armed violent intruder response (a.v.i.r.) ics action … preparedness/avir... · 2016-09-30 ·...

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ARMED VIOLENT INTRUDER RESPONSE (A.V.I.R.)

ICS – ACTION STEP SERIES

SYNOPSIS

The ICS – Action Step Series is a principally based, comprehensive, step-by-step guide for healthcare professionals who

are responding to an armed violent intruder in the hospital; and are involved in the initial activation stages of the Incident

Command. The ICS – Action Step Series is specifically designed to supplement the Hospital Incident Command System

(HICS) and to facilitate an enhanced, deliberate ICS response to the dynamic, unforgiving circumstances of an armed

violent intruder.

Mitigation Dynamics, Inc. (MDI) has provided various training and consultation to thousands of healthcare professionals

throughout the United States. One of MDI’s hospital incident command curriculums entitled, Incident Command

Activation Response Training (I.C.A.R.T.), utilizes scenario based training designed to mirror the dynamic circumstances

of an armed violent intruder; and how incident command staff should consider responding. After facilitating numerous

scenario based exercises, MDI recognized the critical need to create a supplement to the existing HICS structure in order

to effectively manage the hospital response to an armed violent intruder.

MDI staff conducted a collective review of the I.C.A.R.T. training data and identified a series of objectives that were

critical to an effective ICS response. As a result, MDI utilized their collective “real world” critical incident problem

solving experience, combined with information obtained from extensive debriefs of critical incidents throughout the

world, and created the Armed Violent Intruder Response (A.V.I.R.) ICS – Action Step Series.

The spirit of the ICS – Action Step Series is to work in conjunction with HICS and therefore is designed in a format

consistent with Job Action Sheets. The action steps are listed sequentially throughout this packet and are strongly

suggested for healthcare ICS staff to consider for implementation in response to an armed violent intruder. Principally,

the Action Step Series mirrors HICS, however there are elements that do not exactly match; ultimately the result of

creating efficient action step priorities and communication. The most notable enhancement is the implementation of an

additional Section Chief (Security), which was moved from the Operations Section to streamline communication when

responding to the dynamic nature of an armed violent intruder, see attached Organizational Chart.

FACT: The actions of an armed violent intruder (active shooter) create a dynamic, unpredictable environment that has a

high propensity for multiple people to be critically injured or killed in a very small amount of time. In addition,

departments throughout the hospital will be immediately affected and/or compromised, ultimately challenging quality

patient care objectives as well as the general safety for patients, visitors, physicians and staff. Therefore it is critical that

the staff in the Hospital Command Center respond accordingly, and consider the utilization of the ICS – Action Step

Series.

Incident Commander

Public

Information

Officer

Liaison Officer

Safety Officer

Operations

Section Chief

Planning Section

Chief

Security Section

Chief

Logistics Section

Chief

Financial

Administration

Section Chief

Position

Activated

LEGEND:

Medical Care

Branch Director

Staging Manager

HazMat Branch

Director

Infrastructure

Branch Director

Inpatient Care Leader

Casualty Care Leader

Outpatient Care Leader

Patient Registration Unit Leader

Personnel Staging Team Leader

Equipment Supply Staging

Team Leader

Medication Staging Team

Leader

Power / Lighting Unit Leader

Med Gases Unit Leader

Water / Sewer Unit Leader

Detection and Monitoring Unit Leader

Victim Decontamination Unit Leader

Spill Response Unit Leader

Facility / Equipment Decontamination

Unit Leader

Security Branch

Director

Law

Enforcement

Interface Unit

Leader

Access Control Unit Leader

Crowd Control Unit Leader

Traffic Control Unit Leader

Search Unit Leader

Situation Unit

Leader

Resources Unit

Leader

Documentation

Unit Leader

Demobilization

Unit Leader

Patient Tracking Manager

Bed Tracking Manager

Personnel Tracking

Manager

Material Tracking Manager

Support Branch

Manager

Service Branch

Manager

Supply Unit Leader

Facilities Unit Leader

Family Care Unit Leader

Transportation Unit

Leader

Labor Pool Credentialing

Unit Leader

Employee Health and Well

Being Unit Leader

Communications Unit

Leader

IT / IS Unit Leader

Time Unit Leader

Procurement

Unit Leader

Compensation

Claims Unit

Leader

Cost Unit Leader

Security Liaison Officer

Medical /

Technical

Specialist

ICS – ACTION STEP SERIES

Organizational Chart

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INCIDENT COMMANDER (IC) (Administrator on Call / Nursing Supervisor)

