Public health emergency preparedness exercises: lessons learned

Assessment of the effectiveness of hospital external disaster functional drills on health care receivers' performance, using standardized patients and mass cards simulation: a pilot study from Saudi Arabia

BACKGROUND

Given the increasing frequency of disasters globally, it is critical that healthcare systems are prepared for these mass casualty events. The Saudi health system's preparedness for mass casualty incidents needs to be more robust, potentially due to limited disaster drills and inadequate standardized patient (SP) simulation training. This study aims to (i) assess the performance of front-line hospital staff in Saudi Arabia through a functional drill and (ii) evaluate the drill's effectiveness using SP and MAC-SIM cards, providing detailed insights into its design and execution.

METHODS

A functional drill was conducted at a government hospital in Riyadh, Saudi Arabia, on December 19, 2022, using a cross-sectional approach with two phases. 141 healthcare receivers served as subjects, while 23 volunteers acted as SPs. The scenario simulated a building collapse to assess the emergency department (ED) response, interdepartmental communication, and surge capacity. Data were collected through direct observation of healthcare practitioners' interactions with the SPs, analysis of SP data, and participant feedback. Quantitative data were analyzed descriptively, while qualitative data were examined for patterns and themes related to simulation performance and effectiveness.

RESULTS

The hospital receivers' performances demonstrated accurate triage categories. The ED team assessed most patients (67%) in less than 5 min. For patients requiring definitive care, such as intensive care unit, 95% spent less than 2.5 h in the ED. Most patients (65%) required 'other treatments'. Communication was efficient in the triage zone and the yellow treatment area. Participants' feedback on using MAC-SIM cards during the simulation was overwhelmingly positive with 82.61% reporting that MAC-SIM use helped them respond better. Experienced SPs (paramedics) with prior disaster knowledge and experience outperformed inexperienced SPs (nurses) in the functional exercise.

CONCLUSION

This groundbreaking study is the first in the Arabic Gulf region to use SPs with MAC-SIM cards in functional drills. The findings highlight the potential of simulation exercises to improve hospital team knowledge and performance when responding to disasters. Multiple evaluation techniques can effectively identify participant strengths and weaknesses, informing future disaster improvement plans. This information is a valuable resource for Arabic and middle-income countries where disaster medicine is still developing.

Functional Simulation Exercise on Functionality of National Public Health Emergency Operations Centers in the African Region: Review of Strengths and Gaps

National public health emergency operations centers (PHEOCs) serve as hubs for coordinating information and resources for effective emergency management. In the International Health Regulations (IHR 2005) Monitoring and Evaluation Framework, a simulation exercise is 1 of 4 components that can be used to test the functionality of a country's emergency response capabilities in a simulated situation. To test the functionality of PHEOCs in World Health Organization African Region member states, a regional functional exercise simulating an Ebola virus disease outbreak was conducted. The public health actions taken in response to the simulated outbreak were evaluated against the exercise objectives. Thematic analysis was conducted to summarize key strengths and areas for improvement. From December 6 to 7, 2022, more than 1,000 representatives from 36 of the 47 African Region member states participated in the exercise from their respective PHEOCs. Approximately 95% of the 461 participants polled agreed with the positive responses to the postexercise survey. More than half of the PHEOC participants were able to test their existing emergency preparedness and response plans and became familiar with the expected roles to be fulfilled during an event. Of the participants who responded to the survey, over 90% reported that the exercise helped them understand their roles during emergency management. The exercise met its objectives and provided an opportunity to test the functionality of PHEOCs using realistic scenarios, and it helped participants understand existing response systems and procedures. However, the exercise also revealed areas for improvement in terms of the timing and preparation of participants. We recommend conducting functional exercises at the regional and national levels at least once a year, early or midyear, to allow many stakeholders to take part in the exercise. Moreover, there is a need to train country-level evaluators and controllers in designing and conducting functional exercises.

Evaluation of emergency drills effectiveness by center of disease prevention and control staff in Heilongjiang Province, China: an empirical study using the logistic-ISM model

Introduction

Emergency drills are critical practices that can improve the preparedness for crisis situations. This study aims to comprehend the evaluation of emergency drill effectiveness by the staff at the Centers for Disease Control and Prevention (CDC) in Heilongjiang Province, China. It identifies potential factors that could influence the personnel's appraisal of outcomes throughout the emergency drill procedure.

Methods

A cross-sectional survey was conducted among public health professionals from various CDCs in Heilongjiang, a northeastern Chinese province. The binary logistic regression analysis identified the factors associated with the CDC staff's assessment of emergency drill efficacy, while the Interpretative Structural Modeling (ISM) elucidated the hierarchical structure among the influencing factors.

Results

53.3% (95% CI = 50.6-55.4) of participants perceived the emergency drills' effectiveness as low. Binary logistic regression analysis revealed that the following adverse factors associated with the emergency drills increased the risk of a lower evaluation: lack of equipment and poor facilities (OR = 2.324, 95% CI = 1.884-2.867), poor training quality (OR = 1.765, 95% CI = 1.445-2.115), low leadership focus (OR = 1.585, 95% CI = 1.275-1.971), insufficient training frequency (OR = 1.539, 95% CI = 1.258-1.882), low skill in designing emergency drill plans (OR = 1.494, 95% CI = 1.180-1.890), lack of funding (OR = 1.407, 95% CI = 1.111-1.781), and poor coordination between departments (OR = 1.335, 95% CI = 1.085-1.641). The ISM revealed the hierarchical relationship of the influential factors, which were classified into three levels: Surface, Middle and Bottom. The Surface Level factors were training frequency, training quality, leaders' focus, and inter-departmental coordination. The Middle Level factors were equipment availability and skill in designing emergency drill plans. The Bottom Level factor was funding guarantee.

