Learning from Critical Incidents Michael A. Stoto, PhD Georgetown University

Transcription

1 Learning from Critical Incidents Michael A. Stoto, PhD Georgetown University

2 Learning from critical incidents The only way to really know how well a public health emergency preparedness system will perform is to observe how it does perform in an emergency What is a critical incident? Public health played a significant role tested one or more public health preparedness capabilities Incident was meaningful magnitude of morbidity or social disruption stretch response capabilities and reveal critical vulnerabilities in significantly altered systems behavior or beliefs helped to identify best practices captured the PHEP community s attention Appropriate scope (time and organizations) to capture the event ( bite size chunk )

3 But there are challenges Public health system is fragmented City, county, and state departments Structure and function vary Non public health partners Health care, policy, EMS, media, Who s responsible for what? Effective response is complex and multi-factorial Not always clear what is effective and needs to be done

4 And more challenges. Events rare with unique characteristics and context Can t use statistical methods Don t know counterfactuals Effective responses are composed of ad hoc combinations of capabilities Capacity inventories and performance measures may not predict response capabilities or outcomes For QI purposes, should ask How and why the system (not just specific capabilities) performed as it did Not only how many or how well the system performed Need rigorous qualitative methods for analyzing critical incidents

5 Our work has focused on developing rigorous qualitative methods for analyzing small- and largescale emergencies and disasters Anthrax attacks (2001) SARS (2003) Hurricane Katrina (2005) Colorado water crisis (2008) H1N1 influenza (2009) ( ) West Nile Virus (2012) Ebola (2014) West Virginia water crisis (2014) Critical Incident Registry

6 Partial solution: distinguish between preparedness capacities: resources to draw upon infrastructure policies and plans knowledgeable and trained personnel response capabilities: actions a public health system can take to identify, characterize, and respond to emergencies Capabilities vs. capacities Capability Capacity

7 Public Health Emergency Preparedness system capabilities Surveillance, outbreak detection, characterization, and situational awareness Disease control and prevention Mass care and prophylaxis Communication with the public Information sharing within the public health system Leadership and management

8 Peer Assessment for PHEP One challenge with learning from critical incidents is ensuring objective, systematic, and reliable analyses difficult if officials evaluating their own response Assessment by peers offers potential for Reliable and objective analyses by professionals familiar with Public health preparedness Particularities of the responding PHEP system more hands Can be effective way to share best practices across jurisdictions Evidence from Health Officers Assoc. of Calif.,

9 Facilitated look-back methodology Established method for systems-level analysis of a public health systems emergency response capabilities Structured discussion with public health leaders and key staff stakeholders involved with the response Neutral facilitator and a no-fault approach Dimensions of decisions are probed Preceded by in-depth interviews to identify critical issues and players

10 PHEP Root Cause Analysis Process 1. Define the story arc 2. Identify candidate response challenges 3. Select subset for in-depth analysis 4. Assess candidate response challenges 5. Identify factors that contributed to the challenge 6. Suggest corrective actions that address contributing factors likely to affect future responses

11 PHEP Root Cause Analysis Process How did response activities compare with plans? Were deviations from plans reasonable in context? Are there any relevant standards of practice (e.g., in CDC guidance) that apply to the response? How did response activities compare in terms of timeliness, scope, contextual appropriateness, etc.? Adaptations and solutions What-if analysis What if X had been done earlier/later/not at all? What if Y had been done instead of X? Look for convergence/divergence in viewpoints

12 After issuing a Do Not Use order, the water company, in conjunction with state and local health and emergency agencies, had to inform the public about a strategy to flush the system and restore use of water in zones as the concentration of MCMH dropped below an acceptable level. Lessons Learned for Systems Improvement: Process or plan for expressing uncertainty in an effective manner Tell what is known and unknown, and what is being done to get more information Develop trusted communication channels in the community Underlying factors (modifiable & unmodifiable) that lead to the immediate cause Immediate reason(s) for response challenges that affected meeting objective Contributing factors Immediate factors Odor detectable after MCMH concentration below acceptable standards Lack of basic toxicological information on MCMH Ad hoc development of testing methods Aging water distribution infrastructure Differing perspectives on public health vs. economic concerns Lack of established safe level for MCMH exposure Constantly changing risk info. and testing thresholds Complicated plan for flushing homes and the water system Mixed messages on water safety Response challenge Communicate effectively despite deep scientific uncertainty about risk Objective: Inform public of zone based water restoration and flushing strategy. Related Capability: Emergency Public Information and Warning (CDC PHP 4) and Community Recovery (CDC PHP 2) Directly impacted whether the objective was met Shaped the lessons learned and resulting improvement plan

13 Biggest challenges Lessons learned Public distrust stemming from uncertainty about potential harms of the chemicals how this uncertainty was communicated officials should acknowledge uncertainty and tell the public what is known, what is unknown, and what they are doing to get more information Information sharing w/in the public health system established communication protocols were followed, but the number and variety of stakeholders and multiple command and communication centers, made it difficult to get the word out to local health departments, hospitals, businesses, schools and the public more inclusive regional planning process is needed

14 Example: Alamosa County 2008 Salmonella outbreak

15 Context Alamosa County, CO rural community in Southwestern Colorado with a population of approximately 15,000 one of the poorest in Colorado many citizens are home bound or have limited modes of communication large Hispanic and Mormon populations one public school system and one state university County Health Department Alamosa County Nursing Services (ACNS) supported by regional epidemiologist, preparedness staff, City of Alamosa has separate administration responsible for public works including the management of the water supply knew the water supply not, and that there was at least one break in the water system.

