2003 Model Practice Application (Public)

Incident Command Systems for Public Health Agencies

Nassau County Department of Health

Following the appearance of West Nile Virus, the September 11 attacks in New York City, and the anthrax letters, the Nassau County Health Department (HD) developed an Incident Command System (ICS) to improve its response to public health emergencies and to allow it to work more effectively with traditional emergency responders. The ICS development team was headed by an experienced manager and drew resources from each of the department’s major divisions. The system, developed over several months, included detailed organization charts and job action sheets, and supports all aspects of the HD’s bioterrorism response plan. Eventually, all 350 department employees were trained to work under and ICS framework. This process has markedly improved the HD’s emergency response capabilities and has also strengthened ties to police, fire, EMS, and local hospitals.

The HD developed ICS in response to its new responsibilities in emergency preparedness, especially bioterrorism (BT). Under the New York State BT application to CDC, counties were charged with most of the responsibilities for investigating and mitigating the effects of a bioterrorist attack. It became clear to executive staff that even a small “event,” such as the appearance of anthrax-laced letters, would require mobilization of a large part of the department and was far beyond the capabilities of the Division of Disease Control.

The HD ICS is innovative in its level of detail and thoroughness of approach in responding to all types of incidents. The plan is adaptable to small or large events and will be used in the event of mass vaccination or a major disease outbreak. The Operations Section includes a branch that manages a point of distribution (POD) structure to distribute medications or vaccines in response to a bioterrorism event. The CDC Clinic Staffing Guidelines for smallpox vaccination that were subsequently issued are consistent with the POD that was developed. The health department is also able to rapidly integrate workers from other agencies, volunteers, or assistance from neighboring counties or local hospitals.

The HD developed its ICS with the assistance of the New York State Office of Emergency Management, the North Shore Hospital System, and material from the CDC, the Hospital Emergency Incident Command System, and California’s Firescope. Involvement of outside organizations made the final product more complete while increasing the credibility of the HD among other emergency response agencies. ICS also allows the HD to speak a common language when speaking with other emergency response organizations. Still, most of the work was done by HD staff, which helped the HD own the process and plan.

Program costs were primarily in staff time. One senior-level manager worked half time to lead the design team. Between 8 and 12 senior- and mid-level staff participated in the design process, which took two to three hours per week for approximately 16 weeks, with ongoing modification and refinement over two years. Department-wide training required all staff to undergo a full day of training, which was conducted jointly by HD and local hospital staff. Approximately 20 percent of staff time was charged to the BT preparedness grant. The HD intends to conduct periodic training and drills using ICS protocols, some of which may be supported by BT grants. Staff training was charged to HD general expenses.

The HD will have to continue to invest personnel resources to maintain a high state of preparedness and the ability to implement ICS during an emergency. At a minimum, the HD plans to conduct a yearly drill using ICS organization and protocols and to hold annual refresher training for all staff.

The training has been evaluated by pre and post-training assessments, and was generally well received by HD staff. In addition, it helps to instill a sense of mission and department unity during a difficult fiscal period in the country. The ICS has been reviewed by local, state and academic organizations, which have given feedback and suggestions. The health department will also assess ICS as part of the scheduled drills to vaccinate or distribute medication to large populations. The health department has not had to implement ICS in the eight months since it was complemented.

At the start of 2002, as the HD began developing plans to meet the new and largely undefined threat of bioterrorism, it realized that any meaningful response would require all parts of the department to work together, and that the normal lines of authority (i.e., divisions, bureaus, programs) would not be an effective means to allocate resources or communicate during an emergency. The endeavor became a department-wide effort involving physicians, epidemiologists, public health nurses, environmental health sanitarians, fiscal managers, human resource staff, and program analysts. The key to keeping staff involved was active support from the Commissioner and designation of a coordinator to drive the process.

As the interdependence of the ICS Sections became apparent, the synergy and commitment of the group intensified, and previously resistant staff became committed to the process. During the development of ICS, staff members who ordinarily had little contact with one another had to meet and work together regularly. The health department also had to accept that individuals who were supervisors under normal conditions might have to report to lower-level staff during an emergency. Again, the length and level of detail involved in the plan was helpful in getting people to accept ICS as a new way of working during emergencies.

The coordinator was crucial to this effort. It was also essential that staff assigned to the planning and writing understood the assignment and saw it was as important as their other work.