencies
ration is necessary and that the evaluation is con-
and the potential impact these emergencies may
ducted through a collaborative approach.
have on the community. It is a formal assessment
of the risks that could potentially affect the com-
Whether the full extent of emergency prepared-
munity or an agency within the community and
ness is possible given the communitys resources
move it to implement its emergency manage-
is, of course, a critical issue. The Secretary of the
ment plan. Specific strategies for determining the
U.S. Department of Homeland Security, Michael
risks and hazards faced by the community follow.
Chertoff, recently announced that even the U.S.
government, with all its resources, cannot protect
Use an all-hazards approach. the American public from all possible terrorist
An all-hazards approach enables communities to attacks and instead must focus on trying to pre-
be prepared to manage any number or type of vent more serious or catastrophic strikes. In com-
emergencies. It facilitates prevention, preparation, ments made in March 2005, Chertoff advocated
response, and recovery, based on the broad scope adopting a risk-based approach: Risk manage-
of what could happen within and beyond the ment must guide our decision-making as we
community. Conducting a risk assessment examine how we can best organize to prevent,
involves proactively identifying what might affect respond, and recover from an attack. For that rea-
the community and its surrounding area. son, the Department of Homeland Security is
working with state, local, and private sector part-
In addition to other documents such as written ners on a National Preparedness Plan to target
analyses of capabilities and capacities, an HVA can resources where the risk is greatest.13 For more
help to overcome communitywide or stakeholder- information on focusing and funding communi-
specific resistance to emergency preparedness. It ty emergency preparedness efforts, see Sections 4
offers an objective information source and requires and 10.
a cross section of expertise and perspective from
15
Acknowledge the potential for a other natural disasters. Mass casualty events, such
catastrophic event. as transportation accidents, that may be more
If this acknowledgment has not occurred previ- commonly experienced should be listed. The
ously and has not served as the motivator for 9/11 attack has forced Americans to think out-
emergency management planning, the acknowl- side the box about the realm of possible man-
edgment must occur at this point.Team members made incidents. Aircraft used as guided missiles,
must dispel all notions that a catastrophic event nuclear, chemical, and biological weapons, and
is not going to happen to us. other acts of terrorism have become a reality and
have forced emergency management teams to
A study recently conducted by the Joint think broadly. Insidious events, such as those that
Commission indicates that significant progress in could occur from an emerging infectious disease
this area needs to be made.When asked whether outbreak, either intentional or unintentional,
their communities were at increased risk of expe- have also expanded the realm of possible emer-
riencing catastrophic events, such as an act of ter- gencies.
rorism, respondents from urban and rural hospi-
tals had differing perceptions: Respondents from Teams must exercise imagination and challenge
urban hospitals reported slightly more hazards or their assumptions about likely threats.The extent to
threats on average per hospital than respondents which the community may be at risk for terrorist-
from rural hospitals, who were most concerned induced events should be assessed by the team as
about events such as hazardous materials acci- seriously as the risk of natural disaster, industrial
dents, tornadoes, winter storms, and floods.14 accident, or pandemic disease outbreak. The team
should consider the risk to their community as a
primary target of terrorism due to sensitive instal-
Compile a list of potential hazards.
lations (industrial plants, military bases, federal
The list of hazards can be generated during
office buildings) or as a secondary target of terror-
something similar to a brainstorming session,
ism due to larger neighboring towns needing a des-
where every idea is written down without cen-
tination to which they can evacuate residents or
sorship or editorial comment. A review of com-
from which they can borrow assets.
munity historical data may provide additional
items for the list.
Sidebar 7 lists examples of community-based
emergencies.Teams will also want to consider the
When assembling this list, the team should be
threats recently identified by the U.S. Department
careful not to limit it only to incidents that the
of Homeland Security (Sidebar 8).
community has traditionally thought of as disas-
tershurricanes, earthquakes, tornadoes, and
Teams must exercise imagination and challenge their assumptions about likely threats.
16
SIDEBAR 7. EXAMPLES OF COMMUNITY-BASED

list may give the impression that hazards are inde-
EMERGENCIES pendent of one another, when in fact they are
often related (for example, an earthquake might
Extremes of weather/climate/geography
give rise to dam failure). In addition, lists may
earthquake
hurricane
group under one category very different causes or
flood sequences of events that require different types of
tornado response. For example,flood might include dam
blizzard failure, cloudbursts, or heavy rain upstream. Lists
drought also may group a whole range of consequences
volcanic eruption under the category of a single hazard.
mudslide or avalanche Hurricane might include not only high winds,
Dam failure storm surge, and battering waves, but even the
Regional power outage weakened, post-landfall tropical storm system that
Civil disturbance
can cause inland flooding.
Terrorism and weapons of mass destruction
bombs (conventional or nuclear)
biological/chemical agents
It may be necessary, as the hazard analysis evolves,
cyberterrorism to refine the list of hazards to ensure inclusion of
Public health emergencies (such as an outbreak of newly identified hazards (for example, a new
SARS or pandemic influenza) chemical plant in the region) and elimination of
Wildland or community-based fires previously listed hazards that no longer pose a
Commercial transportation accidents hazard (for example, rerouting trucks carrying
train derailments toxic substances).
air crashes
multiple highway casualties
Hazardous materials release
Assess and prioritize the listed hazards.
radiation
The hazards and potential emergencies identified
toxic chemicals in the HVA must be assessed and prioritized so
Sudden influx of residents with health care and that appropriate prevention, preparation,
other basic needs (food, water, shelter, clothing) response, and recovery activities can be undertak-
from neighboring communities en. One place to start this process is with the like-
lihood or probability of occurrence.Very likely, data on
Recognize the problems inherent in the frequency of given incidents already exist.
Disasters that have occurred before in the com-
hazard lists.*
munity or its surrounding area will move toward
Hazard lists pose two problems.The first problem
the top of the list of issues to be addressed, while
is the possibility of exclusion or omission:There is
those with essentially no possibility of occurrence
always a potential for new and unexpected hazards,
will migrate to the bottom. A pandemic flu out-
which is part of why maintaining an all-hazards
break and other occurrences identified as priori-
capability is important.
ty disaster planning events (Sidebar 8) should
appear near the top of the list.
The second problem is that such lists involve
groupings, which can affect subsequent analysis.A
* The section was excerpted from Federal Emergency Management Agency: State and Local Guide (SLG) 101: Guide for All-Hazard
Emergency Operations Planning. 1996, pp. 25. http://www.fema.gov/pdf/rrr/2-ch.pdf (accessed Feb. 2005).
17
For example, a major earthquake or chlorine tank as disruption of services or damage to infrastruc-
explosion would be high on the list of potential ture. The team then adjusts the ranking of the
emergencies for small communities in southern potential hazards according to the answers.
California, but snowstorms and nuclear detona-
tions would be low on the list. Power failure and The final factor that merits consideration is the
flood might be somewhere in between. An communitys level of preparedness.This represents the
explosion in a chemical factory, groundwater vulnerability portion of the HVA. If one of the
contamination from agricultural runoff, or a gas high-ranking incidents on the list took place
main break near the local high school are other tomorrow, how well would the community man-
examples of occurrences that may need to be age the incident? Would other neighboring com-
assessed, depending upon the community. Risk munities be able to provide assistance? Do mutu-
may change if there are major construction pro- al aid agreements exist? For each hazard, the team
jects under way or seasonal events, such as local develops an assessment of the communitys cur-
fairs or the ski season. Location may influence rent susceptibility to the hazard.15 If the commu-
risk, such as whether a communitys industrial nity is not prepared for the incident, that poten-
plant is on a floodplain or near a fault line. Maps tial hazard will need more attention than the ones
will be needed to assess location-related risk. Risk covered by well-established plans and agreements.
assessment matrices can be found on state and
regional agency Web sites (see Tools).
TOOLS:
Tools are available to help local officials identify Map sources include Federal Emergency
and compare potential hazards. For example, the Management Agency (http://www.fema.gov),
Center for Infrastructure Expertise, which is part U.S. Geological Survey (http://www.usgs.gov),
state geological surveys, National Weather
of the National Infrastructure Institute and oper-
Service (http://www.nws.noaa.gov), Federal
ates under a grant from the U.S. Department of
Insurance Administration (http://www.fema.gov/
Commerces National Institute of Standards and
about/fedins.shtm), the Local Emergency
Technology, has developed a software tool, Planning Committee Database
CARVER2. Offered free of charge, the tool (http://www.epa.gov/ceppo/lepclist.htm), and
enables local, state, and national planners to iden- the Multi-Hazard Mapping Initiative
tify and compare potential critical infrastructure (http://www.hazardmaps.gov/atlas.php).
terrorist targets and assists government officials in The Center for Infrastructure Expertises
the allocation of grants and protective resources CARVER2 software is available at
(see Tools). http://www.ni2cie.org.
Pennsylvania Emergency Management Agency
Severity is the next factor in the analysis to be offers an online introduction to hazard mitiga-
considered by the team. If the event occurs, the tion planning that includes hazard risk matrices.
team should consider how it will impact the http://www.pema.state.pa.us/pema/CWP/vie
community. Could lives be lost or the health and w.asp?a=198&Q=179259&pemaNavDLTEST
safety of individuals be threatened? If the answer =%7C4715%7C4749%7C4752%7C4028%7C
is yes, the hazard moves up on the list. If the (accessed Jun. 21, 2005).
answer is no, the team can consider other ways
in which the community may be impacted, such
18
Fine-tune the list by conducting a The hazard vulnerability analysis will help drive
gap analysis. consensus within the planning team about the
A gap analysis of the vulnerabilities helps to iden- risk of specific hazards to the community.
tify incidents for which the community is not However, the community itself will have its own
prepared. The analysis identifies the key compo- priorities related to perceptions of risk that the
nents of each vulnerability, determines compo- planning group will have to understand in order
nents that are common across multiple hazards, to develop preparedness goals and plans, to com-
identifies issues that create high-impact weak- municate effectively with the public, and, ulti-
nesses, and compares the relative costs and bene- mately, to sustain the publics cooperation with
fits of the steps needed to rectify the situation.15 If planning and response activities. These topics are
community resources could not be called on for addressed in Section 7.
assistance in addressing the incident, the team
should move the incident up on the list. This TOOLS:
analysis may result in some less-probable events Federal Emergency Management Agency:
being moved up on the list due to the fact that State and Local Guide (SLG) 101: Guide for
the most anticipated events are usually those for All-Hazard Emergency Operations Planning.
which the community is most prepared. http://www.fema.gov/preparedness/
state_local_prepare_guide.shtm.
The completed list of potential hazards will now
have those events that merit the most attention
near the top, whether because of probability of
occurrence, impact on the community, or level of
preparedness. Hazards that are less serious and not
as likely to happen should be near the bottom.All
of this ranking is dependent on judgment and
evaluation of the various considerations discussed
previously. There should be some rationale for
general placement on the list, although it may be
difficult to distinguish the placement of two
events that are sequenced consecutively. Because
of varying factors and judgment, two similar
communities in the same region may have differ-
ing analyses.
The hazard vulnerability analysis will help drive consensus within the planning team about the
risk of specific hazards to the community.
19
4. Set Goals for Preparedness and Response Planning

Recommended Planning Strategies: hazard risk conducted through the hazard vulnera-
Ensure that planning covers basic bility analysis (HVA) process. Risk can never be
societal functions. totally ameliorated through the planning process;
Make the planning process as doable some level of ongoing risk will always be present.
as possible.
Address the four phases of emergency The emergency management planning team will
management. develop specific goals and objectives based on its
Address human resources require- HVA. However, for any emergency management
ments. plan, the general goals are as follows:
Plan for convergent responders. 1. Save lives and protect health.
Involve the public in community pre- 2. Protect and sustain the critical infrastructure,
paredness efforts. property, and the environment needed to save
Enable people to care for themselves. lives and protect health.
Plan for layered preparedness and 3. Find dual uses for existing or emerging capa-
response. bilities.
Ensure compatibility with unified
command functions and the incident Goals 1 and 2 are inherent to emergency man-
command system. agement planning; goal 3 is a strategic goal that
Link the communitys plan to the will help communities broaden the usage of
NIMS and the NRP. existing or emerging capabilities and investments.
Consider linking to the Joint Field
Office. According to the U.S. Department of Homeland
Link to county and state plans and Securitys (DHSs) National Response Plan, local
planning initiatives. communities develop local emergency prepared-
Establish mutual aid agreements. ness plans to provide a framework for under-
standing vulnerability to and risk from hazards,
Given scarce resources, small, rural, and suburban and identify the pre-disaster and post-disaster
communities must set goals for emergency plan- mitigation measures to reduce the risk from those
ning and response efforts.The basic questions plan- hazards.10(p. 62) Much effort is under way in
ning teams consider are What do we need to pre- numerous government agencies to identify pre-
pare for? Are we prepared? and At what cost? paredness goals and thresholds in an empirical
Tilting at all the windmillstrying to do every- manner. Because smaller communities have more
thingrepresents an impossibility for most small limited resources, planners in these communities
communities. The cost is just too great. will need to derive their planning goals primari-
Preparedness represents the right place on the con- ly from their HVAs and rely on objective thresh-
tinuum between blind complacency (and bureau- olds as a secondary reference tool rather than a
cratic inertia) and overwhelming paranoia, notes primary planning tool.
Irwin Redlener, M.D., associate dean and director
of the National Center for Disaster Preparedness. Specific strategies that can help communities meet
Preparedness must be based on a real assessment of the three goals mentioned in this section follow.
20
Ensure that planning covers basic municipal leagues provide in-depth guidance
societal functions. through their publications and Web sites.
Prioritizing the hazards as described in the previous
sections will support a planning effort that is more TOOLS:
relevant, cost-effective, and engaging for the plan- Federal Emergency Management Agency:
ning team and the community as a whole. It will http://www.fema.gov/preparedness/
support planning around very real crises (for exam- state_local_prepare_guide.shtm.
The National League of Cities, which repre-
ple, pandemic flu may receive a higher planning
sents 49 state municipal leagues, and through
priority than smallpox) and their potential impacts
them more than 18,000 cities and towns
on the basic societal functions. Preparedness and
nationwide, offers links and tools through its
response planning starts with the assumption that
Web site. http://www.nlc.org/
basic societal functions are critical and must be
state_municipal_leagues.
assured during and following an emergency.
Societal functions include the following:
Public health Planning teams will want to review the federal
Medical care governments Universal Task List (UTL), which
Public works defines what tasks need to be performed by fed-
Energy supply eral, state, local, and tribal jurisdictions and the
Environment private sector to prevent, protect against, respond
Economy to, and recover from events defined in the
Water/sanitation National Planning Scenarios.16 Version 2.1 identi-
Shelter/clothing fies approximately 1,600 unique tasks. According
Food to that document,The purpose of the UTL is to
Communication
list what tasks need to be performed, while
Security
Logistics/transport reserving the flexibility to determine who
Search/rescue should perform them and how. No single juris-
diction or agency is expected to perform every
For example, loss of power, whether due to tech- task. Rather, individual jurisdictions will need to
nology failure (as with the blackouts on the East assess and select the tasks based on their own spe-
Coast, fires on the West Coast), or hurricanes on cific roles, missions, and functions.
the eastern seaboard, has a ripple effect on access
to communication systems, water, fuel, and other TOOLS:
basic utilities that support societal functions. U.S. Dept. of Homeland Security: Universal
Task List: Version 2.1. May 23, 2005.
http://www.ojp.usdoj.gov/odp/docs/
Make the planning process as doable UTL2_1.pdf.
as possible.
To get a jump start on emergency preparedness
In addition, the DHS released a list of 15 hypo-
and response planning, teams in small communi-
thetical terrorist attacks, disease outbreaks, and
ties can consult available planning resources. The
natural disasters that is being used to set DHS
Federal Emergency Management Agency
spending priorities and to focus emergency plan-
(FEMA), the National League of Cities, and state
ning efforts (Sidebar 8).
21
SIDEBAR 8. NATIONAL PLANNING SCENARIOS

Prevention involves, according to the National
Response Plan, actions taken to avoid an incident
The U.S. Department of Homeland Security (DHS) or to intervene to stop an incident from occur-
released this list of 15 hypothetical terrorist attacks,
ring. Prevention involves actions taken to protect
disease outbreaks, and natural disasters that is being
lives and property. Prevention actions related to
used to set DHS spending priorities and to focus
emergency planning efforts. terrorism threats and incidents include law
enforcement activities and protective activities.
1. Nuclear detonation Initial prevention efforts include, but are not lim-
2. Pandemic flu disease outbreak ited to, actions to do the following:
3. Aerosolized anthrax biological attack Collect, analyze, and apply intelligence and
4. Pneumonic plague biological attack other information
5. Food contamination biological attack Conduct investigations to determine the full
6. Foot and mouth disease biological attack nature and source of the threat
7. Blister agent chemical attack Implement countermeasures such as surveil-
8. Toxic industrial chemicals attack lance and counterintelligence
9. Nerve agent chemical attack Conduct security operations, including vulner-
10. Chlorine tank explosion chemical attack ability assessments, site security, and infrastruc-
11. Major earthquake ture protection
12. Major hurricane Conduct tactical operations to prevent, inter-
13. Dirty bomb radiological attack dict, preempt, or disrupt illegal activity
14. Improvised bomb explosives attack Conduct attribution investigations, including
15. Cyber attack an assessment of the potential for future relat-
ed incidents
Source: U.S. Dept. of Homeland Security. http:// Conduct activities to prevent terrorists, terror-
www.dhs.gov/dhspublic. ist weapons, and associated materials from
entering or moving within the United States
Address the four phases of emergency The majority of initial actions in the threat or
management. hazard area are taken by first responders and local
Planning should address each of the four phases government authorities and include efforts to
of emergency management, which are prevention, protect the public and minimize damage to prop-
preparation, response, and recovery. The labels and erty and the environment.10(p. 53)
sequence used for these four phases vary slightly
in government and agency documents. At times, The closely related concept of mitigation involves
mitigation, preparedness, and protection appear activities that attempt to lessen the severity and
instead of, or in addition to, one of the previous- impact a potential disaster or emergency may
ly mentioned terms.* This planning guide uses have on a community. Mitigation activities may
the phrases appearing with greatest frequency in reduce, or even eliminate, the possibility of disas-
the National Response Plan. ter occurrence. Often they are required by other
*The Joint Commission uses mitigation, preparedness, response, and recovery. Other presentations will put mitigation or prevention at the end of
the process, recognizing that what is learned in response and recovery should inform future mitigation activities.The National Response
Plan uses six termsprevention, preparation, response, recovery, mitigation, and protectionbut predominantly refers to prevention, preparation,
response, recovery.
22
codes and standards. For example, compliance damage; urban search and rescue; the establishment
with the National Fire Protection Associations of facilities for mass care; the provision of public
Life Safety Code will mitigate the impact of a fire health and medical services, food, ice, water, and
in a facility.* other emergency essentials; debris clearance; the
emergency restoration of critical infrastructure;
control, containment, and removal of environmen-
Preparation (or preparedness) is defined as those
tal contamination; and protection of responder
activities a community undertakes to build capac- health and safety. During the response to a terrorist
ity and identify resources that may be used should event, law enforcement actions to collect and pre-
a disaster or emergency occur. Preparedness serve evidence and to apprehend perpetrators are
involves planning how to respond if a disaster critical.These actions take place simultaneously
occurs. This activity has been the foundation of with response operations necessary to save lives
emergency planning for many years. Some and protect property, and are closely coordinated
important preparation steps include the following with the law enforcement effort to facilitate the
and are outlined in this planning guide: collection of evidence without impacting ongoing
Creating an inventory of resources that may be life-saving operations.10(pp. 53-54)
needed in an emergency, including prear-
ranged agreements with neighboring commu- The recovery phase involves the restoration of the
nities and bordering states communitys functions and activities following a
Maintaining an ongoing planning process disaster. Recovery involves how the community
Training community members in basic will get back to business as usual when the inci-
response actions dent is over, including how the public will be
Implementing communitywide and regional reassured that it is safe to return to normal activ-
exercises and drills ities, such as work and school. Recovery aspects
of an emergency management plan depend, of
Response refers to the actual emergency manage- course, on the nature of the incident, whether the
ment. Response involves identifying and treating emergency is ongoing, and whether the local area
victims, reducing secondary impact to the com- or region is still affected.The recovery section of
munity (for example, the spread of disease in the emergency management plans generally specifies
community), and controlling the negative effects recovery steps or stages. The National Response
of emergency situations. The National Response Plan defines recovery as follows:
Plans definition of response follows: Recovery is the development, coordination, and exe-
Response is those activities that address the short- cution of service- and site-restoration plans and the
term, direct effects of an incident.These activities reconstitution of government operations and ser-
include immediate actions to preserve life, proper- vices through individual, private-sector, nongovern-
ty, and the environment; meet basic human needs; mental, and public assistance programs. Recovery
and maintain the social, economic, and political involves actions needed to help individuals and
structure of the affected community. Response communities return to normal when feasible.10(p. 54)
actions also include immediate law enforcement,
fire, ambulance, and emergency medical service
actions; emergency flood fighting; evacuations; Address human resources requirements.
transportation system detours; emergency public When an emergency occurs, small, rural, and sub-
information; actions taken to minimize additional urban communities often face significant human
* Life Safety Code is a registered trademark of the National Fire Protection Association, Quincy, MA.
23
resources challenges because their populations are Facility safety

