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The Mountain Plains Regional Disaster Health Response System (Mountain Plains RDHRS) works to build disaster capacity across US Federal Region VIII, a rural western six-state region. It conducts an annual rehearsal of concepts and exercises to identify gaps and inform policy development. In 2022, a multi-state exercise was conducted involving responders from individual hospitals coordinating with Healthcare Coalitions and State Public Health. These responses rolled up to a multi-state emergency operations center overseen by the Mountain Plains RDHRS.
A fictitious mass multi-state botulism incident generated a pediatric surge across the region. Individual patient cards with demographic information were given to a set of hospitals in participating states. The communication pathways within states were identified. Communication between local and regional pediatric transfer centers were assessed. Overall situational awareness was tracked.
The exercise format was incident occurrence and notifications by normal channels and a Zoom conference call held on day one. Situational awareness and patient movement occurred in multiple Zoom rooms on day two. An after-exercise review occurred by Zoom on day three including all participants from the exercise.
There was generally good information flow within states, but minimal information exchange across states There was poor regional situational awareness with a lack of complete patient lists and transfers. The Mountain Plains RDHRS planned to exceed the hospital’s patient capacities with a large number of pediatric patients to practice patient movement across state lines. Instead the hospitals showed a surprising willingness to keep and manage critical pediatric patients instead of transferring to tertiary care pediatric centers. This was identified as a consequence of the COVID-19 experience.
Web-based exercises vertically spanning responses from individual hospitals to multi-state regional entities are feasible. This exercise demonstrated multiple gaps in regional disaster response.
Effectively responding to an incident across jurisdictions and coordinating with regional and jurisdictional partners is extremely challenging. The COVID-19 pandemic exemplified the need to develop an operational structure which would serve as a regional medical operations hub. Although there has been guidance for using a Medical Operations Coordination Cell (MOCC), the concept can be difficult to apply and develop for the specific needs of varying regions and jurisdictional entities.
The Mountain Plains Regional Disaster Health Response System (MPRDHRS) has developed a Medical Emergency Operations Center (MEOC) to address gaps in response coordination efforts across the six state Region VIII within the United States. This MEOC has been developed to synchronize and integrate existing systems and processes to manage the medical components of a response. This center is similar to other MOCC concepts. However, in a novel approach, the MPRDHRS organized a response framework that focuses on functional roles based on the specific needs of our region with response coordination and personnel availability. This organization is similar to the use of emergency support functions in a jurisdictional EOC.
While developing the MEOC, a local Lean team collaborated with the MPRDHRS on continuous improvement initiatives. Drills, workshops, and exercises were used to test the MEOC and offer just in time training to MPRDHRS members to staff different positions within the MEOC. The MEOC was activated for an incident response within the MPRDHRS region with many lessons learned.
The MEOC is a new, developing system augmented to meet the needs of regional partners. The system was developed using feedback and ideas from partners, process improvement experts, and internal team members. Additionally, lessons learned from incidents and applications of drills, workshops, and exercises will be shared to leverage within any organization.
As public health emergency management (PHEM) is a growing field, so is the development of its workforce. Ensuring workforce readiness from graduate-level education and courses can be challenging given the limitations of the traditional classroom environment. This presentation highlights a novel curriculum created and taught by first responders consisting of simulation and application of practical skills developed within a public health graduate certificate program.
The semester-long course reviews foundations of PHEM and students progress through a sequence of increasingly complex discussions and operation-based exercises for both domestic and international disaster preparedness and response. Students progress through case studies, tabletops, functional exercises, and full-scale exercises with practical skills interspersed. This includes creation of SMART objectives and incident action planning, crisis communication and public messaging drills, use of radios, personal protective donning and doffing, and Geiger counter use.
During the COVID-19 pandemic, the curriculum was adapted for asynchronous and live virtual sessions with further offerings including various online trainings that are required for most employments in the field and guest speakers with national recognition for their experiences in public health and healthcare emergency management and subject matter expertise in various fields related to preparedness and response.
Since commencing in 2016, approximately 100 students have completed the course and feedback has been overwhelmingly positive even with limitations of in-person activities during the COVID-19 Pandemic. Student feedback has noted that the majority of students feel that the knowledge and skills from the coursework is applicable to future employment and that their ability to think critically about the subject matter increased as a result of taking the course.