ACTION STEPS

Assume command / notify others "I am the Incident Commander"

* Self initiate Incident Command System (ICS) Action Steps, ASAP

* During scenario based drills & "real world" critical incidents, this BASIC, yet KEY step is overlooked

Ensure appropriate hospital Element of Performance (EOP) has been activated (Code Silver, etc.)

Select Command Center (CC) and have contingency location should primary location be compromised

Ensure hospital ICS staff notification has been implemented

Ensure all other ICS staff are informed of selected CC location

Ensure all ICS staff are informed of who is the Incident Commander (IC)

Ensure ONLY those REQUIRED are present in CC (control the number of participants)

Provide an initial briefing to all ICS staff present

Utilize what information is available at the time and act accordingly

Caution: It will not be practical to verify information during an AVIR

Identify and assign Section Chiefs in the following order:

Operations

Security

Security Chief streamlines communication during an A.V.I.R. (See Organizational Chart)

Logistics

Planning

Finance

Establish & Disseminate Primary Objectives / All SECTION CHIEFS:

Continue quality patient care

Ensure safety of patients, visitors, physicians and staff

Provide triage and treatment of those injured in incident

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Maintain relevant span of control

Communicate critical information to ICS staff and Section Chiefs in a timely manner

Identify / select additional ICS Command positions:

Public Information Officer

Safety Officer [Note: Be cognizant to utilize Safety Officer appropriately (SO is not security)]

SO should have a solid clinical background, based on the patient safety concerns during event

Medical Technical Specialist

Liaison

Identify / select IC scribe inside the CC (complete as soon as practical, providing staff is available)

Ensure Section Chiefs are selecting appropriate staff (per HICS)

Establish / disseminate next scheduled briefing time for Section Chiefs

Authorize PIO to release information directly without IC review (not practical to require IC approval

during dynamic incident such as this)

Establish Section Chief Briefing objectives:

Situation Report from Section Chiefs in "60 seconds or less"

Emphasize focus of dialogue on pertinent and relevant information

Sequential order (Operations, Security, Logistics, Planning, Finance)

IC Q&A / redirect efforts as necessary

Establish / disseminate next scheduled Section Chiefs briefing time (15-20 min)

Conclude briefing, "that is all" or "carry on"

Continue briefings as incident evolves (established briefing times that are relevant to situation)

TRANSITIONS OF COMMAND

Out-going IC must include briefing that captures all essential information for continuing safe and

effective operations

Out-going IC should remain as support after initial transition to ensure continuity

(for reasonable amount of time)

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PUBLIC INFORMATION OFFICER (PIO)

ACTION STEPS

Obtain initial briefing from Incident Commander (IC) regarding incident

Obtain authorization from IC to release information to public without prior approval

Maintain HIPAA compliance throughout event and during all releases

Attend all briefings in person when practical

Create initial release to media (consider pre-written releases for Armed Violent Intruder related

incidents)

Example: “The hospital is currently experiencing a critical incident. We are working closely with local

authorities to bring the situation under control. We are asking the public to refrain from

coming to the hospital until the event has been secured. As additional information becomes

available, we will continue to provide updates.”

Utilize various outlets for informational releases

Television, Radio, Facebook, Twitter, Emergency Broadcast, etc.

Prepare information for internal release as directed by IC

Identify best methods for information dissemination

Overhead page, emails, Intranet/Internet postings, text messages, etc.