smaller than those of cities.The availability of first Sheltering for patients and their families
responders and medical personnel often presents a Sheltering for employees and their families
particularly significant problem. For example, the Preparing and securing work areas (personal
already limited number of community members computers, telephones, miscellaneous desktop
items)
who are volunteers in the National Guard or
Payroll and compensation arrangements during
Community Emergency Response Team (CERT) and after the storm
may not be available because they may already be Leave of absence policies
activated and overseas or helping in a different Securing pets and livestock
locale. Double-counting of available resources often
occurs. Whenever possible, lists of possible first Plan for convergent responders.
responders and medical personnel in the commu- In any disaster, the initial search and rescue is usu-
nity should be de-duplicated. ally done by laypeople in the immediate area.The
phenomenon known as convergencepeople
Example:The emergency planning team of a small gathering quickly at a disaster siteis well docu-
suburban community approximately 30 miles out-
mented.18 It is part of human nature to want to
side Cleveland recognized that the community was
totally dependent on its volunteer firefighters and help. Contrary to popular belief, people do not
volunteer paramedics as first responders. Most of panic in the first phases of a disaster; most behave
these individuals had full-time jobs in other commu- in a rational manner and take what seem to them
nities, so any sense of comfort that the individuals logical steps to save themselves and others at a
would be available to the community as first respon- disaster site.19
ders during an areawide disaster was a false sense of
comfort.The teams preparation and response efforts As a result, the actual first responders are likely to
focused on how to prepare the community to respond be not professionals or specially trained personnel
without the full benefit of its all-volunteer first but local school teachers, parents, business execu-
responder force.This involved consideration of appro- tives, teenagers, or other convergent volunteers
priate training programs for community residents.17
who are there at the time of the disaster. The
people who spontaneously come forward to vol-
For agencies and other employers in hurricane-
unteer following a major disaster genuinely want
prone areas and surrounding communities, a
to help disaster victims. But from the perspective
range of staffing-related issues requires considera-
of first responders and relief agencies, their gen-
tion before, during, and after a major storm. For
erosity looks quite different. From their perspec-
example, as part of its annual hurricane prepared-
tive, convergent volunteers can be liabilities, not
ness activities, Health First Health System in
assets. They physically get in the way of people
Melbourne, Florida, maintains and updates
doing vital work, they divert resources away from
extensive human resources policies, procedures,
serving victims to processing the volunteers, and
and communication plans. These policies address
they raise serious questions of liability, both if the
the following:
volunteer is injured and if the volunteer does
Storm staffing and communications
Requirements and exemptions for reporting to injury, notes one report from California.20
work
Childcare enrollment forms for storm volunteers Some observers indicated that convergent
Sleeping arrangements response following the Loma Prieta earthquake
24
in 1989 was the disaster within the disaster in Developing a system to do background checks
some communities. To minimize risks associated and credential checks on volunteers (see infor-
with convergent responders, communities should mation on the federal governments credential-
take steps to prepare its citizenry to participate ing initiative, Emergency System for Advanced
effectively in emergency response efforts. Medical Registration of Volunteer Health Care Personnal
(ESAR-VHP), on page 49)
volunteers also are very likely to arrive at disaster
Developing a system to identify registered pro-
scenes ready to help. Community response fessionals at disaster scenes
plans must address such an influx so that valuable Developing a tracking system to account for
attention and resources are not diverted unneces- volunteers at disaster scenes
sarily from response coordination to managing Addressing legal/liability related to cre-
excess unplanned volunteers. dentialing and other issues
Example: In the Oklahoma City terrorist bombing Some communities are also considering establish-
of the federal building in 1995, the many laypeople ing a personnel processing point or location for
that converged on the scene following the blast per- registering and tracking medical volunteers who
formed a great service to the victims they helped. report to a disaster scene. Robert M. Gougelet,
However, they were also a concern to the trained res- M.D., assistant professor of medicine and medical
cuers. Convergence can be used to advantage if it is
director, disaster response, at the Dartmouth
organized. In Oklahoma City, hospital emergency
rooms and clinics that were overrun by volunteers Hitchcock Medical Center, recommends that med-
sent medical teams to the bombing site.21 This ical volunteers be divided into two distinct groups:
increased risk to the trained fire department rescue Individuals who are members of an established
teams who become responsible not only for the vic- response team, such as a Disaster Medical
tims but also for extra medical personnel. In more Assistance Team (DMAT), Medical Reserve
than one case during this disaster, fire department Corps (MRC), or Metropolitan Medical
personnel removed their own protective gear and Response System (MMRS) strike team, or
placed it over volunteer medical personnel who found who are registered before an event occurs
themselves in dangerous situations. Individuals who arrive spontaneously at the
scene
Strategies for managing volunteers include the
The on-scene incident command should have a
following:
Developing volunteer professional registries process to verify the identification and the cre-
Developing a system to register other volun- dentials of responders.This process should include
teers and provide baseline and just-in-time checking a government-issued identification card
training and a professional identification card such as a
Training volunteers based on emergency pre- hospital identification card. In addition, this pro-
paredness and response competencies (see cess should include independent third-party veri-
Section 11)
The on-scene incident command should have a process to verify the identification and the
credentials of responders.
25
fication, such as confirming with the states medi- institutionalized populations; the homeless; and
cal professional database, says Gougelet.22 those individuals who are significantly geographi-
cally isolated.
Sponsored by the Office of the Surgeon General,
the MRC program, a component of the Citizen The Redefining Readiness Study conducted by
Corps, provides an organized way for medical and the Center for the Advancement of Collaborative
public health volunteers, such as practicing, Strategies in Health indicated that the American
retired, or student physicians, nurses, other health public has had little or no role in developing ter-
professionals, and citizens interested in health rorism preparedness plans and that half of the
issues, to offer their skills and expertise during American people (55%) say their community is not
local large-scale emergency situations.23 The at all or only a little prepared to deal with the kinds
MRC provides surge capacity personnel by pre- of terrorist attacks addressed in the study (a dirty
identifying, training, and credentialing supple- bomb and a smallpox outbreak).24 An important
mental personnel to assist with emergency oper- finding of our study is the documentation that a
ations, such as mass antibiotic dispensing or mass large proportion of the American people are inter-
immunization campaigns. ested in community-level planningnot just in
learning more about plans, but in being actively
Example: In Connecticut hospitals, each specific disci- involved in developing plans, note the studys
pline, such as nursing, diagnostic imaging, respiratory authors.24(p. 44) Similarly, a study by Columbia
therapy, and physicians, has a representative that helps Universitys National Center for Disaster
to recruit and organize fellow practitioners to serve in Preparedness indicated that only 35% of Americans
the MRC.The momentum has been considerable and think their community has an adequate emergency
the state has been selected by the Health Resources
response plan currently in place.25
and Services Administration as one of the 10
advanced credentialing demonstration projects.
Such studies indicate that communities must be
better prepared to handle the more frightening
Involve the public in community
aspects of disasters, about which they often are in
preparedness efforts. the dark. For example, the process could address
Teams should consider plans to educate the public how to handle unknown hazardous agents, how to
about the existence of community preparedness manage an unanticipated influx of victims at the
plans and should communicate with the public local hospitals emergency department, and how to
about how to prepare for and respond to an emer- decontaminate or isolate contaminated victims.
gency situation.This involves targeting the family- Public education and information dissemination
unit level (including individuals living alone) for about isolation and quarantine for infectious dis-
educational initiatives related to emergency equip- eases are critically important inclusions in planning
ment, training, and preparedness.This also involves efforts. The public must know that they may be
identifying and planning to meet the needs of par- isolated at the hospital or quarantined at home, and
ticularly vulnerable populations, including chil- significant preparations will need to be made in
dren; the elderly; non-English-speaking people; advance. Laws may need to be enacted on state or
individuals with mental health issues, chemical local levels, and law enforcement and court system
dependencies, or developmental disabilities; those personnel must be educated about their roles dur-
who are speech, hearing or mobility impaired; ing an event requiring isolation or quarantine.
26
Basic needs for those living under quarantine must Evacuation signs appear throughout the state and
be addressed, such as health services provided at are well-recognized in all communities.
home or the ability of children in the household
to attend school. Public concern about emergencies has not neces-
sarily translated into appropriate protective
Planners should work directly with community actions in personal preparedness.There is strong
residents throughout the planning process. baseline data that support efforts to increase the
Some segments of the community may be pre- publics awareness of the need and necessary steps
pared, but U.S. communities as a whole are not to prepare themselves for a disaster. Only 20 per-
prepared and not involved in preparedness cent report being prepared for a terrorist-related
planning. Citizens can also be part of actual
disaster, and only 13 percent report having a
events or drills that test emergency plans (see
Section 11). neighborhood plan for disasters, notes a DHS
Office of Citizen Corps report.26 Less than half of
survey respondents have both an emergency plan
Enable people to care for themselves.
and at least one emergency supply kit.
The community must be informed and prepared.
The emergency plan needs to include a well-
Example: Consider what might be involved in edu-
defined risk communication plan that contains cating the public to respond to an influenza pan-
information on the guidance that will be provid- demic. In most cases, influenza can be treated at
ed to the public and how that guidance will home.The message to the public can be Stay at
occur. For example, the plan could indicate that home, take care of yourself following basic self-care
in the event of widespread exposure to a certain protocols distributed by the health department; seek
chemical agent, the public will be educated hospital care if you experience any of the severe
through distribution of fliers, other written mate- symptoms described in the protocol.
rial, and public service announcements on local
radio and television stations, that it is better to Plan for layered preparedness and
stay at home and take a shower than to go to the response.
hospital to be decontaminated. Planning that pre- Teams can consider whether and how it might be
pares the community to help itself can reduce the possible to ensure some level of layered prepared-
potential surge in demand for services experi- ness and response mechanisms. For example, to
enced during an actual emergency. avoid systemwide failure, plans could specify pro-
cesses for redundant systems and contingency
Ultimately, the ability of a community to survive plans to pick up the burden in case one part of
a major incident is dependent on its residents the system is disabled or overwhelmed.
ability to provide self-care. Education and risk
communication at a grass roots level through all Example:The local hospital or other health care
kinds of community groups, such as high school organization considers multiple levels of redundancy
football teams, Boy/Girl Scouts, and the local for its communications systems, including backup
civic organizations, are critical to effective self- phone systems, additional radio licenses for portable
care. Community awareness, education, and radios, cell phones, Ham radios, satellite phones, per-
engagement are essential. Hurricane plans in sonal digital assistants, e-mail, and so forth. Use of
Florida provide an excellent example of proac- these technologies assures not only redundancy but a
level of interoperability so that the organizations
tive, multilingual, and pervasive preparedness.
27
emergency command operation can maintain commu- an emerging infectious disease or a bioterrorist
nications with municipal, regional, or state emergen- attack), the ICS provides a flexible core mecha-
cy operations centers and/or fire and emergency nism for coordinated and collaborative incident
medical services (EMS) agencies. management.When a single incident covers a
large geographical area, multiple local ICS orga-
Ensure compatibility with unified nizations may be required. Effective cross-juris-
dictional coordination using processes and sys-
command functions and the incident tems described in the NIMS is absolutely critical
command system. in this instance.27(p. 7)
Community planning templates and processes
should dovetail with unified command functions Link the communitys plan to the NIMS
and the incident command system (ICS). Unified
and the NRP.
command concepts, widely used by civil author-
Commencing in 2005, the DHS has made adop-
ities, provide guidelines and enable agencies with
tion of the NIMS and the National Response Plan
different legal, geographic, and functional respon-
(NRP) a requisite for access to federal funding by
sibilities to coordinate, plan, and interact effec-
local organizations.27 Sidebar 9 is an overview of
tively.27 According to the DHS, The ICS is a
the federal initiatives and how they relate to local
management system designed to enable effective
initiatives. Community plans and initiatives
and efficient domestic incident management by
should link to the NIMS and the NRP for both
integrating a combination of facilities, equip-
funding and coordination purposes.
ment, personnel, procedures, and communica-
tions operating within a common organizational
The NRP requires communities to do the fol-
structure, designed to enable effective and effi-
lowing:
cient domestic incident management.27(p. 7)
Use established incident reporting protocols to
notify local and regional Joint Terrorism Task
The National Incident Management System (NIMS) Forces (JTTFs) and the Homeland Security
adopts the basic tenets of the ICS and outlines the Operations Center (HSOC), as appropriate.
interrelationship of the ICS and the NIMS as fol- Coordinate with the HSOC regarding proce-
lows: dures for establishing connectivity for domes-
The initial response to most domestic incidents tic incident management purposes. Local gov-
is typically handled by local 911 dispatch cen- ernment procedures should be coordinated
ters, emergency responders within a single juris- with the respective state government and/or
diction, and direct supporters of emergency emergency management agency.
responders. Most responses need go no further. Modify existing incident management and
In other instances, incidents that begin with a emergency operations plans to ensure proper
single response discipline within a single juris- alignment with NRP coordinating structures,
diction may rapidly expand to multidiscipline, processes, and protocols.
multijurisdictional incidents requiring significant Notify the secretary of homeland security of
additional resources and operational support. any substantial conflicts between this plan and
Whether for incidents in which additional state or tribal government laws or regulations.
resources are required or are provided from dif- This plan is not intended to compromise
ferent organizations within a single jurisdiction existing state or tribal government laws or
or outside the jurisdiction, or for complex inci- corresponding incident management or emer-
dents with national-level implications (such as gency response plans.10
28
Community planning teams must ensure that SIDEBAR 9. A KEY TOOL FOR SCALABLE INCIDENT
they complete these tasks. MANAGEMENT
The goal of the National Incident Management System
Consider linking to the Joint Field and the National Response Plan (NRP), to be used as a
Office. joint tool, is to provide a consistent nationwide tem-
Community teams can consider assigning a liai- plate to enable federal, state, local, and tribal govern-
son to the Joint Field Office (JFO) to facilitate ments and private-sector and nongovernmental orga-
interaction, communication, and coordination in nizations to work together effectively and efficiently
to prevent, prepare for, respond to, and recover from
an emergency. According to the DHSs National
domestic incidents, regardless of cause, size, or com-
Response Plan, the JFO is a multiagency coordi- plexity, including acts of catastrophic terrorism.
nation center that provides a central point for
federal, state, local, tribal, nongovernmental, and A basic premise of the NRP is that incidents are gen-
private-sector organizations with primary erally handled at the lowest jurisdictional level possi-
responsibility for incident oversight, direction, ble. Police, fire, public health and medical, emergency
and/or assistance.The JFO uses the scalable orga- management, and other personnel are responsible for
nizational structure of the NIMS ICS, not for incident management at the local level. In some
instances, a federal agency in the local area may act as
managing on-scene emergency operations but
a first responder and may provide direction or assis-
for providing support to on-scene efforts and tance consistent with its specific statutory authorities
conducting broader support operations that may and responsibilities. In the vast majority of incidents,
extend beyond the incident site.10 state and local resources and interstate mutual aid nor-
mally provide the first line of emergency response and
Link to county and state plans and incident management support.
planning initiatives. When an incident or potential incident is of such
Local elected officials should ensure that their com- severity, magnitude, and/or complexity that it is con-
munities plans are linked to the regional emergen- sidered an Incident of National Significance accord-
cy plan (for example, at the county or multicounty ing to the criteria established in the NRP, the secre-
level), which should itself be linked to a state- tary of homeland security, in coordination with other
approved emergency plan approved by FEMA.This federal departments and agencies, initiates actions to
can support a more efficient and timely allocation prevent, prepare for, respond to, and recover from the
of resources. Planning can begin with an existing incident.These actions are taken in conjunction with
state, local, tribal, nongovernmental, and private-sec-
county or state plan or initiatives that local leaders
tor entities as appropriate to the threat or incident. In
have already acknowledged or bought into, such as the context of Stafford Act disasters or emergencies,
a local emergency planning committee (LEPC). U.S. Department of Homeland Security (DHS) coor-
dinates supplemental federal assistance when the con-
State planning initiatives include LEPCs, which sequences of the incident exceed state, local, or tribal
are appointed by State Emergency Response capabilities.
Commissions.The focus of these committees has
Source: U.S. Dept. of Homeland Security (DHS): National
traditionally revolved around hazardous materials; Incident Management System.Washington, DC: DHS, Mar. 1,
the federal proponent is the Environmental 2004, p. ix; and U.S. Dept. of Homeland Security (DHS):
Protection Agency. LEPC members are volun- National Response Plan. Washington, DC: DHS, Dec. 2004,
p. 15.
teers and government employees who live with-
29
in a specific local emergency planning district. Establish mutual aid agreements.

Federal legislation states that, at a minimum, each Emergency response agencies establish mutual aid
LEPC shall include representatives from the fol- agreements, sometimes called memorandums of
lowing groups: elected officials, law enforcement, understanding or memorandums of agreement, with
civil defense, fire fighting, first aid, health, local neighboring jurisdictions to support a more
environmental, hospital, transportation personnel, effective response effort. Disaster mutual aid con-
broadcast and print media, community groups, sists of organized and supervised coordination, in
and owners/operators of facilities. For, example, which reciprocal help is given by neighboring or
there are 20 LEPCs in the state of Alaska. contractual communities during public emergen-
cies in the form of personnel, equipment, and
Examples: physical facilities. Mutual aid agreements include
policies and procedures for maintaining coverage
In Illinois, the West Central Municipal Conference on a day-to-day basis and during emergencies.
has created a regional Homeland Security Given the resource limitations of most small,
Coordinating Committee, which includes the mayors
rural, and suburban communities, establishing and
of 38 communities, some large and some small.
Among other activities, this committee monitors alloca- maintaining mutual aid agreements are critical to
tions and expenditures by local, state, federal, and pri- community ability to prepare for and respond to
vate entities for homeland security and develops and an emergency. However, communities, no matter
influences policies, protocols, and coordinated efforts. how small, must not neglect to establish a baseline
level of capacity and capability.
The Mayoral Institute for WMD (Weapons of
Mass Destruction) and Terrorism Incident TOOLS:
Preparedness, provided through the Idaho Institute American Hospital Association: Model Hospital
of Emergency Management, provides the nations Mutual Aid Memorandum of Understanding.
mayors a mayors only forum to discuss strategic http://www.hospitalconnect.com/aha/
and executive-level issues and challenges and to key_issues/disaster_readiness/resources/
share proven strategies and practices related to content/ModelHospitalMou.doc.
WMD/terrorism preparedness.
The Peoria County Emergency Services and Disaster

Agency, in Peoria, Illinois, coordinates all phases of
comprehensive emergency management, defined by the
agency as mitigation, preparedness, response, and
recovery, for Peoria County. It functions collaboratively
within a five-county region to integrate planning and
response across multiple jurisdictions.
Missouris Department of Health and Senior

Services has a close working relationship with the
Missouri Hospital Association (MHA).Three
MHA planners work with the 144 member hospi-
tals and coordinate hospital planning efforts, assuring
that hospital representatives are at the local, regional,
and state planning table and linked to each plan.
30
5. Determine Current Capacities and Capabilities

Recommended Planning Strategies: purview. Strategies to assist communities in
Use federal government asset cate- determining capacities and capabilities follow.
gories and target capabilities as a
guide.
Use federal government asset categories
Specifically consider the public as an
asset category. and target capabilities as a guide.
Consider other groups not yet repre-
To assure a thorough identification of inventory
sented at the planning table. asset categories, community planning teams can use
Identify geographic features and vul-
the national resource typing list published by the
nerabilities that may affect capabilities. federal government in the National Response Plan
Consider surge capacity and consult
(NRP) and National Incident Management Systems
surge planning resources. (NIMS) documents. Sidebar 10 outlines these cate-
Consider all community health
gories, which closely parallel the emergency sup-
resources. port functions (ESFs) outlined in Sidebar 6.When
Define critical capacities for each
community resources are limited in any one cate-
health entity and link to state gory, the resource typing categories can be used as
databases. a guide to areas where mutual aid agreements are
Know the federal governments defi-
needed.
nition of required surge capacity. SIDEBAR 10. RESOURCE CATEGORIES USED IN THE
Consider the issues involved with NATIONAL RESOURCE TYPING SYSTEM
standards of care during mass casualty
Mass care: To support efforts to meet the mass care
events. needs of disaster victims, including delivering
Identify dual uses for existing or such services as supplying victims with shelter,
emerging capabilities. food, and emergency first aid; supplying bulk dis-
Identify alternative care and shelter tribution of emergency relief supplies; and col-
facilities. lecting information to and for a disaster welfare
Identify federal resources in the com- information system designed to report on victim
munity. status and assist in reuniting families.
Identify gaps in community assets. Health and medical: To meet public health and
medical care needs following a disaster or emer-
The planning teams next activity is to determine gency or during a potential developing medical
situation.
the communitys current capacities and capabili-
Food and water: To identify, secure, and arrange for
ties for emergency prevention, preparation,
the transportation of safe food and water to
response, and recovery. A systematic asset inven- affected areas during a disaster or emergency.
tory can be conducted to account for the major Search and rescue: To provide specialized lifesaving
services required to achieve general emergency assistance in the event of a disaster or emergency,
management goals identified in Section 4. including locating, extricating, and providing on-
Created by all relevant planning partners identi- site medical treatment to victims trapped in col-
fied so far, at a minimum those listed in Sidebar lapsed structures.
4, this inventory describes the assets under their continued
31
SIDEBAR 10. RESOURCE CATEGORIES USED IN THE dent management operations and restoration of
NATIONAL RESOURCE TYPING SYSTEM (CONTINUED) the transportation infrastructure.
Animals and agricultural issues: To coordinate activ-
Energy: To help restore energy systems following a
ities responding to an agricultural disaster and/or
disaster or emergency.
when the health or care of animals is at issue.
Fire fighting: To detect and suppress fires.
Law enforcement and security: To provide law
Source: Adapted from U.S. Dept. of Homeland Security
enforcement assistance during response and (DHS): National Incident Management System. Washington,
recovery operations; to assist with site security DC: DHS, Mar. 1, 2004, p. 122.
and investigation.
Hazardous materials response: To support the
response to an actual or potential discharge
The capabilities identified by the federal govern-
and/or release of hazardous materials. ment can also provide helpful guidance. Sidebar
Public works and engineering: To assist those engaged 11 provides the U.S. Department of Homeland
in lifesaving, life-sustaining, damage mitigation, Securitys (DHSs) Target Capabilities List (TCL),
and recovery operations following a major disas- which includes 36 critical capabilities needed to
ter or emergency by providing technical advice, perform the tasks identified in the DHSs
evaluation, and engineering services; contracting Universal Task List described earlier.
for construction management and inspection and
for the emergency repair of water and wastewater TOOLS:
treatment facilities; supplying potable water and U.S. Dept. of Homeland Security: Target
ice and emergency power; and arranging for Capabilities List. http://www.ojp.usdoj.gov/odp/
needed real estate. assessments/hspd8.htm.
Volunteers and donations: To support the manage-
ment of unsolicited goods and unaffiliated volun-
teers, and to help establish a system for managing SIDEBAR 11. TARGET CAPABILITIES LIST
and controlling donated goods and services. (VERSION 1.1)
Information and planning: To collect, analyze, pro- Common-target capabilities
cess, and disseminate information about a poten- 1. Planning (preparedness)
tial or actual disaster or emergency to facilitate 2. Interoperable communications (communica-
overall activities in providing assistance to support tions and information management)
planning and decision making. Prevent mission area-target capabilities
Communications: To provide communications sup- 3. Information collection and threat recognition
port for incident management efforts. (manage data collection)
Resource management: To provide operational assis- 4. Intelligence fusion and analysis (analyze intel-
tance for incident management operations. ligence)
Public information: To contribute to the well-being 5. Information sharing and collaboration (dis-
of the community following a disaster by dissem- seminate threat information)
inating accurate, consistent, timely, and easy-to- 6. Terrorism investigation and apprehension
understand information; to gather and dissemi- (investigate and apprehend terrorist suspects)
nate information about disaster response and 7. CBRNE* detection (defeat weapons)
recovery process. Protect mission area-target capabilities
Transportation: To provide transportation to per- 8. Risk analysis (assess vulnerabilities)
form incident management missions following a 9. Critical infrastructure protection (protect
major disaster or emergency; to coordinate inci- assets and property) continued
* Chemical, biological, radiological, nuclear, or explosive
32
SIDEBAR 11. TARGET CAPABILITIES LIST 31. Mass prophylaxis (distribute prophylaxis)
(VERSION 1.1) (CONTINUED) 32. Mass care (sheltering, feeding, and related
services) (provide mass care)
10. Food and agriculture safety and defense
33. Fatality management (manage fatalities)
(safeguard public health)
Recover mission area-target capabilities
11. Public health epidemiological investigation
34. Structural damage assessment and mitigation
and laboratory testing (safeguard public
(rebuild property)
health)
35. Restoration of lifelines (restore lifelines)
12. Citizen preparedness and participation (pre-
36. Economic and community recovery (restore
pare the public)
economic institutions)
Respond mission area-target capabilities
13. On-site incident management (manage incident)
Source: U.S. Dept. of Homeland Security: Target
14. Emergency operations center management Capabilities List: Version 1.1. May 23, 2005.
(manage incident) http://www.ojp.usdoj.gov/odp/docs/TCL1_1.pdf
15. Critical resource logistics and distribution (accessed Jun. 17, 2005).
(manage incident)
16. Volunteer management and donations (man-
age incident) Specifically consider the public as an
17. Worker health and safety (manage incident) asset category.
18. Public safety and security response (manage Rather than being looked at primarily as poten-
incident) tial casualties, the public can be considered part of
19. Animal health emergency support (respond the communitys assets in emergency manage-
to hazard) ment initiatives. As such, the capacities and capa-
20. Environmental health and vector control
bilities of the general public should be accounted
(respond to hazard)
for where possible.The willingness of the average
21. Explosive device response operations
(respond to hazard) person to be an early responder may vary
22. Fire-fighting operations/support (respond to depending upon whether the event is a slow-
hazard) moving biological event or a sudden-impact nat-
23. Weapons of Mass Destruction/hazardous ural or man-made event. The team thus should
materials response and decontamination carefully consider whether certain assignments
(respond to hazard) might be ones assumed by volunteers as opposed
24. Citizen protection: evacuation and/or in- to trained or professional responders.
place protection (implement protective
actions)
25. Isolation and quarantine (implement protec-
Consider other groups not yet
tive actions) represented at the planning table.
26. Search and rescue (conduct search and res- Such groups may offer additional capabilities in
cue) supporting communication or transportation
27. Emergency public information and warning efforts, providing temporary shelter and supplies,
(distribute public information) and assisting with other emergency needs. One
28. Triage and pre-hospital treatment (provide way to identify such groups is to consider voca-
medical care) tional or avocational special interest groups that
29. Medical surge (provide medical care)
represent certain skills or resources that might be
30. Medical supplies management and distribu-
valuable in an emergency, such as truck drivers,
tion (provide medical care)
33
snowmobile owners, youth group members, (GIS)/mapping resources, which can provide
recreational boaters, and so forth. For example, in valuable information, such as GIS locations of
one community drill that tested distribution of an hospitals, mass prophylactic sites, and regional
emergency pharmaceutical stockpile, high school pharmaceutical and medical equipment
football teams were trained and deployed to sup- resources.
port security around the stockpile prior to its dis-
tribution in the community. Consider surge capacity and consult
surge planning resources.
Identify geographic features and The planning team must consider surge capacity,
vulnerabilities that may affect defined as the ability to expand capabilities in
capabilities. response to sudden or more prolonged
In addressing current and needed capacities and demand,30(p. 19) and identify sources and methods
capabilities, the planning team should note geo- for adding additional capacity (staff, supplies,
graphic and topographic features that may affect technology, medications, transport vehicles).
operations, for example, dependence on a single Although commonly considered in communities
main transportation artery in and out of the juris- as medical surge capacity and capability, the concept
diction. The group will want to map out where of surge capacity applies to all assets. Rural, small,
special needs groups are concentrated and be alert and suburban areas are typically resource-strapped
to other issues that could affect planning assump- and find it difficult to expand capacity in many, if
tions, notes one document.7(pp. 211) Current tech- not most, key capability areas as listed in Sidebars
nology allows planners and responders to consider 10 and 11.
alternative routes for security or weather concerns
and allows for multiple modes of transportation. The focus here is on medical surge capacity, defined
as the ability to care for a markedly increased vol-
Potential areas of vulnerability for terrorism iden- ume of casualties that challenges or exceeds nor-
tified by Federal Emergency Management mal operating capacity.15 Because the first goal of
Agency (FEMA) include traffic (on roads, tun- community emergency preparedness and
nels, bridges, and so forth), trucking and transport response efforts is to save lives (which encom-
activity (including HazMat cargo), waterways, passes preventing the spread of disabling disease
airports, trains/subways, government facilities, and injuries), if the communitys medical system
recreation facilities, military installations, HazMat is overwhelmed, the community simply will lose
facilities, utilities, and nuclear facilities.29 its capacity to meet this goal.
This planning effort should be coordinated with The Medical Reserve Corps, described earlier, is
state or local geographic information systems specifically designed to provide surge capacity
Rather than being looked at primarily as potential casualties, the public can be considered part
of the communitys assets in emergency management initiatives.
34
personnel in the event of a large-scale emergen- Professionals working in all community settings,
cy. Federal resources, available through ESF #8: such as schools, businesses, and health facilities,
Public Health and Medical Services, may be can consult their professional organizations for
called upon to provide additional medical surge assistance in surge planning. Several examples
capacity and capability. For example, under appear in the tool box.
FEMAs National Disaster Medical System,
Disaster Medical Assistance Teams (DMATs) pro- Consider all community health
vide assistance in the event of large-scale disasters. resources.
DMATs are volunteer groups of medical and In communities of all sizes, critical medical surge
nonmedical individuals, usually from the same capacity can come from not only hospitals, but
region where the disaster is occurring. Because urgent care centers, home health agencies, com-
the material in this planning guide is intended to munity health centers, clinics, ambulatory care
help small communities stand on their own for facilities, physicians offices, and long term care
the first day or days and develop and maintain as and other health facilities. Doctors, nurses, home
much capacity as possible, federal and state health aides, social workers, retired health profes-
resources are not itemized here but should be sionals, and all other medically trained profession-
familiar to the community planning team. als can help to meet medical surge personnel
needs. Other required surge needs include
If a hospital or a number of hospitals are present decontamination facilities, laboratory capacity,
in the community, the leaders of these organiza- and immunization supplies, among many other
tions must determine their surge capacity and elements. As part of the planning process, and in
evaluate strategies to enhance capacity. This cal- advance of an emergency, planning teams should
culation of capacity should include at a minimum identify all community health resources and assess
the number and type of beds, personnel, pharma- the ability of each resource to contribute to
ceuticals, supplies, and equipment, among other emergency prevention, preparedness, response,
critical items. and recovery.
TOOLS: Define critical capacities for each

CNA Corporation: Medical Surge Capacity and
health entity and link to state
Capability: A Management System for Integrating
Medical and Health Resources During Large-Scale databases.
Emergencies. http://www.cna.org/ Surge capacity for a hospital is different than surge
documents/mscc_aug2004.pdf. capacity for a long term care facility or a commu-
School administrators: National nity health center.The planning team should agree
Clearinghouse for Educational Facilities. on what role each organization will play in a large-
http://www.edfacilities.org/rl/disaster.cfm. scale emergency and ensure that health facilities
Emergency physicians: American College of are linked to any resource-coordinating databases
Emergency Physicians. http://www.acep.org. operated by the state or region. Figure 1 illustrates
Business owners: National Business Group on a regional planning matrix of critical capabilities
Health. http://www.businessgrouphealth.org. for health carerelated resources.
35
FIGURE 1. CONNECTICUT REGIONAL EMERGENCY AND PUBLIC HEALTH PREPAREDNESS: HEALTH CARE
AGENCY BIOTERRORISM ANNEX PLANNING CRITERIA.
Source: Connecticut Regional Emergency and Public Health Preparedness: Health Care Agency Bioterrorism Annex
Planning Criteria. Used by permission.
Example:The Maryland Institute for Emergency incident or to an emergency operations center.

