Not Just Another Acronym

As EMS providers, in order to safely accomplish our goals of triaging, treating and transporting our patients, we must frequently work with and rely upon other agencies to provide personnel, equipment and other resources and support functions. What if there was a system that allowed this to happen in an organized manner, every time an incident occurred, no matter how large or small, regardless of location or jurisdiction? Science fiction, right? Actually, a system for achieving those goals currently exists. It is called the National Incident Management System (NIMS).

Chances are, if you're not directly affiliated with a fire department or some other government entity, you probably weren't included in the introduction of NIMS by the Department of Homeland Security. Many EMS providers are not fully aware of the requirements, set forth by the federal government, making NIMS the national standard for responding to and managing emergency incidents of all types. NIMS is a new way of doing business. As an EMS provider, it is imperative for you to understand how you and your organization fit into the NIMS framework.

The birth of NIMS
Many of the large-scale events that have occurred in recent history have produced the same lessons learned. Among these have been questions about who was in charge, along with personnel receiving multiple, conflicting orders from more than one "commander," the inability to communicate with others operating at the same incident, and a duplication of effort resulting from an unwillingness to integrate game plans or resources. Other problems included confusion sparked by inconsistent use of terminology and an inability to obtain additional resources when local resources ran out.

Since the early 1990s, public-safety innovators had been working to integrate our procedures for managing major events. Many succeeded in doing so at local or even regional levels. However, after the tragic events of September 11, 2001, a determination was made to integrate our command systems, resources and game plans on a national level.

In February 2003, Homeland Security Presidential Directive #5 (HSPD-5) was issued by President Bush. HSPD-5 deals directly with the concepts of managing domestic incidents. In this directive, Bush charged the Department of Homeland Security (DHS) with developing and administering a National Incident Management System. By March 2004, DHS had implemented NIMS.

The Same Sheet Of Music
All of us should be at least somewhat familiar with the concepts of the Incident Command System (ICS). As EMS providers, we may have varying levels of experience utilizing or operating within incident command structures. Some of us are comfortable with ICS concepts because our systems use them all the time. Others may be the exact opposite, essentially becoming victims of ICS as other entities with which we respond utilize it, while we remain on the outside looking in.

It is important to understand that NIMS is not just another acronym atop the pile of ever-changing monikers for the Incident Command System. NIMS is an all-encompassing system unto itself.

NIMS was developed to provide a practical system to be used by all disciplines (EMS, law enforcement, fire-rescue, public works, hospitals, the private sector and government) for all hazards (any incident you can think of, large or small). It provides a framework that allows all local, state, tribal and federal resources to come together under a unified command structure, essentially working off the same sheet of music. NIMS also creates an ability to integrate all of our resources effectively into the overall effort to safely bring the incident to an end as quickly as possible.

The NIMS Umbrella
NIMS consists of six functioning divisions, each contributing to the management of an emergency environment:

1. Command and Management
2. Preparation
3. Resource Management
4. Communications and Information Management
5. Supporting Technologies
6. Ongoing Management and Maintenance.

Command and Management
This first division focuses on three concepts:

1. The Incident Command System (ICS)
2. Multi-Agency Coordination Systems (MACS)
3. Public Information Systems.

Incident Command System-The birth of the modern ICS is typically traced back to California wildland firefighters of the early 1970s. Through use of basic management principles, common terminology, personnel and resource classifications and methods that allowed all incident stakeholders to communicate with one another, the FIRESCOPE method of incident management was born. At first it was thought by the urban fire-service community to be too wildland-oriented, so throughout the 1970s, alternative incident command models were developed by urban fire departments across the country.

Utilizing an incident command system in the fire service became a recognized practice during the 1980s. Organizations like OSHA, the EPA and the NFPA developed standards and mandates regarding the use of ICS. The problem at this point was that there were many versions from which to choose, and often, as agencies adopted their particular versions, further modifications occurred in order to better accommodate the specific needs of those agencies. Utilizing these individualized versions of ICS worked well when operating as single agencies on small incidents in single jurisdictions, but such a system proved problematic when it came to multiple organizations in large incidents or incidents that involved more than one jurisdiction. The vast diversity of incident command models in use created problems with integrating resources, using common terminology and following standard procedures. For instance, how does your command system define the front of a building, Side A or Side 1? Do you go clockwise or counterclockwise to label the other sides? Does your command system define the front of the building as the street address side or as the side that has the main entrance? Does it divide management of your incidents into sectors, divisions, groups or branches? What is your definition of staging (Level I, II, III, primary, secondary, etc.)? Do these definitions match the definitions created by your EMS organization? If your EMS crews were requested to report to Side B of the high school to set up triage, would they know where to go? NIMS has addressed this problem on a national level. By becoming NIMS-compliant, all entities will be operating under the same ICS structure. With the exception of a few minor changes, NIMS has adopted the FIRESCOPE version of ICS.