Discussion

This survey revealed that over half of the CDC staff rated the effectiveness of public health emergency drills as low. The Logistic-ISM Model results indicated that the evaluation of drill effectiveness was negatively influenced by insufficient facility and equipment support, financial constraints, lack of departmental coordination, and inadequate leadership attention. Among these factors, funding guarantee was the most fundamental one. Therefore, this calls for strategic decisions to increase funding for equipment, leadership training support, and effective emergency coordination.

Influenza outbreak management tabletop exercise for congregate living settings

We conducted a tabletop exercise on influenza outbreak preparedness that engaged a large group of congregate living settings (CLS), with improvements in self-reported knowledge and readiness. This proactive approach to responding to communicable disease threats has potential to build infection prevention and control capacity beyond COVID-19 in the CLS sector.

Knowledge exchange in crisis settings: A scoping review

BACKGROUND

Public health practice and efforts to improve the social determinants of health operate within a climate characterised by multiple and intersecting crises. This includes the Covid-19 pandemic as well as more protracted crises such as climate change and persistent social inequalities that impact health. We sought to understand and compare how knowledge exchange (KE) processes occur across different crises, and how knowledge on improving social determinants of health can be utilised at times of crisis to reduce health inequalities and strengthen public systems.

METHODS

We conducted a scoping review to understand how KE on improving social determinants of health can occur across different types of crises (e.g. environmental, pandemics, humanitarian). Relevant studies were identified through electronic searching of Medline, EMBASE, Global Health, Scopus and Web of Science databases.

RESULTS

We identified 86 studies for inclusion in the review. Most studies concerned pandemic or environmental crises. Fewer studies explored KE during technical (e.g. nuclear), terror-related or humanitarian crises. This may reflect a limitation of the searches. Few studies assessed KE as part of longer-term responses to social and economic impacts of crises, with studies more likely to focus on immediate response or early recovery stages. Exchange of research evidence or data with policy or practice contextual knowledge was common but there was variation in the extent that lay (public) knowledge was included as part of KE processes.

CONCLUSION

As ongoing crises continue with significant public health implications, KE processes should appropriately reflect the complexity inherent in crises and foreground health inequalities. Doing so could include the utilisation of systems or complexity-informed methods to support planning and evaluation of KE, a greater focus on KE to support action to address social determinants of health, and the inclusion of a plurality of knowledge-including lived experience-in planning and responding to crises.

Full-scale simulations to improve disaster preparedness in hospital pharmacies

Purpose

Assess whether full-scale simulation exercises improved hospital pharmacies’ disaster preparedness.

Methods

Swiss hospital pharmacies performed successive full-scale simulation exercises at least four months apart. An interprofessional team created two scenarios, each representing credible regional-scale disasters involving approximately fifty casualties (a major road accident and a terrorist attack). Four exercise assessors used appraisal forms to evaluate participants’ actions and responses during the simulation (rating them using five-point Likert scales).

Results

Four hospital pharmacies performed two full-scale simulation exercises each. Differences between exercises one and two were observed. On average, the four hospitals accomplished 69% ± 6% of the actions expected of them during exercise one. The mean rate of expected actions accomplished increased to 84% ± 7% (p < 0.005) during exercise two. Moreover, the average quality of actions improved from 3.0/5 to 3.6/5 (p = 0.01), and the time required to gather a crisis management team drastically decreased between simulations (from 23 to 5 min). The main challenges were communication (reformulation) and crisis management. Simulation exercise number one resulted in three hospital pharmacies creating disaster action plans and the fourth improving its already existing plan.

Conclusion

This study highlighted the value of carrying out full-scale disaster simulations for hospital pharmacies as they improved overall institutional preparedness and increased staff awareness. The number of expected actions accomplished increased significantly. In the future, large-scale studies and concept dissemination are warranted.

Phishing simulation exercise in a large hospital: A case study

Background

Phishing is a major threat to the data and infrastructure of healthcare organizations and many cyberattacks utilize this socially engineered pathway. Phishing simulation is used to identify weaknesses and risks in the human defences of organizations. There are many factors influencing the difficulty of detecting a phishing email including fatigue and the nature of the deceptive message.

Method

A major Italian Hospital with over 6000 healthcare staff performed a phishing simulation as part of its annual training and risk assessment. Three campaigns were launched at approx. 4-month intervals, to compare staff reaction to a general phishing email and a customized one.

Results

The results show that customization of phishing emails makes them much more likely to be acted on. In the first campaign, 64% of staff did not open the general phish, significantly more than the 38% that did not open the custom phish. A significant difference was also found for the click rate, with significantly more staff clicking on the custom phish. However, the campaigns could not be run as intended, due to issues raised within the organization.

Conclusions

Phishing simulation is useful but not without its limitations. It requires contextual knowledge, skill and experience to ensure that it is effective. The exercise raised many issues within the Hospital. Successful, ethical phishing simulations require coordination across the organization, precise timing and lack of staff awareness. This can be complex to coordinate. Misleading messages containing false threats or promises can cause a backlash from staff and unions. The effectiveness of the message is dependent on the personalization of the message to current, local events. The lessons learned can be useful for other hospitals.