Medical Services Systems maintains a Web-based Hospitals, public health, 911 centers, specialty refer-
Facility Resource Emergency Database to expedite ral centers, law enforcement agencies, and other com-
the flow of resources (including emergency depart ponents of the emergency medical services system
ment and pediatric bed availability, medications, monitor this Web page.
blood, medic unit availability, and emergency
response personnel and apparatus) to the scene of an
36
Know the federal governments pediatric patients, as well as health care person-
nel, who have been exposed during a chemical,
definition of required surge capacity. biological, radiological, or explosive incident in
The Health Resources and Services accordance with the numbers associated with
Administrations (HRSAs) capacity projections CBM # 2-1 (those indicated above). As stated
in a mass casualty event are based on a population in OSHA (Occupational Safety and Health
of one million, which obviously exceeds the pop- Agency) Best Practices for Hospital-Based First
ulation of small, rural, and suburban communities Receivers of Victims from Mass Casualty Incidents
addressed in this planning guide. However, local Involving the Release of Hazardous Substances: All
planners should be aware of HRSA guidance participating hospitals shall be capable of pro-
related to surge capacity because it impacts the viding decontamination to individual(s) with
ability of surrounding communities to handle potential or actual hazardous agents in or on
victims of mass casualty events. A critical bench- their body. It is essential that these facilities have
the capability to decontaminate more than one
mark identified by the HRSA for regional surge
patient at a time and be able to decontaminate
capacity for the care of adult and pediatric vic- both ambulatory and stretcher bound patients.
tims of terrorism and other public health emer- The decontamination process must be integrat-
gencies is as follows: ed with local, regional and state planning. All
decontamination assets must be based on how
Establish systems that, at a minimum, can provide many patients/providers can be decontaminated
triage treatment and initial stabilization, above the on an hourly basis.The awardee should plan to
current daily staffed bed capacity, for the following be able to decontaminate all patients and
classes of adult and pediatric patients requiring providers within three hours of the onset of the
hospitalization within three hours in the wake of event.31(p. 34)
a terrorism incident or other public health emer-
gency: Example: Numerous states are considering or have
500 cases per million population for patients purchased deployable, mobile, military-type trailers to
with symptoms of acute infectious disease, meet some of the needs for surge capacity.These
especially smallpox, anthrax, plague, trailers can offer extra bed and additional isolation
tularemia, and influenza capacity. Although small communities are unlikely to
50 cases per million population for patients have the financial resources to purchase such trailers,
with symptoms of acute botulinum intoxica- resource pooling may be a possibility.
tion or other acute chemical poisoning,
especially that resulting from nerve agent
exposure
Consider the issues involved with
50 cases per million population for patients standards of care during mass
suffering burn or trauma casualty events.
50 cases per million population for patients Americans are hesitant to think about austere
manifesting the symptoms of radiation- caredefined as the level of medical care that is
induced injury, especially bone marrow sup- provided when health care resources, medical
pression31(p. 3) supplies, and medical personnel are limited or
For decontamination surge capacity related to the
unavailable for an extended response
numbers of patients indicated above, the critical
benchmark is as follows: periodand expect to obtain only the highest
Insure that adequate portable or fixed decon- level of care.This obviously may be difficult if not
tamination systems exist for managing adult and impossible for small communities to provide in
37
mass casualty events involving thousands of vic- strapped small, rural, and suburban communities.
tims. As part of the planning process, planning A reverse 911 call system established by a com-
teams should wrestle with the issues involved munity for law enforcement emergencies, for
with standards of care in mass casualty events. example, could also communicate other types of
emergencies. Investments made by local public
To assist in doing so, in May 2005, the Agency for health departments in upgrading laboratory ser-
Healthcare Research and Quality (AHRQ) and vices for smallpox, SARS, anthrax, and other spe-
the Office of Public Health Emergency cialized testing can benefit more routine labora-
Preparedness issued a report for officials on how tory services in the community as well.The plan-
to plan for delivering health and medical care in ning team can identify businesses with call-center
a mass casualty event.32 The report recommends capabilities, such as telemarketing and airline
that planners at all levels, including the commu- operations, as potential emergency call centers
nity level and health systems level, develop or during disasters.
revise both triage guidelines for specific types of
events and allocation guidelines for the use of Identify alternative care and shelter
scarce resources such as ventilators, burn beds, or facilities.
surgical suites. The report also addresses such Most individual health care facilities in small,
issues as what circumstances would trigger a call rural, suburban, and even urban communities
for altered standards of care, who is authorized to have limited, if any, surge supplies, personnel, and
make that call, and the sources of relief available equipment. Backup systems for critical assets are
to address concerns about financial resources and often shared among community facilities. This
reimbursement of medical care costs. Planning double counting of resources diminishes the abil-
teams should be alert for further reports on this ity to meet individual projected surge demands
important topic. across multiple institutions during a medical
emergency, notes one report.15(pp. 3-5)
TOOLS:
Agency for Healthcare Research and Quality:
The planning team should identify supplemental
Altered Standards of Care in Mass Casualty
Events. http://www.ahrq.gov/research/altstand. facilities, such as hotels, motels, college infir-
maries, dormitories, libraries, high schools, places
of worship, and other structures that could meet
Identify dual uses for existing or health care and shelter surge needs. For example,
emerging capabilities. a small town in Texas identified its community
Finding dual uses for existing or emerging capa- college as a facility that could be turned into a
bilities is particularly critical for resource- surge hospital. However, the team should also
Investments made by local public health departments in upgrading laboratory services for
smallpox, SARS, anthrax, and other specialized testing can benefit more routine laboratory
services offered to the community.
38
remember that the facilities cannot function technical, and advisory services might not be
without concurrent plans for additional staffing, available to the community.
supplies, and equipment and that the alternative
facilities must be accessible to the disabled. Identify gaps in community assets.
Checklists are available for assessing the adequacy The planning team then reviews the asset inven-
of facility accessibility (see Tools). tory information so that gaps and areas of com-
monality can be identified. During development
TOOLS: of the integrated planthe next activity
New York State Office of Advocate for (addressed in Section 6)the team begins to
Persons with Disabilities: ADA Accessibility identify strategies to close the gap between what
Checklist for Existing Facilities. is needed and what is available for disaster pre-
http://www.ghi.com/pdf/adachecklist.pdf paredness and response. Shortfalls may require
(accessed Jun. 20, 2005). negotiating agreements with private suppliers or
other jurisdictions. Determination of the
Identify federal resources in the resource base also should include a consideration
community. of what facilities are vital to emergency opera-
Federal resources located in the community may tions and how they might be affected by hazards:
or may not be available to the community in the problems that cannot be mitigated should be
event of a large-scale emergency. Communities taken into account in the emergency operations
near military installations can consider military plan, not assumed away, notes the FEMA plan-
assets that might be available as appropriate, such ning guide.7(pp. 2-10)
as beds in Veterans Administration (VA) hospitals,
naval search and rescue capabilities, army heli-
copters, and so forth. The planning team deter-
mines who initiates contact with these assets to
help determine how their resources may be
incorporated in planning and response activities.
The planning team also needs to consider that

during a major emergency, as defined in the
Stafford Act, the president can direct federally
controlled resources located in the community,
such as VA hospitals, Bureau of Primary Health
Care facilities, military hospitals, and any other
medical or nonmedical federal assets, to respond
in ways directed by the president.As this directive
may or may not include assistance to the particu-
lar community in which such resources are per-
manently housed,10 the planners need to prepare
for contingencies when such personnel, equip-
ment, supplies, facilities, and managerial,
39
6. Develop the Integrated Plan Plans, of course, have both a political and strate-
gic value in their quantification and description
Recommended Planning Strategies: of available and needed resources. Small, rural,
Maintain a collaborative effort; and suburban communities must be realistic; the
broaden planning partnerships where planning and asset allocation process will
necessary. undoubtedly require trade-offs. The integrated
Choose an approach to developing plans objectives include achieving a level of pre-
the plan. paredness and response that is sustainable and
Use available guidance and resources. building capabilities for the future as needs
Determine how the plan is to be evolve. It addresses the four phases of emergency
drafted and the expected time frame. management described in Section 4preven-
Agree on meeting frequency. tion, preparation, response, and recovery.
Review existing plans, laws, and
mutual aid agreements. The plan is a living document and must be
Commit to the use of simple language. reviewed, updated, and tested as risks, goals, and
Clearly delineate roles and capabilities change over time (Section 12).
responsibilities. Transitions in team leadership and responsibility
Determine how the plan will be must also be considered as the planning process
organized. matures and moves into implementation and
Address all types of events and cover maintenance phases.
all defined goals.
Specifically address health and medi- The plans coverage of issues related to commu-
cal facility emergency planning. nication, mental health needs, and the needs of
Specifically address how to meet special populations warrants in-depth descrip-
needs for pharmaceuticals and medi- tion. Thus, these issues are covered in separate
cal supplies. sections in this planning guide: Section 7 address-
Identify and address hazards and es communication, Section 8 addresses mental
resources that cross jurisdictions. health needs, and Section 9 addresses the needs of
Identify how preparedness and special populations.Teams must ensure that these
response success will be measured. topics are thoroughly covered in their final inte-
Consider the lessons learned from 9/11. grated plan. A description of selected strategies
that can help teams to develop high-quality inte-
The integrated emergency management plan is grated plans follows.
designed to meet the needs defined for the com-
munity based on its hazard vulnerability analysis Maintain a collaborative effort;
(HVA; Section 3), its goals for preparedness and broaden planning partnerships where
response planning (Section 4), and its current
necessary.
capacities and capabilities (Section 5). Through
All stakeholders, including the media and others
the HVA, goal setting, and capabilities identifica-
as identified in Section 2, are included as partners
tion processes, the team determines what is being
in plan development.The value of a collaborative
planned for and what assets might be needed and
planning process cannot be overemphasized.
allocated.
Although a document is the tangible result at this
40
stage, intangible results, such as new and another, cookie-cutter style, is extremely risky
improved relationships, have significant positive and ill-advised.The four approaches are as follows:
value above and beyond the document. Planning Develop the plan from a blank sheet.
conducted with a group over an extended period Adapt a plan that already exists in one of the
of time builds and enhances partnerships and communitys organizations (for example, fire
communication that will be essential during an department, school system, local hospital).
Adapt a plan obtained through the emergency
actual emergency. Partnerships often also extend
management literature.
to neighboring communities and the surround-
Adapt a county, regional, state, or national plan.
ing region. Subgroups or committees can be
formed to focus on particular areas of planning. Again, whether starting from a blank sheet or
Communication, reporting, and decision-making adapting an existing plan, the planning team must
channels must be developed and maintained so tailor the plan to the risks, capabilities, and goals
that the efforts of subset groups are integrated defined for the specific community through its
into overall plans. HVA.
Example: Arlington, Massachusetts (population
43,000), formed a subcommittee of the local emer- Use available guidance and resources.
gency planning committee to enhance the communi- The blank sheet approach may be more time-con-
tys ability to respond to the threat of terrorism. suming than other approaches. Most states can pro-
Subcommittee initiatives included targeted hardening vide valuable assistance to local jurisdictions. States
of critical infrastructure; specialized police training for typically publish their own planning guides, con-
incident command; updating of mutual aid agree- duct training, and may assign planners to work with
ments; acquisition of protective equipment and emer- local community planners. Federal guidance, such
gency operations planning software; enhancement of as the Public Health Emergency Response Guide for
the towns emergency management plan; develop- State, Local, and Tribal Public Health Directors, pub-
ment of emergency plans for specific locations, such
lished by the Centers for Disease Control and
as schools; and emergency operations exercises at a
high-profile institution.33 Prevention (CDC), can provide valuable planning
guidance and templates for documentation of con-
tacts and actions, leadership assignments, and inci-
Choose an approach to developing the
dent-specific preparedness (see Tools).
plan.
The planning team can take one or a combination
Determine how the plan is to be drafted
of four general approaches to creating an integrat-
ed plan based on the HVA.The team should note and the expected time frame.
that three of the four approaches involve adapting Decisions include Who will draft the plan and
existing plans, not adopting existing plans. The dis- prepare the needed graphics? To whom will the
tinction between adapting and adopting is critical. If draft plan be circulated? How will changes be
the team chooses one of the adaptation options, it agreed upon and incorporated? Who will receive
will need to carefully review all elements of the a copy of the final plan? and What is the desired
existing plan and revise plan elements to meet the time frame for the plans drafting, revision, and
communitys unique needs and resources as identi- finalization? Sidebar 12 provides selected sample
fied through the teams HVA. Adopting a plan and steps outlined by the Federal Emergency
transferring it wholesale from one community to Management Agency (FEMA).
41
TOOLS: Commit to the use of simple language.

Centers for Disease Control and Prevention The emergency management plan should be
(CDC): Public Health Emergency Response written in plain English. Team members can
Guide for State, Local, and Tribal Public Health define all terms at the beginning and avoid using
Directors, Version 1.0. http://www.bt.cdc.gov/ too many acronyms or abbreviations. A clearly
planning/responseguide.asp. marked glossary at the end of the document may
National Association of County & City Health define the acronyms or abbreviations that are
Officials: Bt PREP:A Bioterrorism Response Plan used.
Design Guide for Local Public Health Agencies, 1st
ed., 2003. http://www.naccho.org/pubs. SIDEBAR 12. SAMPLE STEPS TOWARD CREATING A
Resources for local planning for pandemic dis- WRITTEN EMERGENCY OPERATIONS PLAN
ease, available through the CDC, include:
Develop a rough draft of the basic plan to serve as
Pandemic Influenza Preparedness and Response:
a point of departure for the planning team.
http://www.hhs.gov/nvpo; State and Local
Develop agendas and invitation lists for the first
Pandemic Planning Guide: http://www.hhs.gov/
cycle of planning meetings.
nvpo/pubs/pandemicflu.htm. Conduct a presentation meeting, establish com-
Northern New England Metropolitan Medical
mittees for parts of the plan, appoint committee
Response System: Community Planning Guide: chairs, and schedule a follow-up meeting.
Improving Local and State Agency Response to Work with committees on successive drafts.
Terrorist Incidents Involving Biological Weapons, Jun. Prepare necessary graphics (for example, maps
2003. http://www.nnemmrs.org/surge.html. and organizational charts).
Produce a final draft and circulate the draft to the
Agree on meeting frequency. planning team for review and comment.
The planning team and its subcommittees or task Hold a meeting to incorporate final changes, dis-
groups may meet weekly or monthly during differ- cuss an implementation strategy and necessary
ent phases of planning and implementation. distribution, and obtain informal commitments to
Meetings with neighboring, regional, state, or fed- provide information that could necessitate revi-
eral partners may occur on a monthly, quarterly, or sion.
Obtain concurrence from organizations with
biannual basis after the relationships are established.
identified responsibilities for implementing the
plan.
Review existing plans, laws, and Obtain official promulgation of the plan by local
mutual aid agreements. elected officials and advise the media of this in
Local, state, and federal laws, rules, and regulations advance.
may impact the plans that are developed. Print and distribute the plan, with a copy (or press
Appropriate plans, laws, codes, and regulations release) to local media. Maintain a record of the
organizations and persons that received a copy (or
and existing agreements with neighboring com-
copies) of the plan.
munities, private-sector organizations, and others
should be reviewed carefully by the team.7 These Source: Adapted from Federal Emergency Management
should include plans concerning command and Agency: State and Local Guide (SLG) 101: Guide for All-
control and, in particular, the integration from an Hazard Emergency Operations Planning. 1996. pp. 2-112-
incident command system structure to a unified 12. http://www.fema.gov/rrr/gaheop.shtm (accessed
command system. Feb. 2005).
42
Clearly delineate roles and A functional approach to the plans structure

responsibilities. enables communities to address the effects com-
The plan should clearly describe areas of respon- mon to hazards without having to develop sepa-
sibility, the circumstances under which the plan is rate plans for each hazard. For example, as men-
to be activated, who is initially in charge, and tioned earlier, the National Response Plan is orga-
who is authorized to activate the plan. As men- nized around 15 emergency support functions,
tioned earlier, coordinated emergency manage- such as transportation; mass care, housing, and
ment planning and decision making require com- human services; and others (Sidebar 6). FEMA
munity leaders and team players to play different provides the following list of core functions that
roles in different circumstances. The plan also warrant attention and may require that specific
should outline alternative roles for personnel dur- actions be taken during emergency response
ing emergency situations, including who they operations:
Direction and control
should report to within a command structure.
Communications
Roles and responsibilities must be determined in
Warning
advance because, during an emergency, turf bat- Emergency public information
tles or lack of clarity about who is to do what can Evacuation
result in lost time, resources, and perhaps lives. Mass care
Operational duties and goals for key positions can Health and medical services
be provided in checklist format. Resource management7(p. 5-1)
Determine how the plan will be Figure 2 illustrates how each core function can be
organized. assigned to specific organizations or individuals.
FEMA and other government agencies do not Sidebar 13 outlines the components of an integrat-
mandate a particular format for emergency plans. ed plan that uses a functional structural approach.
However, it is important that the plan be orga-
nized in a format that the team is comfortable Address all types of events and cover
with and one that enables users to obtain with all defined goals.
ease the information they need. Additional issues Plan contents should address all those elements
includes sequencing of the material (is it logical?), outlined as goals for preparedness and response in
consistency of sections, adaptability of material to Section 4. For example, the emergency manage-
multiple situations, and compatibility with plans ment plan should include a brief description of
of other jurisdictions.7 the various activities the organization plans to
Roles and responsibilities must be determined in advance; during an emergency,

turf battles or lack of clarity about who is to do what can result in lost
time, resources, and perhaps lives.
43
FIGURE 2. RESPONSIBILITIES FOR RESPONSE FUNCTIONS
Source: Federal Emergency Management Agency: State and Local Guide (SLG) 101: Guide for All-Hazard
Emergency Operations Planning, 1996. http://www.fema.gov/rrr/gaheop.shtm (accessed Feb. 2005).
SIDEBAR 13. COMPONENTS OF A FUNCTIONALLY STRUCTURED EMERGENCY PLAN

The Basic Plan: The basic plan is an overview of the jurisdictions emergency response organization and policies. It
cites the legal authority for emergency operations, summarizes the situations addressed by the emergency opera-
tions plan (EOP), explains the general concept of operations, and assigns responsibilities for emergency planning
and operations.
continued
44
SIDEBAR 13. COMPONENTS OF A FUNCTIONALLY

undertake in each of the four emergency man-
STRUCTURED EMERGENCY PLAN (CONTINUED) agement phases (prevention, preparation,
response, and recovery).
Functional Annexes: Functional annexes are plans
organized around the performance of a broad task.
Each annex focuses on one of the critical emergen- The plans also should include the following:
cy functions that the jurisdiction will perform in Organizations and individuals responsible for
response to an emergency. The number and type of carrying out specific actions at projected times
functional annexes included in the EOP may vary and places in an emergency that exceeds the
from one jurisdiction to another, depending on capability or routine responsibility of any one
needs, capabilities, and organization. Because func- agency (for example, the fire department)
tional annexes are oriented toward operations, their Authority and organizational relationships, and
primary audience consists of those who perform the how all actions will be coordinated
tasks. They do not repeat general information con- How people and property will be protected in
tained in the basic plan. emergencies and disasters
Personnel, equipment, facilities, supplies, and
Hazard-Specific Appendixes: Hazard-specific appendix- other resources availablewithin the jurisdic-
es provide additional detailed information applicable tion or by agreement with other
to the performance of a particular function in the jurisdictionsfor use during response and
face of a particular hazard. They are prepared when recovery operations
hazard characteristics and regulatory requirements Steps to address mitigation concerns during
warrant and are attached to the relevant functional response and recovery activities7
annex(es).
However the plan is organized, the team should
SOPs and Checklists: Standard operating procedures ensure that the plan is flexible enough to respond
(SOPs) and checklists provide the detailed instruc- to different situations. Communities must be pre-
tions that an organization or an individual needs to pared for natural disasters, unintentional disasters,
fulfill responsibilities and perform tasks assigned in and intentional disasters.
the EOP. They may be attached to the EOP or ref-
erenced as deemed appropriate.
Specifically address health and medical
Source: Federal Emergency Management Agency: State facility emergency planning.
and Local Guide (SLG) 101: Guide for All-Hazard Local planners must take into account the ser-
Emergency Operations Planning. 1996, pp. 3-23-3. vices required to support operations for health
http://www.fema.gov/rrr/gaheop.shtm (accessed Feb. care delivery during and after a disaster affecting
2005).
the community. For example, planners must con-
sider the following:
TOOLS: Plans and decisions regarding water reservoirs,
A suggested format for a terrorist incident tanks, or other sources can impact a health
appendix to a basic all-hazards emergency plan care facilitys access to water essential for sani-
can be found in Federal Emergency tation, sterilization, cooling of generators, and
Management Agency: State and Local Guide other utility-related functions.
(SLG) 101: Guide for All-Hazard Emergency Closure of or limited access to banks and
Operations Planning: Chapter 6, Attachment G. ATMs impacts a health care providers ability
Apr. 2001. http://www.fema.gov/pdf/rrr/ to pay essential staff continuing to work
allhzpln.pdf. through the crisis.
45
The receipt, storage, and distribution sequence Commission, however, so communities with
of mass prophylaxis for first responders and acute care and other health facilities should
their families, first receivers and their families, address such facilities capacities and capabilities
other health and public safety workers, and the to meet needs, including (but not limited to) the
general public must be determined collabora- following:
tively and in advance to avoid confusion.
Plans and decisions regarding curfew, road clo-
sures, or traffic routing can impact the ability Ongoing risk assessment: A risk assessment process,
of health care professionals to get to and from such as HVA, ensures that the health care organi-
health care facilities and alternative care sites. zation identifies potential emergencies that could
affect the need for its services or its ability to pro-
Health care organizations accredited by the Joint vide those services.
Commission on Accreditation of Healthcare
Organizations must meet emergency manage- Surge capacity: Surge capacity is not just a hospital
ment planning and drill requirements as outlined issue, but a community issue, as described in
in Joint Commission accreditation manuals for Section 5. During disasters, surge capacity is per-
ambulatory care, behavioral health care, critical haps the most fundamental component of a
access hospitals, health care staffing, home care, health care organizations emergency prepared-
hospitals, laboratory, long term care, and office- ness program. Surge capacity is the organizations
based surgery facilities.The goal of these require- ability to expand care capabilities in response to
ments is to ensure that health care organizations sudden or more prolonged demand. It encom-
prepare for and can respond to an emergency passes the following elements:
within their organizations or in their communi- Potential patient beds
ties that suddenly and significantly affects the Available space in which patients may be
need for their services or their ability to provide triaged, managed, treated, vaccinated, decon-
taminated, or simply located
those services.34
Available personnel of all types
Necessary medications, supplies, and equipment
Health facility leaders on the community plan- Legal capacity to deliver health care services
ning team, who represent Joint Commission- under situations that exceed authorized capacity
accredited facilities, will be familiar with Joint
Commission emergency management require- Surge capacity has both a point-in-time aspect
ments and can advise the team on their facilities (that is, the ability to accommodate patients for a
ability to provide capacities and capabilities in the limited time period during the acute crisis) and a
areas outlined in this section. Not all health care longitudinal dimension (the ability to manage
organizations are accredited by the Joint longer-term care needs).
Plans and decisions regarding water reservoirs, tanks, or other sources can impact a health
care facilitys access to water essential for sanitation, sterilization, cooling of generators, and
other utility-related functions.
46
Evacuation and alternative care sites: When a facili- SIDEBAR 14. COMMUNICATION AND POWER
tys physical environment can no longer support CONSIDERATIONS FOR HEALTH CARE FACILITIES
adequate care and treatment, the organization
The major information categories of the draft guidelines
must have plans for both horizontal (on the same in development at the Greater New York Hospital
floor or level) and vertical (to a different floor) Association include the following:
evacuation. Procedures for horizontal evacuation
Communication considerations: internal phone switches, ana-
to areas of safety beyond closed smoke barriers log phone lines, long-distance service provider trunks,
are written into every health care facilitys fire runner system, radios, walkie-talkies, cell phones, overhead
plans and should be familiar to all staff. Even speaker and paging system, stand-alone computer and
though less common, vertical evacuation must Internet access, access to external information systems,
also be considered in the planning process. Other communications directories, and vendor contact numbers.
evacuation planning considerations include Who Power considerations: standards, fuel supplies, supplemental
is responsible for the decision to evacuate? With emergency generators, operation of emergency generators,
what company(ies) will transportation of patients placement and security of emergency generators, elevators,
radios, critical equipment, and contingency planning.
be arranged (for example, local paratransit or
ambulance services)? What evacuation routes will Source: Greater New York Hospital Association, New York. Used
be used? Where will these routes be posted? Who with permission.
is responsible for maintaining the medical and

medication profile sheet throughout the event Facilities must identify an alternative means of
and after?35 meeting essential building utility needs when the
facility must provide continuous service during
Hospitals and long term care organizations are an emergency. Electricity, water, ventilation, fuel
required by the Joint Commission to identify an sources, and medical gas/vacuum systems may
alternative care site(s) that has the capabilities to each require special consideration. Key questions
meet the needs of patients when their own facil- related to utility failure include Does the organi-
ities are not able to do so due to the effects of a zations emergency management plan address
disaster. Consideration must be made for the type how the organization would handle a utility fail-
of patients being relocated, with assurance that ure caused by an interruption in service by a util-
the chosen alternative site can meet the clinical ity provider? By a lightening strike? What effect
needs of the individuals it receives. would a utility failure have on the organization?
How has the plan addressed such effects? What
Emergency communications and building utility systems: backup systems are in place in the event of a util-
Health facilities must ensure an appropriate back- ity failure? Sidebar 14 provides Greater New York
up for key internal and external communications Hospital Associations planning categories related
systems in the event of failure during emergen- to communication and power issues.
cies. Hospitals or other health care organizations
frequently consider multiple levels of communi- Emergency education and training of health care staff:
cations systems redundancy, including backup Orientation and education about potential emer-
phone systems, additional radio licenses for gencies and their expected risks and conse-
portable radios, cell phones, Ham radios, satellite quences, how to respond to each type of emer-
phones, personal digital assistants, e-mail, and so gency, and how to provide the best possible care
forth. to disaster victims, as appropriate, should be pro-
47
vided to health care staff before a disaster occurs. that their community plan addresses the hospitals
When a disaster or emergency occurs, there is lit- capacity to isolate individuals, as needed, and to
tle or no time for staff training to be conducted. support ventilator-dependent patients.
An orientation and education program for all
personnel, including licensed independent practi- Security/lockdown: According to some experts, a
tioners who participate in implementing the plan to secure the facility within a few minutes of
emergency management plan, is required by the an internal or known external biologic or chem-
Joint Commission for accreditation and is recom- ical incident in order to protect current care
mended for all organizations. Education address- recipients, the facility, and staff is appropriate, and
es, as appropriate to the individual, the following: entry should be permitted only to noncontami-
Specific roles and responsibilities during emer- nated staff and decontaminated care recipients.36
gencies Good perimeter control and access control points
How to recognize specific types of emergencies around health facilities are often critical to pre-
The information and skills required to per- vent the spread of infectious diseases and agents.
form assigned duties during emergencies Security planning issues include What additional
The backup communication system used dur-
security staff is required in the event of a com-
ing emergencies
How supplies and equipment are obtained munitywide disaster? How might such staff be
during emergencies obtained during an emergency? What emergen-
cy lock-down control procedures should be
Incident command system (ICS)/unified command: implemented in the event of a disaster? How will
The health care organizations command struc- these occur? Who will implement them? What
ture must link with the communitys command role will local law enforcement agencies play in
structure. The Hospital Emergency Incident assisting the organization during a community-
Command System (HEICS), used by many hos- wide incident? How will the organizations secu-
pitals nationwide, is based upon public safetys rity staff communicate with local agencies during
ICS all-hazards structure. a communitywide incident?
Isolation and decontamination: A community must Example:To decrease the possibility of contamina-
know what is available for radioactive, biological, tion of treatment areas, the Medical Center of
Central Georgia in Macon designed a physically
and chemical isolation and decontamination and
separate space for decontamination. If an individual
how to access such capabilities. Not all hospitals is or may be contaminated, staff posted at the emer-
have facilities for such decontamination, but cur- gency medical services (EMS) entrance ramp ensures
rent belief is that it is advisable for hospitals to that the person is directed from the private vehicle or
work with the community to develop decontam- ambulance into a decontamination room prior to
ination plans and capabilities. The team should entering the emergency department.37
also obtain information on hospital/health facili-
ty capacity to support ventilator-dependent indi- Surveillance and laboratory capacity: The team
viduals and to isolate and quarantine individuals should also work to ensure that hospitals and
who require isolation and quarantine. According public health agencies in the area have a collabo-
to a recent study of hospital and community rative plan for timely and appropriate identifica-
emergency preparedness linkages,14 only about tion and testing of suspected agents of bioterror-
half of respondents from rural hospitals reported ism, which include anthrax, smallpox, and others.
48
Drills/exercises: Health care organizations must mon approach to credentialing licensed health
give drills and exercises serious and comprehen- care professionals.ESAR-VHP will be a nation-
sive attention.Testing of every aspect of an emer- al system in the sense that every state and juris-
gency management plan includes all equipment diction will have developed their systems using
the organization will be using during an emer- the ESAR-VHP national guidelines. States and
gency (for example, communications backups, jurisdictions will be encouraged to enter into
emergency generators), involving community agreements to create local and regional consor-
agencies, deploying the clinical staff, setting up tia, notes Marilyn Biviano, chief of HRSAs
the incident command center, evacuating and ESAR-VHP Branch.38
transporting the patient population, and request-
ing and receiving emergency supplies and equip- With the assistance of state licensing boards and
ment from other organizations. medical staff offices at local hospitals, some com-
munities and community hospitals are establish-
Emergency credentialing: Credentialing of disaster ing databases that include information (and pho-
volunteers in order to expand community capa- tos) of credentialed medical volunteers. Photo
bility warrants special focus. As described in identification cards facilitate the accurate identifi-
Sections 4 and 5, the team should consider the cation of credentialed volunteers.
range of potential volunteers, from local health
care professionals such as Medical Reserve Corps Specifically address how to meet needs
and Community Emergency Response Team, for pharmaceuticals and medical
through Disaster Medical Response teams at the
supplies.
federal level. The planning team or a subgroup
Health care organizations and health departments
will need to establish appropriate credentialing
have routine medical and pharmaceutical suppli-
processes. Approximately one third of study
ers and often negotiate special supply arrange-
respondents from hospitals in rural communities
ments with these and other suppliers for emer-
have no established mechanism for credentialing
gency situations. Supply arrangements must be
volunteer staff during an emergency.14 This issue
identified as part of the community planning
has been a big problem in those communities that
effort in order to ensure that all potential surge
have already experienced a variety of different
supply sources are included in the community
kinds of disasters, and deserves significant atten-
plan and to prevent multiple organizations from
tion, comments Jerod M. Loeb, Ph.D., executive
unknowingly relying on the same supplier, there-
vice president of the Joint Commissions Division
by running the risk of an early depletion of sup-
of Research.
plies with no alternative supply arrangements in
place.
Credentialing of disaster volunteers appears to be
lacking nationwide in both urban and rural areas
Successful emergency management planning
and should be examined by community planners.
includes identifying contingency suppliers that
Through a program called Emergency System for
can provide the resources that may be needed to
Advance Registration of Volunteer Health Care
handle a patient surge. Resources include people,
Personnel (ESAR-VHP), the Health Resources
equipment, food, and medical supplies, among
and Services Administration (HRSA) is working
other items. Leaders should establish agreements
with states and jurisdictions to establish a com-
ahead of time with community agencies, other
49
health care providers, and backup suppliers to will be essential in the effort to reach all citizens
ensure that the organizations resource needs can who need medical help after a terrorist incident.
be met during a dramatic patient surge. Having However, these partners need to become fully
adequate quantities of ventilators and personal aware of the NPS to ensure that they are able to
protective equipment is of particular concern most effectively plan for and use this valuable
with a large influx of patients with severe respira- resource.40
tory problems.
To meet this need, the CDC is now offering
In the event of major emergencies or disasters, extensive training to fully prepare state and local
hospitals in local communities contact the local partners. According to the CDC, The prepared-
health department or, in jurisdictions with no ness training and education program is for state
local health department, hospitals call the state and local health care providers, first responders,
health department to request state assistance in and governments (to include federal officials,
meeting needs for drug and medical supplies that governors offices, state and local health depart-
exceed local resources. Sidebar 15 provides addi- ments, and emergency management agencies).
tional information on this process. The states This training not only explains the SNS pro-
governors office can request federal assistance if grams mission and operations, it alerts state and
local needs exceed state resources. The CDCs local emergency response officials to the impor-
Strategic National Stockpile (SNS), formerly tant issues they must plan for in order to receive,
known as the National Pharmaceutical Stockpile secure, and distribute SNS assets.41 Training
(NPS), can be made available to any community information is available at www.bt.cdc.gov/train-
in need of additional medicinal support in ing.
response to an event involving a number of dif-
ferent threat agents. It consists of several tons of Given the availability to hospitals of external
needed pharmaceutical supplies and equipment, sources of drugs and related supplies from the
strategically located throughout the United CDCs SNS, the American Hospital Association
States, which will be delivered to the local com- recommends that hospitals be prepared to sustain
munity within 12 hours of an event.The National a 24-hour supply of pharmaceutical products at
Response Plan does not need to be activated in the most common dosage and that a standardized
order for the stockpile to be requested by the formulary should be developed to adequately
governor for use in a local community.39 determine stock requirements for medical/surgi-
cal supplies and equipment.42 In its white paper,
All communities, both large and small, must the Joint Commission recommends ensuring a
address how they will procure and distribute 48- to 72-hour stand-alone capability through the
additional supplies from local stockpiles and the appropriate stockpiling of necessary medications
national stockpile. Responsibility currently varies and supplies.30
widely by community and includes local health
care providers, public health officials, EMS, fire Identify and address hazards and
services, law enforcement, and other services. In resources that cross jurisdictions.
testimony before a U.S. House of Representatives Disasters do not recognize jurisdictional lines (for
subcommittee, a CDC official stated:Local orga- example, hurricanes affect multiple municipalities
nizations at the city, county, and regional level and counties simultaneously); similarly, resources
50
SIDEBAR 15. ASSURING DRUGS AND MEDICAL

