ICS and NIMS for EMS: ICS-100, ICS-200 and the Incident Command System

The Incident Command System, ICS, is the standard way US emergency responders organize themselves on a scene, from a two-car crash to a hurricane. It is the reason a paramedic from one agency can arrive at an incident run by a fire department from another county and know who to report to, what the words mean and where the patients go. It sits inside a larger national framework, the National Incident Management System, NIMS. Every EMS student meets both, usually first as the FEMA independent study courses ICS-100, ICS-200 and IS-700, and later on a scene where getting the structure right is what lets the medicine happen.

NIMS and ICS: the framework and the structure

NIMS is the national framework for managing incidents. It was developed by FEMA under the Department of Homeland Security after Homeland Security Presidential Directive 5 in 2003, and it gives every level of government, and the private and nonprofit sectors, one shared approach to preparing for, responding to and recovering from incidents of any kind and size. The current FEMA document, the 2017 third edition, organizes NIMS into three components: resource management, command and coordination, and communications and information management.

ICS is the part of NIMS that runs the scene. It is a standardized, on-scene management structure that lets responders from different agencies and disciplines work under one organization with one set of objectives. It grew out of the California wildfire seasons of the 1970s, when the FIRESCOPE program found that fire agencies working the same fires were failing not for lack of resources but for lack of a common organization, common terms and common communications. Those three failures are still the ones ICS exists to prevent.

The principles that make ICS work

NIMS describes a set of management characteristics that ICS is built on. The ones an EMS provider uses on every incident are these.

• Common terminology. The same words mean the same thing to every agency: positions, facilities, resources and functions all have standard names. Radio traffic is in plain language rather than agency codes, because a ten-code that means one thing to your service can mean something else to the department beside you.
• Modular organization. The structure grows and shrinks with the incident. A small call may be one incident commander doing every job; a large one adds sections, branches and units only as they are needed, and removes them when they are not.
• Management by objectives. The incident commander sets specific, measurable objectives, and every assignment traces back to one of them. Nobody freelances.
• Manageable span of control. FEMA's ICS training teaches that a supervisor should directly manage between three and seven people or resources, and NIMS describes one supervisor to five as optimal, while noting that actual ratios vary with the incident. When a span grows past that, the answer is another layer of organization, not a busier supervisor.
• Unified command. When more than one agency or jurisdiction has responsibility, their leaders share command and agree on one set of objectives and one plan, while each keeps authority over its own people.
• Incident action planning. Objectives, strategies and assignments are written down for each operational period, the block of time the plan covers. On a small incident the plan may be spoken; on a large one it is a written incident action plan.
• Chain of command and unity of command. Chain of command is the orderly line of authority. Unity of command means every person reports to one supervisor only, so nobody receives two conflicting orders.
• Accountability. Everybody checks in, works where they were assigned and reports to their own supervisor, and resources are tracked from arrival to release. This is how command knows who is on the scene and where they are.
• Establishment and transfer of command. Command is established by the first arriving unit and is transferred, with a briefing, when a more qualified person takes over or when the incident's needs change, such as a change of jurisdiction, growing complexity or routine relief.
• Dispatch and deployment. Resources respond when requested through the system, not on their own initiative. Self-dispatched units are one of the commonest problems at large incidents.
• Integrated communications and incident facilities. A communications plan everybody uses, and standard facilities such as the incident command post and the staging area.

The command and general staff

Every incident has an incident commander, and on a small incident the incident commander does everything. As an incident grows, the incident commander delegates in two directions: to the command staff, who report directly to the incident commander, and to the general staff, who lead the four functional sections.

NIMS also allows an intelligence and investigations function where an incident needs one, placed where the incident commander decides. Each level of the structure has its own title: sections are led by a Chief, branches by a Director, divisions and groups by a Supervisor, and units by a Leader. Facilities such as staging are run by a Manager.

The building blocks below the sections

• Branch: used when the number of divisions or groups exceeds a manageable span of control, or to organize by function, such as a medical branch.
• Division: an area of the incident defined by geography, such as a floor of a building or a stretch of highway.
• Group: a part of the incident defined by function, such as a triage group or an extrication group, wherever on the scene it works.
• Unit: in NIMS terms, the element with functional responsibility for a specific planning, logistics or finance activity. Many MCI plans also use the word for EMS functions such as triage or transport, as in the transport unit.
• Task force: a mix of different kinds of resources under one leader. A strike team is a set number of the same kind of resource under one leader. A single resource is one vehicle or one crew working alone.