Assessment of pandemic (COVID-19) preparedness in a teaching hospital in northern India using available (CDC-Atlanta) checklist

Background:

Hospitals are at the forefront of dealing infectious public health emergencies. Recently, COVID-19 has been declared as pandemic by the World Health Organization. Dealing with COVID-19 pandemic requires high intensity of administrative activity.

Objective:

We conducted this study to assess and compare, objectively, hospital preparedness with available Centre of Disease Control and Prevention (CDC) standards.

Methods:

CDC has issued checklist for the assessment of hospital preparedness for COVID-19 pandemic, globally. This list contains 10 elements with sub-sections. We objectified the same and scored the hospital preparations accordingly. Various financial efforts made by the hospital to procure COVID19-specified items was also recorded.

Results:

As per the CDC checklist, the hospital scored 197 points (72.06%) out of 270 points with highest points in element two and eight. Element two is for the development for written COVID-19 plan. Element eight consists of addressing the occupational health of healthcare workers. Lowest scoring was in the element seven represented visitor access and movement within facility. During the study period, the hospital procured items of approximately 55 lakhs. In the study period, doctors, nursing staff, housekeeping staff, and security staff were channelized for doing COVID-19 duties.

Conclusions:

We obtained a score above 70% (good) which is quite encouraging, and we concluded that pandemic preparations in hospitals are necessary and it can be assessed objectively against prevailing standards. It is important in poor countries like India where spending on healthcare is minimal compared to other countries. Additionally, this assessment can be used to guide us further changes in policies and identifying the gaps in pandemic preparedness in hospitals which require special attention.

Developing Public Health Emergency Response Leaders in Incident Management: A Scoping Review of Educational Interventions

During emergency responses, public health leaders frequently serve in incident management roles that differ from their routine job functions. Leaders' familiarity with incident management principles and functions can influence response outcomes. Therefore, training and exercises in incident management are often required for public health leaders. To describe existing methods of incident management training and exercises in the literature, we queried 6 English language databases and found 786 relevant articles. Five themes emerged: (1) experiential learning as an established approach to foster engaging and interactive learning environments and optimize training design; (2) technology-aided decision support tools are increasingly common for crisis decision-making; (3) integration of leadership training in the education continuum is needed for developing public health response leaders; (4) equal emphasis on competency and character is needed for developing capable and adaptable leaders; and (5) consistent evaluation methodologies and metrics are needed to assess the effectiveness of educational interventions.These findings offer important strategic and practical considerations for improving the design and delivery of educational interventions to develop public health emergency response leaders. This review and ongoing real-world events could facilitate further exploration of current practices, emerging trends, and challenges for continuous improvements in developing public health emergency response leaders.

Improving rural disaster response preparedness

BACKGROUND

Disasters happen in all communities and negatively impact the health and safety of populations if not well managed. Rural health organizations face greater challenges when implementing emergency preparedness policies and need unique resources to help ensure the health of their communities. The purpose of this article is to describe the development and evaluation of an agricultural simulation scenario designed for rural health organizations.

METHODS

The agricultural disaster scenario was developed after determining the desired content domains. Forty students from nursing, medicine, public health, and social work participated in a functional simulation using the scenario. Outcomes were measured using a pre-post measurement with one cohort design. Data were analyzed using paired-samples t-tests.

RESULTS

Students reported a 30% increase in self-confidence, 38% increase in disaster competence, and 19% increase in interprofessional collaboration competence after the simulation. Statistically significant increases in student scores were noted on all surveys across professions.

CONCLUSION

The agricultural disaster simulation is a valid scenario to use for disaster preparation using emergency operations plans.

How are healthcare provider systems preparing for health emergency situations?

Natural disasters, disease outbreaks, famine, and human conflict have strained communities everywhere over the course of human existence. However, modern changes in climate, human mobility, and other factors have increased the global community's vulnerability to widespread emergencies. We are in the midst of a disruptive health event, with the COVID-19 pandemic testing our health provider systems globally. This study presents a qualitative analysis of published literature, obtained systematically, to examine approaches health providers are taking to prepare for and respond to mass casualty incidents around the globe. The research reveals emerging trends in the weaknesses of systems' disaster responses while highlighting proposed solutions, so that others may better prepare for future disasters. Additionally, the research examines gaps in the literature, to foster more targeted and actionable contributions to the literature.

Educating, training, and exercising for infectious disease control with emphasis on cross-border settings: an integrative review

INTRODUCTION

Points of entry and other border regions educate, train, and exercise (ETEs) their staff to improve preparedness and response to cross-border health threats. However, no conclusive knowledge of these ETEs' effectiveness exists. This study aimed to review the literature on ETEs in infectious disease control concerning their methods and effect, with an emphasis on cross-border settings and methods that enlarge ETEs' reach.

METHODOLOGY

We systematically searched for studies in the databases Embase, Medline, Web of Science, PsycInfo, ERIC, and Cinahl. After successively screening titles and abstracts, full-texts, and citations, 62 studies were included using in- and exclusion criteria. Data were extracted using a data-extraction form. Quality assessment was performed. We developed a theoretical framework based on which we analyzed the ETE context (target group, recruitment, autonomy, training needs), input (topic, trainers, development and quality of materials), process (design, duration, interval, goals), evaluation (pre-, post- follow-up tests), and outcome (reaction, learning, behavior, and system).

RESULTS

We found a limited number of published evaluations of ETEs in general (n = 62) and of cross-border settings (n = 5) in particular. The quality assessment resulted in seven ETE methodologies and 23 evaluations with a 'good' score. Both general studies and those in a cross-border setting contain a low-moderate detail level on context, input, and process. The evaluations were performed on reaction (n = 45), learning (n = 45), behavior (n = 9) and system (n = 4), mainly using pre- and post-tests (n = 22). Online learning methods have a high potential in enlarging the reach and are effective, particularly in combination with offline training. Training-of-trainer approaches are effective for learning; new ETEs were developed by 20-44% of participants until six months after the initial training.