16

17 Date Timeline Mar. 7 First cases of severe GI illness present at local medical facility Mar. 8 Alamosa county public health nurses begin interviewing cases Regional outbreak response team begins to be assembled Mar. 12 Salmonella is confirmed Mar. 15 Emergency Operations Center (EOC) is established with internal incident command system lead by the Alamosa County Nursing Service and regional emergency planners Mar. 19 Water supply is confirmed as the source of the outbreak Disaster emergency is declared by the city and county of Alamosa Mar. 20 Outside resources arrive to Alamosa including food, water, and volunteers to aid the local efforts Water distribution sites are identified and staffed Mar Emergency Operations continue Pamphlets re water filtration printed without consulting the EOC Pamphlets are distributed door to door by volunteers Apr. 3 Regional volunteers arrive to relieve the incident command team

18 Identifying the source of the problem Fri., Mar. 7: First cases of severe GI disease present at local medical facility Sat., Mar. 8: Regional epidemiologist assembles team and starts to interview cases Wed., Mar. 12: State lab confirms Salmonella, 25 people ill McDonald s originally thought to be the source, but case in infant and mapping suggested water system

19 Identifying the source of the problem Nursing services department (ACNS) had no environmental health expert asked state health department for health didn t think that salmonella could be transmitted through water City public works knew of breaches in water supply water wasn t chlorinated but coordinated with state environmental agency, not public health

20 Story Arc: Residents of Alamosa County, were becoming ill with a severe gastrointestinal illness at abnormally high rates. Approximately twenty cases were identified before the public works department admitted that the water system could be to blame. Underlying factors (modifiable & un modifiable) that lead to the immediate cause Contributing factors Immediate causes Immediate reason(s) for response challenges that affected meeting objective Response challenges Lessons for Systems Improvement: The city and county must communicate to conduct outbreak investigations successfully The water supply must be chlorinated to prevent outbreak Public works needs to develop an ongoing relationship with public health and emergency operations Public works department had organizational knowledge that there was a break in the water supply, and public health did not Nursing services department and did not have an environmental health component The city and county did not have a history of working together Salmonella is not commonly found in the water supply City of Alamosa runs the water system but County of Alamosa health department was responding to the outbreak Identify the source of the Salmonella oubtreak Objective: Identify the source of the outbreak causing residents of the Alamosa area to get sick to mitigate the spread of the disease. Related Capability: Public Health Surveillance and Epidemiological Investigation (CDC PHP 13) Directly impacted whether the objective was met Shaped the lessons learned and resulting improvement plan

21 Incident management Sat., Mar. 15: EOC established in county office building Wed., Mar. 19: City and County jointly declare emergency through Colorado Dept. of Emergency Management Wed., Mar. 19: Bottled water advisory order issued by City Thurs., Mar. 20: Outside resources, including water and volunteers, begin reaching Alamosa

22 Salmonella Disaster One Big Family San Luis Valley Public Health EOC Environmental Health CDOT Denver Water Alamosa County Public Health JIC SLV RETAC SLV Exercise Design Team Alamosa County Alamosa Fire & Police Dept City of Alamosa Red Cross Water Resources CDEM SLV Homeland Security Alamosa County Sheriff s Office CDPHE Consumer Protection

23 Incident management Sat. Mar. 22: Local politicians come to observe EOC Daily press briefings held by ACNS director as PIO However complicated mixture of players ACNS not in emergency plans county and city radios operated on different channels some not trained in ICS lots of coming and going in EOC

24 The discovery of salmonella in the water supply in Alamosa County, involved a multi party response from Alamosa public works, nursing services, and emergency managers. None of these parties had dealt with an incident of this nature or worked together in this way before. Underlying factors (modifiable & un modifiable) that lead to the immediate cause Contributing factors Immediate causes Immediate reason(s) for response challenges that affected meeting objective Response challenges Lessons Learned for Systems Improvement: Ongoing process for Valley to figure out how to share the environmental health responsibility Need for planning and exercises and training Need to make lists and requirements of who is to be at the incident command center Vertical communication channels in public works & environmental matters versus public health & emergency management There was no existing plan involving public health in ICS Nursing services department and did not contain environmental health City officials had no ICS training Staff from different agencies had different training and perspectives Poor communication between public works, public health, and emergency management Difficulties in managing ICS operations Establishing lines of communication among various individuals and organizations involved in the response Police department shared their radios with the public works department to get public health and public works got on the same radio frequency with emergency management Objective: Communicate the roles and responsibilities of involved EOC and Alamosa personnel internally to decide what is going to happen and then get that out to the public Related Capability: Emergency Operations Coordination (CDC PHP 3) Directly impacted whether the objective was met Shaped the lessons learned and resulting improvement plan

25 Volunteer management Thurs., Mar. 20: Volunteers (eventually > 1,000), begin reaching Alamosa from Alamosa, San Luis Valley, and elsewhere Red Cross, state agencies, unaffiliated, Volunteers do not self organize had not worked together before no volunteer training in place Solution: appoint uniformed officers who were already seen as having authority and were respected by most volunteers

26 Story Arc: During the 2008 Salmonella Outbreak in Alamosa County, hundreds of volunteers came from outside the area and within the region to help distribute water and help local responders. Underlying factors (modifiable & un modifiable) that lead to the immediate cause Contributing factors Immediate causes Immediate reason(s) for response challenges that affected meeting objective Response challenges Lessons Learned for Systems Improvement: Plans are needed for managing volunteers Training is needed at the managerial level on the roles and responsibilities to manage these people People were from various places and had not worked together before There was no volunteer training Volunteers do not self organize Effectively managing the large number of volunteers Two individuals were identified to organize the volunteers. Additionally, ICS capitalized on using uniformed officers who were seen as authorities in the community. Objective: Utilize volunteers to distribute water notify citizens. Related Capability: Volunteer Management (CDC PHP 14) Directly impacted whether the objective was met Shaped the lessons learned and resulting improvement plan