Where EMS fits

On an ordinary call the ICS structure is invisible because one crew is the whole of it. It becomes visible when the patients outnumber the people caring for them: a mass-casualty incident. Then the EMS functions are organized, usually inside the Operations Section, as a medical group on a smaller incident or a medical branch on a larger one. The exact names and structure are set by your regional MCI plan, and they vary, but the functions are close to universal.

Some plans add a morgue function for the dead and a separate staging area just for ambulances. The person coordinating with hospitals, often within transport, is the one who keeps a single receiving facility from being sent every patient on the scene.

Practice the START and JumpSTART triage algorithm

If your unit arrives first

On many incidents the first arriving unit is an ambulance, and in ICS the first arriving unit establishes command until somebody more qualified takes it. That means the most important early job is not patient care. It is a size-up and a report: what you have, roughly how many patients, what hazards, what resources you need, where incoming units should stage, and who has command. That report starts the incident's plan, and it is the thing everybody arriving after you depends on. On a small incident the ICS 201 incident briefing form can serve as the initial incident action plan. The ICS 201 incident briefing form is FEMA's template for writing it down and for briefing whoever takes command from you.

1. Make sure the scene is safe for you and your partner before you commit.
2. Give a size-up report and announce that you have established command, naming the incident.
3. Request the resources you expect to need, early. Cancelling resources is easy; making up for a late request is not.
4. Name a staging location so incoming units do not drive into the scene.
5. Begin triage, or assign it, rather than treating the first patient you reach.
6. When a more qualified officer arrives, give a face-to-face briefing and formally transfer command.

Structure a briefing before you hand it over

The FEMA courses: ICS-100, ICS-200 and IS-700

FEMA's training institute for emergency management, known as EMI, runs an Independent Study program of free online courses, and three of them are the ones most EMS programs and employers ask for. Each is completed online and ends with an online final exam, and a certificate is issued on passing. FEMA revises these courses from time to time, so the current version, length and requirements are on EMI's own course pages rather than here.

The next steps, ICS-300 and ICS-400, are taught in a classroom for people who will manage expanding and complex incidents. Which courses you need, and by when, is decided by your EMS program, your employer, your state or the terms of a grant, and it varies.

What an emergency operations plan is

An emergency operations plan, EOP, is the document a jurisdiction or an organization writes ahead of time to say how it will respond to an emergency: who is in charge of what, how resources are requested, how agencies coordinate and how the public is warned. Counties, cities, states, hospitals, schools and EMS agencies all have them. FEMA's Comprehensive Preparedness Guide 101, CPG 101, is the federal guidance most jurisdictions use to write one.

• Most EOPs are all-hazards: one core plan for any emergency, rather than a separate plan for every possible disaster.
• A basic plan sets out the concept of operations, roles and responsibilities and lines of authority.
• Functional annexes cover jobs that recur in any emergency, such as communications, evacuation, mass care and health and medical services.
• Hazard-specific annexes cover what is particular to a hazard, such as a hurricane, a hazardous materials release or a pandemic.
• The plan is exercised and revised. A plan nobody has practiced is a document, not a capability.

For an EMS agency, the plans that matter most day to day are its own operations plan, its part in the county or regional EOP, the regional MCI plan that names the triage system and the hospital coordination process, and a continuity of operations plan for keeping the service running when the agency itself is affected. An emergency operations center, EOC, is the place where a jurisdiction coordinates support and resources during a large emergency. It supports the incident command post on the scene; it does not command the scene.

The short version

• NIMS is the national framework. ICS is the standardized on-scene management structure within it.
• The core ICS ideas: common terminology and plain language, modular organization, management by objectives, manageable span of control, unified command, incident action planning, unity of command and accountability.
• FEMA's ICS training teaches a span of control of three to seven per supervisor; NIMS describes one to five as optimal, and actual ratios vary.
• Command staff: Safety, Public Information and Liaison Officers. General staff: Operations, Planning, Logistics and Finance/Administration.
• At a mass-casualty incident EMS usually works as a medical group or branch with triage, treatment and transport. Your MCI plan names the exact structure.
• If you arrive first, you have command until you hand it over: size up, report, request, stage, triage.
• IS-100, IS-200 and IS-700 are free FEMA independent study courses. Learn the structure, not the answer key.
• An emergency operations plan is the written, all-hazards plan an agency or jurisdiction makes before the emergency.