CONCLUSION

Our study reveals a limited number of publications on ETEs in infectious disease control. Studies provide few details on methodology, and use mainly short-term evaluations and low level outcomes. We call for more extensive, higher-level evaluation standards of ETEs, and an easy and sustainable way to exchange evaluations within the workforce of infectious disease control in cross-border settings. The theoretical framework developed in this study could guide future development and evaluation of ETEs in infectious disease control.

The role of emergency preparedness exercises in the response to a mass casualty terrorist incident: A mixed methods study

Simulation exercises are an important part of emergency preparedness activities for the healthcare community but evidence of their impact on the response to real major incidents is limited. This project studied the impact of health emergency preparedness exercises (HEPEs) on the response to a mass casualty terrorist incident. The mixed methods study design was adopted comprising an on-line survey and follow up individual interviews. Participants were healthcare staff who took part in responses to three major terrorist incidents in the UK in 2017. Descriptive statistics and analysis of variance were undertaken with quantitative data. Content and thematic analysis methods were used for qualitative data analysis. The online survey generated 86 responses; 79 (92%) were from the responders to the Manchester Arena bombing. Twenty-one survey respondents shared their experiences in in-depth interviews. Healthcare staff who took part in HEPEs felt better prepared to respond than those who did not attend an exercise. The most commonly reported benefits from HEPEs were awareness of major incident plans and having the opportunity to practice responding to a similar scenario in the recent exercise. Specific benefits included: improved coordination of the response through adherence to recently practiced incident plans; confidence with response roles; real-time modifications of the response and support provided to staff who did not take part in exercises. Exercise recency was highlighted as an important facilitating factor. The study provides strong objective evidence that the response to a mass casualty terrorist incident was enhanced by training and service development achieved through HEPEs.

Performance of the Public Health System During a Full-Scale Yellow Fever Simulation Exercise in Lagos State, Nigeria, in 2018: How Prepared Are We for the Next Outbreak?

Recurring outbreaks of infectious diseases have characterized the West African region in the past 4 decades. There is a moderate to high risk of yellow fever in countries in the region, and the disease has reemerged in Nigeria after 21 years. A full-scale simulation exercise of the outbreak of yellow fever was conducted to assess preparedness and response in the event of a full-scale outbreak. The exercise was a multi-agency exercise conducted in Lagos, and it involved health facilities, points of entry, state and national public health emergency operation centers, and laboratories. An evaluation of the exercise assessed the capability of the system to identify, respond to, and recover from the emergency using adapted WHO tools. The majority of participants, observers, and evaluators agreed that the exercise was well-structured and organized. Participants also strongly agreed that the exercise helped them to identify strengths and gaps in their understanding of the emergency response systems and plans. Overall, the exercise identified existing gaps in the current capabilities of several thematic areas involved in a yellow fever response. The evaluation presented an opportunity to assess the response capabilities of multisectoral collaborations in the national public health system. It also demonstrated the usefulness of the exercise in understanding public health officials' roles and responsibilities; enabling knowledge transfer among these individuals and organizations; and identifying specific public health systems-level strengths, weaknesses, and challenges.

Review of school fires in Iran: the causes, consequences and lessons learned

Fire in Iranian schools has led to death, serious injury and disability for dozens of students and teachers. The aim of this study was to explore the causes, consequences and lessons learned from school fires in Iran. The available literature, including scientific texts, previous research and media reports, was searched using English and Persian keywords. The keywords were: "students, school, Iran, fire, burn and incidents". No time limitation was imposed. Results showed that 62 school and student dormitory fires have been reported in Iran, of which 14 school fires and 2 student dormitory fires led to human injuries or casualties (25.8%). In these incidents, thirty students (19 girls and 11 boys) and one teacher died. More than 60 students, 8 teachers, and 2 staff suffered burn injuries or disabilities. The main causes of the fire incidents were use of non-standard kerosene heaters (38.7%) and faulty electrical wiring (35.4%). Lack of knowledge about dealing with accidents, inappropriate physical conditions of the school building, lack of fire extinguishers in the building, and carelessness were the main reasons for the deaths and injuries. In conclusion, it is essential to reduce the incidence of fire and prevent its casualties with proper management and standardization of school buildings.

Addressing Children's Needs in Disasters: A Regional Pediatric Tabletop Exercise

OBJECTIVE

Preparing and responding to the needs of children during public health emergencies continues to be challenging. The purpose of this study was to assess the usefulness of a tabletop exercise in initiating pediatric preparedness strategies and assessing the impact of the exercise on participants' understanding of and confidence in their roles during pediatric public health emergencies.

METHODS

A tabletop exercise was developed to simulate a public health emergency scenario involving smallpox in a child, with subsequent spread to multiple states. During the exercise, participants discussed and developed communication, collaboration, and medical countermeasure strategies to enhance pediatric public health preparedness. Exercise evaluation was designed to assess participants' knowledge gained and level of confidence surrounding pediatric public health emergencies.

RESULTS

In total, 22 participants identified over 100 communication and collaboration strategies to promote pediatric public health preparedness during the exercise and found that the most beneficial aspect during the exercise was the partnership between pediatricians and public health officials. Participants' knowledge and level of confidence surrounding a pediatric public health emergency increased after the exercise.