must cross jurisdictional lines to meet the needs
SUPPLIES IN LOCAL COMMUNITIES of communities affected by disasters (for example,
by transporting residents of one county without
During the occurrence of a major emergency or dis-
an acute care facility to another county with such
aster, a hospital in the local region may quickly need
additional support in the form of drugs and medical a facility).The plan should address both realities.
supplies. The hospital will have activated its emer-
gency response plans using the Hospital Emergency Identify how preparedness and
Incident Command System (HEICS) or another response success will be measured.
incident command system (ICS). Drills, exercises, and real events described in
Section 10 can shed light on the success (or lack
The individual functioning as Incident Commander,
thereof) of preparedness and response efforts out-
as specified under the ICS structure, or a person to
whom he or she has delegated this responsibility, will lined in the plan. However, while developing the
initiate a request with the local public health depart- plan, the team will want to consider parameters
ment (LHD) that serves the jurisdiction in which or indicators that will be used to measure success.
the hospital is located. The Incident Commander Communities need realistic feedback regarding
alerts the LHD to the fact that the hospital is expe- the true level of preparedness.This helps to estab-
riencing rapid depletion of certain medications or lish realistic expectations, ensure identification of
supplies due, perhaps, to a widespread problem gaps, and enable these gaps to be filled in the best
affecting the areas residents. possible way, given the communitys resources.
Before an emergency occurs, it therefore is critical
that the Incident Commander and other hospital Consider the lessons learned from 9/11.
leaders know who the hospitals public health offi- The Pentagons use of a unified command system
cials are and how to contact them. Hospital leaders during the 9/11 attack was considered by many to
must establish ongoing relationships with their pub- be a model of implementation in terms of coordi-
lic health officials. In rural areas of the nation, where nating the roles of emergency responders, first
there is no local public health department, the state receivers (hospitals), public health, law enforce-
health department provides public health services to ment, the FBI, and others.The emergency response
local jurisdictions. at the World Trade Center was heroic, yet there
were significant lessons learned. Communities, no
Local health departments can request further sup-
matter how small, can learn from what went right
port from state health departments. State health
and what went wrong. The 9/11 Commission
departments, through the governor, can request fed-
eral support, including pharmaceuticals and medical Report11 cited the following lessons:
supplies from the CDCs Strategic National Avoid bureaucratic inertia.
Stockpile. Simplify oversight and clarify accountability.
Too many parties dilute the effectiveness of
Source: Christine C. Bradshaw, D.O., M.P.H., M.B.A., response and run the risk that no one assumes
medical officer, Centers for Disease Control and responsibility.
Prevention, Coordinating Office of Terrorism Challenge assumptions about what the likely
Preparedness and Emergency Response. threats will be.Think outside the box.
Assure joint operational planning. Give up turf
and collaborate for efficiency. Avoid duplica-
tion of effort.
51
Provide layered preparedness and response covering how different commands should
mechanisms. communicate during an incident.
Designate who will be the communicator at Make sure first responder civilians know what
each response and operations entity. to do.
Technology is an asset but can also be a liability. Assure that each participant of the unified
If power fails, is there a means for communica- incident management system has command
tion and other functions served by technology? and control of its own units and adequate
Train people as backup for technology. internal communications.
Ensure detailed and effective transfer of Conduct regional drills in order to establish
knowledge when new persons come into professional relationships and trusts.
important roles or during other transitions/ Promote and reward information sharing.
transfers of authority or responsibility. Match resources to responsibility and function.
Develop standardized operating procedures
TOOLS:
Federal Emergency Management Agency (FEMA): Managing the Emergency Consequences of Terrorist
State and Local Guide (SLG) 101: Guide for All-Hazard IncidentsInterim Guidelines: http://
Emergency Operations Planning, 1996. http:// www.fema.gov/preparedness/managing.shtm.
www.fema.gov/rrr/gaheop.shtm.
This interim planning guide provides state and local
Published in 1996, this guide outlines the preparedness, emergency management planners with a framework for
response, and short-term recovery planning components developing supplemental emergency operations plans
that FEMA recommends be included in state and local that address the consequences of a terrorist attack
emergency operations plans. Attachment G, published in involving WMD. It encourages the efficient integration
April 2001, provides specific guidance for terrorism plan- of state, local, and federal terrorism response activities
ning. http://www.fema.gov/pdf/rrr/allhzpln.pdf. and provides current information regarding planning
and operational challenges faced by communities that
State and Local Preparedness Guidance: have dealt with terrorist events.
http://www.fema.gov/preparedness/
state_local_prepare_guide.shtm. National Capability Assurance:
http://www.fema.gov/preparedness/nca.shtm.
Emergency Operations Planning Guidance is designed
to help state and local governments fine-tune their FEMAs Capability Assurance effort focuses on
EOPs and address critical planning considerations to resources and programs to help the state, tribal, and
include a focus on weapons of mass destruction local emergency management and response communi-
(WMD) incidents, interstate and intrastate mutual aid ties be better prepared to respond to disasters and inci-
agreements, resource typing, resource standards, protec- dents of all kinds. These processes and resources focus
tion of critical infrastructure, inventory of critical primarily on assessment and exercise-related programs,
response equipment and teams, continuity of opera- processes, and systems.
tions, and family and community preparedness.
Train people as backup for technology.
52
7. Ensure Thorough Communication Planning

Recommended Planning Strategies: fire fighters to arrive at the World Trade Center
Understand how communication is were hampered by radio communications prob-
transmitted. lems. Those first responders thus actually had less
Plan for alternative and backup com- knowledge about what was happening inside the
munications links and systems. buildings than those outside the buildings.
Plan and provide for emergency back-
up power to communications systems. In any community, communication patterns devel-
Ensure interoperability of communi- op and change to fit the day-to-day needs of the
cations systems. community. These communication patterns, both
Use available communications plan- internal and external, are influenced by equipment
ning resources. use, procedures, and channels for collecting, orga-
Review and build on existing com- nizing, and exchanging information among com-
munications planning initiatives. munity agencies and organizations. Planning for the
Obtain/prepare information for crisis provisions that should be available for communica-
communications. tions during an emergency is difficult because
Define emergency communications emergencies are by their very nature unpredictable,
protocols or procedures. and so are their effects on the community. Elements
Establish communications credibility of an emergency response plan for communications
with the public. that works for one community may not meet the
Recognize and plan for the critical needs of other communities due to differing com-
role played by the media. munications infrastructure, equipment, channels of
Identify how every community mem- communication, and dozens of other possible fac-
ber can be reached in an emergency. tors. Strategies that can help communities achieve
Plan to provide decisional support. thorough communications planning follow.
Ensure culturally sensitive communi-
cation.
Understand how communication is
Use publicly available communica-
tions materials. transmitted.
Ensure integration of the local health
An understanding of how communication meth-
care organizations communications ods work is critical to effectively planning for the
plans. communications consequences of an emergency
because emergencies can interrupt established
Two principal goals of communications planning in communication systems (see section on Plan for
emergency management are (1) to establish and alternative and backup communication links and
maintain a common operating picture and (2) to systems.). Communications are usually transmit-
ensure accessibility and interoperability across juris- ted by wire line, radio, or a combination of the
dictions and functional agencies.27 Although two. Wire line communications, such as tele-
progress toward meeting these goals has been made, phone and telegraph, involve sending and receiv-
much work remains to be done. During the 9/11 ing an electromagnetic signal by a closed con-
attacks, for example, the response efforts of the first ducting path, such as a copper wire or fiber-optic
53
cable. In radio communications, signals are sent Plan for alternative and backup
and received by electromagnetic radiation, gener- communications links and systems.
ally through the atmosphere, without a connect- Although many small communities may find it
ing wire. Combination communications systems, challenging enough to establish and maintain need-
such as cellular radio, use both wire line and radio ed communications links and systems, backup links
transmission paths. Sidebar 16 itemizes types of and systems may be equally critical to effective
communications equipment. emergency response. (see Sidebar 17 on page 55.)
For example, the public telephone network can be
SIDEBAR 16. COMMUNICATIONS EQUIPMENT
overloaded easily by increased traffic or become
physically disrupted during a major disaster.
Radio
Equipment Wire Line Combination Because radio and microwave systems can also be
damaged, communities should consider available
Two-way Cellular replacement supplies of antennas, coaxial cable, and
radio Telephone telephone other hardware susceptible to damage. Make sure
Satellite that telephone lines coming into community com-
Pagers Fax machine telephone munications centers are buried (where feasible),
clearly marked, and protected from damage.
Broadcast Computer
radio modem
A designated radio frequency can be used for
Public address point-to-point community disaster coordination.
Television system Because a single frequency is often easily over-
Satellite Intercom loaded and abused during even minor emergen-
cies, incorporate into the system a method for
preventing overload. This might include a prac-
For effective emergency response, reliable commu- ticed system discipline (such as limitations on the
nications must exist between specific fixed loca- lengths of messages) and alternative communica-
tions, between fixed and nonfixed (mobile) locations paths (such as switching to cellular radio
tions, and between two or more mobile locations. telephone to handle a communications overload).
Some of the communication paths that must be When possible, radio transmitter/receivers
planned for and established include local emergen- equipped to operate on multiple frequencies
cy medical services (EMS) radio dispatching, health should be available.
care organizations to each other and to ambulances,
ambulances to a medical communications control Example:The Huntington Beach (California) Fire
center, fire and law enforcement to command cen- Department has a volunteer program called Radio
ters and to each other, and so forth. Amateur Civil Emergency Services (RACES), which
provides backup communications during disasters. In
For effective emergency response, reliable communications must exist between specific fixed loca-
tions, between fixed and nonfixed (mobile) locations, and between two or more mobile locations.
54
2001 the fire department trained RACES to back up Plan and provide for emergency backup
its 800 MHz system. In September 2004, just two
weeks after an exercise to test preparedness, the fire
power to communications systems.
departments 800MHz fire radio system went down Facilities with fixed communications systems
for the entire county.The fire department placed a should have adequate standby power sources that
RACES member in the police dispatch where the are independent (batteries or generators, for
911 calls came in and one in each fire engine, truck, example) to avoid dependence on commercial
and ambulance. RACES provided emergency commu- power. Important locations in a service area, such
nications for the city for several hours.43 as health care organizations, should have more
SIDEBAR 17. BACKUP COMMUNICATIONS

The State of New Hampshire, as part of the Critical Benchmark expectations of the Cooperative Agreement Grant:
The National Bioterrorism Hospital Preparedness Program with the Health Resources and Services Administration
(HRSA), has developed a strategy to update ambulance-to-hospital (HEAR) radio equipment and provide for redun-
dant communications for the 26 acute care hospitals in New Hampshire.The benchmark in the grant is as follows:
Critical Benchmark #2-10: Surge Capacity: Communications and Information Technology

Establish a secure and redundant communications system that ensures connectivity during a terror-
ist incident or other public health emergency between health care facilities and state and local health
departments, emergency medical services, emergency management agencies, public safety agencies,
neighboring jurisdictions and federal public health officials.
A survey of each hospitals HEAR radio system was completed. It was discovered that some, but not all, hospitals had
a backup radio. Many of the hospitals had very old equipment, especially in small rural hospitals. Few if any hospitals
had digital capability. Concurrent with this effort has been an ongoing statewide radio interoperability project for police
and fire services.
The radio subcommittee of the New Hampshire Hospital Associations Hospital Emergency Preparedness Working
Group developed the following simple objectives for the radio purchase project to ensure that each hospital:
has APCO 25 compliant equipment (http://www.apcointl.org/frequency/project25/information.html)

has digital capability (part of APCO 25 compliance)
has redundant radio capability (by preserving their existing system)
Another objective of the committee is to have the same equipment in hospitals throughout the State in order for it
to be familiar to personnel in the event they are called to respond to a mass casualty event where they are working
in another hospital, etc.
Based on these criteria, we decided to purchase a base station radio that has 16 channels and can work in either ana-
log or digital (some of our more rural and mountainous parts of the State cannot support digital). It is understood that
though a hospital may choose to use the new radio for their primary radio for continuous EMS monitoring/commu-
nication, having the built-in capability on the other channels is prudent and could be useful during a large scale emer-
gency.
Source: Personal communication from JoseTheir Montero, M.D., state epidemiologist of New Hampshire,Aug. 10, 2005.
55
than one radio site so that communications will The Federal Emergency Management Agency
not be totally lost if one radio site fails. If possi- (FEMA) eGov Disaster Management Program
ble, teams can consider whether it is possible to provides responders with a Web-based service
install extra equipment at different geographic called the Disaster Management Interoperability
locations throughout the community. Services Interoperability Backbone, which offers
free communication tools that allow responders
The systems design should allow for enough to share information with other responder orga-
telephone lines, radio channel capacity, and oper- nizations. Responder groups receive and trans-
ating positions, or rapid expansion capability to mit information over the web, enabling them to
handle the heavy communications traffic loads rapidly develop and exchange incident informa-
generated by disasters. For example, health care tion with other responder organizations. This
facilities can consider having several telephone capability of sharing incident information gives
lines with unlisted numbers, which makes it eas- all responders greater knowledge of a particular
ier to make outgoing telephone calls when there disaster event by leveraging technology to gain
is heavy incoming telephone traffic. efficiency, notes the Web site44 (see Tools).
Ensure interoperability of TOOLS:

The goals of the DMIS Interoperability
communications systems. Backbone Web site are to improve disaster
Interoperability of communications systems in
response by enabling responders to share
emergency planning involves primarily the abili- information seamlessly between organizations,
ty of first responders and emergency coordinators and to provide new software tools at no cost
to communicate directly by radio with individu- to responder organizations for increased disas-
als from other agencies.The ability of computers, ter response effectiveness. http://
mutual aid entities, and planning groups across www.cmi-services.org/dmishp_what_is_
jurisdictions to participate in joint efforts is also dmis.html.
often considered part of interoperability.
Example: Laurel, Maryland, a city of 22,000 locat-
Lack of interoperability is a significant problem
ed near Washington, D.C., created a low-cost com-
nationwide and was a well-publicized obstacle
mand center with used computers and donated soft-
faced by the New York City fire and police ware from the federal government.The center pro-
departments during the 9/11 attacks. Local and vides interoperability with four counties surrounding
state first responders currently are spread across D.C. Its software includes instant messaging capa-
10 different radio frequency bands and often can- bilities that allow users to access and share docu-
not communicate directly with each other. ments over a private network.33
Interoperability challenges result from spectrum
limitations, funding limitations, incompatible Use available communications planning
technology, and lack of systems planning. In resources.
response, the 9/11 Commission called for Like other planning efforts, communications
Congress to support pending legislation for the planning need not involve reinventing the wheel.
expedited and increased assignment of radio Teams can consult available resources. For exam-
spectrum for public safety purposes.11 ple, a Web-based guide and toolkit provided by
56
the National Education Association for school Review and build on existing
administrators includes tips, resources, ideas, and communications planning initiatives.
examples for being prepared before a crisis, being Communications planning may already have
responsive during a crisis, being diligent in mov- occurred in numerous agencies within small
ing beyond a crisis, and for hands-on assistance communities, such as law enforcement, fire, hos-
for educators (see Tools). pitals, and school systems. These initiatives might
provide an appropriate starting point for overall
Local planners can consult federal Web sites that community communications planning. Plans
provide free access to collaborative communica- should be reviewed thoroughly and adapted as
tion tools. One such Web site is http:// needed.
www.disasterhelp.gov (see Tools).
Example: Nuclear power plants are required by law
TOOLS :
to facilitate and fund community-based emergency
Agency for Toxic Substances and Disease
planning and to engage in education, information,
Registry: A Primer on Health Risk
preparedness, and drills with their community resi-
Communication Principles and Practices. http:// dents on a regular basis. Such relationships, which
www.atsdr.cdc.gov/HEC/primer.html. cross jurisdictional lines, can serve as models for other
communities to engage in integrated communication
American Red Cross: Talking About Disasters: planning, coordination, and public education.
Guide for Standard Messages (2004). http://
www.redcross.org/disaster/safety/guide.html.
Obtain/prepare information for crisis
National Education Association: Crisis communications.
Communications Guide and Toolkit, 2003. Lists of contacts, with addresses and phone num-
http://www.nea.org/crisis. bers, should be established and maintained regu-
larly45 to support timely access to critical individ-
U.S. Department of Health and Human uals, information and resources. The team can
Services (DHHS): Communicating in a Crisis: prepare emergency proclamations, citizen alerts,
Risk Communication Guidelines for Public Officials. and other important documents in advance.46
Washington, DC: DHHS, 2002. http:// Much of the success of effective crisis communica-
www.riskcommunication.samhsa.gov/ tion, communication that occurs during an actu-
index.htm. al crisis, is predicated on the effort that goes into
communications planning, information provision
Wyatt W.: Be Prepared: Communicating in a Crisis. prior to a crisis, and ongoing public education
http://www.ncsl.org/programs/legman/nlssa/ often called risk communication.
402crisis.htm.
Sidebar 18 provides the rules of risk communica-
DisasterHelp offers collaborative tools, includ- tion recommended by the U.S. Environmental
ing instant messaging and chat, discussion Protection Agency.
threads, and secured document sharing to the
responder community.
http://www.diasterhelp.gov.
57
SIDEBAR 18. SEVEN CARDINAL RULES OF RISK

The planning team should ensure intact protocols
COMMUNICATION that allow law enforcement, fire, EMS, and hospi-
tals to communicate with each other during disas-
1. Accept and involve the public as a partner. Your
ter operations. A crisis communication protocol is
goal is to produce an informed public, not to
defuse public concerns. a key element of community plans; community
2. Plan carefully and evaluate your efforts. Different planners should be aware of protocol contents.
goals, audiences, and media require different According to the study of hospital and communi-
actions. ty emergency preparedness linkages,14 the majority
3. Listen to the publics specific concerns. People of respondents from rural hospitals indicated that a
often care more about trust, credibility, compe- crisis communication protocol existed in their
tence, fairness, and empathy than about statistics community, but many still did not know whether
and details. such a protocol was available.
4. Be honest, frank, and open. Trust and credibility
are difficult to obtain; once lost, they are almost
Some communications techniques include using
impossible to regain.
common disaster channels and multichannel radios
5. Work with other credible sources. Conflicts and
disagreements among organizations make com- and cross-banding or cross-patching of channels
munication with the public much more difficult. through communication-center consoles.
6. Meet the needs of the media.The media are usu-
ally more interested in politics than risk, simplic- Establish communications credibility
ity than complexity, danger than safety. with the public.
7. Speak clearly and with compassion. Never let
Communication with the public during and fol-
your efforts prevent your acknowledging the
lowing an emergency must be clear, credible, and
tragedy of an illness, injury, or death.
consistent. This requires thorough planning in
Source: Covello V., Allen F.: Seven Cardinal Rules of Risk advance of any major occurrence. Residents of
Communication. Washington, DC: U.S. Environmental small towns and rural communities often turn to
Protection Agency, Office of Policy Analysis, 1988. local leaders as the most direct source of informa-
tion in their towns and communities.46
Define emergency communications Identification of a spokesperson who is well
protocols or procedures. respected is key. In some communities, this might
Disaster communications procedures should be be the mayor or other elected official, hospital
clearly defined, with an emphasis on interagency leader, religious leader, or others. Prior to any
coordination. These procedures should be a emergency, this individual can be involved in edu-
straightforward expansion of day-to-day proce- cating and building trust with the community.
dures rather than a radical change in normal oper- People are more likely to follow official instruc-
ating procedures.There should be established com- tions when they have a lot of trust in what officials
munications paths with military, amateur, air, pub- tell them to do and are confident that their com-
lic utility, and other radio operations outside the munity is prepared to meet their needs, notes one
Public Safety Radio Service. Communication study.24
must be accurate and up-to-date and provide
Example: Poison control centers, nurse call lines, and
information in real time so that messages will be
other types of medical contact systems can serve as a
correct and consistent across all entities. conduit of credible information to the public.As part
58
of their normal, day-to-day operations, they become a channels, including telephone, television, radio,
familiar source of health and safety information for the and computer (for Internet and e-mail, for exam-
public. During an emergency, the public is likely to ple), can be thoroughly considered by the plan-
seek information from these sources, which become an ning team.According to a recent survey conduct-
important means of community response support. By ed for the U.S. Department of Homeland
addressing questions on exposure, symptoms, and care
Securitys (DHSs) Office of Citizen Corps, there
over the telephone, they can help reduce the demand
on acute care facilities. is no one channel of communication that all
Americans prefer for receiving information.26
Example:To answer questions about how residents
can prepare for all types of emergencies and how their Example: Many communities have developed and
city and county were preparing for emergencies, are using a reverse 911 system to contact residents
Roseville, Minnesota (population 34,000), hosted a in the event of an emergency and to provide ongoing
community emergency readiness night.46 The presenta- guidance during an emergency (for example, indicat-
tion and discussion were open to all residents.Topics ing that hospital X cannot take more patients, but to
included how to prepare for all types of severe weather go for care at hospital Y instead). Depending upon
and preparing for Y2K problems, which was an issue the length of the message and system capabilities,
of concern at that time. automated telephone calling systems can, within a
one-minute period, dial a dozen to hundreds of tele-
phone numbers and deliver a prerecorded message.
Recognize and plan for the critical role Targeted messages can be delivered to certain areas
played by the media. and in different languages, as appropriate.Through
The media observe and report, but they also edu- educational efforts, residents can be encouraged to
cate and warn.As indicated in Section 2, the plan- provide the reverse 911 agency with their unpub-
ning team includes the media, but special effort lished or cell phone numbers.
can be made to integrate the medias two key
functions in planning.In the first role (to observe Plan to provide decisional support.
and report), the media acts as an outsider to the During an emergency, people want to know what
community; in the second role (to educate and is happening, what they should do, and where to
warn), the media is an integral part of the emer- get help. For events such as a terrorist attack, it is
gency preparedness system. Seldom are the two not always possible to provide complete informa-
roles well integrated, leading to a weaving back tion. However, it is imperative that communication
and forth from one role to the other, and confus- occurs and that the spokesperson plans to establish
ing media users. News stories provide the opera- an immediate presence and provide as much accu-
tive reality about the crisis period for almost rate and timely information as possible.46
everyone, notes E.L. Quarantelli, cofounder of the
Disaster Research Center at the University of Although we live in an electronic age and a lot
Delaware.47 of information is available through the Internet,
obtaining information or advice from another
Identify how every community member human being appears to be critically important to
can be reached in an emergency. the American public in this situation. Both the
Community preparedness requires a locational survey and our discussions with community resi-
system that can reach every person in a communi- dents around the country document that people
ty, from cradle to rocking chair. Communication are looking for decision-making support, not just
59
facts. People want to talk to someone to (1) con- consulted to assure that the most effective strate-
firm what they are hearing from government gies, messages, and modes of communication for
officials or through the media, (2) get additional those groups are incorporated in the planning.
information to answer their questions, and (3) The anthrax attacks in 2001 illustrated the risk of
help them resolve difficult tradeoffs so they can providing mixed messages to different communi-
make the best decisions for themselves and their ties. Ethnic groups who have experienced dispar-
families, indicates the Redefining Readiness ities in health care and/or social services may
study.24(p. 19) look upon certain pronouncements with an atti-
tude of skepticism rather than cooperation, espe-
Good communication is perceived differently cially messages regarding, for example, the phased
by the communicator, who wants public cooper- distribution of prophylaxis or the need for isola-
ation and understanding in a time of crisis, and tion or quarantine. Houses of worship, business
the public, which wants inclusion, consideration, groups, and ethnic radio/TV and print media are
respect, expert guidance, and proof that officials frequently trusted sources of information within
have justly considered the public. (High quality) ethnic communities. Community-organized tele-
risk communication bridges this gap by providing phone support networks can provide culturally
individuals and communities with information in-tune and accurate advice when integrated into
that allows them to make the best possible deci- the planning process. Other high-touch meth-
sions about their well-being, notes an Institute of ods, including in-person outreach, may be need-
Medicine (IOM) report.48(p. S-38) ed in some communities.
Ensure culturally sensitive Unless public messages are tailored to gain the
communication. attention of specific segments of our racially and
Consideration of the communication form and culturally diverse society, they are likely to be
language is critical. Given the large portion of ignored. (For example,) clear communication will
non-English-speaking residents in the United be essential to obtaining adherence to mass vac-
States, cultural sensitivity must be assured. cination campaigns during a pandemic, notes a
Communities with significant cultural diversity recent IOM report.48(p. S-37)
need to plan for communication in the appropri-
Example:The hurricanes of 2004 hit hard in por-
ate languages.
tions of DeSoto County, Florida, where migrant
farm workers lived and worked in the areas citrus
The planning team should consider if there are groves.The local hospital, health department, and the
cultural or linguistic groups not represented at Centers for Disease Control and Prevention (CDC)
the planning table. These should be included or were concerned about the communitywide risks posed
Good communication is perceived differently by the communicator, who wants public cooperation
and understanding in a time of crisis, and the public, which wants inclusion, respect,
expert guidance, and proof that officials have justly considered their needs.
60
by standing and contaminated water and other health health status, simply for general information on
hazards. In the past, migrant workers typically used disaster response, or as a safe haven, these facilities
the local hospital to meet their health care and infor- must have a communications plan that includes a
mation needs. However, leery of contact with govern- triage communication procedure. The plan must
ment officials on the scene, many workers chose to stay be integrated with the communitywide plan to
in the citrus groves rather than seek hospital care.The
ensure consistency between the message deliv-
hospital sent mobile care units, staffed by bilingual
individuals, into the citrus groves to identify and treat ered by the health facilitys administrator and the
injuries, provide information on safe water use, and try communitywide spokesperson. Hospitals need
to reestablish contact and trust. to work with local emergency service organiza-
tions to provide clear, accurate information dur-
Use publicly available communications ing large-scale emergencies.To avoid disseminat-
ing conflicting information, hospitals that use
materials.
incident command systems provide for an indi-
Small communities need not create their own
vidual who will coordinate with other response
public awareness and readiness advertisements,
groups and communicate with the media and
materials, and other communications vehicles
other outside organizations, notes an
concerning certain standardized content. Such
Occupational Safety and Health Agency
information is available through numerous
report.49(p. A-16) A well-designed communication
sources, including the American Red Cross
plan can decrease the flood of individuals not
(http://www.redcross.org/press/psa/psaPrint.html),
requiring care but coming to health facilities as a
FEMA (http://www.fema.gov), and other agen-
preventive measure, as was experienced by many
cies. Resources offered by the American Red
New York health facilities on 9/11 and the days
Cross include preparedness print advertisements
following the attacks.
devoted to specific emergencies (for example,
Are you ready for an earthquake?), and televi-
sion, radio, and Web banner public service
announcements in English and Spanish. FEMA
offers guides, educational materials for teachers,
fact sheets, and so forth.
Example: A Midwestern town hung on its down-

town lamp posts two American Red Cross banners:
One banner read Together We Prepare.The sec-
ond banner listed five activities people could carry
out to get prepared: make a plan; build a kit; get
trained; volunteer; and give blood.
Ensure integration of the local health

care organizations communications
plans.
Because many community residents will call or
come to the local health facility for care, for
information on their loved ones location or
61
8. Ensure Thorough Mental Health Planning