NIMS encourages the concept of unified command, as opposed to the traditional approach of single command. Traditionally, an incident would be under the direction of a single person, usually a representative from the lead agency responsible for bringing the situation under control (e.g., a representative from the police department would be the incident commander of a hostage situation; a representative from the fire department would be the incident commander of a structure fire, etc.) Since NIMS provides a structure for all disciplines to be able to manage all hazards, the concept of unified command comes into play for situations with a need for multiple resources or involving multiple jurisdictions. The incident commander becomes the incident command "group" (working under the concept of unified command), which is still a single voice, but now coming from a gathering of leaders working together. The Incident Action Plan (IAP) is developed through collaboration with the unified command staff. Unified command ensures an integrated approach to bringing the incident to a safe and effective conclusion.

Multi-Agency Coordination Systems (MACS)-Since the structure of NIMS attempts to prepare us to effectively respond to large-scale emergencies, we need to be ready to utilize the talents of personnel from many different entities as they arrive on scene. A facility (fixed or temporary), a reliable method of communication and the appropriate equipment to manage the planning, logistics and administration sections of the incident response help to make a reliable multi-agency coordination system. Every state has an emergency operations center (EOC), as do many counties and some cities/communities. An EOC serves as an incident support center. You don't need a lofty budget to create a useful EOC that will adequately support a multi-agency coordination system.

Public Information Systems-Today's society has come to expect accurate, real-time information. Ignoring this expectation can lead to inaccurate representations of your operations and cause many negative repercussions. Media outlets are willing and able to function as strong allies by transmitting important information and instructions to the public. There are also other sources outside the media that can be developed and deployed to broadcast important information during times of crisis.

A constant flow of accurate information is imperative internally as well. Part of becoming NIMS-compliant is developing a Joint Information System (JIS) to ensure that integrated procedures, plans and protocols are in place to get information where it needs to go.

Most of us have become familiar with the title of Public Information Officer (PIO). Over the last decade, many organizations have designated personnel with the responsibility of funneling timely and accurate information to the public. Responding to an incident that involves multiple agencies and/or jurisdictions means each organization may be bringing their PIO along for the ride. As with the concept of unified command, we need to have a method of gathering each agency's PIO into a team that collaborates in gathering and disseminating information in a way that adequately represents each organization involved. Building on the concepts provided by the MACS, the Joint Information Center (JIC) provides a gathering point for the PIOs. Although it is not required, the EOC is frequently chosen as a reliable location for the JIC. It is here where all available information can be organized, categorized and prioritized. Clear, understandable, consistent messages can then be presented to the media and the public at large.

Preparedness
This division encourages each entity to work through the developmental phases of emergency management planning. Many organizations have worked diligently to develop elaborate emergency operations plans (EOPs), but can those plans effectively incorporate other entities? NIMS compliance means that local EOPs integrate with regional EOPs. Regional EOPs must jell with states' EOPs. In order for the states' EOPs to fit into the National Response Plan (NRP), they must be unified efforts, including all disciplines and able to address all hazards.

Obviously, an effort this ambitious is not going to be realized overnight. DHS realizes this and has adopted a "baby steps" approach to achieving the overall goal. Becoming NIMS-compliant is not a one-time deal. As DHS continues to develop and improve the NIMS standards, each entity will be informed of the most current requirements and given a reasonable time frame in which to achieve its goals and objectives.

Training and Exercises-Once you have an integrated, written plan in place, it is essential to train on it. In much the same way as you developed your plan, start with small-scale local exercises and eventually grow into large-scale, multidisciplinary, multijurisdictional regional exercises. Some exercise-planning experts advise against the concept of real-time exercises; however, your particular agency may find real-time training to be beneficial, provided you have the resources to make the experience as realistic as possible. Your local and/or state office of emergency management (OEM) can provide you with many resources regarding development and delivery of training exercises.

Being NIMS-compliant will mean we'll need to show proof that our organizations are regularly participating in exercises that provide an opportunity to work with other disciplines and other jurisdictions under a unified command structure. The annual "bus wreck" mass-casualty scenario we all snore through will no longer suffice. The scenarios involved will need to be challenging and reflect myriad potential problems to meet the goal of all-hazards preparedness.

Personnel Qualification and Certification-Just as we all had to complete defined curricula to function as EMS providers, DHS expects that we successfully complete a standard curriculum on incident command and NIMS. Unlike our discipline-specific training and certification standards, NIMS training is multidisciplinary. The same curriculum is provided to all members of the response community.