CONCLUSION

The tabletop exercise was effective in identifying strategies to improve pediatric public health preparedness as well as enhancing participants' knowledge and confidence surrounding a potential pediatric public health emergency. (Disaster Med Public Health Preparedness. 2018;12:582-586).

Using an Electronic Bulletin Board Platform in a Disaster Tabletop Exercise

Introduction

We evaluate the use of an electronic bulletin board system in a tabletop disaster exercise.

Methods

Two tabletop exercises were carried out during a 5 hour course for 26 members of the Singapore Disaster Site Management Command (DSMC). As the events happened, the participants were updated via the electronic bulletin board. Response to the events was through the bulletin board. A written survey was held upon completion.

Result

Most (96.2%) felt that the exercise had helped identify issues in current operating procedures. The electronic bulletin board was deemed easy to use and learn, and that it helped in their learning (61.5%, 88.5% and 73.1% respectively). Using the electronic platform was an effective (76.9%) and efficient way (65.4%) of conducting the exercises. 53.8% of participants prefer the use of the electronic bulletin board and 61.5% felt that it was more realistic using the electronic platform. However the electronic bulletin board did not improve the participant's understanding of the current operating procedures (43.2%) and their role in DSMC (50%).

Conclusion

The use of the electronic platform is easy and over half of the involved participants thought it is preferred over the traditional tabletop exercise.

Lessons Learned From Implementing an Incident Command System During a Local Multiagency Response to a Legionnaires' Disease Cluster in Sydney, NSW

The incident command system (ICS) provides a common structure to control and coordinate an emergency response, regardless of scale or predicted impact. The lessons learned from the application of an ICS for large infectious disease outbreaks are documented. However, there is scant evidence on the application of an ICS to manage a local multiagency response to a disease cluster with environmental health risks. The Sydney Local Health District Public Health Unit (PHU) in New South Wales, Australia, was notified of 5 cases of Legionnaires' disease during 2 weeks in May 2016. This unusual incident triggered a multiagency investigation involving an ICS with staff from the PHU, 3 local councils, and the state health department to help prevent any further public health risk. The early and judicious use of ICS enabled a timely and effective response by supporting clear communication lines between the incident controller and field staff. The field team was key in preventing any ongoing public health risk through inspection, sampling, testing, and management of water systems identified to be at-risk for transmission of legionella. Good working relationships between partner agencies and trust in the technical proficiency of environmental health staff aided in the effective management of the response. (Disaster Med Public Health Preparedness. 2018;12:539-542).

Hypothetical scenario exercises to improve planning and readiness for drinking water quality management during extreme weather events

Two hypothetical scenario exercises were designed and conducted to reflect the increasingly extreme weather-related challenges faced by water utilities as the global climate changes. The first event was based on an extreme flood scenario. The second scenario involved a combination of weather events, including a wild forest fire ('bushfire') followed by runoff due to significant rainfall. For each scenario, a panel of diverse personnel from water utilities and relevant agencies (e.g. health departments) formed a hypothetical water utility and associated regulatory body to manage water quality following the simulated extreme weather event. A larger audience participated by asking questions and contributing key insights. Participants were confronted with unanticipated developments as the simulated scenarios unfolded, introduced by a facilitator. Participants were presented with information that may have challenged their conventional experiences regarding operational procedures in order to identify limitations in current procedures, assumptions, and readily available information. The process worked toward the identification of a list of specific key lessons for each event. At the conclusion of each simulation a facilitated discussion was used to establish key lessons of value to water utilities in preparing them for similar future extreme events.

Utilization of Functional Exercises to Build Regional Emergency Preparedness among Rural Health Organizations in the US

Rural communities face barriers to disaster preparedness and considerable risk of disasters. Emergency preparedness among rural communities has improved with funding from federal programs and implementation of a National Incident Management System. The objective of this project was to design and implement disaster exercises to test decision making by rural response partners to improve regional planning, collaboration, and readiness. Six functional exercises were developed and conducted among three rural Nebraska (USA) regions by the Center for Preparedness Education (CPE) at the University of Nebraska Medical Center (Omaha, Nebraska USA). A total of 83 command centers participated. Six functional exercises were designed to test regional response and command-level decision making, and each 3-hour exercise was followed by a 3-hour regional after action conference. Participant feedback, single agency debriefing feedback, and regional After Action Reports were analyzed. Functional exercises were able to test command-level decision making and operations at multiple agencies simultaneously with limited funding. Observations included emergency management jurisdiction barriers to utilization of unified command and establishment of joint information centers, limited utilization of documentation necessary for reimbursement, and the need to develop coordinated public messaging. Functional exercises are a key tool for testing command-level decision making and response at a higher level than what is typically achieved in tabletop or short, full-scale exercises. Functional exercises enable evaluation of command staff, identification of areas for improvement, and advancing regional collaboration among diverse response partners.

ObaidJM, BaileyG, WheelerH, MeyersL, MedcalfSJ, HansenKF, SangerKK, LoweJJ. Utilization of functional exercises to build regional emergency preparedness among rural health organizations in the US. Prehosp Disaster Med. 2017;32(2):224–230.

Extreme weather events: Should drinking water quality management systems adapt to changing risk profiles?