Recommended Planning Strategies: health field is plagued by disparities in the avail-
Use available mental health disaster ability of and access to its services. These dispari-
planning resources. ties are viewed readily through the lenses of racial
Link to pastoral care resources. and cultural diversity, age, and gender, notes a
Consider organizing self-help groups. U.S. Surgeon Generals report.52(p. vi)
Link to and know how to access fed-
eral and state disaster mental health Strategies teams can use to address mental health
plans/resources. needs follow.
Recognize and plan for the emotion-
al effect of crises on rescue and
health care workers. Use available mental health disaster
planning resources.
Reactions to disasters may vary from one indi- Since publication in 2003 of the Mental Health
vidual to another, and stress reactions can occur All-Hazards Disaster Planning Guidance by the
immediately following the disaster or many Center for Mental Health Services of the U.S.
months later.50,51 These reactions may include Department of Health and Human Services,53
physiological symptoms (nausea, dizziness, chills), state and local mental health leaders have had a
cognitive/intellectual symptoms (distractibility, key resource for the creation or revision of all-
difficulty communicating thoughts), emotional hazards mental health response plans (see Tools).
symptoms (anxiety, grief, depression), behavioral The publication outlines the planning process,
symptoms (insomnia, substance abuse), and spiri- plan contents, and resources. An appendix out-
tual symptoms (challenges to faith beliefs, anger lines the discrete elements of an all-hazards state
and blaming, and so forth). These reactions may disaster mental health plan.
be experienced by both victims of the disaster
and those who responded to help the victims. Sidebar 19 lists numerous organizations that pro-
Some of these reactions may be severe enough to vide information on the behavioral consequences
require an individuals referral to behavioral of disasters.
health services.
Link to pastoral care resources.
Mental health problems following natural or man- In times of crisis and long after the crisis is over,
made disasters impact communities of all sizes, but many people look to their familiar clergy and
rural and small communities may find it particu- other religious leaders in the community for
larly challenging to respond to the needs of their comfort and guidance. Planning teams should
residents. In the best of circumstances, such com- consider community faith-based social support
munities lack a sufficient number of mental health systems and how to link to pastoral and spiritual
specialists. Moreover, their residents, whether due caregivers who can provide assistance to individ-
to geographic, economic, cultural, ethnic, or other uals seeking spiritual and emotional support, reas-
impediments, may be unable or unwilling to surance, and guidance. National pastoral crisis
access mental health specialists. Even more than resources, including the American Red Cross, the
other areas of health and medicine, the mental- International Critical Incident Stress Foundation,
62
SIDEBAR 19. BEHAVIORAL HEALTH INFORMATION

Inc., and the Salvation Army, can also be consid-
RESOURCES FOR DEALING WITH THE EFFECTS OF ered. In a disaster relief operation, Salvation Army
DISASTERS volunteers offer emotional comfort and spiritual
comfort through a ministry of presence.
The following list identifies a few of the numerous
organizations that provide information on the
Recognition of the diversity of faith traditions
behavioral consequences of disasters. and belief systems is critical to the effectiveness of
pastoral services.
American Academy of Child and Adolescent
TOOLS:
Psychiatry
Institute of Medicine: Preparing for the
http://www.aacap.org
International Critical Incident Stress Psychological Consequences of Terrorism: A Public
Foundation, Inc. Health Strategy. Washington, DC: National
http://www.icisf.org Academies Press, 2003. http://www.nap.edu/
American Academy of Experts in Traumatic Stress openbook/0309089530/html.
http://www.aaets.org
National Alliance for the Mentally Ill U.S. Department of Health and Human
http://www.nami.org Services (DHHS). Mental Health All-Hazards
American Psychiatric Association Disaster Planning Guidance. DHHS Pub. No.
http://www.psych.org SMA 3829. Rockville, MD: Center for
National Association of School Psychologists Mental Health Services, Substance Abuse and
http://www.nasponline.org Mental Health Services Administration, 2003.
American Psychiatric Nurses Association http://www.mentalhealth.samhsa.gov/
http://www.apna.org publications/allpubs/SMA03-3829/default.asp.
National Association of Social Workers
http://www.naswdc.org U.S. Department of Health and Human
American Psychological Association Services (DHHS): Mental Health Response to
http://www.apa.org Mass Violence and Terrorism: A Training Manual.
National Center for Post-Traumatic Stress Disorder DHHS Pub. No. SMA 3959. Rockville, MD:
http://www.ncptsd.org Center for Mental Health Services, Substance
American Red Cross
Abuse and Mental Health Services
http://www.redcross.org
Administration, 2004. http://
National Depressive and Manic Depressive
www.mentalhealth.samhsa.gov/publications/
Association
http://www.ndmda.org allpubs/SMA-3959/default.asp.
The Center for Mental Health Services
http://www.mentalhealth.org Consider organizing self-help groups.
National Institute of Mental Health Self-help groups or teams can be helpful in pro-
http://www.nimh.nih.gov viding needed assistance following a disaster, par-
Disaster Mental Health Institute at the University ticularly if mental health professionals are not avail-
of South Dakota able in or to the community. Emotional encour-
http://www.usd.edu/dmh agement and practical support (working with
National Mental Health Association
neighbors to board up windows and clean homes
http://www.nmha.org
Federal Emergency Management Agency after a catastrophic fire, escorting neighborhood
http://www.fema.gov children to school past tornado-damaged homes,
63
and so forth) are invaluable during a disaster and response to critical incidents came from two
throughout the recovery phase as people try to areas: community mental health centers and the
respond to the crisis and rebuild their lives. Red Cross mental health branch. Following the
events of 9/11 it soon became apparent that New
Example:Westport, Connecticut, developed a com- Hampshire like many other states lacked the
munity support and counseling team to address the capacity to respond to the behavioral health
mental health needs of its approximately 26,000 needs of its citizens if a major disaster were to
residents in times of crisis.The team is developing occur. The Substance Abuse and Mental Health
training for mental health professionals, school and Services Administration (SAMHSA) issued a
community clinicians, home health care providers,
request for proposal to increase state behavioral
child care workers, and volunteers.33
health response capacity. New Hampshire was
one of 35 states to receive a $200,000 grant from
Link to and know how to access federal SAMHSA for this purpose.The majority of these
and state disaster mental health funds have been used to identify behavioral
plans/resources. health professionals, encourage them to volun-
When disasters strike, regional or state mental teer, and train them in the unique aspects of dis-
health/substance abuse agencies and local service aster behavioral health response. In addition,
providers may be suddenly thrust onto the front training has been provided to emergency medi-
line for response and recovery efforts because of cal, public health, and public safety organizations
geographic proximity to the area affected by dis- to familiarize them with the psychosocial impact
asters. Often they find themselves confronting of disasters and the existence of behavioral health
new or unknown problems for which no amount response in New Hampshire.
of preplanning is possible.54 The provision of
mental health services following a disaster will be The New Hampshire Department of Safetys
beyond the capability of many small, rural, and Bureau of Emergency Management (BEM) has
suburban communities. Such communities must developed organized teams of behavioral health
link their plans to state disaster mental health providers to respond to the mental health needs
plans and must know how to access regional, of New Hampshire residents following disasters.
state, or federal services (Sidebar 20). Five regional disaster behavioral health response
teams (DBHRTs) totaling over 500 professionals
The state of New Hampshire has little experience have been created and can be deployed immedi-
with terrorism, and the most rural areas lack the ately anywhere in the state. These teams would
resources to prepare for and respond to disasters. respond to disasters or critical incidents when
Historically New Hampshires behavioral health local behavioral health resources have been
Planning teams should consider community faith-based social support systems and how to
link to pastoral and spiritual caregivers who can provide assistance to individuals seeking
spiritual and emotional support, reassurance, and guidance.
64
depleted or are overwhelmed. The goal of the The American Red Cross (http://www.
DBHRTs is to provide an organized response to redcross.org/services/disaster) also provides men-
individual victims, family members, survivors, or tal health services to anyone in affected areas fol-
the community affected by critical incidents or lowing any emergency and to families outside the
disasters. Teams include individuals with experi- disaster area. Services, which are available on
ence in human services, psychology, mental average for a few days or a week following the
health, substance abuse, social work, psychiatry, event, include counseling and referral by licensed
education, or spirituality. DBHRT members have mental health professionals.
completed specialized training. Team members
operate under the supervision of BEMs disaster The Department of Justices Office for Victims of
behavioral health coordinator, receive ongoing Crime (http://www.ojp.usdoj.gov/ovc) provides
training, and participate in communitywide drills. advocacy and other services, including support
Team members can provide interventions in for short- and long-term mental health services,
three distinct phases that may be delivered at a to victims of criminal acts (including terrorism).
disaster site, in an affected community, or
statewide. The phases and interventions include SIDEBAR 20. FEDERAL MENTAL HEALTH
the following: RESOURCES
SAMHSA DTAC
Immediate Response: Behavioral health needs Established by the Substance Abuse and Mental
assessment, psychological first aid, crisis interven- Health Services Administration (SAMHSA), the
tion, community outreach, public information, Disaster Technical Assistance Centers (DTACs) mis-
sion is to ensure that the United States is prepared
and behavioral health consultation
and able to respond rapidly when events increase the
need for trauma-related mental health and substance
Transition to Recovery: Brief supportive counsel- abuse services. The agency performs the following
ing, information dissemination, screening and functions:
referral, support groups, and public education Preparation: Assists states and territories with all-
hazards disaster response planning by providing
Preparedness and Mitigation: Disaster behavioral consultation to review disaster plans, conducting
health planning and networking, prevention ser- literature reviews, and brokering knowledge and
vices designed to strengthen community support.
resilience, specialized training initiatives for team Response: Assists in identifying suitable publica-
members and community partners, and research tions, psychoeducational materials, and expert
consultants, and organizes training events and
workshops to share the experiences of states that
Activation of the DBHRT is done through the have confronted certain types of disasters.
governor, or a designee at the BEM, during fed- Communication and resources: Maintains a contact
eral or state emergencies. If an emergency is not database of state/territory mental health commis-
declared, local municipalities or emergency sioners, substance abuse directors, and disaster
response systems may request assistance in order coordinators, and a roster of federal agencies and
to meet the behavioral health needs of commu- nongovernmental organizations involved in disas-
nities in local crises by contacting the disaster ter and trauma research and/or service delivery.
behavioral health coordinator located at the Also maintains a collection of technical assistance
BEM.55 publications.
continued
65
SIDEBAR 20. FEDERAL MENTAL HEALTH Recognize and plan for the emotional
RESOURCES (CONTINUED) effect of crises on rescue and health
For more information: care workers.
http://www.mentalhealth.samhsa.gov/dtac/default.asp Numerous national crises have taught important
lessons about the extent of the emotional effect
FEMA Crisis Counseling Program of crises on rescue and health care workers. No
The Federal Emergency Management Agencys one who responds to a mass casualty incident is
(FEMAs) Crisis Counseling Program provides untouched by it; training as a first responder or
short-term services to eligible survivors of presiden-
caregiver does not provide such immunity. Stress
tially declared major disasters who are experiencing
management assistance is often needed and
normal reactions to very abnormal situations. Its
mission is to help relieve any grieving, stress, or should be considered by community planning
mental health problems caused or aggravated by a teams. One form of assistancepsychological
disaster or its aftermath. The confidential services, debriefingwhich usually occurs within days of
typically lasting for about a year following a disaster, a critical event, aims to help first responders and
are provided by FEMA as supplemental funds grant- others exposed to a traumatic event to talk about
ed to state and local mental health agencies. their feelings and reactions in order to reduce
Individuals may contact FEMAs toll-free helpline traumatic stress.56 Planning teams should consider
number, 1-800-621-FEMA (TTY 1-800-462- the possible range of staff support needs, match
7585), to learn where these services can be obtained. the plans and potential interventions to those
Crisis counselors are often on hand at disaster recov-
needs, and prepare to solicit additional mental
ery centers (when they are established). Crisis
health resources from local, state, or federal
Counseling grants are applied for by a State Mental
Health Authority when local resources cannot meet sources should staff needs during response and
local needs in a presidentially declared disaster. recovery exceed expectations and plans.
For more information:

http://www.fema.gov/rrr/inassist.shtm
66
9. Ensure Thorough Planning Related to Vulnerable Populations

Recommended Planning Strategies: not-for-profit organizations, and commercial com-
Identify special-needs populations to panies are available to local planners preparing to
support effective communication, serve vulnerable populations. For example,
outreach, and planning. PrepareNow.org provides tools, expertise, and
Include a cross section of partners in access to resources to assist anyone engaged in dis-
planning and response efforts related aster planning for individuals with special needs.
to vulnerable populations.
Consider the unique needs of children. Older and disabled people are particularly vul-
Involve the school nurse in emergency nerable during and following a disaster. Following
preparedness and response. the 9/11 World Trade Center attacks, older peo-
ple and those with disabilities living near the dis-
The needs of vulnerable populations should be
aster area were trapped for days before being res-
considered by planning teams. These individuals
cued.58 Even in a city as large as New York, at that
can easily suffer harm disproportionately during
time there was no effective way to identify vul-
or following an emergency because they may not
nerable people who were not connected to a
be able to seek help, care for themselves, or pur-
community service agency. There also was no
sue other survival and recovery strategies pursued
means for community service providers to enter
by nonvulnerable populations. Strategies teams
the disaster area to provide critical assistance and
can use to address the needs of vulnerable popu-
information to older and disabled people.
lations follow.
Identifying vulnerable individuals as part of the
emergency management plan and alerting, relo-
Identify special-needs populations to cating, or otherwise aiding them when disaster
support effective communication, appears imminent is essential in preventing harm.
outreach, and planning. For example, the National Organization on
In disaster preparedness and response, the Centers Disability urges media outlets to follow closed-
for Disease Control and Prevention (CDC) defines captioning guidelines for persons with hearing
special populations as groups whose needs are not disabilities when broadcasting emergency infor-
fully addressed by traditional service providers or mation to the general community.
who feel they cannot comfortably or safely access
and use the standard resources offered in disaster Include a cross section of partners in
preparedness, relief, and recovery.They include, but planning and response efforts related
are not limited to, those who are physically or
to vulnerable populations.
mentally disabled (blind, deaf, hard-of-hearing,
The Disability Preparedness Center advises plan-
cognitive disorders, mobility limitations), limited
ners to include individuals and organizations with
or non-English-speaking, geographically or cultur-
disabilities not only as information resources, but
ally isolated, medically or chemically dependent,
as active planning partners and in drills and exer-
homeless, frail/elderly, and children.57 They may
cises so that responders can refine the necessary
also include certain institutionalized populations,
skills in working with these populations.
such as those in foster care or nursing homes. A
number of resources from governmental agencies,
67
SIDEBAR 21. NEEDS ASSESSMENT ON DISABILITY TOOLS:

PREPAREDNESS Pennsylvania Department of Health: Special
In February 2005 the Disability Preparedness Center Populations Emergency Preparedness Planning.
conducted a needs assessment on disability preparedness, http://www.dsf.health.state.pa.us/health/
which generated a number of valuable findings and rec- cwp/view.asp?a=171&q=233957.
ommendations regarding strategies for including people
with disabilities in emergency management planning Federal Emergency Management Agencys
activities. Their specific recommendations were focused Emergency Management Institute offers a
on the National Capital Region (NCR), but many of the course on emergency planning and special
recommendations are applicable to different types of
needs populations (EMI - G197) that can be
communities across the country:
downloaded from its Web site: http://
1. Survey first responders and regional and local plan-
ners to assess (and raise awareness of) resources and training.fema.gov/EMIWeb/pub/register.html.
needs for disability preparedness in localities
throughout the region. National Organization on Disability
2. Provide technical assistance and skills development http://www.nod.org.
to first responders to assist them in including per-
sons with disabilities in planning activities and in Disability Preparedness Center
response and recovery plans. http://www.disabilitypreparedness.org.
3. Identify people with disabilities living indepen-
dently, with family, or in residential facilities and
recruit them to participate in planning activities. The team might involve social workers and home
4. Plan and implement an information campaign to health care agencies in locating vulnerable indi-
inform the public about ways to better prepare in viduals who will need special assistance. High
the event of an emergency.
5. Establish an NCR Disability Advisory Committee
school and college students can also play a signif-
to be a visible public presence and oversee devel- icant role in planning and response activities.
opment of inclusive emergency preparedness,
response, and recovery. Example: AmeriCorps Emergency Readiness teams
6. Hold a one-day regional conference on the roles in California provide opportunities for students in
and responsibilities in emergency preparedness of local community colleges to provide disaster/emergen-
people with disabilities, advocates, agencies, and cy preparedness services to vulnerable populations.59
service providers.
7. Develop a curriculum for persons with disabilities Example:The Teen School Emergency Response
to prepare them to participate effectively in plan- Training (SERT) program is an in-class curriculum-
ning and to pass on their skills to other people with based program that helps students make informed
disabilities. decisions regarding emergency readiness and
8. Develop a planning participation course for dis-
response.60 Pilot-tested for the nation at Pueblo West
ability agency staff and service provider staff to help
High School in Colorado in November 2003, the
prepare them to do effective emergency planning
program is offered over a nine-week period for one
and implementation.
9. Develop an enhanced emergency communication hour per day.
network for persons with disabilities.
Consider the unique needs of children.
Source: Disability Preparedness Center (DPC): NCR Needs According to the National Center for Disaster
Assessment on Disability Preparedness. Washington, DC: DPC, Preparedness (NCDP) at Columbia Universitys
2005.
Mailman School of Public Health, the needs of
68
children have rarely been highlighted in disaster The American Academy of Pediatrics sponsors a
planning and, hence, have rarely been planned Web page titled Children, Terrorism &
for.61 Special pediatric considerations cited at the Disasters, which provides extensive information
2003 NCDP Pediatric Preparedness for Disasters not only for physicians and parents, but also for
and Terrorism National Consensus Conference teachers and community planners.
include the following:
Children are more vulnerable to chemical TOOLS:
agents that are absorbed through the skin or Resources for planning, care, and treatment
inhaled, and are closer to the ground, thereby concerning children in disasters is offered by
more susceptible to gases that are heavier than the American Academy of Pediatrics at
air. http://www.aap.org/terrorism/index.html.
Children have special susceptibilities to dehy-
dration and shock from biological agents.
Children require different dosages or different Involve the school nurse in emergency
antibiotics and antidotes to many agents. preparedness and response.
Children are more susceptible to the effects of The more than 60,000 school nurses in the
radiation exposure and require different nations public and private elementary and sec-
responses than adults. ondary schools represent an important resource
Children have unique psychological vulnera- for emergency preparedness and response for
bilities, and special management plans are
children in small communities nationwide, par-
needed in the event of mass casualties and
evacuation. ticularly in the area of bioterrorism preparedness
Childrens developmental ability and cognitive and response.School nurses have easier access to
levels may impede their ability to escape dan- large populations of people than most health pro-
ger. fessionals and are, therefore, in positions to mon-
Emergency medical services, medical, and hos- itor unusual symptoms or signs, recognize pat-
pital staff may not have pediatric training, terns of symptom presentation, act to protect
equipment, or facilities available. against spread of communicable diseases, and pro-
vide immediate treatment and decontamination
The Program for Pediatric Preparedness is cur- for members of the school community, notes the
rently working on a Model Pediatric Component National Association of School Nurses.62 School
for State Disaster Plans.61 In addition, initiatives nurses are in a unique position to monitor school
are under way in a group of California hospitals absenteeism and to follow up with students and
to enhance training of emergency department the local public health department on any suspi-
staff in treatment, equipment, supplies, medica- cious patterns of symptoms.
tions, and techniques required to treat pediatric
patients more effectively in a disaster situation.
Involve social workers and home health care agencies in locating vulnerable individuals who
will need special assistance.
69
10. Identify, Cultivate, and Sustain Funding Sources

Recommended Planning Strategies: Proactively pursue funding.
Proactively pursue funding.
Many small communities for a variety of reasons
Include all planning partners in the
have not been proactive in providing states with
funding requests.
plans and initiatives eligible for federal funds
Consider revenue-raising opportunities.
through the state. As a result, some state govern-
Seek funding collaboratively and
ments have not allocated all funds or have applied
regionally.
funds to other projects. To gain access to federal
Consider the impact of funding
funding to which they are entitled, local planning
reductions.
bodies must be proactive and persistent. A good
one-stop shopping source of information relat-
Many local governments are hard-pressed to pro-
ed to available grants appears in the Tools box.
vide basic services and, as a result, funds and
resources needed for special activities, including TOOLS:
emergency preparedness, often are sorely lacking. U.S. Department of Homeland Security (DHS)
Federal and state governments provide for fund- grants Web site: http://www.dhs.gov/
ing at the local level for emergency preparedness dhspublic/display?theme=18.
planning; however, many communities have
either not attained or not pursued the funding This site provides information on homeland security
that will enable them to develop and implement and public safety grant opportunities offered by agen-
cies across the federal government and is intended to
emergency management plans.
simplify access to these grants by placing information
in a single, easily accessible site. It includes grants
In some states, fire, law enforcement, public offered by the DHS, as well as other federal depart-
health, emergency medical services, or hospitals ments and agencies. Critical state and local missions
may be designated to receive the lions share of supported through these grants include the prepared-
federal funding. However, collaborative planning ness of first responders and citizens, public health,
and preparedness require funding of and training infrastructure security, and other public safety activi-
for all response partners. Commenting on fund- ties. Grants described can be awarded to a variety of
ing disparities in the public health arena, entities, including local governments, Native
researchers involved in a study of public health American tribal government partners, and private
preparedness in 12 U.S. communities noted: nonprofit organizations.
Despite the large inflow of federal dollars to DHS grants listed include those administered by the
some communities, the cost of implementing or Office of Domestic Preparedness, the Federal
improving communications and surveillance sys- Emergency Management Agency, and the
tems, training, planning, and labs remains daunt- Transportation Security Administration. Other feder-
ing.63 Because details pertaining to funding al agency programs include public health prepared-
sources and requirements can change rapidly, this ness grants from the Department of Health and
section focuses on broad strategies that can be Human Services, Department of Justice grants for
counterterrorism and general-purpose law enforce-
used to identify, cultivate, and sustain funding and
ment activities, and Environmental Protection
identifies a key resource for obtaining current
Agency grants for enhancing the security of the
information on a range of funding sources. nations water supplies.
70
Include all planning partners in the their communities and across jurisdictions to
funding requests. coordinate funding requests. Leaders of small,
Many communities do not receive their full share rural, and suburban communities with a hospital
of funding because the role of all partners in the or hospitals can make special effort to partner
emergency management plan is not represented with hospital leaders in emergency preparedness
in the funding requests. Requests for funding planning. Hospitals may have access to numerous
made to county, state, federal, and other entities emergency preparedness funding streams, and
should present the full spectrum of participants collaborative grant-seeking can be productive.
that require support.
States often allocate federal funds on a regional
basis. Mayors and other leaders of small commu-
Consider revenue-raising opportunities.
nities should consider participating in the plan-
The chief executive of small communities can
ning and hazard mitigation efforts of multijuris-
support funding within his or her community,
dictional regional councils of government, for
region, or state by sponsoring or supporting tax
example, in order to increase awareness of plan-
incentives, bonding bills, grants, and other mea-
ning and funding initiatives. Through linkages to
sures. Such measures can either direct funding to
regional and state planning efforts, elected and
the community or incentivize planning partners
other leaders of small communities can partici-
to participate more fully in planning and response
pate in funding requests, thereby securing the
efforts.The incentives can be especially important
necessary seat at the table and a voice to articu-
for increased access to response capabilities and
late the communitys full range of planning, train-
assets held by industrial and telecommunications
ing, response, and recovery needs.
entities, hospitals, and other private businesses.
Consider the impact of funding

Seek funding collaboratively and
reductions.
regionally.
A risk that must be considered in the funding
Distribution of funds may be a bigger problem in
strategy is that budgets at the state and federal
some states than the actual availability of funds.
level change with fiscal and political pressures.
Getting resources into the right hands often is
The planning team can prepare for potential
related to the availability of all key players at the
reductions in funding by identifying alternative
table.To increase leverage in funding negotiations
or creative sources and methods for sustaining
or to take advantage of economies of scale, chief
preparedness funding levels.
executives should foster collaboration within
Through linkages to regional and state planning efforts, elected and other leaders of small
communities can participate in funding requests, thereby securing the necessary seat at the
table and a voice to articulate the communitys full range of planning, training, response, and
recovery needs.
71
11. Train, Exercise, and Drill Collaboratively

