EMS Continuity of Operations Plan: A Critical Lifeline Component

“A lifeline enables the continuous operation of critical government and business functions and is essential to human health and safety or economic security.” The Federal Emergency Management Agency (FEMA) developed the Community Lifelines construct after the 2017 and 2018 hurricane seasons. The framework of Community Lifelines allows the whole community to assess the status of and impact to each of the seven lifelines so that the optimal and correct essential action can be executed to support those lifelines not operating at full capacity during a disaster or emergency event.

FEMA has identified seven Community Lifelines: Safety and Security; Food, Water, and Sheltering; Health and Medical; Energy (Power and Fuel); Communications; Transportation; and Hazardous Materials. Emergency medical services (EMS) fall under the Health and Medical lifeline and in the specific category of patient movement. County EMS systems generally move patients with illnesses or injuries to hospitals. Private sector EMS systems usually provide inter-hospital transport, nursing home transports, and hospital evacuations during disaster events. Despite the critical importance of patient movement as identified by FEMA in its Health and Medical Community Lifeline, not enough effort has been made to address the sustainment (continuity) of this component at the state and federal levels.

EMS Interdependence on All Other Community Lifelines

With the criticality of EMS to the Healthcare and Medical Lifeline, EMS continuity planners must also understand their interdependence on all of the Community Lifelines and how the strengths or vulnerabilities of the lifelines in their communities will benefit or impact EMS continuity of operations during a disaster or emergency. The following examples show this interdependence:

  • EMS crews depend on other agencies to provide safety and security in dangerous scenes like active shooter incidents. If the Safety and Security Lifeline is broken, EMS responders may delay patient care or transport due to high safety risks.
  • EMS responders depend on the Food, Water, and Sheltering Lifeline in the same way as normal citizens.
  • If major impacts to the Health and Medical Lifeline occur such as hospital destruction or closure, EMS agencies will face longer transport times to other areas.
  • EMS systems require a steady supply of fuel and power to maintain operations. Any impact on the Fuel and Power lifeline can potentially affect operations.
  • Without a strong Communications Lifeline, 911 calls from citizens may be lost. EMS agencies may lose their ability to navigate to incident locations as well as lose their communication with hospitals and other agencies. EMS patient care documentation and record keeping could be negatively affected.
  • EMS systems rely on a strong community Transportation Lifeline to maintain supply chains medical and oxygen supply deliveries and ensure a reliable network of roads and bridges for responding to and transporting patients.
  • When responding to hazardous materials incidents, EMS organizations must understand their community’s Hazardous Materials Lifeline and the risks they may encounter.

Clearly, EMS systems must understand their roles and relationships in all identified Community Lifelines to better develop an effective continuity of operations planning process as well as improve overall organizational resilience.

Fig. 1. FEMA Community Lifelines graphic: The Argument that EMS Systems Already have Built In Continuity Components.

Fig. 1. FEMA Community Lifelines graphic: The Argument that EMS Systems Already have Built In Continuity Components.

When routine daily tactical activities (e.g., maintenance, supply, equipment, and communications checks; thorough documentation) are practiced as required, they promote continuity of operations (COOP) for EMS. Although these activities are critical to each ambulance and crew, this is only a small portion of the full potential of a COOP program. It is dangerous to assume that, if EMS responders perform a checklist of pre- and post-shift requirements, that the whole EMS system is resilient and a worst-case scenario COOP plan is not needed.

The fact that EMS systems operate 24 hours a day and seven days a week does not make them less vulnerable to a disaster or emergency event that could suddenly or gradually impact their service to the community. Various disruptions must be accounted for:

  • EMS responders not coming to work or not running calls;
  • Communications systems going down;
  • Navigation aids and documentation technology failing;
  • Oxygen and medical supply chains being disrupted;
  • Fuel supply to department and community being interrupted;
  • EMS stations being rendered hazardous or destroyed;
  • EMS stations being cut off due to flooding or debris blocking response routes; and
  • Hospitals being impacted or reaching surge capacity.

Although “checking ambulances” each shift has demonstrated positive outcomes for keeping EMS units and crews in a mission ready status, it is not nearly enough to assume that it covers an all-hazards COOP plan.

Examples of Existing EMS COOP

Although EMS COOP planning is not a novel concept, open source material on the subject is limited. Following are examples of COOP planning from selected organizations around the United States.

On 24 March 2020, Pettis County Ambulance District in Missouri made a public announcement that it was proactively implementing its COOP plan in response to the COVID-19 pandemic. Pettis County described key details on how they would continue to provide Community Lifeline service despite the hazards from a global pandemic. In the press release, Pettis County EMS announced specific changes to their normal operations that included:

  • Screening questions from 911 communications operators to callers;
  • Requests for patients to be close to an exit to limit exposures when EMS arrives; and
  • EMS buildings closing to visitors and public.

Pettis County did not wait until the pandemic began to overwhelm them before considering what to do next.