Among the most widely predicted and accepted consequences of global climate change are increases in both the frequency and severity of a variety of extreme weather events. Such weather events include heavy rainfall and floods, cyclones, droughts, heatwaves, extreme cold, and wildfires, each of which can potentially impact drinking water quality by affecting water catchments, storage reservoirs, the performance of water treatment processes or the integrity of distribution systems. Drinking water guidelines, such as the Australian Drinking Water Guidelines and the World Health Organization Guidelines for Drinking-water Quality, provide guidance for the safe management of drinking water. These documents present principles and strategies for managing risks that may be posed to drinking water quality. While these principles and strategies are applicable to all types of water quality risks, very little specific attention has been paid to the management of extreme weather events. We present a review of recent literature on water quality impacts of extreme weather events and consider practical opportunities for improved guidance for water managers. We conclude that there is a case for an enhanced focus on the management of water quality impacts from extreme weather events in future revisions of water quality guidance documents.

Development of an Online Toolkit for Measuring Performance in Health Emergency Response Exercises

Introduction

Exercises that simulate emergency scenarios are accepted widely as an essential component of a robust Emergency Preparedness program. Unfortunately, the variability in the quality of the exercises conducted, and the lack of standardized processes to measure performance, has limited the value of exercises in measuring preparedness.

Methods

In order to help health organizations improve the quality and standardization of the performance data they collect during simulated emergencies, a model online exercise evaluation toolkit was developed using performance measures tested in over 60 Emergency Preparedness exercises. The exercise evaluation toolkit contains three major components: (1) a database of measures that can be used to assess performance during an emergency response exercise; (2) a standardized data collection tool (form); and (3) a program that populates the data collection tool with the measures that have been selected by the user from the database. The evaluation toolkit was pilot tested from January through September 2014 in collaboration with 14 partnering organizations representing 10 public health agencies and four health care agencies from eight states across the US. Exercise planners from the partnering organizations were asked to use the toolkit for their exercise evaluation process and were interviewed to provide feedback on the use of the toolkit, the generated evaluation tool, and the usefulness of the data being gathered for the development of the exercise after-action report.

Results

Ninety-three percent (93%) of exercise planners reported that they found the online database of performance measures appropriate for the creation of exercise evaluation forms, and they stated that they would use it again for future exercises. Seventy-two percent (72%) liked the exercise evaluation form that was generated from the toolkit, and 93% reported that the data collected by the use of the evaluation form were useful in gauging their organization’s performance during the exercise. Seventy-nine percent (79%) of exercise planners preferred the evaluation form generated by the toolkit to other forms of evaluations.

Conclusion

Results of this project show that users found the newly developed toolkit to be user friendly and more relevant to measurement of specific public health and health care capabilities than other tools currently available. The developed toolkit may contribute to the further advancement of developing a valid approach to exercise performance measurement.

AgboolaF, BernardD, SavoiaE, BiddingerPD. Development of an online toolkit for measuring performance in health emergency response exercises. Prehosp Disaster Med. 2015;30(5):503–508.

Enhancing the Relevance of Incident Management Systems in Public Health Emergency Preparedness: A Novel Conceptual Framework

We outline a conceptual framework developed to meet the needs of public health professionals in the province of Ontario for incident management system-related education and training. By using visual models, this framework applies a public health lens to emergency management, introducing concepts relevant to public health and thereby shifting the focus of emergency preparedness from a strict "doctrine" to a more dynamic and flexible approach grounded in the traditional principles of incident management systems. These models provide a foundation for further exploration of the theoretical foundations for public health emergency preparedness in practice.

Preparedness and emergency response research centers: using a public health systems approach to improve all-hazards preparedness and response

In 2008, at the request of the Centers for Disease Control and Prevention (CDC), the Institute of Medicine (IOM) prepared a report identifying knowledge gaps in public health systems preparedness and emergency response and recommending near-term priority research areas. In accordance with the Pandemic and All-Hazards Preparedness Act mandating new public health systems research for preparedness and emergency response, CDC provided competitive awards establishing nine Preparedness and Emergency Response Research Centers (PERRCs) in accredited U.S. schools of public health. The PERRCs conducted research in four IOM-recommended priority areas: (1) enhancing the usefulness of public health preparedness and response (PHPR) training, (2) creating and maintaining sustainable preparedness and response systems, (3) improving PHPR communications, and (4) identifying evaluation criteria and metrics to improve PHPR for all hazards. The PERRCs worked closely with state and local public health, community partners, and advisory committees to produce practice-relevant research findings. PERRC research has generated more than 130 peer-reviewed publications and nearly 80 practice and policy tools and recommendations with the potential to significantly enhance our nation's PHPR to all hazards and that highlight the need for further improvements in public health systems.

A conceptual framework to measure systems' performance during emergency preparedness exercises

Large-scale public health emergencies require a sophisticated, coordinated response involving multiple entities to protect health and minimize suffering. However, the rarity of such emergencies presents a barrier to gathering observational data about the effectiveness of the public health response before such events occur. For this reason, public health practitioners increasingly have relied on simulated emergencies, known as "exercises" as proxies to test their emergency capabilities. However, the formal evaluation of performance in these exercises, historically has been inconsistent, and there is little research to describe how data acquired from simulated emergencies actually support conclusions about the quality of the public health emergency response system. Over the past six years, we have designed and evaluated more than seventy public health emergency exercises, collaborating with public health agencies, hospitals and others to test a wide variety of systems and their capabilities. Using the data and experience that we gathered, we have developed a conceptual framework that describes the essential elements necessary to consider when applying performance measurement science to public health emergency exercises. We suggest that this framework may assist practitioners and researchers who wish to better measure performance in exercises and to improve public health emergency preparedness.