Mutual Aid Agreements-Does your agency maintain agreements with other agencies to offer or receive support when requested? Are they formal or informal agreements? If they're formal, when were they last updated? If they're informal, they need to become formal to be in compliance with NIMS standards.

NIMS Resources

• The textbook National Incident Management System: Principles and Practice, from Jones and Bartlett, has already been adopted as several states' official NIMS training manual. Its high-profile expert contributors include Hank Christen, Frank Cilluffo and Paul Maniscalco. See www.jbpub.com.

• The pocket-sized NIMS Incident Command System Field Guide comes from Informed Publishing. It covers NIMS concepts and components, as well as incident operations, planning, logistics and finance. See www.informedguides.com.
• New in May was Beyond Initial Response: Using the National Incident Management System's Incident Command System, self-published through AuthorHouse. Among its focuses is explaining various ICS positions. See www.authorhouse.com.
• For a video primer, Emergency Film Group offers NIMS: Introduction to the National Incident Management System, a 25-minute summation that includes a model-procedures guide.
• There's a new online NIMS Resource Management course (IS-703) from the NIMS Integration Center and Emergency Management Institute. See https://training.fema.gov/emiweb/is/is703.asp.

Resource Management
Irrespective of the size or complexity of your incident, effective resource management is critical to bringing it to a safe and expedient end. Resources can be divided into people and things.

When tasked with managing people at the scene of an emergency, some basic questions you might ask are: How many people are at this incident? Where are they? What are they doing? What training do they have? What are they capable of? When you're dealing with a large-scale incident, chances are you will not know or have an opportunity to interview all of the personnel who show up to help before assigning them to tasks.

How many things do we need? Who is bringing what? Where do we put these things? How do we make sure everyone gets back the equipment they brought? How do we dispose of and replace disposable items? Having a method of inventorying and tracking resources is also essential, as is having a standard procedure for requesting resources. NIMS helps us standardize the entire resource management process.

Common terminology is a huge component of resource standardization. For instance, functioning under NIMS, you request five Type I ambulances. You know you'll receive five transport-capable vehicles that will arrive with specific capabilities and a predetermined number of personnel trained to provide a certain level of care (see Table 1).

The Resource Ordering and Status System (ROSS) is one example of how NIMS standardizes the approach to requesting resources. If you participate in ROSS, your available resources can be identified, requested and deployed anywhere in the country. The other major benefit is that the person requesting that resource knows what they're getting.

To be NIMS-compliant, your organization will need to categorize all of its available resources (people and things) based on definitions provided by NIMS standards. Your completed resource list should then be submitted to your local emergency management entity. Eventually, each state OEM will have a detailed list of all the state's available resources.

With all of the required components in place, a resource unit leader, utilizing standard forms, could effectively request, receive, track and inventory a vast array of resources. Wildland firefighters have been utilizing this method of resource management under FIRESCOPE for decades.

Communications and Information Management
Breakdowns in communication are recognized as contributing to the deaths of emergency responders of all disciplines and leading to the overall failure of incident operations of all sizes and types. Interoperability is always a major concern. Redundancy is also addressed by this section of NIMS. Not only should we have the ability to communicate with everyone involved in an incident, we should have more than one way of communicating in the event of a system failure. This is an issue many of us are still struggling with.

To be NIMS-compliant, a clear communications plan needs to be developed early and included in the IAP so everyone is informed and following procedure.

Supporting Technologies
All of us can think of examples of technology that we use on a daily basis to assist us in the performance of our EMS duties (portable radios, cell phones, alphanumeric pagers, mobile data and computer terminals, personal digital/data assistants, etc.). To support the concepts of interoperability, compatibility and redundancy, DHS recognizes a need to develop standards and specify requirements for these supporting technologies.

Of all of the NIMS divisions, this one appears to be the least developed at this point. DHS has established a Homeland Security Institute (HSI) for purposes of brainstorming research and technology ideas in order to further develop it.

Training Levels
ICS-100: Awareness- or introductory-level content regarding basic concepts of the Incident Command System.
ICS-200: Operations- or mid-level content. Geared toward frontline providers and line officers or field supervisors.
ICS-300: Technician- or mid- to high-level content. Geared toward experienced line officers/field supervisors and chief officers/department managers.
ICS-400: Specialist- or high-level content. Geared toward experienced chief officers/department managers and administrators.
IS-700: Introduction to NIMS. Required for all levels.
IS-800: Introduction to the National Response Plan. Generally required for all supervisory/management/administrative staff.