Coordinate with Section Chiefs regarding information pertaining to critical functions

Patient tracking

Set up family staging area

Patient family staging area

Identify method(s) to share information with patients, visitors, physicians and staff

Provide regular updates to patients, visitors, physicians, and staff

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Coordinate with EMS, police and fire (first responders) PIO's regarding media staging areas and

interviews

Consider regular briefings to the media

Develop outlines for media release regarding the incident

Press release - written (coordinate with responding PIO's regarding information to be released)

Limit to one page

Provide only confirmed information pertaining to hospital response

Be aware of the criminal aspects of the current event and ongoing investigations

Provide information only related to the hospital response (not first responders)

Do not discuss specifics

Provide contact information

Recorded interviews

Deliver information in 20 second sound bytes




Live interviews

Television, Radio, Print

Be prepared to answer and redirect questions

Defer sensitive information to first responders’ PIOs


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Post Incident

Identify location within facility to conduct media briefings once safe/applicable to do so

Prepare press conference information by coordinating with IC and first responders’ PIOs

Press Conference

Prepared written statement

Focus on efforts of hospital staff and the collective response

Focus on "the positives" / the other first responders’ PIO's to discuss "the negatives"

Emphasize the appropriate actions

Be aware of the criminal aspects of the event and ongoing investigations



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SAFETY OFFICER (SO)

ACTION STEPS

Monitor the safety, welfare and accountability of incident staff

Conduct on-going analysis of existing response practices for health and safety issues related to

patients, visitors, physicians, staff and hospital. Implement corrective actions to address safety issues

Oversee hospital response to the event is within hospital policy and standard operating procedures

Provide input to Incident Commander (IC) when concerns become known

Core responsibilities:

Recognize potentially hazardous situations

Inform staff and physicians of hazards

Ensure special precautions are taken when extraordinary hazards exist

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MEDICAL TECHNICAL SPECIALIST (MTS)

ACTION STEPS

Role: Advisory position to Incident Commander (IC) with no supervisory authority for incident

Provide IC with appropriate advice and information regarding specialty

Anticipate probable challenges

Formulate three (3) sequential, relative solutions to present to IC for consideration

Coordinate appropriate response to existing critical incident

Medical Technical Specialist examples:

Physician - Patient Care issues

Engineer - Infrastructure issues

Hazardous Material Technician - HazMat / Bio Hazard issues

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COMMAND LIAISON OFFICER (CLO)

ACTION STEPS

Act as a point of contact for outside agency representatives

Disseminate contact information to their respective Incident Commander (IC)

Create / obtain a list of assisting agencies and their representatives

Assist with the establishment and coordination of inter-agency contacts

Monitor incident operations to identify current or potential inter-organizational challenges

Participate in planning meetings:

Provide resource status

Provide overview of limitations and capabilities of assisting agency resources

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OPERATIONS SECTION CHIEF (Or Incident Commander if Position not filled)

ACTION STEPS

Immediately recommend 'Divert' status of the Emergency Room to Incident Commander (IC)

Via EMS system (or equivalent)

Establish appropriate staff within the HICS structure

Medical Care Branch Director

Staging Manager

Infrastructure Branch Director

HazMat Branch Director (Situational Dependent)

Disseminate Incident Commander (IC) objectives to Directors and Manager:




Maintain relevant span of control (1: 3-7)

Ensure all non-essential services are suspended, CONFIRM with Medical Care Branch Director:

Elective Surgery

Laboratory

Diagnostic Imaging

Physical and Occupational Therapy

Education / Recreation Events

Inform PIO of hospital closure and suspension of non-essential services

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Establish next scheduled time for Directors and Manager to brief Operations Section Chief

Follow up with Branch Directors and Manager:

Ensure continuation of patient care activities in the hospital

Ensure preparation is underway to render care to injured persons, CONFIRM with Medical Care

Branch Director:

Triage of victims

Movement of victims to treatment areas

Treatment of victims

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OPERATIONS SECTION BRANCH DIRECTORS

ACTION STEPS

Establish appropriate staff within the HICS structure:

Medical Care Branch Director:

Assign Positions as needed:

In Patient Care Unit Leader

Casualty Care Unit Leader

Outpatient Care Unit Leader


Disseminate Incident Commander (IC) objectives:





Medical Care Branch Director:

Follow up with Unit Leaders to ensure:

In Patient Care Unit Leader

Confirm hospital bed census

Reallocate nursing staff to provide causality care

Casualty Care Unit Leader

Identify triage and treatment areas

Identify plan to move victims to treatment areas

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Identify alternate treatment areas

Utilize hospital's Mass Casualty Incident Plan

Out Patient Care Unit Leader

Ensure Out Patient Care non essential services are suspended

Verify safety measure implementation with Out Patient Units

Consider Out Patient Units for casualty care treatment areas


Establish plan to ensure quick registration for those injured in the incident

Prepare to provide medical records for patients transferred as a result of transfer or

evacuation

Staging Manager



Equipment Supply Staging Team Leader

Medication Staging Team Leader

Disseminate IC objectives:





Consult with Supply Unit Leader in Logistics to verify a safe staging area

Consult with Security Liaison to ascertain locations where staging resources can respond

Follow up with Team Leaders to ensure:


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Maintain a roster of personnel and assignments

Equipment Supply Staging Team Leader

Maintain an inventory of equipment, to include location and destination

Medication Staging Team Leader

Maintain an inventory of medications, to include location and destination



Power/ Lighting Unit Leader


Water/ Sewer Unit Leader






Increase the capacity when patient surge requirements dictate

Identify and fix utility service - delivery failures

Assign Assessment Strike Teams to assess hospital damage



Power/ Lighting Unit Leader

Be prepared, should urgent circumstances exist, to maintain or repair the normal

operating capability of the hospital

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Water / Sewer Unit Leader



HazMat Branch Director (situational dependent)

Assign positions as needed:

Detection and Monitoring Unit Leader

Victim Decontamination Unit Leader

Spill Response Unit Leader

Facility / Equipment Decontamination Unit Leader






HazMat Branch Director follow up with Unit Leaders to ensure compliance with

hospital's Hazardous Materials Response SOP

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LOGISTICS SECTION CHIEF

ACTION STEPS


Support Branch Director

Service Branch Director






Establish next scheduled time for Directors to brief Logistics Section Chief

Follow up with Branch Directors to ensure:

Resources are effectively and efficiently being requested and procured

Specificity for materials requisitions

Establish Logistics Section Objectives:

Locate and provide additional staffing resources for patient care, support functions and

infrastructure

Locate and provide additional patient care equipment as needed

Locate and provide facility communications equipment

Locate and provide food for staff during incident

Identify known and anticipated incident service and support requirements

Provide mental health support for patients, visitors, physicians and staff

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LOGISTICS SECTION DIRECTOR(S)

ACTION STEPS


Support Branch Director

Focuses efforts on meeting needs of facility to continue operations

Supply Unit Leader – it is CRITICAL to work closely with Planning Section Resource

Unit Leader

Acquires needed supplies through both standard and emergency acquisition

procedures

Facilities Unit Leader - CRITICAL to work closely with Infrastructure Branch Director

Supports infrastructure operations

Family Care Unit Leader - works with PIO to establish off site information center for families

Provides resources to meet the needs of patient families

Transportation Unit Leader

Coordinates internal and external transportation

Labor Pool Credentialing Unit - works closely with Personnel Staging Team Leader

Provide identifying credentials for responding personnel

Employee Health and Well Being Unit Leader

Ensures processes exist for the health and well being of staff

Employee Assistance Program

Service Branch Director

Focuses on internal staff needs

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Communications Unit Leader

Provides methods and resources for staff communications

IT / IS Unit Leader

Provides methods and resources for connectivity to support internal and external

communications and documentation

Disseminate Incident Commander objectives:





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PLANNING SECTION CHIEF

ACTION STEPS

Establish appropriate personnel within the HICS structure

Situation Unit Leader

Resources Unit Leader

Documentation Unit Leader

Demobilization Unit Leader






Establish next scheduled time for Unit Leaders to brief Planning Section Chief


Collection, evaluation and dissemination of incident situation information to IC

Verify preparation of status reports

Verify preparation of Incident Action Plan

Conduct briefing to ensure understanding of existing Emergency Operations Plan to IC

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PLANNING SECTION UNIT LEADER(S)

ACTION STEPS


Situation Unit Leader

Responsible for writing and maintaining incident updates based on internal and external events

Patient Tracking Manager

Stay current with patient location assignments and make information available

to ICS staff and external agencies through Liaison Officer

Bed Tracking Manager

Stay current with hospital bed availability

Resources Unit Leader

Tracks the status of staff and resources that are being utilized in the various locations in the

hospital. It is CRITICAL to work closely with the Logistics Section Supply Unit Leader to:

Ensure effective communication.