A public health emergency preparedness critical incident registry

Health departments use after-action reports to collect data on their experience in responding to actual public health emergencies. To address deficiencies in the use of such reports revealed in the 2009 H1N1 influenza pandemic and to develop an effective approach to learning from actual public health emergencies, we sought to understand how the concept and operations of a "critical incident registry," commonly used in other industries, could be adapted for public health emergency preparedness. We conducted a workshop with public health researchers and practitioners, reviewed the literature on learning from rare events, and sought to identify the optimal characteristics of a critical incident registry (CIR) for public health emergency preparedness. Several key critical characteristics are needed for a CIR to be feasible and useful. A registry should: (1) include incidents in the response in which public health agencies played a substantial role, are "meaningful," test one or more emergency preparedness capabilities, and are sufficiently limited in scope to isolate specific response issues; (2) be supported by a framework and standard protocols for including reports based on rigorous analysis of individual incidents and methods for cross-case analysis; and (3) include explicit incentives for reporting, to overcome intrinsic disincentives. With proper incentives in place, a critical incident registry can be a useful tool for improving public health emergency preparedness. Standard protocols for reporting critical events and probing analysis are needed to enable identification of patterns of successes and failures.

Continued vigilance - development of an online evaluation tool for assessing preparedness of medical facilities for biological events

OBJECTIVE

Effective response to biological events necessitates ongoing evaluation of preparedness. This study was a bilateral German-Israeli collaboration aimed at developing an evaluation tool for assessing preparedness of medical facilities for biological events.

METHODS

Measurable parameters were identified through a literature review for inclusion in the evaluation tool and disseminated to 228 content experts in two modified Delphi cycles. Focus groups were conducted to identify psychosocial needs of the medical teams. Table-top and functional exercises were implemented to review applicability of the tool.

RESULTS

One hundred seventeen experts from Germany and Israel participated in the modified Delphi. Out of 188 parameters that were identified, 183 achieved a consensus of >75% of the content experts. Following comments recommended in the Delphi cycles, and feedback from focus groups and hospital exercises, the final tool consisted of 172 parameters. Median level of importance of each parameter was calculated based on ranking recommended in the Delphi process. Computerized web-based software was developed to calculate scores of preparedness for biological events.

CONCLUSION

Ongoing evaluation means, such as the tool developed in the study, can facilitate the need for a valid and reliable mechanism that may be widely adopted and implemented as quality assurance measures. The tool is based on measurable parameters and indicators that can effectively present strengths and weaknesses in managing a response to a public health threat, and accordingly, steps can be implemented to improve readiness. Adoption of such a tool is an important component of assuring public health and effective emergency management.

Improving emergency preparedness system readiness through simulation and interprofessional education

We applied emerging evidence in simulation science to create a curriculum in emergency response for health science students and professionals. Our research project was designed to (1) test the effectiveness of specific immersive simulations, (2) create reliable assessment tools for emergency response and team communication skills, and (3) assess participants' retention and transfer of skills over time. We collected both quantitative and qualitative data about individual and team knowledge, skills, and attitudes. Content experts designed and pilot-tested scaled quantitative tools. Qualitative evaluations administered immediately after simulations and longitudinal surveys administered 6-12 months later measured student participants' individual perceptions of their confidence, readiness for emergency response, and transfer of skills to their day-to-day experience. Results from 312 participants enrolled in nine workshops during a 24-month period indicated that the 10-hour curriculum is efficient (compared with larger-scale or longer training programs) and effective in improving skills. The curriculum may be useful for public health practitioners interested in addressing public health emergency preparedness competencies and Institute of Medicine research priority areas.

Modelling mass casualty decontamination systems informed by field exercise data

In the event of a large-scale chemical release in the UK decontamination of ambulant casualties would be undertaken by the Fire and Rescue Service (FRS). The aim of this study was to track the movement of volunteer casualties at two mass decontamination field exercises using passive Radio Frequency Identification tags and detection mats that were placed at pre-defined locations. The exercise data were then used to inform a computer model of the FRS component of the mass decontamination process. Having removed all clothing and having showered, the re-dressing (termed re-robing) of casualties was found to be a bottleneck in the mass decontamination process during both exercises. Computer simulations showed that increasing the capacity of each lane of the re-robe section to accommodate 10 rather than five casualties would be optimal in general, but that a capacity of 15 might be required to accommodate vulnerable individuals. If the duration of the shower was decreased from three minutes to one minute then a per lane re-robe capacity of 20 might be necessary to maximise the throughput of casualties. In conclusion, one practical enhancement to the FRS response may be to provide at least one additional re-robe section per mass decontamination unit.

Developing a health system approach to disaster management: A qualitative analysis of the core literature to complement the WHO Toolkit for assessing health-system capacity for crisis management

BACKGROUND The World Health Organisation's (WHO) sixty-fourth World Health Assembly in May 2011 adopted a resolution on 'strengthening national health emergency and disaster management capacities and resilience of health systems'. Disaster management is a topical issue globally and countries are being encouraged to improve their disaster preparedness, along with growing international commitment to strengthening health systems. Lessons identified from disasters have not been effectively collated; essential experience is forgotten. METHODS This paper describes the analysis of the worldwide experience of disasters through a health systems approach. A systematic search of the core literature from January 2000 to November 2011 was conducted. Components drawn from the WHO's Global assessment of national health sector emergency preparedness and response baseline survey were combined with WHO's six health system building blocks (or levers) to act as the initial analysis anchors, with a further grounded theory qualitative analysis of the literature allowing the identification of emerging themes and insights. The priority areas identified by this literature review were then compared with the topics covered by the new expert-consensus-derived Toolkit for assessing health-system capacity for crisis management developed by the WHO Regional Office for Europe. FINDINGS 143 publications identified from a literature search were analysed and appraised. Themes and examples from the literature demonstrate how health system strengthening should contribute to disaster management. Priority areas under-represented in the WHO Toolkit and identified by the qualitative analysis are discussed. INTERPRETATION Collation and analysis of the disaster management literature identifies how health system strengthening can promote resilience and efficient recovery in the face of disasters. These findings support and complement the WHO Toolkit. Countries can use the literature evidence with the WHO Toolkit to assess their disaster management capacities and identify priorities for strengthening their health system.

