Homeland Security Presidential Directive - 5 Management of Domestic Incidents (HSPD-5) was issued in 2003 to “enhance the ability of the United States to manage domestic incidents by establishing a single, comprehensive national incident management system.” The National Incident Management System (NIMS) is a nationally standardized and comprehensive system of incident command and management that is scalable to incident magnitude, location, and complexity. NIMS applies to all entities who may respond to a disaster, whether it is public, private, tribal, state, and federal. However, the system has its basis upon the premise that all responses begin and end locally. It was designed to improve interoperability between all responders, provide unity of effort, and ensure a common operating picture for any entity or individual arriving to support an incident. NIMS Certification training and understanding of the Incident Command System response framework allows for resource planning and allocation, communication strategy development, and identification of information, resources, and communication management systems. It provides for readiness preparation at all levels from the individual to the organizational to the federal level. The Federal Emergency Management Institute (FEMA) offers standardized NIMS core curriculum courses available to all individuals, organizations, and leadership to ensure a unified and coordinated response to incidents nationwide.
Training for a response to an emergency, whether it be a natural disaster such as Hurricane Katrina, or human-made as the events on 9/11, is the responsibility of everyone who may be called to assist from first responders (fire, medical, police) to emergency operation center personnel and elected officials. It is this common training that provides an understanding of the language used, the command structure, and the preparedness requirements to support efficient and effective incident response. Having a unified language and framework enables responders from multiple agencies, (i.e. Red Cross, Department of Transportation, military support of civil authorities, local rescue, state and federal response operations) and across multiple jurisdictions work together with little notice, seamlessly, with standardized expectations and a non-competitive unity of effort to achieve the best outcome for those affected. The intent is for any event to begin and end with the local responder. When resources are anticipated to be overwhelmed, larger and larger response resources may be called in to support the response in gradual escalation (i.e., city, county, non-government organizations, state, federal), but the command remains with the local response Incident Commander 
Training is free and located on the FEMA website. According to FEMA, general first responders should complete ICS-100 and IS-800 courses to have a working knowledge of the NIMS Incident Command System and the National Response Framework. ICS-200 may be taken additionally to increase expertise in basic response operations. Advanced training for increasing incident complexity includes all of the following free online courses.
The National Response Framework established by HSPD-5 works with NIMS to integrate the response capabilities and resources as well as provide uncontested and unified leadership across multiple disciplines, agencies, non-governmental organizations, state and federal governments, and volunteer efforts. All events, regardless of size, begin with the first local responder on the scene and end at the release of local authorities. The scaled response between those two moments in time is based on a request by that first responder and later the incident commander (most senior responder trained in the Incident Command System) when that person’s resources are anticipated to become overwhelmed. The request for assistance from the local supporting agencies, volunteers, the state, tribal, or federal governments can be orchestrated by the Emergency Operations Center (EOC) but directed by the Incident Commander (IC) or Unified Command (UC). In these instances, it is essential to note that the military may be requested to support these efforts but never take command. Instead, the military works in a “defense support to civil authority” capacity as approved by their commander in chief. Elected or appointed civilian officials request and direct assets anticipated or needed by the IC responsible for ensuring the safety of those within their area of responsibility with preparation and coordination of available resources, ensuring interoperability and cross-agency communication, data flow, and real-time updates - often providing support to EOC personnel. In this construct, Medical systems fall under the Operations arm of support to the Incident Commander. The Medical Branch resembles a busy hospital emergency room organization. Medical Branch sections include triage, treatment, transport, and morgue sections, with designated personnel to be responsible for each section.
Implementation involves contingency plan development and rehearsal in exercises designed to ensure awareness of responsibilities, stimulate the identification of shortfalls in response, and allow for the update of emergency management plans.  Historically, communication and information management has been a key point of failure and must be planned to ensure integration with emergency responders and incident management to get the right people to the right place with the right supplies during a response., Stakeholders in plans meet in tabletop discussion to address the pitfalls that may occur at each juncture of a theoretical response during which they may amend policy, improve infrastructure, create partnerships, and identify areas where local capacity will be exceeded so that the threshold for the request of emergency assistance from State and Federal authorities is identified. Medical providers may support the medical response section but must be prepared to lead as the Incident Commander, should the need arise, therefore a firm understanding of both the medical supply plan under the logistics section and the Operations specific sections (Triage, Treatment, Transport, and Morgue) of the ICS is necessary.
Pre-coordination of those requests and agreements for anticipated needs, including delivery, storage, and distribution plans, and how it will be incorporated can ensure the response is smooth, rapid, and effective. Some requirements for medical facilities depend on the types of emergencies anticipated. For instance, top floor back-up generators are necessary if located in a flood zone. Some requirements are universal, i.e., the ability to communicate on universal frequencies to emergency operations centers and first responders. To assist medical providers in understanding and implementing these preparedness measures, the Center for Disease Control (CDC) and Johns Hopkins Center for Public Health Preparedness (JH-CPHP) offer a public health-specific NIMS training for local health departments for possible future emergencies such as pandemics, natural disasters, and attack responses. “NIMS Implementation for Healthcare Organizations Guidance,” published in 2015, gives specific organizational level objectives to hospital management for ensuring the readiness of hospital staff and facilities, including planning, training and exercises, communications and information management, and command. This information is available on the website of the U.S. Department of Health and Human Services.
The NIMS Incident Command System may be called upon for any incident from train derailing to a hurricane to terrorist attack affecting large populations and crossing lines of jurisdiction. The immediate response will require establishing scene safety and equipment and staging, and when established and personnel is available, each IC supporting section, operations, planning, logistics, and finance, will be identified and start supporting the response effort. The first step in a medical capacity is to establish communications with the Incident Commander and identify who is acting as the Operations Section Chief. These members will be directing the response as it relates to the big picture. As medical providers, after establishing communications and scene safety, it is essential to stage equipment by creating a care station, designing a logical flow of traffic in and out. The next steps include coordination with emergency rescue crews for patient delivery and triage personnel to ensure timely care, location for a morgue, and identification of lanes of resupply.
After Action Review
After each response, a meeting is held with all stakeholders to review the event response and ensure the lessons learned are collected and shared to improve practices for future interventions. Upon arriving at a new organization or when planning for training or execution of the response plan, it is prudent to review the after-action lessons learned from previous events to identify shortfalls and avoid them in the future.
The NIMS is a nationwide standard template to enable local responders to access scalable support in response to incidents, regardless of location, size, or cause to protect citizens and create an efficient and effective collaboration under a trained Incident Commander. Medical support to the logistics arm of the Incident Command must include providers familiar with the NIMS and ICS constructs which can take command if necessary, as the first responder on the scene. Communication with medical support, mobility, and leadership is critical for an effective response. Readiness is the responsibility of every provider, as is passing forward lessons learned to continue to improve response efforts and reduce morbidity and mortality of those affected.
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