Prevent duplication of effort

Facilitate efficient decision making

Personnel Tracking Manager

Maintain a roster and location of staff present at time of incident inside

the hospital

Track staff as they deploy from Staging Area

Material Tracking Manager

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Maintain an inventory of all supplies and equipment present at time of incident inside

the hospital

Track equipment and supplies as they are delivered from Staging Area

Documentation Unit Leader

Completes Incident Action Plans and other supporting documents and archives them

Demobilization Unit Leader

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SECURITY SECTION CHIEF (SC) (Or Incident Commander if Position not filled)

ACTION STEPS

Establish prescribed staffing to immediately respond to the situation:

Note: If security officers are armed, they should be working toward mitigating the threat

Note: If security officers are not armed, they should be implementing R.A.L.M. Principles

Security Branch Director

Disseminate Incident Commander (IC) objectives to Security Branch Director





Establish & Disseminate Security Section objectives to Security Branch Director

Restrict Access / Limit Mobility (R.A.L.M. Principles)

Attempt to secure primary entrance points to the hospital (if applicable)

Anticipate possible path of intruder and secure access points accordingly

Attempt to create multiple “layers” of objects to hinder intruder(s) movement

Establish direct communication with law enforcement via Security Liaison

Follow up directly with Branch Director regularly for updates

Provide regular briefings regarding response and status to IC

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SECURITY SECTION BRANCH DIRECTOR / UNIT LEADER(S)

ACTION STEPS

Establish prescribed staffing positions in response to the Incident Commander (IC) and Security

Chief (SC) objectives:

Security Branch Director:

Assign immediate positions:


Law Enforcement Interface Unit Leader

Disseminate Incident Commander (IC) objectives to Unit Leader(s):





Disseminate Security Section Chief objectives to Unit Leader(s):

Restrict Access / Limit Mobility (R.A.L.M. Principles)

Attempt to secure primary entrance points to the hospital (if applicable)

Anticipate possible path of intruder and secure entrance points accordingly

Attempt to create multiple “layers” of objects to hinder intruder(s) movement

Establish direct communication with law enforcement via Security Liaison

Follow up with Unit Leader(s) regularly in order to streamline consistent flow of information to the SC

Consider and plan for the possibility of additional intruder(s)

Initiate planning for the implementation of crowd control, traffic control and Search Unit Leaders

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Disseminate Security Section Chief objectives to security personnel:

Initiate the R.A.L.M. Principles and assign personnel to areas relative to threat location

in a proactive attempt to restrict the access / limit the mobility of the intruder by securing

relative access points or creating multiple “layers” to hinder ease of movement for the

intruder.

Law Enforcement Interface Unit Leader

Select from staff and assign the role of Security Liaison

Disseminate Security Section Chief objectives to Security Liaison

Establish and disseminate Law Enforcement Interface Unit Leader Objectives:

Identify location of the Unified Command on exterior and respond

Liaison with law enforcement and provide a direct link for IC

Assist with establishing and coordinating inter-agency law enforcement contacts

Provide information regarding hospital facility and utility information

Attend related law enforcement briefings in order to provide information to Law

Enforcement Unit Leader

Establish a list of assisting law enforcement representatives and contact information

Follow up with Security Branch Director regularly in order to streamline consistent flow of information

to the SC

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FINANCE SECTION CHIEF / UNIT LEADER(S)

ACTION STEPS


Time Unit Leader

Procurement Unit Leader

Consider additional unit leaders with adequate staff

Compensation/ Claims Unit Leader

Cost Unit Leader






Establish Finance Section Objectives:

Works with Planning and Logistics to determine what staff and supplies are being brought into

the incident

Track hours worked

Ensure goods and services are procured for incident

Gathers evidence and prepare claims documents

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