CITATION

Bayntun C, Rockenschaub G, Murray V. Developing a health system approach to disaster management: A qualitative analysis of the core literature to complement the WHO Toolkit for assessing health-system capacity for crisis management. PLOS Currents Disasters. 2012 Aug 22. doi: 10.1371/5028b6037259a.

Integrating a framework for conducting public health systems research into statewide operations-based exercises to improve emergency preparedness

Background

Due to the uncommon nature of large-scale disasters and emergencies, public health practitioners often turn to simulated emergencies, known as “exercises”, for preparedness assessment and improvement. Under the right conditions, exercises can also be used to conduct original public health systems research. This paper describes the integration of a research framework into a statewide operations-based exercise program in California as a systems-based approach for studying public health emergency preparedness and response.

Methods

We developed a research framework based on the premise that operations-based exercises conducted by medical and public health agencies can be described using epidemiologic concepts. Using this framework, we conducted a survey of key local and regional medical and health agencies throughout California following the 2010 Statewide Medical and Health Exercise. The survey evaluated: (1) the emergency preparedness capabilities activated and functions performed in response to the emergency scenario, and (2) the major challenges to inter-organizational communications and information management.

Results

Thirty-five local health departments (LHDs), 24 local emergency medical services (EMS) agencies, 121 hospitals, and 5 Regional Disaster Medical and Health Coordinators/Specialists (RDMHC) responded to our survey, representing 57%, 77%, 26% and 83%, respectively, of target agencies in California. We found two sets of response capabilities were activated during the 2010 Statewide Exercise: a set of core capabilities that were common across all agencies, and a set of agency-specific capabilities that were more common among certain agency types. With respect to one response capability in particular, inter-organizational information sharing, we found that the majority of respondents’ comments were related to the complete or partial failure of communications equipment or systems.

Conclusions

Using the 2010 Statewide Exercise in California as an opportunity to develop our research framework, we characterized several aspects of the public health and medical system’s response to a standardized emergency scenario. From a research perspective, this study provides a potential new framework for conducting exercise-based research. From a practitioner’s perspective, our results provide a starting point for preparedness professionals’ dialogue about expected and actual organizational roles, responsibilities, and resource capacities within the public health system. Additionally, the identification of specific challenges to inter-organizational communications and information management offer specific areas for intervention.

Hospital Incident Command System (HICS) performance in Iran; decision making during disasters

Background

Hospitals are cornerstones for health care in a community and must continue to function in the face of a disaster. The Hospital Incident Command System (HICS) is a method by which the hospital operates when an emergency is declared. Hospitals are often ill equipped to evaluate the strengths and vulnerabilities of their own management systems before the occurrence of an actual disaster. The main objective of this study was to measure the decision making performance according to HICS job actions sheets using tabletop exercises.

Methods

This observational study was conducted between May 1st 2008 and August 31st 2009. Twenty three Iranian hospitals were included. A tabletop exercise was developed for each hospital which in turn was based on the highest probable risk. The job action sheets of the HICS were used as measurements of performance. Each indicator was considered as 1, 2 or 3 in accordance with the HICS. Fair performance was determined as < 40%; intermediate as 41-70%; high as 71-100% of the maximum score of 192. Descriptive statistics, T-test, and Univariate Analysis of Variance were used.

Results

None of the participating hospitals had a hospital disaster management plan. The performance according to HICS was intermediate for 83% (n = 19) of the participating hospitals. No hospital had a high level of performance. The performance level for the individual sections was intermediate or fair, except for the logistic and finance sections which demonstrated a higher level of performance. The public hospitals had overall higher performances than university hospitals (P = 0.04).

Conclusions

The decision making performance in the Iranian hospitals, as measured during table top exercises and using the indicators proposed by HICS was intermediate to poor. In addition, this study demonstrates that the HICS job action sheets can be used as a template for measuring the hospital response. Simulations can be used to assess preparedness, but the correlation with outcome remains to be studied.

Lessons learned from North Carolina public health regional surveillance teams' regional exercises

All-hazards exercises bring together emergency response partners at the local, regional, state, and federal levels for the primary purposes of testing response plans, defining roles and responsibilities, assessing capabilities, and making necessary improvements prior to an actual incident. To better understand the benefits and challenges of conducting regional (ie, multicounty) exercises, a study was carried out by the North Carolina Preparedness and Emergency Response Research Center at the University of North Carolina Gillings School of Global Public Health. This article describes 5 all-hazards regional exercises conducted by Public Health Regional Surveillance Teams (PHRSTs) in North Carolina in 2009 and highlights 4 unique benefits that resulted from the exercises beyond meeting explicit objectives to test plans and identify areas for improvement: (1) building relationships among response partners, (2) promoting public health assets, (3) testing multiple communications systems, and (4) training exercise evaluators. Challenges of planning and conducting regional exercises also are addressed, followed by recommendations for maximizing the effectiveness of regional public health exercises.