Recommended Planning Strategies: the general public, and all response partners
Identify who should be trained and require training and practice in their intended
the training needs for each. roles.
Ensure competency-based training
programs.
Identify who should be trained and the
Identify cross-training opportunities.
Consider offering the CERT program.
training needs for each.
Access other training programs offered
Individuals responsible for responding to a disas-
through the federal government. ter situation must be identified and trained. Not
Ensure incident command training
everyone is capable of performing every func-
for appropriate personnel. tion. For example, not all individuals working in
Recognize drills or exercises as a
the health field may wish to participate or are
critical element of the emergency suited to enter a disaster environment; some staff
preparedness process. will require training in decontamination proce-
Involve all players in exercises and
dures and others will not.
drills.
Example: In various communities in Texas, selected
Be sure to include local businesses in
mental health workers, social workers, school coun-
training, exercises, and drills.
selors, drug abuse counselors, faith-based counselors,
Access available resources.
and others can attend a 16-hour training program in
Practice with other communities. emergency response. If the community or a neighbor-
Identify performance measures for ing community requires mental health support, these
drills and exercises. individuals are activated to provide mental health
Ensure the realism of drills and exer- services through the emergency operation center.64
cises.
Include alternative care sites and Training sessions ideally are provided to represen-
shelters in disaster drills. tatives of the major organizations or agencies
Activate the emergency plan. involved in emergency response, including emer-
gency medical services (EMS) personnel, fire ser-
Communitywide emergency preparedness and vice, law enforcement, emergency management
response training, exercises, and drills allow com- personnel, business leaders, local health care facil-
munities to test their plans, identify weaknesses, ity personnel, public health officials, and others as
and correct those to reduce the risk of process appropriate.
failures during an actual emergency.The planning
and response partners are required to work col- In smaller communities, face-to-face training and
laboratively, many of them for the first time, to drills can be challenging, especially where one per-
test their communication and coordination sys- son may wear several hats.To meet this challenge,
tems designed to save lives, protect health and the planning team can identify a variety of training
property, and restore operability of essential com- methodologies and schedules as appropriate to
munity functions and services. Health care meet required competencies, roles and responsibil-
providers, public health officials, first responders, ities, and time and technology constraints. Some
72
preparedness partners (for example, an EMS agen- very broadly among possible first responders, health
cy) may be able to obtain extensive classroom care personnel, and other citizens in the community.
training for each staff member; others may need to
use Web-based training, CDs, or videos. Consider offering the CERT program.
Communities whose residents have not yet expe-
Ensure competency-based training rienced the Community Emergency Response
programs. Team (CERT) program65 may wish to consider
Education and training programs should be com- offering the program. CERT is funded by
petency based, with programming that is specific Congress through Citizen Corps program grants,
to the individuals role in emergency response. which may be available to local communities.
Individuals responding to a disaster situation must Citizen Corps is the community-based initiative
have the knowledge, skills, abilities, and behaviors to engage citizens in homeland security and
needed to perform tasks correctly and skillfully. community and family preparedness through
Some education and training will be appropriate public education and outreach, training opportu-
for both the general public and emergency nities, and volunteer service.A key component of
responders (for example, CPR), while other pro- Citizen Corps, the CERT program trains citizens
grams will be appropriate only for specialized to be better prepared to respond to emergency
personnel (for example, decontamination). situations in their communities. When emergen-
cies occur, CERT members can give critical sup-
port to first responders, provide immediate assis-
Identify cross-training opportunities.
tance to victims, and organize volunteers at a dis-
In small communities, cross training of first
aster site.
responders increases the ability of individuals to
respond appropriately in different situations, such
The CERT program is a 20-hour course, typical-
as fire, rescue, hazardous materials, and weapons
ly delivered over a seven-week period. Training
of mass destruction. Cross training also extends
sessions cover disaster preparedness, disaster fire
available skill sets during disasters involving dis-
suppression, basic disaster medical operations,
placement of large numbers of people, evacuation
light search and rescue, and team operations.The
of hospitals, nursing homes, or other settings, and
training also includes a disaster simulation in
emergencies of long duration.
which participants practice skills that they learned
throughout the course.
Example:Tyler,Texas (population 84,000), recently
purchased several hundred low-cost ventilators and
the training program to use these ventilators. The CERT course is taught in the community by
Emergency personnel are teaching disaster life support a trained team that has completed a CERT Train-
Some preparedness partners (for example, an EMS agency) may be able to obtain extensive
classroom training for their team members; other partners may need to use
Web-based training, CDs, or videos.
73
the-Trainer course conducted by their state train- Corps council and local emergency planning commit-
ing office for emergency management or by the tee to support the CERT efforts/programs.66 Says
Federal Emergency Management Agencys Tracy Jackson, the countys Director of Emergency
(FEMAs) Emergency Management Institute Services, An effective disaster preparedness program
(EMI). CERT programs currently serve in more must reach out to and educate all citizens and orga-
nizations within the community.The CERT pro-
than 170 communities nationwide. A local gov-
gram is a great means to do just that.67
ernment agency, such as the emergency manage-
ment agency, fire department, or police depart-
ment, typically provides the CERT classes. Access other training programs offered
through the federal government.
CERTs are active in the community before a dis- Training courses developed by numerous federal
aster strikes, sponsoring events such as drills, agencies provide a broad curriculum and enable
neighborhood cleanups, and disaster education local communities to tailor programs to their spe-
fairs. Trainers offer periodic refresher sessions to cific training needs. For example, FEMAs EMI
CERT members to reinforce the basic training offers independent-study training programs on
and to keep participants involved and practiced in such topics as special-events contingency plan-
their skills. ning for public safety agencies, livestock in disas-
ters, radiological emergency management, devel-
TOOLS: oping and managing volunteers, community hur-
Federal Emergency Management Agencys ricane preparedness, principles of emergency
Emergency Management Institute Web site management, multihazard emergency planning
provides a resource center on best practices for schools, and dozens of others (see Tools).
for starting and maintaining a Community
Emergency Response Team program. http:// TOOLS:
training.fema.gov/EMIWeb/CERT/ A complete list of training resources offered
new_CERT/index.htm. Funding information through the Federal Emergency Management
is available through State Citizen Corps Agency can be accessed at http://
points of contact listed at http:// training.fema.gov/EMIWeb.
www.citizencorps.gov/citizenCorps/statepoc.do.
A complete list of training resources offered
Example: Iredell County in North Carolina (popu- through the U.S. Department of Homeland
lation 130,000) applied and obtained a $10,000 Security is available at http://www.dhs.gov/
grant through the state Citizen Corps to offer three dhspublic/display?theme=63.
CERT training programs during 2003.The coun-
tys Board of Commissioners defined the programs Training offered by the Centers for Disease
purpose as follows: (1) enhance the overall prepared- Control and Preventions Agency for Toxic
ness of Iredell Countys citizenry; (2) provide infor- Substances and Disease Registry is available at
mation about the CERT program and improve pre- http://www.atsdr.cdc.gov/
paredness and safety; (3) use local agencies in the hazmat-emergency-preparedness.html.
training; (4) collaborate with local agencies to pro- Emergency preparedness and response training
mote/support Neighborhood Watch/Community programs related to biological, nuclear, and
Watch programs and Volunteers in Policing pro- radiological terrorism are listed at http://
grams; and (5) obtain commitment from the Citizen www.bt.cdc.gov/training.
74
Ensure incident command training for organization discovered that the lost paper patients
were actually transferred to an off-site location, but
appropriate personnel. there was no way to indicate this on the emergency
The National Incident Management System (NIMS) response patient transfer form.
and the National Response Plan (NRP) require
incident management personnel to be appropri-
ately trained to improve all-hazards incident SIDEBAR 22. DEFINITIONS OF VARIOUS FORMS OF
management capability nationwide.27 The EMI DRILLS AND EXERCISES

offers training related to key elements of the Tabletop Exercises
NIMS. The EMI also offers courses in prepared- Tabletop exercises focus on facilitating understand-
ness and resource management. Both the NIMS ing of concepts, identifying strengths and shortfalls,
and/or achieving a change in attitude. Exercises gen-
and the NRP are being incorporated into virtu-
erally involve senior staff, middle management, and
ally every course offered by the EMI. For more other key personnel who are encouraged to discuss
information, access http://training.fema.gov/ issues in depth and develop decisions through slow-
emiweb/emicourses/e449.asp. paced problem solving rather than rapid, sponta-
neous decision making.
Recognize drills or exercises as a
critical element of the emergency pre- Games
A game is a simulation of emergency management
paredness process. operations that often involves teams, usually in a
Drills are integral to the process of troubleshoot- competitive environment, and does not involve the
ing weaknesses in emergency management plans. use of actual resources. The goal is to explore
They are designed both to provide training exer- decision-making processes and the consequences of
cises and to identify weaknesses in the response those decisions. Players are commonly presented
plan so that shortcomings can be addressed. with scenarios and asked to perform a task associat-
Communities should regularly test (at least annu- ed with the scenario episode.
ally) their emergency preparedness plans through
reality-based drills for the purpose of identifying Operations-Based Exercises
Operations-based exercises represent the next level
opportunities for improving and refining the
in the exercise cycle and are used to validate the
plan. Sidebar 22 provides the U.S. Department of plans, policies, agreements, and procedures.
Homeland Securitys definitions for various types Operations-based exercises include drills, functional
of drills and exercises. exercises, and full-scale exercises and are character-
ized by mobilization of resources and commitment
Example: During a semiannual communitywide of personnel over an extended period of time.
emergency management plan drill in California, the
medical center that organized the drill discovered Drills
some holes in its emergency management response A drill is a coordinated test used to evaluate a spe-
plan.68 The scenario was a radioactive waste spill. cific operation or function in a single department or
After scrambling to locate the appropriate personal nursing unit. Drills can be used to provide training
protective equipment, staff discovered that the decon- on new equipment, test new policies or procedures,
tamination suits did not fit. Several even ripped or practice skills.
while the engineers tried to put them on. continued
Furthermore, several paper patients were lost in
transit.When investigating what went wrong, the
75
SIDEBAR 22. DEFINITIONS OF VARIOUS FORMS OF

full-scale value in terms of lessons learned. Local
DRILLS AND EXERCISES (CONTINUED) leaders, public health authorities, EMS, fire, law
enforcement, volunteers, the general public, and
Functional Exercises
all other appropriate parties should be involved in
Functional exercises are designed to test multiple
functions, activities, and departments with a focus on communitywide drills.The key to making prac-
exercising the plans, policies, procedures, and staffs. tice pay off for your city or town is to seek out
Functional exercises simulate the operations by pre- opportunities to test your plan in as many ways as
senting realistic problems requiring responses. possible, at all levels of your government.
Everyone who works for the city should at some
Full-Scale Exercises point be part of the testing, with a special focus
The full-scale exercise is the most comprehensive on first responders and managers of all city
level in the exercise cycle and usually includes mul- departments, advises the National League of
tidepartment, multiorganization, multijurisdiction Cities.46 (p. 14)
agencies. The full-scale exercise simulates the reality
of operations in multiple functional areas through
Health care organizations accredited by the Joint
the presentation of realistic problems requiring crit-
ical thinking, rapid problem solving, and effective Commission will be experienced partners
responses. Full-scale exercises are used to assess orga- because they are required to conduct drills relat-
nizational and individual performance, demonstrate ed to their emergency management plan at least
interagency cooperation, review allocation of twice yearly; one of these drills is expected to be
resources and personnel, assess equipment capabili- a communitywide one. However, not all health
ties, activate personnel, assess interjurisdictional care organizations are accredited, and, according
cooperation, test public information and communi- to a recent study of hospital and community
cation systems and analyze memoranda of under- emergency preparedness linkages,14 involvement
standing, standard operating procedures, plans, poli- of key players in hospital-initiated community-
cies, and procedures.
wide emergency drills in rural areas is inconsis-
Source: U.S. Department of Homeland Security, Office of
tent. Local health departments and government
Domestic Preparedness: Homeland Security Exercise and agencies were reported to be involved in fewer
Evaluation Program,Vol. 1: Overview and Doctrine Revised. May than half of communitywide drills; traditional
2004. http://www.ojp.usdoj.gov/odp/docs/HSEEPv1.pdf first responders (fire, EMS, law enforcement)
(accessed Jun. 21, 2005). were most commonly included in community-
wide drills.
Involve all players in exercises and
drills. Example: Using FEMAs Comprehensive Hazmat
Full-scale exercises and drills, involving all the Emergency Response - Capability Assessment
major emergency response participants, provide Program (CHER-CAP), Lake Havasu City,
Local leaders, public health authorities, emergency medical services, fire, law enforcement,
volunteers, the general public, and all other appropriate parties should be involved in
communitywide drills.
76
Arizona (population 50,000), conducted a full-scale work consisting of 27 municipalities, county and
field exercise that was supported by 40 agencies.The state governments, school districts, hospitals, fire com-
exercise provided weapons of mass destruction panies, ambulance and EMS, and federal agencies.
(chemical bomb) training to emergency management The level of response to an event depends on the
personnel. A follow-up tabletop exercise included potential threat to public health and safety.69
newly elected city officials and assisted the school
district and local hospital with their emergency Be sure to include local businesses in
plans.The CHER-CAP exercise program is used
nationwide to increase response capabilities to tech- training, exercises, and drills.
nological hazards.33 Involvement of local businesses in the training
and exercise process is very important. First
Example: In December 2004, the Northern New responders, fire, law enforcement, and other agen-
England Metropolitan Medical Response System, in cies can provide basic training sessions in compa-
coordination with Dartmouth Hitchcock Medical nies, covering such topics as what to do in an
Center and community emergency planners, offered a emergency, what can be expected from local law
successful flu vaccination clinic in an indoor sports enforcement or fire personnel, where to obtain
arena at Dartmouth College. More than 1,900 pri- information, and so forth.
marily high-risk patients were vaccinated.
Involvement of multiple agencies and organizations Example:Saco, Maine (population 16,000), held a
in this type of routine care reinforced the concept disaster recovery workshop and simulation exercise
of working together but also provided valuable expe- focused on its information technology infrastructure.
rience and insight into what may occur within that The city tested its plan to safeguard data and sys-
community during an actual emergency. tems in the event of a natural disaster, or even a
man-made technological disaster, such as computer
Example: Every U.S. nuclear plant is required by hacking. Representatives from all city agencies and
law to develop and periodically test an on-site com- some local businesses participated in the simulation.
prehensive emergency response plan and ensure that Backup computer storage, telecommunications, and
off-site plans exist.These plans are approved by the backup power generation were among the systems
Nuclear Regulatory Commission (NRC) and tested.46
FEMA. Local, state, and national officials are
included in the plans and in periodic exercises. Corporate America has become increasingly
Every two years, each nuclear plant conducts a full-
involved in emergency preparedness. The
scale emergency exercise involving a confidential
emergency scenario to be handled by on-site and off- tragedies of 9/11 showed once again that many
site emergency response organizations, including disasters occur while individuals are at work.
plant employees, local hospitals, county emergency Incidents result in significant interruption of
management agencies, and radiological monitoring business operations, lost productivity, and
teams.The NRC evaluates performance and identi- increased employee stress. In response, the
fies improvements of the on-site plan; FEMA evalu- National Business Group on Health developed a
ates the off-site plan. In alternate years, plants con- project with the Centers for Disease Control and
duct on-site training drills involving such key factors Prevention to explore ways that private-sector
as coordination; communications; assessment of emer- employers and public health agencies can partner
gency, medical, and fire brigade response; and radia- to better prepare communities for bioterrorism
tion dose measurement. For example, a nuclear
and other public health emergencies12 (see Tools ).
plant sited on the Susquehanna River in
Pennsylvania has a large emergency response net-
77
TOOLS: should prospectively identify appropriate metrics

The National Business Group on Health
for drill/exercise evaluation.
offers numerous resources, including an
employer toolkit on terrorism preparedness Ensure the realism of drills and
and planning and an employer checklist on exercises.
forming business and public health prepared- As the realism of drills and exercises increases, so
ness partnerships.These are available at too do the learning and improvement opportuni-
http://www.businessgrouphealth.org/ ties.To achieve real value, a drill or exercise should
prevention/et_terrorismpreparedness.cfm. be planned to truly inconvenience the participants
The Building Owners and Managers
and the communityas a real disaster would.30
Association offers numerous resources to help Communities should be encouraged to rigorous-
building managers and owners fight terror-
ly exercise and drill the system or function being
ism. http://www.boma.org.
tested.An exercise that tests the limits of a plan or
its subparts can effectively identify weak spots and
Access available resources. opportunities for improvement.
Whenever possible, communities should use train-
ing programs and exercises, such as tabletop drills, Example: Santa Monica, California (population
that are already in place and available through fed- 88,000), obtained a Federal Transit Administration
eral, state, professional associations, and other grant to conduct a full-scale functional exercise in
which armed terrorist role players, who claimed to
sources. For example, the National Association of
have a bomb, commandeered a city bus with 20
County & City Health Officials offers customiz- civilians on board.33
able bioterrorism tabletop exercises and a bt tool-
box with links to other available exercises and Communities can consider conducting drills and
programs (http://www.naccho.org/bttoolbox). exercises involving the most likely disaster scenar-
ios, such as pandemic influenza in any communi-
Practice with other communities. ty, hurricanes in Florida, or earthquakes in
It may be particularly cost- and time-effective for California, for example, and potentially the most
small, rural, and suburban communities to conduct vulnerable function or system within the
joint exercises and drills with neighboring com- response plan. For example, disaster communica-
munities. Because natural and man-made disasters tions systems and procedures should be tested
cross borders, and emergency response services are regularly, and the results of these tests should be
likely to overlap in small and rural areas, joint exer- reviewed so that any failures can be corrected.
cises are not only desirable, but necessary.
Critical backup systems should also be tested as
Identify performance measures for part of the drill or exercise.
drills and exercises.
The purpose of drills and exercisesto improve Include alternative care sites and
performancecannot be accomplished without shelters in disaster drills.
agreement about what constitutes success and Although testing of current health care sheltering
how indicators of success are to be measured.The capabilities is critical, it may be equally important
communitys emergency management team to include alternative health care sites and shelters
78
in the exercises and drills. During drills and exer-

cises, the community can test the use of sites such
as ambulatory clinics, doctors offices, schools,
churches, and other facilities identified in the
emergency management plan. Such testing
increases communitywide awareness of the exis-
tence, location, strengths, and challenges of such
facilities.
Activate the emergency plan.

Activating the communitys emergency plan
provides a way of testing, reinforcing, and refin-
ing communication, technology, coordination,
decision making, and other issues. Even non-
catastrophic emergencies, such as when a hospi-
tal air conditioner malfunctions in August in the
South, can be used to test, stress, and improve
coordinated response before a catastrophic emer-
gency hits. Emergency plans should be activated
when smaller-scale emergencies occur. Regular
tests of communications systems and plans enable
response partners to become familiar with each
others roles and processes and will help to ensure
that people know what to do when a large-scale
disaster occurs.
79
12. Critique and Improve the Integrated Community Plan

Recommended Planning Strategies: reinforced the inevitability of catastrophic pan-
Conduct periodic review and reprior- demics. Every community should be redefining the
itization of possible emergency inci- realm of possible disasters, community needs, and
dents. preparedness and response mechanisms on an
Review the emergency management ongoing basis. The priority issues identified in the
plan on an annual basis. communitys hazard vulnerability analysis provide
Base the review on an analysis of the foundation for planning efforts. Building and
performance. sustaining capabilities to address disasters in the
Discuss posttest problems and assign community and region are integral to the planning
remedial actions. goals, processes, and collaborative efforts with part-
Consider obtaining external feedback. ners across disciplines and organizations.
Review the planning process.
Review the emergency management

Community emergency management plans can-
not be static documents; they must be evaluated plan on an annual basis.
and revised on an ongoing basis through an inte- The communitys emergency plan should be
grated, iterative, team-based process.The commu- reviewed on at least an annual basis. Collaborative
nitys hazard vulnerability analysis (Section 3), and regular review keeps the plans current and
goals for preparedness and response (Section 4), relevant, incorporates new partners or processes,
and current capacities and capabilities (Section 5) and retires obsolete content. The emergency
require review on a regular basis in order to pro- operations plan is a living document. Problems
vide for changing environmental conditions, fed- emerge, situations change, gaps become apparent,
eral and state regulations, standards and require- requirements are alteredand the plan must be
ments, community resources, and many other adapted to remain useful and up-to-date, notes
factors. Use of a matrix that outlines key plan ele- the Federal Emergency Management Agencys
ments can help teams ensure a thorough guide for local communities.7(p. 2-12)
approach to plan review and improvement.
Base the review on an analysis of
Conduct periodic review and performance.
reprioritization of possible Following an actual emergency, a community
identifies and analyzes data related to its imple-
emergency incidents.
mentation of the emergency management plan.
Before 9/11, crashing a civilian airplane into a
In the absence of an actual emergency, data from
high-rise building was unthinkable.Anthrax attacks
plan drills, training, and exercises should be col-
in fall 2001 also made the possibility of biological,
lected and analyzed. Performance-monitoring
chemical, and radiation incidents all too real. The
data form the backbone of regular evaluation.
majority of disaster scenarios identified by U.S.
Thus, it is appropriate that these data be present-
Department of Homeland Security for planning
ed, trended, and analyzed. Documentation pro-
purposes (Sidebar 8) were, in fact, not on the radar
vided by drill observers, for example, can provide
screens of most emergency preparedness planners.
relevant performance data on the adequacy of
SARS and recent outbreaks of avian influenza have
80
training, risks and needs, missing steps, and

opportunities for improvement. Example:The public health bio-defense team in
Montgomery County, Maryland, conducted a table-
Exercises and drills can be critiqued through an top training exercise to test the system for accessing
after-action report, which summarizes the the Strategic National Stockpile (SNS) and dissem-
event and the response, identifies strengths and inating the SNS supplies to public and private
points of distribution.The exercise involved 18 pub-
weaknesses in the response effort, and offers
lic and private agencies. An after-action, lessons
explicit recommendations for improvement. learned report summarized problems encountered
After-action reports should be based on predeter- and potential solutions as follows:
mined performance objectives.
Notes: PHCC is Public Health Command Center; RSS is receipt, store, and stage; FLOP is finance, logistics, operations, and
planning. Full report available at http://www.naccho.org/bttoolbox/index.cfm (accessed Jun. 24, 2005).
81
TOOLS: Discuss posttest problems and assign

The Federal Emergency Management Agency has remedial actions.
developed the Hazardous Materials Exercise Information captured from tests, exercises, and
Evaluation Manual (HM-EEM), and its companion after-action reports must be used to improve cur-
guidance, the HM-EEM Evaluation Forms, as guid- rent preparedness and response plans.The planning
ance and technical assistance to assist state and team meets to discuss problems that were evident
local governments, first responders, and industry in or that emerged during drills and exercises and to
the development, implementation, and evaluation objectively assess performance.The team identifies
of their own realistic and challenging exercise pro- and agrees on remedies and assigns to appropriate
grams.The evaluation form has many sections that individuals and organizations the responsibility for
can be helpful to community emergency manage- corrective actions. Needed actions may involve
ment planning teams.The section evaluating alert
revision of planning goals, assumptions, training,
and notification of the public appears here, and
communication, or a myriad of other issues.
the whole document is available at http://
www.training.fema.gov/emiweb/downloads/
HMFormsEval%20forms.doc.
After corrective actions have been implemented, a
tabletop exercise can be scheduled as a follow-up
activity to ensure that the corrective actions did in
fact address the issues identified during the drill.
The critiques of the plan, the exercises, and the drill

after-action analyses must have the support of the
leadership of the planning team and of the indi-
vidual agencies and organizations involved, par-
82
ticularly in terms of accountability, follow-up, and often identified in emergency management plans
resources for improvement. appear as Sidebar 23.
Consider obtaining external feedback. Review the planning process.

Emergency planning teams can consider selecting A communitys emergency management plan-
an external reviewer or an internal reviewer with ning team would be well served to regularly
limited exposure to the plan to provide objective review not only the plan, but the planning pro-
feedback on a continuing basis. Neighboring cess used to create the plan. Sidebar 24 offers 10
communities, the county, or the state can be asked possible assessment criteria.
to review the communitys emergency plan to
suggest improvements based on their accumulat- SIDEBAR 24. TEN CRITERIA FOR ASSESSING
ed experience.7 External feedback can be helpful COMMUNITY DISASTER PLANNING
in identifying gaps and assumptions that need to High-quality local disaster planning is characterized
be filled or rethought. The top 10 weaknesses by the following:
1. Focuses on the planning process rather than the
SIDEBAR 23. TOP TEN WEAKNESSES IN EMERGENCY production of a written document.
MANAGEMENT PLANS 2. Recognizes that disasters are both quantitatively
1. Have a lack of critical information. and qualitatively different from minor emergen-
2. Are not flexible enough. cies and everyday crises.
3. Do not address communication issues broadly or in 3. Is generic rather than agent specific.
enough detail. 4. Avoids the development of a command and
4. Do not contain enough multidisciplinary input. control model.
5. Do not contain adaptable forms for managing 5. Focuses on general principles and not specific
information. details.
6. Do not consider enough scenarios (or enough haz- 6. Is based on what is likely to happen.
ard vulnerabilities). 7. Is vertically and horizontally integrated.
7. Do not document incidents well. 8. Strives to evoke appropriate actions by anticipat-
8. Do not include troubleshooting tools. ing likely problems and possible solutions or
9. Lack alarm points signaling that critical supplies are options.
running low. 9. Uses the best social science knowledge possible
10. Have not undergone a detailed review with all and not myths and misconceptions.
appropriate local agencies and do not consider 10. Recognizes that crisis disaster planning and dis-
community linkages or processes. aster management are separate processes.
Source: Bruce C.: Troubleshooting your top ten weaknesses
in emergency preparedness plans. Environment of Care News Source: E.L. Quarantelli, Disaster Research Center,
3(2):11, 2000. University of Delaware. Used with permission.
The critiques of the plan, the exercises, and the drill after-action analyses must have the support of
the planning team leadership and of the individual organizations involved, particularly
in terms of accountability, follow-up, and resources for improvement.
83
13. Sustain Collaboration, Communication, and Coordination

Recommended Planning Strategies: tained and periodically reviewed to assure accura-
Ensure proper documentation and cy and relevance to community preparedness and
dissemination of plans and support- response. In addition to having a copy of the inte-
ing information. grated community plan, all partners must have
Establish mechanisms for receiving copies of each organizations individual plans to
and reviewing regional, state, and which they are a party, either as a recipient or as a
federal plans. supplier. This facilitates a comprehensive under-
Collect and disseminate information standing of roles and resources that should be
about effective models, practices, and maintained and adjusted over time, as needed.
lessons learned.
Build multilayered relationships and Ideally, the community emergency management
prepare for transitions. plan has elements that are integral to the normal
Ensure ongoing communication with operations of some of the partners who support
the public. communication and coordination as part of their
regular business or service functions within the
The final activity described in this planning community. In other cases, contact between part-
guidesustaining collaboration, communication, ners will be limited to emergencies and disasters.
and coordinationassures the continued viabili-
ty of community emergency preparedness and
response. The planning process and the plan that Establish mechanisms for receiving and
results from this process are only as good as their reviewing regional, state, and federal
weakest link. Continued collaboration, coordina- plans.
tion, and communication are critical to reinforc- Just as local community plans change and require
ing and maintaining established links, processes, updating, so too do plans created by regional,
and plans. Strategies for sustaining the processes state, and federal agencies. Local communities
and plans outlined in this publication follow. should establish a means to receive and review the
changes made to regional, state, and federal plans.
Ensure proper documentation and Such changes can have a significant impact on
community resources and preparedness and
dissemination of plans and
response initiatives.
supporting information.
As described in Section 11, policies, procedures, The National Response Plan (NRP) will be reviewed
contact information, and plans must be main- and updated every four years but will have interim
Ideally, the community emergency management plan has elements that are integral to the
normal operations of some of the partners who support communication and coordination as
part of their regular business or service functions within the community.
84
revisions as needed between full reviews.The U.S. TOOLS:

Department of Homeland Security is required to The Medical Reserve Corps (MRC) Web site
distribute notices of changes to the NRP to all includes information on promising prac-
regional offices and state emergency management tices, such as Guidelines for Spiritual Care
offices.Thus, local community planning teams can Providers, Volunteerism Flyer, and Agency
access the information through these sources.10 Needs Assessment, obtained from MRC
units: http://www.medicalreservecorps.gov/
Collect and disseminate information resources/result.asp?subcategory_id=43.
about effective models, practices, and National Memorial Institute for the Prevention
of Terrorism (http://www.mipt.org) hosts
lessons learned. Lessons Learned Information Sharing, which
All planning partners can benefit from receiving is a national network of lessons learned and
information about effective models, practices, and best practices for emergency response
lessons learned in other communities and in the providers and homeland security officials.
region, state, and nation. Developing an informa- http://www.llis.dhs.gov.
tion stockpile to support educational and commu- The Federal Emergency Management Agencys
nications activities can be helpful. Such information Mitigation Division provides best practices and
can be gathered from a variety of sources, including case studies. http://www.fema.gov/fima/
local and regional meetings, Internet resources, bp.shtm.
desktop exercises, and reviews of how other com- The National Governors Associations Center
munities are planning for or have responded to for Best Practices: Homeland Security &
emergencies and disasters. The Tools section pro- Technology Section includes best practices
vides a sampling of sources for best-practice and related to agroterrorism, bioterrorism prepared-
lessons learnedrelated information. ness, critical infrastructure protection, energy
assurance, emergency management, information
Build multilayered relationships and sharing and technology, intelligence, interoper-
ability, nuclear and radiological terrorism, and
prepare for transitions. telecommunications and digital infrastructure.
Over time, individuals leave organizations or http://www.nga.org/center.
change jobs, organizations change the scope or The Rand Corporation makes available on its
nature of their services, planning partners drop Web site a publication titled Protecting
out of the planning process, and new partners Emergency Responders: Lessons Learned from
emerge.The planning team must prepare for tran- Terrorist Attacks by Brian Jackson et al.
sitions in roles and responsibilities. Relationship http://www.rand.org/publications/CF/CF176.
building for long-term sustainability requires
multiple relationships within groups with differ- should be provided to the multiple levels of
ent levels and types of stakeholders. response partners and to the public and should
include information about the functions and
Ensure ongoing communication with the responsibilities of preparedness and response part-
public. ners. The media provide a primary means for
An active and disciplined communication effort communicating with the public, as described in
will help to mitigate the impact of changes that Section 7.
occur over time. Ongoing communication
85
Ongoing communication with the community is 5. Rural Health Resource Center (RHRC): An
essential to managing concerns within the popula- Alternative Approach to Defining Rural for the Purpose of
Providing Emergency Medical Services. Duluth, MN:
tion about risk, maintaining public interest in and RHRC, Jul. 2004.
involvement with preparedness activities, and sus- 6. U.S. Department of Agriculture, Economic
taining trust and dialogue that will be essential in Research Service: Measuring rurality: New defini-
directing the public effectively during a disaster. tions in 2003. http;//www.ers.usda.gov/briefing/
rurality/NewDefinitions (accessed Feb. 2005).
7. Federal Emergency Management Agency: State and
Example:The Rocky Mountain Poison and Drug
Local Guide (SLG) 101: Guide for All-Hazard Emergency
Center (the Center) in Colorado worked with the Operations Planning. 1996. http;//www.fema.gov/
state health department to create a public emergency rrr/gaheop.shtm (accessed Feb. 2005).
information line.The Center had a long-standing and 8. Personal Communication from Richard McCann,
well-recognized public role in providing accurate and Jun. 2005.
timely information. Following 9/11, its role expand- 9. Personal communication from Ron Hilliard, Oct.
ed to providing information to the public on a small- 2004.
pox vaccination program, providing clinical decision 10. U.S. Department of Homeland Security (DHS):
support for vaccinees and their health care providers, National Response Plan.Washington, DC: DHS, Dec.
and collecting reported adverse reactions to smallpox 2004.
11. National Commission on Terrorist Attacks Upon the
vaccinations.The demand for smallpox information
United States: The 9/11 Commission Report. New
was very modest, but the emergence of outbreaks of York:W.W. Norton, 2004.
the West Nile virus in 2003 allowed the Center to 12. National Business Group on Health (Terrorism and
adapt its capabilities to include tracking virus occur- Public Health Emergency Preparedness Initiative):
rence in the state and providing the public with con- The Business Case: Why and How Employers Need to
sistent, accurate information about virus risks and dis- Partner with Public Health. Jun. 2004. http://
ease management strategies. By asking people to www.businessg rouphealth.org/prevention/
report on dead birds in their yards, the service involved et_terrorismpreparedness.cfm (accessed Feb. 2005).
the public in the response effort, helped establish a 13. U.S. Department of Homeland Security. Press
mechanism for information exchange, and resulted in Release: Secretary Chertoff Outlines Risk-Based
Approach to Homeland Security. Mar. 16, 2005.
a meaningful role for the public in the process. Since
http://www.dhs.gov/dhspublic (accessed Mar. 18,
then the service has been expanded to monitor and 2005).
support other public health issues such as influenza, 14. Loeb J.M.: Assessing Hospital and Community
mold, hantavirus, and plague.The Centers capabilities Emergency Preparedness Linkages. Oakbrook Terrace,
continue to expand based upon emerging public health IL: Joint Commission on Accreditation of
concerns and requests for information. Healthcare Organizations, Oct. 2004.
15. CNA Corporation: Medical Surge Capacity and
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pdf/rrr/allhzpln.pdf (accessed Feb. 2005). Mar. 18, 2004).
30. Joint Commission on Accreditation of Healthcare 43. Morrison G.: Fire communications system
Organizations (JCAHO): Health Care at the failures....RACES saves the day! The Connection:
Crossroads: Strategies for Creating and Sustaining Americas Bridge to Preparedness 7, Winter 2005.
Community-wide Emergency Preparedness Systems. http://www.naem.com/connection.html (accessed
Oakbrook Terrace, IL: JCAHO, 2003. Mar. 2005).
31. Health Resources and Services Administration 44. Disaster Management Interoperability Services.
(HRSA): National Bioterrorism Hospital Preparedness h t t p : / / w w w. c m i - s e r v i c e s . o r g /
Program: FY 2005 Continuation Guidance. HRSA dmishp_what_is_dmis.html (accessed Jul. 2005).
87
45. U.S. Department of Health and Human Services 58. OBrien N.: Emergency preparedness for older peo-
(HHS): Communicating in a Crisis: Risk ple. International Longevity Center Issue Brief Jan.Feb.
Communication Guidelines for Public Officials. 2003. http://www.ilcusa.org/_lib/pdf/epopib.pdf
Washington, DC: HHS, 2002. (accessed Mar. 2005).
46. National League of Cities (NCL): Homeland Security: 59. AmeriCorps: ALERT: AmeriCorps Local Emergency
Practical Tools for Local Governments. Washington, DC: Readiness Teams Project. http://www.foundationccc.org/
NCL, Nov. 2002. fccc/americorps/americorps_alert.html (accessed Mar.
47. Quarantelli E.L.: Disaster-related social behavior: 2005).
Summary of 50 years of research findings.Paper prepared 60. Rich H.:Teen SERT. The Connection:Americas Bridge
for presentation at the Joint Commission on to Preparedness 7, Winter 2005. http://
Accreditation of Healthcare Organizations,May 7,2004. www.naem.com/connection.html (accessed Mar.
48. Institute of Medicine: The Threat of Pandemic 2005).
Influenza: Are We Ready? A Workshop Summary. 61. Columbia University Mailman School of Public
Washington, DC: National Academies Press, 2004. Health, National Center for Disaster Preparedness:
49. Occupational Safety and Health Administration Pediatric Preparedness for Disasters and Terrorism:A National
(OSHA): OSHA Best Practices for Hospital-Based First Consensus Conference, Executive Summary. 2003.
Receivers of Victims from Mass Casualty Incidents h t t p : / / w w w. n c d p. m a i l m a n . c o l u m b i a . e d u /
Involving the Release of Hazardous Substances. pediatric.html (accessed Mar. 2005).
Washington, DC: OSHA, Dec. 2004. 62. National Association of School Nurses: School Nurse
50. New York State Office of Mental Health. Role in Bioterrorism Emergency Preparedness. Jun. 2002.
http://www.omh.state.ny.us/omhweb/cr isis/ h t t p : / / w w w. n a s n . o r g / p o s i t i o n s /
crisiscounseling2.html. 2002psbioterrorism.htm. (accessed Jul. 2005).
51. Center for Mental Health Services (part of the U.S. 63. McHugh M., Staiti A.B., Felland L.E.: How prepared
Department of Health and Human Services): Self- are Americans for public health emergencies? Twelve
Care Tips for Emergency and Disaster Response Workers. communities weigh in. Health Affairs 23(3):201209.
http://www.mentalhealth.org/publications/ 64. Personal communication from Ron Hilliard, Oct.
allpubs/KEN-01-0098/default.asp. 2004.
52. U.S. Department of Health and Human Services: 65. Federal Emergency Management Agency:
Mental Health: A Report of the Surgeon General. 1999. Community Emergency Response Teams (CERT).
http://www.mentalhealth.samhsa.gov/cre/ h t t p : / / t r a i n i n g . f e m a . g ov / E M I We b / C E RT
ch1_intro.asp. (accessed Mar. 11, 2005).
53. U.S. Department of Health and Human Services. 66. Iredell County Board of Commissioners: Regular
Mental Health All-Hazards Disaster Planning Guidance. Minutes. Jun. 3, 2003. http://www.co.iredell.nc.us/
DHHS Pub. No. SMA 3829. Rockville, MD: Center Commissioners/minutes/Regular/June%203%
for Mental Health Services, Substance Abuse and 202003%20Regular%20Minutes.pdf (accessed Mar.
Mental Health Services Administration, 2003. 2005).
54. Federal Emergency Management Agency: Individual 67. CERT program launched in Statesville, North
assistance programs. http://www.fema.gov/rrr/ Carolina. The Connection: Americas Bridge to
inassist.shtm (accessed Mar. 2005). Preparedness 7, Winter 2005. http://www.naem.com/
55. Personal communication from Jose Their Montero, connection.html (accessed Mar. 2005).
MD, state epidemiologist of New Hampshire, Aug. 68. Bruce C.: Troubleshooting your top ten weaknesses
10, 2005. in emergency preparedness plans. Environment of
56. McNally R.J.: Psychological debriefing does not Care News 3(2):11, 2000.
prevent posttraumatic stress disorder. Psych Times 21, 69. Susquehanna Energy Information Center:
Apr. 2004. http://www.psychiatrictimes.com/ Emergency Preparedness. http://www.pplweb.com/
p040471.html (accessed Jul. 2005). susquehanna+energy+infor mation+center/
57. Pennsylvania Department of Health: Special susquehanna+plant/emergency+preparedness.htm
Populations Emergency Preparedness Planning. (accessed Jun. 24, 2005).
http://www.dsf.health.state.pa.us/health/cwp/
view.asp?a=171&q=233957 (accessed Jul. 2005).
88
Closing Comment
Continued collaboration, coordination, and communication provide the glue needed for a truly strong and
interconnected community fabric. Returning to Melvilles quotation,We cannot live for ourselves alone.
Our lives are connected by a thousand invisible threads, and along these sympathetic fibers, our actions run
as causes and return to us as results.To achieve the results desired in a disaster situationsurvival for two
or three days before help arrivessmall, rural, and suburban communities must develop and sustain emer-
gency preparedness and response capabilities.The 13-step process outlined in this planning guide is offered
as one template for doing so. Whatever resources are used, small communities must prepare for disasters
that would inflict significant destruction in the form of lost lives, injured residents, and damage to critical
community infrastructure and property.The time for preparedness effortsfor weaving together thousands
of invisible threadsis now.
89
Acknowledgment of Roundtable Members
The Joint Commission sincerely thanks the roundtable members for providing their time
and expertise in the development of this planning guide.
Community-Based Emergency Management Roundtable Members
Veronica Aberle, M.S.N., R.N. Commander Duane C. Caneva, M.C., U.S.N.R.

Nurse Manager Head, Medical Plans and Policies
Alexandria Health Department Navy Medicine Office of Homeland Security
Alexandria,VA Bureau of Medicine and Surgery
Washington, DC
Ross Anthony, Ph.D.
Associate Director Christopher Cannon, M.S.N., M.P.H., M.B.A.
Global Health RAND Health Security System Director, Office of Emergency
Arlington,VA Preparedness
Yale New Haven Health System
Robert Bass, M.D. New Haven, CT
Executive Director
Maryland Institute of Emergency Medical Paul K. Carlton, Jr., M.D., FACS (Roundtable
Services Systems Moderator)
Baltimore, MD Lt. General, USAF (Ret.)
Director, Homeland Security
Commander Daniel S. Beck A&M System Health Science Center
Medical Readiness Manager College Station,TX
Office of Force Readiness and Deployment
Office of the Surgeon General Ralph Conner
Rockville, MD Former Mayor
City of Maywood
Gregory M. Bogdan, Ph.D. Maywood, IL
Research Director & Medical Toxicology
Coordinator Charles Cook, L.C.S.W.
Rocky Mountain Poison and Drug Center - Project Officer
Denver Health Emergency Services & Disaster Relief Branch
Denver, CO Center for Mental Health Services
Rockville, MD
Christine Bradshaw, D.O., M.P.H., M.B.A.
Medical Officer Stephen Curren
Centers for Disease Control and Prevention Director, Public Health Security
Coordinating Office of Terrorism Preparedness Association of State and Territorial Health
and Emergency Response Officials
Division of State and Local Readiness Washington, DC
Atlanta, GA
90
Emily DeMers Dr. Ann R. Knebel, R.N., D.N.S.c, FAAN

Executive Director Captain, U.S. Public Health Service
Emergency Management Accreditation Program Commissioned Corps
Lexington, KY Senior Program Manager, Preparedness and
Planning Team
Brett Ewig Office of the Assistant Secretary for Public
Principal Director, Health Prevention and Health Emergency Preparedness
Promotion Programs Office of the Secretary, Depy. of Health and
Association of State and Territorial Health Human Services
Officials Washington, DC
Washington, DC
Howard Levitin, M.D.
Michael R. Fraser, Ph.D. President
Deputy Executive Director DQE, Inc., and Indiana University School of
National Association of County and City Health Medicine
Officials Indianapolis, IN
Washington, DC
Patrick M. Libbey
Robert Gougelet, M.D. Executive Director
Medical Director for Emergency Response National Association of County & City Health
Dartmouth Hitchcock Medical Center Officials
Lebanon, New Hampshire Washington, DC
Kathy Hadlock, B.S.N., Nurse Consultant Scott Lillibridge, M.D.

Hospital Preparedness Program Manager Principal Investigator
Center for Emergency Response and Terrorism University of Texas Health Science Center at
Missouri Dept. of Health and Senior Services Houston School of Public Health
Springfield, MO Academic Center for Public Health
Preparedness
Ron Hilliard, R.N., L.P. Houston,TX
Manager, Bioterrorism Hospital Preparedness
Program Rocky Lopes, Ph.D.
Center for Public Health Preparedness and Former Manager, Public Education and
Response Outreach for Disasters
Texas Department of Health American Red Cross
Austin,TX Community Disaster Education
Washington, DC
Michael Hopmeier
Chief, Innovative and Unconventional Concepts
Unconventional Concepts, Inc.
Washington, DC
91
Mauricio Lynn, M.D. Enrico L. Quarantelli, Ph.D.

Director for Mass Casualty Preparedness Research Professor, Disaster Research Center
Program University of Delaware
Medical Director,Trauma Resuscitation Unit, Newark, DE
Ryder Trauma Center, Jackson Memorial
Hospital Irwin Redlener, M.D.
University of Miami Associate Dean and Director
Miami, FL National Center for Disaster Preparedness
Columbia University Mailman School of Public
Angela Martinelli, D.N.S.c, R.N., CNOR Health
Commander, USPHS New York, NY
U.S. Public Health Service
Commissioned Corps Readiness Force Karen Roth
Office of the Surgeon General Senior Director
Gaithersburg, MD Office of Behavioral Health, New York City
Health and Hospitals Corporation
Commander Ludlow B. McKay New York, NY
National Bioterrorism Hospital Preparedness
Program Gili Shenhar
Health Resources and Services Administration Director
Rockville, MD CERBERUS ENTERPRISES, LLC
Israel
Richard McCann
Principal Chief John Sinclair
McCann & McCann Health Care Consultants Chairman, EMS Section
Chagrin Falls, OH International Association of Fire Chiefs
Puyallup,WA
Gerald Murphy
Director, Homeland Security and Technology Sue Skidmore, R.N.
Division Product Manager, Consulting Services
NGA Center for Best Practices DQE, Inc.
Washington, DC Arlington,VA
James Pearson, Dr.P.H., B.C.L.D. Rick Smith

Committee Chairman Director, Division of Healthcare Emergency
Emergency Preparedness and Response Preparedness
Committee Health Resources and Services Administration
Richmond,VA Rockville, MD
92
Terri Spear Boaz Tadmore

National Bioterrorism Hospital Preparedness CERBERUS ENTERPRISES, LLC
Program Israel
Health Resources and Services Administration
Rockville, MD Joe Waeckerle
Chairman, Dept. of Emergency Medicine
Leslee Stein-Spencer R.N., M.S. Clinical Professor
Director, Health Systems Programs University of Missouri Baptist Medical Center
Community Research Associates Baptist Lutheran Medical Center
Chicago, IL Leawood, KS
Gina Swehla Mike Wahl, M.D.

Training Center Manager Administrative Medical Director
Illinois Dept. of Public Health Illinois Poison Center
Springfield, IL Chicago, IL
93
Selected Resources
Agency for Healthcare Research and Quality: FEMA: State and Local Guide (SLG) 101: Guide
Altered Standards of Care in Mass Casualty Events. for All-Hazard Emergency Operations Planning,
http://www.ahrq.gov/research/altstand. Chapter 6, Attachment G:Terrorism, Apr. 2001.
http://www.fema.gov/pdf/rrr/allhzpln.pdf.
Centers for Disease Control and Prevention:
Public Health Emergency Response Guide for State, Institute of Medicine: Preparing for the
Local, and Tribal Public Health Directors, Version Psychological Consequences of Terrorism: A Public
1.0. http://www.bt.cdc.gov/planning/ Health Strategy.Washington, DC: National
responseguide.asp. Academies Press, 2003. http://www.nap.edu/
openbook/0309089530/html.
CNA Corporation: Medical Surge Capacity and
Capability: A Management System for Integrating Institute of Medicine: The Threat of Pandemic
Medical and Health Resources During Large-Scale Influenza: Are We Ready? A Workshop Summary.
Emergencies. http://www.cna.org/documents/ Washington, DC: National Academies Press,
mscc_aug2004.pdf. Nov. 16, 2004. http://www.iom.edu/
report.asp?id=23639.
Columbia University Mailman School of Public
Health, National Center for Disaster Joint Commission on Accreditation of
Preparedness: How Americans Feel About Terrorism Healthcare Organizations (Joint Commission):
and Security:Two Years After 9/11, Aug. 2003. Health Care at the Crossroads: Strategies for Creating
http://www.ncdp.mailman.columbia.edu/ and Sustaining Community-wide Emergency
How_Americans_Feel_About_Terrorism.pdf. Preparedness Systems. Oakbrook Terrace, IL: Joint
Commission, 2003. http://www.jcaho.org/
Columbia University Mailman School of Public about+us/public+policy+initiatives/
Health, National Center for Disaster Preparedness: emergency.htm.
Pediatric Preparedness for Disasters and Terrorism:A
National Consensus Conference, Executive Summary, Lasker R.D.: Redefining Readiness:Terrorism
2003. http://www.ncdp.mailman.columbia.edu/ Planning Through the Eyes of the Public. New York:
pediatric.html. New York Academy of Medicine, 2004.
http://www.cacsh.org.
Connecticut Department of Public Health:
Preparedness Planning Guidance for a Regional Loeb J.M.: Assessing Hospital and Community
Response to a Public Health Emergency, Apr. 2004. Emergency Preparedness Linkages. Oakbrook
http://www.ct.gov/oem/lib/oem/ Terrace, IL: Joint Commission on Accreditation
homelandsecurity/joint_dph_oem_regional_ of Healthcare Organizations, Oct. 2004.
planning_guidance.pdf.
McHugh M., Staiti A.B., Felland L.E.: How pre-
FEMA: State and Local Guide (SLG) 101: Guide pared are Americans for public health emergen-
for All-Hazard Emergency Operations Planning, cies? Twelve communities weigh in. Health
1996. http://www.fema.gov/rrr/gaheop.shtm. Affairs 23(3): 201209.
94
National Association of County & City Health Rural Health Resource Center (RHRC): An
Officials (NACCHO): Local Public Health Alternative Approach to Defining Rural for the
Agencies Better Equipped to Handle Bioterrorist Purpose of Providing Emergency Medical Services.
Attacks.Washington, DC: NACCHO, Jan. 2003. Duluth, MN: RHRC, Jul. 2004. http://
tasc.ruralheatlh.hrsa.gov.
National Association of County & City Health
Officials (NACCHO): Bt PREP: A Bioterrorism Texas Department of Health and the Texas
Response Plan Design Guide for Local Public Health Institute for Health Policy Research: Disaster
Agencies, 1st ed.Washington, DC: NACCHO, Preparedness and Response in Texas Hospitals, Mar.
2003. 24, 2003.
National Business Group on Health (Terrorism U.S. Department of Health and Human Services
and Public Health Emergency Preparedness (DHHS): Communicating in a Crisis: Risk
Initiative): The Business Case:Why and How Communication Guidelines for Public Officials.
Employers Need to Partner with Public Health, Jun. Washington, DC: DHHS, 2002. http://
2004. http://www.businessgrouphealth.org/ www.riskcommunication.samhsa.gov/index.htm.
prevention/et_terrorismpreparedness.cfm.
U.S. Department of Health and Human
National Commission on Terrorist Attacks Upon Services, Office of Rural Health Policy: Rural
the United States: The 9/11 Commission Report. Communities and Emergency Preparedness, Apr.
New York:W.W. Norton, 2004. 2002. ftp://ftp.hrsa.gov/ruralhealth/
RuralPreparedness.pdf.
National League of Cities: Homeland Security:
Practical Tools for Local Governments, Nov. 2002. U.S. Department of Health and Human Services
(DHHS): Mental Health All-Hazards Disaster
Northern New England Metropolitan Medical Planning Guidance.Washington, DC: DHHS,
Response System: Community Planning Guide: 2003. http://www.mentalhealth.org/
Improving Local and State Agency Response to publications/allpubs/SMA03-3829/
Terrorist Incidents Involving Biological Weapons, Jun. introduction.asp.
2003. http://www.nnemmrs.org/surge.html.
U.S. Department of Homeland Security (DHS):
Occupational Safety and Health Administration National Incident Management System.
(OSHA): OSHA Best Practices for Hospital-Based Washington, DC: DHS, Mar. 1, 2004. http://
First Receivers of Victims from Mass Casualty www.fema.gov/nims.
Incidents Involving the Release of Hazardous
Substances. Washington, DC: OSHA, Dec. 2004. U.S. Department of Homeland Security (DHS):
http://www.osha.gov/dts/osta/bestpractices/ National Response Plan.Washington, DC: DHS,
html/hospital_firstreceivers.html. Dec. 2004. http://www.dhs.gov/interweb/
assetlibrary/NRPbaseplan.pdf.
95
U.S. Department of Homeland Security, Office Washington State Emergency Management

of Citizen Corps: 2003 Citizen Corps Survey of Association: Elected Officials Guide to Emergency
U.S. Households: Final Survey Report. Management, Feb. 2003. http://
www.emctaskforce.org/Resources/
U.S. General Accounting Office (GAO): ElectedOfficials/ElectedOfficialsGuide%20to%
Bioterrorism: Preparedness Varied across State and 20EM.pdf (accessed Feb. 17, 2005).
Local Jurisdictions. Washington, DC: GAO, Apr.
2002. Washington University School of Medicine:
Department Emergency Planning Guidelines. St. Louis:
U.S. General Accounting Office (GAO): Hospital Washington U., http://www.ehs.wustl.edu/
Preparedness: Most Urban Hospitals Have Emergency emergency/dptemplate.doc.
Plans but Lack Capacities for Bioterrorism Response.
Washington, DC: GAO, Aug. 2003.
96
Index
911 call system, 6, 28, 36, 38, 55, 59 Backup systems for critical assets, 38, 78
Bed capacity, 37
A Behavioral health, 63. See also Mental health planning
Acute care hospitals, 36 Best Practices for Hospital-Based First Receivers of Victims
Adapting emergency plans, 41 from Mass Casualty Incidents Involving the Release of
Adopting emergency plans, 41 Hazardous Substances, 37
After-action reports, 81 Bioterrorism annex planning criteria, 36
Agency for Toxic Substances and Disease Registry Bioterrorism preparedness, 69
A Primer on Health Risk Communication Principles and Brainstorming sessions, compiling lists of potential hazards,
Practices, 57 1617
training programs, 74 Building Owners and Managers Association, 78
Agricultural issues, 7, 18, 32, 86 Bureau of Emergency Management, 6465
Agriculture and natural resources, emergency support func- Bureau of Primary Health Care Facilities, 39
tions, 12 Business owners, 35
AHRQ (Agency for Healthcare Research and Quality), Altered
Standards of Care in Mass Casualty Events, 38, 94 C
All-hazards approach, 15 Capability Assurance effort, 52
Alternative care and shelter facilities, 3839, 47, 7879 Catastrophic events, potential for, 16
Ambulatory care Census 2000 data, 8
emergency support functions, 11 Center for Infrastructure Expertise, 18
medical surge capacity, 35 CARVER2 software, 18
American Academy of Child and Adolescent Psychiatry, 63 State and Local Pandemic Planning Guide, 42
American Academy of Experts in Traumatic Stress, 63 Strategic National Stockpile (SNS), 50
American Academy of Pediatrics, Children, Terrorism & The Center for Mental Health Services
Disasters, 69 disaster planning resources, 62
American College of Emergency Physicians, 35 information resources, 63
American Hospital Association: Model Hospital Mutual Aid Center for the Advancement of Collaborative Strategies in
Memorandum of Understanding, 30 Health, 26
American National Red Cross, 1314 Centers for Disease Control and Prevention (CDC). See also
American Psychiatric Association, 63 Agency for Toxic Substances and Disease Registry
American Psychiatric Nurses Association, 63 definition of special populations, 67
American Psychological Association, 63 Pandemic Influenza Preparedness and Response, 42
American Red Cross Public Health Emergency Response Guide for State,
emergency response, 13 Local, and Tribal Public Health Directors, 4142, 94
information resources, 63 Strategic National Stockpile (SNS), 51
mental health services, 65 training programs, 74
pastoral care resources, 6263 CERTs. See Community Emergency Response Teams
public awareness and readiness, 61 Checklists, 39, 43, 45
Talking About Disasters: Guide for Standard Messages, Chemical factory explosions, hazard analysis, 18
57 Chief executive, 4, 10, 14
AmeriCorps Emergency Readiness teams, 68 Children
Animals, resources, 32 Pediatric Preparedness for Disasters and Terrorism: A
Anthrax, vi, 38, 60, 80 National Consensus Conference, Executive Summary, 94
Antibiotic dispensing, 26 school nurses and, 69
Asset allocation process, 40 special needs, 6869
Austere care, 3738 Chlorine tank explosion, hazard analysis, 18
Avian influenza, 80 Citizen Corps. See also Community Emergency Response
Avocational special interest groups, 3334 Teams
2003 Citizen Corps Survey of U.S. Households: Final
B Survey Report, 96
Backup communications, 5455 emergency planning, 13, 59
97
managing volunteers, 26 roles and responsibilities, 43

