Equity and Disasters: Reframing Incident Command Systems

In the late 1980s, the hospital emergency incident command system (now HICS) was developed to align with the National Interagency Incident Management System, the federal plan for improving coordination among agencies in a broad range of large-scale emergencies 2 As HICS have been deployed over recent decades, we have deepened our understanding of the strengths and weaknesses of their structure for addressing the needs of diverse populations Recurrent experiences with large-scale disasters, including the COVID-19 pandemic and Hurricanes Katrina, Maria, Harvey, and Sandy, have underscored the ways in which health care responses, emergency preparedness, and broader social determinants of health lead to preventable morbidity and mortality in marginalized communities 3 Here we share the case for embedding an equity element in HICS, our institutional experiences in operationalizing equity, and our recommendation for a structural change in the national HICS guidelines: including a defined equity officer (EO) and subject matter experts in health care equity to ensure that actions are taken to improve outcomes for diverse groups during public health emergencies or disasters The absence of equity as an emergency management principle in responses to COVID-19 has resulted in a slow and incomplete hospital response to the disproportionate mortality and morbidity in several historically marginalized populations 4 For example, hospitals have access to detailed information on the demographic composition of their inpatient populations, the ability to screen patients for social needs, and the opportunity to conduct coordinated community outreach to address the needs of communities of color through HICS infrastructure An after-action review is a structured process developed by the US Army to identify strengths and weaknesses in event response 10 This concept has been adapted as a critical step after public health emergencies to gather information on quantitative and qualitative issues to improve preparedness, mitigation, response, and recovery for future incidents 11 Our institution has conducted several after-action reviews within the past decade after local events including the Boston Marathon bombings and an active shooter incident in our hospital 1214 We have also facilitated reviews in the wake of other large-scale events such as the urban terror attacks in Paris and Brussels 15 Since our initial patient surge in Boston, Massachusetts, in April 2020 (and given the concern for future surges), we have conducted several debriefings with more than 150 staff members across an academic medical center and community hospital within our larger multihospital health care system