Implementation of this innovative graduate level course can serve as a model to enrich students’ education through practical activities and hands-on simulations.
The current Incident Command System (ICS) was developed to manage wildland fires, then was adopted by general firefighting. It has since been adapted to multiple other sectors and widely used. The Hospital Emergency Incident Command (HICS) was introduced in 1991. An ICS currently is required to be used for hospital incident management in the US.
The overarching structure of traditional HICS consists of Command Staff (Incident Commander, Public Information Officer, Safety Officer, Liaison Officer and Medical/Technical Specialist) and General Staff. The General Staff has Sections consisting of Operations, Planning, Logistics and Finance/Administration. Multiple and flexible subgroups carry out the processes in these areas.
This HICS structure does not adapt easily to hospital daily functions and alternatives have been proposed. This includes structuring around essential functions and mixed models. Over time hospital systems have become larger, and incidents more complex and sustained. New more expansive and flexible ICS structures are needed for complex responses.
We reviewed both the published and grey literature for examples of different incident management structures and evidence of their effectiveness.
There is very little scientific literature on this topic. Several different descriptive reports exist. Multiple examples of hospital incident command organization structures from the hospital level progressing to hospital (and healthcare) system level and then multistate regional models will be reviewed. This includes the standard HICS model, emergency support function models and modifications following advanced ICS principles such as area command.
Different ICS models exist that may offer individual healthcare systems improved ways to manage disasters.
Macronutrient inputs to annual cropping systems can benefit weeds as well as crops, sometimes decreasing or eliminating the benefits of fertilization. This interaction between fertility management and integrated weed management is becoming increasingly important as these fields increase their focus on efficiency and prevention, respectively. The risk of increased weed competition reflects the fact that weed biomass and height may be highly responsive to nitrogen, phosphorus, and/or potassium. This generalization is supported by monoculture studies of species such as redroot pigweed (Amaranthus retroflexus L.), common lambsquarters (Chenopodium album L.), and barnyardgrass [Echinochloa crus-galli (L.) P. Beauv.] and by ecological theory. However, field studies indicate variation in the effects of macronutrients on weed–crop competition and crop yield, even within species groups. To address challenges in interpreting, comparing, and extrapolating from these diverse reports, we propose a conceptual framework that summarizes the mechanisms underlying observed variation within and between studies. This framework highlights functional traits and trends that help predict yield outcomes in binary weed–crop interactions. Important factors include timing of emergence, maximum heights of the weed and crop, and relative responsiveness to the added nutrient. We also survey recent work on the effects of nutrient source (e.g., the composition of organic amendments) on weed–crop competition. Because different sources vary in their nutrient release dynamics and supplied nutrient ratios, they may have dramatically different effects on weed–crop competition and crop yield. Finally, we offer a guide to best practices for studies of fertility effects on weed–crop competition. Although this review highlights several topics requiring further research, including fertility effects on multispecies interactions and interactions with other environmental factors, emerging methods offer considerable promise. Ultimately, an improved understanding of nutrient effects on weed–crop competition will contribute to the efficient and effective management of diverse cropping systems.
Disaster Medicine (DM) education for Emergency Medicine (EM) residents is highly variable due to time constraints, competing priorities, and program expertise. The investigators’ aim was to define and prioritize DM core competencies for EM residency programs through consensus opinion of experts and EM professional organization representatives.
Investigators utilized a modified Delphi methodology to generate a recommended, prioritized core curriculum of 40 DM educational topics for EM residencies.
The DM topics recommended and outlined for inclusion in EM residency training included: patient triage in disasters, surge capacity, introduction to disaster nomenclature, blast injuries, hospital disaster mitigation, preparedness, planning and response, hospital response to chemical mass-casualty incident (MCI), decontamination indications and issues, trauma MCI, disaster exercises and training, biological agents, personal protective equipment, and hospital response to radiation MCI.
This expert-consensus-driven, prioritized ranking of DM topics may serve as the core curriculum for US EM residency programs.