training programs, v, 73 stakeholders, 78
Civic responsibilities, emergency planning, 27 terrorism threats, 16
Civilian representation, emergency planning, 13 Community-based planning, 13
Clinics, 11, 25, 35 Community emergency preparedness
CNA Corporation, Medical Surge Capacity and Capability: A demand for services, 27
Management System for Integrating Medical and Health examples of emergencies, 17
Resources During Large-Scale Emergencies, 35 funding, 15
Collaboration, 78, 4041, 80, 84. See also Planning team HVA (hazard vulnerability analysis), 18
Colleges, critical resources, 1112 incident management, 29
Columbia University, Mailman School of Public Health, initiatives linking to NIMS and NRP, 28
6869, 94 publics involvement, 2627
Communication. See also Documentation saving lives, 34
alternative and backup links and systems, 5455 Community Emergency Response Teams (CERTs). See also
building utility systems, 47 Emergency preparedness
communicating with the public, 14 emergency credentialing, 49
community locational system, 59 existing relationships, 10
credibility with the public, 5859 funding through Citizen Corps, v
crisis communications, 5758 human resources, 24
culturally sensitive, 6061 program, 7374
decisional support, 5960 Community health resources, 35, 36
emergency backup power, 5455 Community medical providers, 36
emergency communications, 36 Community planning teams, 2829
emergency communications procedures, 58 Community response plans, managing volunteers, 25
emergency support functions, 11 Competency-based training programs, 73
equipment, 54 Complacency, 12
goals, 53 Connecticut Department of Public Health. Preparedness
initiatives, 57 Planning Guidance for a Regional Response to a Public
integration with local health care organizations, 61 Health Emergency, 94
interoperability of communications systems, 56 Connecticut regional emergency and public health prepared-
medias role, 59 ness, 36
planning resources, 5657 Contingency plans, 27
planning strategies, 53, 84 Convergent responders, 2426
power considerations, 47 Cooperative Agreement Grant: The National Bioterrorism
public awareness and readiness, 61 Hospital Preparedness Program, 55
resources, 32 Coordination. See also Collaboration; Communication
risk communication plan, 27, 36 Corporate America, 77
rules of risk communication, 58 Corrective actions, 82
transmission, 5354 County planning initiatives, 29
Community awareness. See also Emergency management; Court system personnel, 26
Funding; Integrated community plan; Risks and hazards Credentials
communication patterns, 53 capabilities, 36
education, 27, 36 emergency credentialing, 49
existing relationships, vvi, 910 medical volunteers, 26
federal resources, 39 Crisis communications, 5758
gaps in community assets, 39 Critical assets, backup systems, 38
geopolitical and definitional factors, 8 Critical benchmark, HRSA, 37
grass roots level, v, 27 Critical medical surge capacity, 35
intrusive reality events, 1 Cross-training opportunities, 73
planning strategies, 7, 9 Cultural diversity, 62
readiness and, 61
98
Current capacities and capabilities Emergency credentialing, 49

alternative care and shelter facilities, 3839 Emergency management. See also FEMA; Integrated emer-
asset categories and target capabilities, 3133 gency management plan
community health resources, 35 developmental process, 3
dual uses for existing or emerging capabilities, 38 emergency support functions, 12
federal resources in communities, 39 funding, 2
gaps in community assets, 39 in homes, v, 63
geographic features and vulnerabilities, 34 leadership, 4
groups involved in planning, 3334 phases, 2223
health care-related resources, 3536 planning partners, 1014
planning strategies, 31 planning process, 23, 6
public as an asset category, 33 planning strategies, 8485
surge capacity and consult-surge planning resources, response functions, 44
3435, 37 strategies for managing volunteers, 25
weaknesses, 83
D Emergency Management Institute (EMI), 75
Decontamination, 27, 35, 36, 37, 48 Emergency medical services. See EMS
Department of Health and Senior Services, Missouri, 30 Emergency operations plan (EOP), 42, 44, 80
DHS. See U.S. Department of Homeland Security Emergency physicians, 35
Disability Preparedness Center, 6768 Emergency preparedness. See also Community Emergency
Disabled population, 26, 39, 67 Response Teams; Current capacities and capabilities;
Disaster behavioral health response teams (DBHRT), 6465 Planning team; Preparedness and response planning;
Disaster Management Interoperability Services (DMIS), 56 Vulnerable populations
Disaster Medical Assistance Team (DMAT), 25, 35, 49 Assessing Hospital and Community Emergency
Disaster Mental Health Institute at the University of South Preparedness Linkages, 94
Dakota, 63 communitywide training, exercises and drills
Disaster mental health plans/resources, 6465 activating emergency plans, 79
Disaster mutual aid, 30 alternative care sites and shelters, 3839, 47, 7879
Disaster planning, 27, 83. See also Preparedness and competency-based programs, 73
response planning cross-training opportunities, 73
Disaster Technical Assistance Centers (DTAC), 64 emergency response personnel, 7273
DisasterHelp, 57 federal government programs, 74
Disasters incident command training, 75
information resources, 63 involving local businesses, 7778
stress reactions, 62 participants, 7677
DMAT. See Disaster Medical Assistance Team performance measures, 78
Doctors, medical surge capacity, 35 planning strategies, 72
Documentation. See also Communication practice with other communities, 78
community-level planning, 26 resources, 78
draft of emergency plan, 4142 troubleshooting weaknesses, 7576
emergency operations plan, 42, 44, 80 Corporate America, 77
guidance and resources, 41 functionally structured emergency plan, 4445
information and planning, 32 local planning, 45, 14
integrated emergency management plan, 4243 measuring, 51
provided by drill observers, 8081 planning group, 10
Donated goods and services, 32 readiness barriers, 2
Drills, 36, 75, 80-81. See also Emergency preparedness risk-based approach, 15
school nurses and, 69
E teams, 2728
Earthquakes, hazard analysis, 18 Emergency supply kit, 27
Elderly population, 67
99
Emergency Support Function (ESF), 11, 35 State and Local Guide (SLG) 101: Guide for All-Hazard
Emergency System for Advance Registration of Volunteer Emergency Operations Planning, 19, 45, 52, 94
Health Care Personnel (ESAR-VHP), 49 Firefighting
Emotional support, 6263 emergency support functions, 12
EMS (emergency medical services) Life Safety Code, 23
community relationships, vi resources, 32
geopolitical and definitional factors, 8 First responders, 1314, 29
medical surge capacity, 36 Fliers, 27
Energy Floods, hazard analysis, 18
emergency support functions, 12 Flu, pandemic outbreaks, 17
resources, 32 Food, 31
English Team members, 4243 Full-scale exercises, 76
EPA. See U.S. Environmental Protection Agency Functional annexes, 45
Equipment, planning criteria, 36 Functional exercises, 76
Evacuation planning criteria, 36, 47 Funding
Evacuation signs, 27 emergency management programs, 2
Exercises, 36 impact of funding reductions, 71
External affairs, emergency support functions, 12 planning partners, 71
planning strategies, 70
F proactive approaches, 70
Facility preparedness, 36 regional resources, 71
Federal Emergency Management Agency (FEMA), 10, 13 revenue-raising opportunities, 71
Federal government
asset categories and target capabilities, 3133 G
definition of required surge capacity, 37 Games, 75
emergency preparedness programs, 74 Gap analysis, 19
encouraging the private sector, 13 Gas main break, hazard analysis, 18
guidance and resources, 41 Geographic Information Systems (GIS) mapping, 34
mental health plans/resources, 6466 Geopolitical factors, 8
Federal legislation, local planning initiatives, 2930 Grants, as funding sources, 70
FEMA (Federal Emergency Management Agency) Groundwater contamination, hazard analysis, 18
Capability Assurance effort, 52
Comprehensive Hazmat Emergency Response - Capability H
Assessment Program (CHER-CAP), 7677 Hazard-specific appendixes, 45
Crisis Counseling Program, 66 Hazard vulnerability analysis (HVA), 15, 1718, 41, 80
educational materials, 61 Hazardous materials
eGov Disaster Management Program, 56 Best Practices for Hospital-Based First Receivers of
Emergency Management Institute, 68, 74 Victims from Mass Casualty Incidents Involving the
emergency operations plan, 42 Release of Hazardous Substances, 37
grants offered, 70 interstate transit, 1
Hazardous Materials Exercise Evaluation Manual (HM- resources, 32
EEM), 82 Hazards, compiling lists of, 1617
independent study training programs, 74 Health Affairs, 95
information resources, 63 Health and medical facilities, emergency planning, 4549
list of core functions, 43 Health Care at the Crossroads: Strategies for Creating and
Mitigation Division, 85 Sustaining Community-wide Emergency Preparedness
National Disaster Medical System, 35 Systems, 2
nuclear plants, response plans, 77 Health care organizations
planning guide, 39 bioterrorism annex planning criteria, 36
potential areas of vulnerability, 34 communications, 61
resources, 18, 21, 29 drills and exercises, 49
100
emergency preparedness, 1011 decisional support, 60

Health care staff, orientation and education, 48 future pandemic, 1
Health department mass vaccination campaigns, 60
communitywide training, exercises and drills, 76 Preparing for the Psychological Consequences of
emergency management, 4 Terrorism: A Public Health Strategy, 63, 94
emergency preparedness, 910, 69 Integrated community plan
laboratory services, 38 annual emergency management review, 90
pharmaceuticals and medical supplies, 4950 external feedback, 93
Health First Health System, Florida, 24 performance analysis, 9092
Health Resources and Services Administration (HRSA), 37, planning process review, 93
55 planning strategies, 80
High-touch methods, 60 posttest problems and remedial actions, 9293
Home health care Integrated emergency management plan
emergency support functions, 11 collaborative efforts, 4041
medical surge capacity, 35 documentation, 4243
Homeland Security Grants Web site, 70 draft of emergency plan, 4142
Homeland Security Operations Center (HSOC), 28. See also emergency planning, 41
U.S. Department of Homeland Security goals, 45
Hospital catchment areas, 8 guidance and resources, 41
Hospital Emergency Incident Command System (HEICS), 48, health and medical facility emergency planning, 4549
51 jurisdictional lines, 51
Hospitals lessons learned from 9/11, 5152
Assessing Hospital and Community Emergency measuring preparedness and response success, 51
Preparedness Linkages, 94 meetings, 42
bed capacity, 37 organization, 4345
communication procedures, 61 pharmaceuticals and medical supplies, 4951
emergency preparedness, 1011 planning strategies, 40
funding efforts, 71 responsibilities, 43, 44
GIS locations of, 34 review of existing plans, laws, and mutual aid agree-
identifying alternative care sites, 47 ments, 42
medical surge capacity, 35 International Critical Incident Stress Foundation, 6263
National Bioterrorism Hospital Preparedness Program, 55 International Red Cross, 13
planning initiatives, 30 Interoperability Backbone, 56
Veterans hospitals, 39 Interstate mutual aid, 29
Human resources requirements, 2324 Isolation, 36, 37, 48
Humanitarian organizations, emergency response, 13
Hurricane plans, in Florida, v, 27 J
Hurricanes, hazard analysis, 17 Joint Commission on Accreditation of Healthcare
HVA (hazard vulnerability analysis), 15, 1718 Organizations
Division of Research, 49
I emergency management planning and drill requirements,
ICS. See Incident Command System 46
Idaho Institute of Emergency Management, 30 Health Care at the Crossroads: Strategies for Creating and
Immunization supplies, 35, 36 Sustaining Community-wide Emergency Preparedness
Incident Command System (ICS), 27, 36, 48, 51 Systems, 94
Incident of National Significance, 29 study on potential for catastrophic events, 16
Industry-based planning, 113 Joint Field Office (JFO), 29
Information and planning, 32 Joint Terrorism Task Forces (JTTFs), 28
Initial stabilization, 37 Jurisdictional lines, 41, 51
Institute of Medicine (IOM)
culturally sensitive communication, 60-61
101
L Mayors only forum, 30

Laboratory services Media, 59. See also Communication
capabilities, vi, 36 Medical equipment resources, 34
capacity, 48 Medical Reserve Corps (MRC), 25, 26, 3435, 85
medical surge capacity, 35 Medical supplies, 4951
upgrading, 38 Medical surge capacity, 3435
Law enforcement regions, 8, 2627, 32, 42 Medical volunteers, 25
Layered preparedness and response, 27 Meeting frequency, 42
LEPC. See Local Emergency Planning Committee Mental health planning
Liaisons, local elected officials, 5 disaster planning resources, 6264
Local emergency planning. See also FEMA emotional effect of crises on rescue and health care
communications, 57 workers, 66
large-scale emergencies, 26 federal and state disaster plans and resources, 6466
planning process, 10 Mental Health All-Hazards Disaster Planning Guidance,
public education, 27 62, 95
roles and responsibilities, 5 planning strategies, 62
services required, 4546 Metropolitan Medical Response System (MMRS), 10. See
Local Emergency Planning Committee Database, 18 Medical Reserve Corps
Local Emergency Planning Committee (LEPC), 2930 Military assets, 39
Local Emergency Planning District, 2930 Missouri Hospital Association (MHA), 30
Local governments, 70 Mitigation, 2223, 85
Local health departments, 36 Model Pediatric Component for State Disaster Plans, 69
Local planner, 4, 14 MRC. See Medical Reserve Corps
Local public health department (LHD), 51 Multi-Hazard Mapping Initiative, 18
Lockdown, 36, 48 Mutual aid agreements, 29, 30, 42
Loma Prieta earthquake, 2425
Long term care N
emergency support functions, 11 National Alliance for the Mentally Ill, 63
identifying alternative care sites, 47 National Association of County & City Health Officials
medical surge capacity, 35 Bt PREP: A Bioterrorism Response Plan Design Guide for
Long-term community recovery and management, emergen- Local Public Health Agencies, 42, 95
cy support functions, 12 Local Public Health Agencies Better Equipped to Handle
Bioterrorist Attacks, 95
M National Association of School Nurses, 69
Major construction projects, hazard analysis, 18 National Association of School Psychologists, 63
Man-made disasters, 78 National Association of Social Workers, 63
Map sources, 18 National Bioterrorism Hospital Preparedness Program, 55
Maryland Institute for Emergency Medical Services, 36 National Business Group, 35
Mass care, housing, and human services, 12, 31 National Business Group on Health, 77, 78, 95
Mass casualty event, 3738 National Center for Disaster Preparedness (NCDP), 20, 26,
Mass immunization campaigns, 26, 36 6869
Mass prophylactic sites, 34 National Center for Post-Traumatic Stress Disorder, 63
Mayoral Institute for WMD (Weapons of Mass Destruction) National Clearinghouse for Educational Facilities, 35
and Terrorism Incident Preparedness, 30 National Commission on Terrorist Attacks upon the United
Mayors office States, The 9/11 Commission Report, 95
credibility with the public, 58 National Depressive and Manic Depressive Association, 63
existing relationships, 9 National Disaster Medical System, 35
funding efforts, 71 National Education Association, Crisis Communications
geopolitical and definitional factors, 8 Guide and Toolkit, 5657
leadership, 14 National Fire Protection Association, Life Safety Code, 23
National Governors Association, Center for Best Practices:
102
Homeland Security & Technology Section, 85 Office of the Surgeon General, 26

National Guard, human resources, 24 Oil and hazardous materials, emergency support functions,
National Incident Management System (NIMS), 3, 28, 29, 12
3133, 75, 96 On-scene incident command, 25
National Infrastructure Institute, 18 Ongoing risk assessment, 36, 46
National Institute of Mental Health, 63 Operations-based exercises, 75
National Institute of Standards and Technology, 18 OSHA (Occupational Safety and Health Agency), 37, 61, 95
National League of Cities, 21, 76, 95
National Memorial Institute for the Prevention of Terrorism, P
85 Pandemic influenza outbreaks, 17
National Mental Health Association, 63 Partnerships, 41. See also Collaboration
National Organization on Disability, 67, 68 Pastoral care resources, 62-63, 64
National Pharmaceutical Stockpile (NPS), 50 Patient surge, 4950
National Preparedness Plan, 15 Pediatric patients, 37, 69, 94
National resource typing system, 3132 Pennsylvania Department of Health, Special Populations
National Response Plan (NRP). See also U.S. Department of Emergency Preparedness Planning, 68
Homeland Security Pentagon, unified command system, 51
all-hazards incidence management, 75 Peoria County Emergency Services, 30
basic premise, 29 Performance measures, for drills and exercises, 78
categories, 3133 Performance-monitoring data, 8081
linking communitys plan to, 28 Personnel processing point, managing volunteers, 25
phases of emergency management, 22 Pharmaceutical resources, 34, 4951
reviewing and updating, 8485 Physicians offices, medical surge capacity, 35
Strategic National Stockpile (SNS) and, 50 Planning partners, 1014
Web site, 96 Planning team. See also Communication; Current capacities
National Weather Service, 18 and capabilities
Natural disasters, 78 activating emergency plans, 79
NCDP. See National Center for Disaster Preparedness advantages, 9
Needs assessment on disability preparedness, 68 approaches, 41
New Hampshire Department of Safety, Bureau of Emergency leadership and responsibility, 40
Management (BEM), 6465 participants, 11
New York State Office of Advocate for Persons with responsibilities, 4
Disabilities: ADA Accessibility Checklist for Existing Facilities, subgroups and committees, 41
39 Power failure
NIMS. See National Incident Management System communications and, 47
NIST. See National Institute of Standards and Technology hazard analysis, 18
Noncatastrophic emergencies, 79 Preparation, National Response Plan definition, 2223
Northern New England Metropolitan Medical Response Preparedness and response planning. See also Emergency
System, Community Planning Guide: Improving Local and management
State Agency Response to Terrorist Incidents Involving basic societal functions, 2021
Biological Weapons, 42, 95 community awareness, 27
NRP. See National Response Plan compatibility with unified command functions and ICS,
Nuclear detonations, hazard analysis, 18 27
Nuclear Regulatory Commission (NRC), 77 convergent responders, 2426
Nurses, medical surge capacity, 35 human resources requirements, 2324
Nursing homes, 67, 73 layered approach, 27
linking communitys plan to NIMS and NRP, 28
O linking to county and state plans, 29
Office of Citizen Corps, DHS, 27 linking to Joint Field Office, 29
Office of Domestic Preparedness (ODP), 70 mutual aid agreements, 30
Office of Public Health Emergency Preparedness, 38 plan for layered preparedness and response, 27
103
planning process, 2122 Revenue-raising opportunities, 71

planning strategies, 20 Reverse 911 call system, vi, 38
publics involvement, 2627 Risk assessment
self-care, 27 matrices, 18
Preparedness, National Response Plan definition, 2223 ongoing, 36, 46
PrepareNow.org, 67 Risk-based approach, 15
Prevention, National Response Plan definition, 22 Risk communication plan, 27
Private sector Risks and hazards
emergency planning, 13 assessing and prioritizing hazards, 1718
first responders, 1314 catastrophic events, 16
Program for Pediatric Preparedness, 69 gap analysis, 19
Protocols, 36 planning strategies, all-hazards approach, 15
Psychological support, 6263, 66 problems inherent in hazard lists, 17
Public education, 2627 Robert T. Stafford Disaster Relief and Emergency Assistance
Public Health and Medical Services Act, 13, 29, 39
emergency support functions, 12 Rocky Mountain Poison and Drug Center, 86
medical surge capacity, 35 Rural areas
resources, 31 federal definition, 8
Public information, 32, 41 vulnerability to terrorist threats, 1
Public involvement, community preparedness efforts, 2627 Rural Health Resource Center, An Alternative Approach to
Public safety and security, emergency support functions, 12 Defining Rural for the Purpose of Providing Emergency
Public Safety Radio Service, 58 Medical Services, 95
Public service announcements, 27
Public works and engineering S
emergency support functions, 11 Salvation Army, 63
resources, 32 SARS (severe acute respiratory syndrome), vi, 38, 80
School administrators, 35
Q School nurses, 69
Quarantine, 2627, 36 Search and rescue, 31
Security, 32, 36, 48. See also Law enforcement regions
R Security planning, 48
Racial diversity, 62 Self-care, 27
Radio communications, 54 Self-help groups, 6364
Rand Corporation, Protecting Emergency Responders: Severity, risk assessment, 18
Lessons Learned from Terrorist Attacks, 85 Shelter
Readiness barriers, 2 current capacities and capabilities, 38
Recovery, National Response Plan definition, 2223 disaster drills, 7879
Redefining Readiness Study, 26 hurricane preparedness, 24
Redundant systems, 27 temporary, 33
Regional agencies Skilled nursing facilities, 36
funding efforts, 71 Smallpox, vi, 38, 86
Homeland Security Coordinating Committee, 30 Snowstorms, hazard analysis, 18
risk assessment resources, 18 Social support systems, 64
Regional planning, 3536 Social workers, medical surge capacity, 35
Representatives, local elected officials, 5 Societal functions, 7, 2021
Rescue workers, emotional effect of crises, 66 SOPs (standard operating procedures), 36, 45
Resource management, 32 Special activities, 70
Resource support, emergency support functions, 12 Special Needs Population Task Force, 13
Resource typing, 3132, 52 Special needs populations, vi, 67, 6869
Response, National Response Plan definition, 2223 Spiritual support, 6263, 64
Retired health professionals, 35 Stafford Act. See Robert T. Stafford Disaster Relief and
104
Emergency Assistance Act Transportation

Stakeholders, defining the community, 78 emergency support functions, 11
Standards of care, 3738 resources, 32
State agencies. See also FEMA Transportation Security Administration (TSA), 70
funding efforts, 71 Triage treatment, 11, 37, 38
mental health plans/resources, 6465 Tribal chief executives, 4, 28
risk assessment resources, 18 Turf battles, 43
State Emergency Response Commissions, 29
State planning initiatives, 29 U
State resources, 41 Unified command. See also Incident command system
Stockpiling, 36 all-hazards approach, 48
Strategic National Stockpile (SNS), 50, 51, 81 guidelines, 28
Stress reactions to disasters, 62, 66 integration from an ICS to, 42
Students, role in planning and response activities, 68 Pentagons use of, 51
Substance Abuse and Mental Health Services Administration Universal Task List (UTL), 21, 32
(SAMHSA), 64 Universities, critical resources, 1112
Supplemental facilities, 38 Urban areas, federal definition, 8
Surge capacity, 3435, 36, 37, 46 Urban hospitals, hazards, 16
Surge needs, 35 Urban search and rescue, emergency support functions, 12
Surgical centers, emergency support functions, 11 Urgent care centers, medical surge capacity, 35, 36
Surveillance, 14, 36, 48 U.S. Citizen Corps. See Citizen Corps
System wide failure, 27 U.S. Department of Commerce, 18
U.S. Department of Health and Human Services
T Center for Mental Health Services, 62
Tabletop exercises, 75 Communicating in a Crisis: Risk Communication
Target Capabilities List (TCL), 3233 Guidelines for Public Officials, 95
Team. See Emergency preparedness; Planning team grants offered, 70
Teen SERT (School Emergency Response Training) program, Mental Health All-Hazards Disaster Planning Guidance,
68 62, 63, 95
Temporary shelter, 33 Mental Health Response to Mass Violence and Terrorism:
Terrorism National Consensus Conference, 69 A Training Manual, 63
Terrorism threats Rural Communities and Emergency Preparedness, 95
assessing risks in communities, 16 U.S. Department of Homeland Security. See also National
How Americans Feel About Terrorism and Security: Two Incident Management System; National Response Plan
Years After 9/11, 94 2003 Citizen Corps Survey of U.S. Households: Final
information resources, 63 Survey Report, 96
Managing the Emergency Consequences of Terrorist emergency support functions, 10
Incidents-Interim Guidelines, 52 grants offered, 70
National Memorial Institute for the Prevention of incident management, 29
Terrorism, 85 National Response Plan, 3, 20
potential areas of vulnerability, 34 Office of Citizen Corps, 27, 59
Redefining Readiness study, 60, 94 review and reprioritization of possible emergency inci-
in rural areas, 1 dents, 80
Testing. See also Community awareness risk-based approach, 15
communitywide, 76 spending priorities, 2122
of emergency management plan, 49 Target Capabilities List (TCL), 3233
specialized, 38 training programs, 74
Texas Department of Health and the Texas Institute for Universal Task List, 21
Health Policy Research, Disaster Preparedness and Universal Task List (UTL), 32
Response in Texas Hospitals, 95 U.S. Department of Justice
Training. See Emergency preparedness grants offered, 70
105
Office for Victims of Crime, 6465 Volunteers

U.S. Environmental Protection Agency credentialing, 49
grants offered, 70 managing, 25
hazardous materials initiatives, 29 resources, 32
rules of risk communication, 5758 Vulnerable populations
U.S. General Accounting Office (GAO) community preparedness, 26
Bioterrorism: Preparedness Varied across State and Local needs assessment on disability preparedness, 68
Jurisdictions, 96 partners in planning and response efforts, 6768
Hospital Preparedness: Most Urban Hospitals Have planning strategies, 67
Emergency Plans but Lack Capacities for Bioterrorism special needs populations, vi, 67
Response, 94 tools, 68
U.S. Geological Survey, 18
U.S. Surgeon General, mental health planning, 62 W
Utility-related functions, 46, 47 Washington State Emergency Management Association,
Elected Officials Guide to Emergency Management, 96
V Washington University School of Medicine, Department
Vaccination Emergency Planning Guidelines, 96
for high-risk patients, 77 Water, 31
mass vaccination campaigns, 60 West Central Municipal Conference, Illinois, 30
smallpox vaccination program, 86 Wire line communications, 5354
Veterans hospitals, 39 World Trade Center attacks, lessons learned, 13, 5152, 67
Vocational special interest groups, 3334
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Standing Together

An Emergency Planning Guide for Americas Communities

The Joint Commission is proud to acknowledge its partnership

Emergency Management Leadership

SIDEBAR 3. POSSIBLE ROLES OF LOCAL ELECTED Reference

Liaison: Local elected officials will also find them-

Representative: Local officials act as representatives of

Source: Adapted from National League of Cities (NLC):

Essential Components of the Planning Process

The 13 essential components of an effective community-based emergency management planning process

1. Define the community.

The effectiveness of planning is dependent on the ability of communities nationwide to deter-

2. Identify and Establish the Emergency Management Preparedness

SIDEBAR 5. PARTICIPANTS AT THE PLANNING TABLE

ESF #1.Transportation Federal and civil transportation support

SIDEBAR 6. EMERGENCY SUPPORT FUNCTIONS (CONTINUED)

ESF #4. Firefighting Firefighting activities on Federal lands

ESF #5. Emergency Coordination of incident management efforts

ESF #6. Mass Care, Mass care

ESF #9. Urban Search and Life-saving assistance

ESF #10. Oil and Materials Response

ESF #11. Agriculture and Nutrition assistance

ESF #12. Energy Energy infrastructure assessment, repair, and restoration

ESF #13. Public Safety and Facility and resource security

ESF #14. Long-Term Social and economic community impact assessment

Initial decisions will need to be made regarding the

3. Determine the Risks and Hazards the Community Faces

SIDEBAR 7. EXAMPLES OF COMMUNITY-BASED

4. Set Goals for Preparedness and Response Planning

SIDEBAR 8. NATIONAL PLANNING SCENARIOS

resources challenges because their populations are Facility safety

in a specific local emergency planning district. Establish mutual aid agreements.

The Peoria County Emergency Services and Disaster

Missouris Department of Health and Senior

5. Determine Current Capacities and Capabilities

* Chemical, biological, radiological, nuclear, or explosive

TOOLS: Define critical capacities for each

Example:The Maryland Institute for Emergency incident or to an emergency operations center.

The planning team also needs to consider that

TOOLS: Commit to the use of simple language.

Clearly delineate roles and A functional approach to the plans structure

Roles and responsibilities must be determined in advance; during an emergency,

FIGURE 2. RESPONSIBILITIES FOR RESPONSE FUNCTIONS

SIDEBAR 13. COMPONENTS OF A FUNCTIONALLY STRUCTURED EMERGENCY PLAN

SIDEBAR 13. COMPONENTS OF A FUNCTIONALLY

is responsible for maintaining the medical and

SIDEBAR 15. ASSURING DRUGS AND MEDICAL

Train people as backup for technology.

7. Ensure Thorough Communication Planning

SIDEBAR 17. BACKUP COMMUNICATIONS

Critical Benchmark #2-10: Surge Capacity: Communications and Information Technology

has APCO 25 compliant equipment (http://www.apcointl.org/frequency/project25/information.html)

Ensure interoperability of TOOLS:

SIDEBAR 18. SEVEN CARDINAL RULES OF RISK

Example: A Midwestern town hung on its down-

Ensure integration of the local health

8. Ensure Thorough Mental Health Planning

SIDEBAR 19. BEHAVIORAL HEALTH INFORMATION

For more information:

9. Ensure Thorough Planning Related to Vulnerable Populations

SIDEBAR 21. NEEDS ASSESSMENT ON DISABILITY TOOLS:

10. Identify, Cultivate, and Sustain Funding Sources

Consider the impact of funding