Ongoing Management and Maintenance
One of the components required of a valid EMS system is a regular method of ensuring quality and making improvements to everyday functions. To assure NIMS's longevity, DHS will continuously develop and evaluate the standards and procedures it espouses. In effect, the ongoing management/maintenance component represents the QA/QI process for NIMS.

Making sense of it
If, at first glance, the entire process seems intimidating, just think back to 1994, when the current DOT National Standard Curriculum for EMT-Basics was introduced. The old primary and secondary survey was replaced with a new format that seemed confusing and cumbersome. The new assessment format was terminology-specific and acronym-driven (initial assessment, focused history and physical examination, BSI, AVPU, OPQRST, SAMPLE, DCAP-BTLS). Now, almost 12 years later, an entire generation of EMS providers has been trained in this format, and they're using it without any issues. It has since been included in the curriculum for first responders, intermediates and paramedics alike. We realize now that the current assessment format, while seemingly more complicated, provides us with more practical options and allows us to make better treatment decisions for our patients based on their specific trauma or medical needs. NIMS is also terminology-specific and acronym-driven, and in time we will come to realize that it provides us with many options, gives us a standard framework and allows us to make good decisions based on the specific needs of the incident.

Remember that DHS is not expecting us to swallow NIMS in one big gulp. Focus on one piece at a time. Becoming compliant is not a onetime process. Compliance will be ongoing for the rest of our careers.

Don't be discouraged
Recent developments, including the slow, disorganized response to and poor management of Hurricane Katrina, has led some emergency-service leaders to question the effectiveness and long-term viability of NIMS. But before scrapping the idea of NIMS altogether, we should consider that the goal of training all emergency responders in NIMS had not yet been accomplished when Katrina hit. Therefore, the typing of all nationally available resources and teams had not yet been completed. Clear lines of authority and communication were not yet in place everywhere. As stated earlier, many local communities have achieved some measure of interoperability with their immediate neighbors, but the concept of national interoperability is something we still need to work on.

Critics have used the circumstances surrounding Hurricane Katrina as a reason to denounce NIMS. Maybe we should look at what happened during Katrina as motivation to continue our efforts to achieve national preparedness through a national incident management system. The goal of national preparedness will be achieved only by breaking our efforts into manageable pieces and being patient with the process. It will not occur overnight.

Start Now
Agencies of the federal government were the first to adopt NIMS. State, tribal and local response entities are required to show compliance by the end of fiscal year 2006. This means personnel in your EMS organization are expected to receive introductory NIMS education (IS-700) and operations-level training in the Incident Command System (ICS-200) by the end of September! Agencies unable to show compliance will eventually lose their eligibility to obtain federal grant money.

Following the "baby steps" method of implementation, an additional set of requirements will be published for completion by the ends of succeeding fiscal years. Compliance requirements will be cumulative. By the time you read this article, if you've not already taken steps to become compliant, your organization will be significantly behind.

Much of the specific information you need to get started can be found on the Internet. FEMA's home page for NIMS is www.fema.gov/emergency/nims/index.shtm. You should download HSPD-5 and other related presidential directives, the actual NIMS document and the letter outlining requirements for compliance in 2006. All of your personnel can successfully complete the Introduction to NIMS training program online by accessing https://training.fema.gov/EMIWeb/IS/is700.asp. The NIMS Integration Center (NIC) is the branch of DHS responsible for the continuing development of NIMS. The NIC also exists to assist agencies in becoming NIMS-compliant. Officials there developed a self-assessment tool called NIMCAST (NIMS Capability Assessment Tool). This assessment can be accessed free of charge through FEMA's NIMS page referenced above. You can e-mail the NIC with any questions at nims-integration-center@dhs.gov. You can also download the resource typing system utilized by NIMS by accessing www.nimsonline.com. There are NIMS-specific publications available to assist you in better understanding the NIMS framework.

Diligent application of NIMS principles will produce long-lasting positive results for your organization and ultimately assist all of us in better managing our incidents by improving safety and efficiency.

Bibliography
Brunacini AV. Fire Command: The Essentials of Local IMS, 2nd ed. NFPA/Heritage Publishers, 2002.
Brunacini N. Staring into the sun: NIMS or NIIMS? (Is a beast with one "I" better than a beast with two?) FireRescue 24(4), April 2006.
Christen H, Maniscalco P. The EMS Incident Management System: EMS Operations for Mass Casualty and High Impact Incidents. Brady/Prentice Hall, 1998.
Walsh DW, ed. National Incident Management System: Principles and Practice. Jones and Bartlett, 2005.

Carl Craigle's background includes over 20 years of EMS, fire and rescue experience. He is the chief paramedic for Platte Valley Ambulance in Brighton, CO. Contact him at ccraigle@pvmc.org.