Modern hospital systems are highly dependent on computerized information technology (IT) systems. The integration of laboratory and radiology ordering and resulting cannot be easily replicated with a “paper” processes. This poses challenges for no-notice events, where the rapid registration of patients is a must for effective clinical care. This weakness in hospital response has been demonstrated in events such as the Boston Marathon bombing, the Aurora Theater (to be discussed), and Las Vegas shootings.
To discuss lessons learned in configuring IT systems for disasters.
A integrated system of IT system preparation was implemented at the University of Colorado Hospital. This system has been demonstrated to be effective in multiple real-world events.
Four areas of IT preparedness are needed for hospital IT response to disasters. First is rapid disaster registration with prepared disaster medical record numbers and packets. The medical records must be active in the hospital IT environment, and a visit or case number must be preassigned or rapidly generated. The medical record number alone in the IT environment will allow the initiation of test ordering. The packet should include preprinted labels, a demographic data sheet, and downtime charting and ordering forms. The second item for response is templated order sets to allow rapid ordering of multiple studies such as laboratory, and especially radiology, without having to reenter clinical information. The third is a method of patient care charting scalable, from paper to electronic, depending on the patient volume, acuity, and workstation access. The fourth is a method for patient care in the IT downtime in a disaster setting. Simple inexpensive measures will allow rapid placement of patients in the IT environment and therefore allow rapid and accurate test ordering and resulting.
The aim of this study is to enrich public health emergency management (PHEM) curricula and increase the workforce readiness of graduates through the implementation of an innovative curriculum structure centered around simulation and the creation of authentic learning experiences into a mastery-based Disaster Preparedness graduate certificate program launched in 2016 at the Colorado School of Public Health. Learners progress through a sequence of increasingly complex discussion and operations-based exercises designed to align with training methodologies used by future employers in the disaster response field, covering PHEM fundamentals and domestic and international disaster preparedness and response. Preliminary feedback is overwhelmingly positive, equating the experience to securing an internship. Embedding simulation-based exercises and authentic learning environments into graduate curricula exposes learners to diverse disaster scenarios, provides occasion for practicing critical thinking and dynamic problem solving, increases familiarity with anticipated emergency situations, and builds the confidence necessary for exercising judgment in a real-world situation. This novel curriculum should serve as a model for graduate programs wishing to enrich traditional training tactics using a typical school of public health support and alignment with community resources. (Disaster Med Public Health Preparedness. 2019;13:777–781)
The use of after-action reviews (AARs) following major emergency events, such as a disaster, is common and mandated for hospitals and similar organizations. There is a recurrent challenge of identified problems not being resolved and repeated in subsequent events. A process improvement technique called a rapid improvement event (RIE) was used to conduct an AAR following a complete information technology (IT) outage at a large urban hospital. Using RIE methodology to conduct the AAR allowed for the rapid development and implementation of major process improvements to prepare for future IT downtime events. Thus, process improvement methodology, particularly the RIE, is suited for conducting AARs following disasters and holds promise for improving outcomes in emergency management.
LittleCM, McStayC, OethJ, KoehlerA, BookmanK. Using Rapid Improvement Events for Disaster After-Action Reviews: Experience in a Hospital Information Technology Outage and Response. Prehosp Disaster Med. 2018;33(1):98–100.
Sufficient fertility is important for crop growth and yield but supplying a balanced amount of N, P, and K with compost and manure is a challenge and nutrient imbalances can benefit weeds more than crops. The goal of this study was to compare the aboveground growth responses of common northeastern U.S. crops and weeds to addition of composted poultry manure (CPM). A secondary goal was to test whether the observed growth responses to CPM could be attributed to the three macronutrients—N, P, and K—supplied in the CPM. Two field experiments were conducted over 2 yr. Species grown were corn, lettuce, kale, Powell amaranth, common lambsquarters, giant foxtail, and velvetleaf. Plants were grown in soil amended with CPM or single-nutrient organic N, P, and K fertility amendments. Single-nutrient P treatments with bone char did not adequately mimic P supply from CPM. In both years, biomass of all weeds studied increased with CPM amendment rate. Powell amaranth was the most responsive to CPM addition, increasing 1,775 and 159% from the control to the highest CPM rate in 2010 and 2011, respectively. Corn biomass increased by 22% with CPM rate in 2010 but did not increase with CPM rate in 2011. Lettuce biomass increased with CPM amendment rate (175% in 2010 and 109% in 2011), but due to the increased weed biomass at high CPM amendment rates, good weed control will be necessary to maintain this yield benefit. The increase in growth of Powell amaranth, common lambsquarters, and giant foxtail with CPM amendment was not due to N or K, and may have been influenced by P or another factor in the CPM. Velvetleaf was the only species that exhibited increased biomass with N addition (as blood meal), similarly to the increase with added CPM, suggesting the velvetleaf growth response to CPM was due to N in the CPM. The results show that nutrient ratios should be considered when applying organic amendments, because application rates of organic amendments that meet the crop's needs for one nutrient may oversupply other nutrients. Overfertilization will not benefit crop yield, but the results of this study show that high organic fertility application rates are likely to increase weed growth.
