5.3 Support to Local Jurisdiction Response

• 5.3.1 Coordinating Multijurisdictional Incident Management
• 5.3.2 Coordinating Tactical Mutual Aid

Because incident management is usually based at the local level, the role of State Government in a mass casualty and/or mass effect incident is often to support the jurisdictional (Tier 3) response effort when local resources are severely challenged. This may come in the form of coordinating incident management activities among affected jurisdictions, and/or coordinating tactical mutual aid support between local jurisdictions.

5.3.1 Coordinating Multijurisdictional Incident Management

Response to multijurisdictional events can be greatly strengthened by coordinating incident management activities across affected jurisdictions. State-level incident support (Tier 4) should focus on facilitating information sharing via a robust State information management function. Important considerations for public health and medical response may include the following:

• Standardized reporting requirements to promote uniform reporting of medical and health issues from affected jurisdictions. These processes should be established by the State EMA (in coordination with State public health) during preparedness planning, and (at a minimum) they should address the following parameters:
  • When to report: The timing of reports should be announced to jurisdiction incident commanders at the outset of a response, and should coincide with established operational periods to ensure that the information is included in the development of incident action plans (IAPs).^[4]
  • What to report: Specific content needs should be determined that will be useful in coordinating the medical and health response across jurisdictions. Examples may include situation reports, IAPs, and HCO or other resource status updates.
  • Where to report: The destination for transmitting reports should be established during preparedness planning, as well as who the primary point of contact is at the State level (Tier 4).
  • How to report: Standardized formats should be used, if possible, to record pertinent information. This may greatly hasten the process of collecting, aggregating, and analyzing the data, and disseminating the information back to affected jurisdictions (Tier 3).
• Standardized response actions such as operational tactics ("protocols") for patient triage, evaluation, and treatment can be shared across jurisdictions. Similarly, disease case definitions and medical advice for the concerned public should be coordinated. The intent is not to tell individual jurisdictions what to do, but to share what other jurisdictions are doing so they can make informed decisions about adjusting their practices, or prepare to explain response variance to patients and healthcare providers.
• Coordinated regional resources for the optimal use of medical and health resources that are unevenly distributed across jurisdictions. A prime example is medical laboratories. Many States already coordinate these particular assets through the Centers for Disease Control and Prevention's Laboratory Response Network (LRN). Other resources (e.g., critical care transport, mass fatality services) should be similarly integrated.

5.3.2 Coordinating Tactical Mutual Aid

In a mass casualty and/or mass effect incident, it is often necessary to obtain response resources from outside an affected jurisdiction to meet medical surge demands. Depending on the need, resources may come directly from the State (e.g., public health epidemiology expertise) or, more commonly, from an unaffected jurisdiction (e.g., medication supplies, critical care equipment). State Government can play a critical role in establishing processes for mutual aid distribution.

Important preparedness considerations for medical and health mutual aid include the following:

• Processes for requesting assistance: Clearly defined processes for requesting, accepting, and supervising mutual aid must be developed during preparedness activities. They should describe the circumstances in which mutual aid can be requested, as well as specific procedures for making such requests. For example, master mutual aid guidelines may stipulate that the State be informed when mutual aid between jurisdictions is being requested, so they can monitor the situation and maintain awareness of asset allocation. Mutual aid arrangements should specify which officials are authorized to request and/or accept resources.
• Resource typing: Establish standardized specifications of expertise and/or the size of resources commonly requested through mutual aid. For medical and public health disciplines, this might mean stipulating requisite qualifications for certain personnel (e.g., specialty training, licensure) and standardizing the description of a "resource unit," such as a critical care team. According to NIMS terminology, resources are classified by resource "kind" (i.e., generally what they do), and the variations within each resource kind are categorized as "types." Healthcare resource typing as a national initiative is underway but incomplete, so it is important to carefully describe the type of assistance being requested. Additionally, States may wish to stipulate that medical professionals filling the requests include only practitioners with formal credentials or hospital privileges, thereby avoiding the deployment of students, physicians-in-training, or inactive practitioners unless explicitly included in the request. Some States have already developed similar agreements concerning the sharing of personnel from other disciplines.
  
  Emergency Managers Mutual Aid (EMMA)
  
  While mutual aid agreements may be broad in scope and cover a variety of assets or personnel, some are written to address a very specific type of resource. California has established a mutual aid agreement for situations in which additional professional emergency management personnel are needed to assist with emergency response. This agreement, known as the EMMA Plan, describes processes for employing emergency managers from unaffected areas to support local or regional response efforts in affected communities.^[5] It follows the basic framework of the California master mutual aid agreement, and addresses such issues as liability and staff training. Similar agreements could be established for medical or public health personnel under master mutual aid agreements that already exist in States.
• Transportation: Delineate how donated aid will be physically transported to a requesting facility. For medical personnel, this may include specifying to whom or where they will report, and what forms of identification they should bring (e.g., copy of State licensure). Mutual aid agreements should also address how patients will be transported between facilities and at what point responsibility for patient care is officially transferred.
• Staging: Define how assets are managed, supported, and positioned until officially assigned to the incident. In some instances, this may require the provision of logistical support to the staged assets until they are assigned.
• Reimbursement/compensation: Define how costs and charges will be assigned to the receiving jurisdiction or facility. This is important because emergency funds may provide needed financial relief for incurred expenses. In the case of personal injury to donated staff, the requesting facility usually assumes financial responsibility. Reimbursement is made to the workers' care program of the donor facility.
• Liability: Establish guidelines for the assumption of liability. Except in cases of gross negligence or willful misconduct, liability is usually accepted by the requesting entity. This issue is particularly important to address for medical providers.
• Documentation: Define guidelines for the use of documentation to effectively support mutual aid assistance (e.g., standardizing time logs for deployed personnel, stipulating that patient records are transported with patients, protecting both physical and electronic medical records, and others).
• Notification to higher tiers: Delineate processes to notify other tiers when mutual aid is activated. Notification of the jurisdiction or State EOC is critical when any local mutual aid is activated, and information must be provided that describes the deployed mutual aid assets. This enables the jurisdictions and the State to track the availability of their response assets.

4. Appendix C provides a more detailed description of incident action plans.
5. Emergency Managers Mutual Aid (EMMA) Plan. California Office of Emergency Services, November 1997

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