Northern California Emergency Medical Services (Nor-Cal) already had an established COOP plan. Although developed before COVID-19, Nor-Cal EMS also addressed the possibility of pandemic influenza events (i.e., in its Class 3 Scenario: Pandemic Influenza/Infectious Outbreak), which shows the proactive nature of Nor-Cal EMS at a time when many organizations were unprepared for the current pandemic. By understanding that threats and hazards continually evolve, Nor-Cal EMS established plans to adjust as their critical functions change during a disaster or emergency incident.

Two other examples are presentations specific to EMS COOP. First, Linda Reissman, who is a health care emergency management and COOP planner presented “Continuity of Operations (COOP) for EMS Agencies: When the disaster hits home” in 2011 to the New York State Volunteer Ambulance & Rescue Association Inc. at the annual Pulse Check Conference. Reissman’s informal presentation provides an overview of continuity planning specifically for EMS organizations. During her presentation, she posed the following questions:

  • What would your community do without you?
  • Are your members impacted too?
  • What happens if call volume dramatically increases and is prolonged?
  • Will limited service & mutual aid really be enough if the entire region is impacted?
  • Are you relying on federal resources for timely & prolonged assistance?

These are the types of questions requiring answers before the next disaster or emergency event threatens EMS’s ability to continue critical essential functions.

Second, in 2013, Raphael M. Barishansky, the deputy secretary for Health Preparedness and Community Protection at the Pennsylvania Department of Health, developed: “Continuity of Operations Planning for EMS Agencies” for his presentation at the EMS EXPO conference. He included the following “Essential Steps” toward building an EMS COOP program in his presentation:

  • Create a plan and procedures that address all-hazards assumptions
  • Develop a statement of purpose
  • Identify risks/hazards
  • Plan objectives
  • Identify critical functions and services
  • Identify key personnel and orders of succession
  • Delegate authority
  • Identify communications systems and emergency lists
  • Identify alternate facilities
  • Create comprehensive emergency contact lists

Barishansky and Reissman’s presentations serve as guides to develop similar but specific EMS COOP information for any EMS organization.

Action Plan: The Path Forward

The challenges of implementing a COOP program for EMS organizations can be classified into the following three categories:

  • Intentionally insular and not receptive to COOP planning;
  • In “survival mode” and overwhelmed daily with usual response and already limited resources; and
  • Have an interest in COOP but are financially limited in ways to fund an effective COOP program.

Addressing these categories is ultimately the responsibility of individual EMS organizations. For the insular and non-receptive organization, it may be prudent to confirm if they are even familiar with COOP to begin with. Even some of those who have experienced disasters or major emergency events have not yet formed action plans based on their lessons learned. In response to a social media post by the author 8 March 2020 (in reference to the COVID-19 pandemic), a Pee Dee Region EMS lieutenant responded:

We don’t have isolation protocols for the influenza. We didn’t in case of bird flu or Zeka virus or mad cow disease or etc. It’s pretty simple to wash your hands and maintain a clean unit. Let’s not create a panic unjustly by alarming every county EMS that there is a pandemic when we don’t have one.

Most agencies would agree that EMS is a critical lifeline, and those who serve are dedicated to saving lives. These assertions, though, are not always enough to create proactive plans to keep this lifeline functioning should it become impacted by a disaster.

Available Online Training & Education

COOP training is available in several forms. One of the most convenient ways to build a foundation in COOP basics is through the FEMA Emergency Management Institute’s Individual Study Program, which is free of charge:

  • IS-1300: Introduction to Continuity of Operations
  • IS-520: Introduction to Continuity of Operations Planning for Pandemic Influenzas
  • IS-522: Exercising Continuity Plans for Pandemics
  • IS-545: Reconstitution Planning

Reconstitution typically begins when the disaster or emergency incident that triggered the COOP event is over and the crisis mentality of the organization coming out of a COOP phase has been relieved. The IS-545 course promotes prioritizing toward a return to complete normal operations. The reconstitution phase is also a time to initiate an after-action report and capture data for corrective action or an organizational improvement plan.

Exercises and testing of a COOP plan during normal times is a vital component to evaluate COOP plans and capture plan improvement data. During an actual pandemic is not the time to be addressing problems with an organization’s COOP plan.

FEMA Training Beyond Independent Study Courses

L0550: Continuity of Operations Planner’s Course is a 16-hour, two-day program for improving the functionality of COOP plans and programs. L0550 would be an ideal course to help build continuity planning capabilities in EMS organizations. E0548: Continuity of Operations Program Manager Course is another two-day class (15 hours) FEMA offers for current or future COOP program managers.

Both courses are free of charge, but the two-day course conducted in a classroom may create scheduling, travel, and, funding issues for some potential participants. For this reason, state emergency management agencies may consider hosting these courses to minimize participation hurdles.

Ron Cain

Ron Cain is a radiological emergency preparedness coordinator for a state emergency management agency. He has previous experience as a hospital and small county emergency manager. He has over 25 years of experience as a paramedic in county, military, and private EMS systems. He is a graduate of the National Fire Academy’s EMS Special Operations and Advanced Life Support for Hazardous Materials Incidents Course and a graduate from the REAC/TS Radiation Emergency Medicine Course. He is a state certified emergency manager and has earned undergraduate and graduate degrees in disaster and emergency management.



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