This study aimed to review available disaster training options for health care providers, and to provide specific recommendations for developing and delivering a disaster-response-training program for non-disaster-trained emergency physicians, residents, and trainees prior to acute deployment.
A comprehensive review of the peer-reviewed and grey literature of the existing training options for health care providers was conducted to provide specific recommendations.
A comprehensive search of the Pubmed, Embase, Web of Science, Scopus, and Cochrane databases was performed to identify publications related to courses for disaster preparedness and response training for health care professionals. This search revealed 7,681 unique titles, of which 53 articles were included in the full review. A total of 384 courses were found through the grey literature search, and many of these were available online for no charge and could be completed in less than six hours. The majority of courses focused on management and disaster planning; few focused on clinical care and acute response.
There is need for a course that is targeted toward emergency physicians and trainees without formal disaster training. This course should be available online and should utilize a mix of educational modalities, including lectures, scenarios, and virtual simulations. An ideal course should focus on disaster preparedness, and the clinical and non-clinical aspects of response, with a focus on an all-hazards approach, including both terrorism-related and environmental disasters.
HansotiB, KelloggDS, AberleSJ, BroccoliMC, FedenJ, FrenchA, LittleCM, MooreB, SabatoJJr., SheetsT, WeinbergR, ElmesP, KangC. Preparing Emergency Physicians for Acute Disaster Response: A Review of Current Training Opportunities in the US. Prehosp Disaster Med. 2016;31(6):643–647.
As attention to emergency preparedness becomes a critical element of health care facility operations planning, efforts to recognize and integrate the needs of vulnerable populations in a comprehensive manner have lagged. This not only results in decreased levels of equitable service, but also affects the functioning of the health care system in disasters. While this report emphasizes the United States context, the concepts and approaches apply beyond this setting.
This report: (1) describes a conceptual framework that provides a model for the inclusion of vulnerable populations into integrated health care and public health preparedness; and (2) applies this model to a pilot study.
The framework is derived from literature, hospital regulatory policy, and health care standards, laying out the communication and relational interfaces that must occur at the systems, organizational, and community levels for a successful multi-level health care systems response that is inclusive of diverse populations explicitly. The pilot study illustrates the application of key elements of the framework, using a four-pronged approach that incorporates both quantitative and qualitative methods for deriving information that can inform hospital and health facility preparedness planning.
The conceptual framework and model, applied to a pilot project, guide expanded work that ultimately can result in methodologically robust approaches to comprehensively incorporating vulnerable populations into the fabric of hospital disaster preparedness at levels from local to national, thus supporting best practices for a community resilience approach to disaster preparedness.
KreisbergD, ThomasDSK, ValleyM, NewellS, JanesE, LittleC. Vulnerable Populations in Hospital and Health Care Emergency Preparedness Planning: A Comprehensive Framework for Inclusion. Prehosp Disaster Med. 2016;31(2):211–219.
In order to adequately appraise a district's potential for economic growth and development, it is important to know as much as possible about the economic structure of the particular district under analysis. Recent input-output analysis research conducted for the state of Oklahoma provided an examination of the economic base of the state, but this examination proved inadequate when considering the economic structure of the districts within the state.
The Oklahoma model provided an “average” or “aggregate” description of the various economic structures found in the state.