Category Archives: Health Care

Academia, Clinical, Culture, Emergency Medical Services, Health Care, Society

Quality and Safety Measurement

In regards to the incident surrounding the death of Josie King (Josie King Foundation, 2002), there have been many great improvements in the delivery of care at Johns Hopkins (Niedowski, 2003; Zimmerman, 2004). Those aside, and if I was faced with having to develop performance measures of quality and safety in the context of such a tragedy, I would strive to ensure that my measures were accurate and valid to identify areas of grave concern where Johns Hopkins would do good to improve.

First, I would consider measuring the structure of the care delivered. In Josie’s case, a medical response team responded when it was identified that she was in the midst of a medical crisis. The first measurement would serve to identify the availability of such teams and the adequacy of the team’s staffing. The measure would indicate the response time of the team and the licensing and certification level of each team member.

Second, I would consider measuring processes that might have contributed to the death of Josie King. In this instance, Josie was administered a narcotic while suffering acute dehydration. The administration of this medication was contrary to the physician’s orders regarding pain medication for this patient. This measure would indicate the appropriate use of narcotic analgesia in patients faced with contraindications, such as acute dehydration or shock. This measure would be a cross tabulation of recent vital signs and laboratory results.

Third, I would consider measuring outcomes. In cases where pediatric patients are downgraded from the pediatric intensive care unit (PICU) to a general ward, any adverse condition should prompt an upgrade back to the PICU. This measure would identify the number of cases in each reporting period that any recently downgraded patient was upgraded back to the PICU. This measure should account for the time between a crisis and upgrade along with a statement indicating the cause of the crisis and resultant upgrade. This measure should be augmented by a mortality and morbidity subset involving any patients who were downgraded from PICU.

My considerations for these processes are to determine if general ward nurses should be administering any medications on standing order or if there should be a requirement to ensure that any medication administered to a general ward patient is explicitly written in the patient’s chart at the time of administration. Also, nurses should be acutely aware of the contraindications of any medications that they are administering. The process measure will, hopefully, identify misuse of narcotic analgesia and any failure to assess the patient for other possible causes of distress before assuming the distress is in response to pain. Ultimately, a more timely and efficient use of medical response teams should result, which would avail physicians and more experienced nurses to the original patient care team. This should lead to an open discussion of how to better manage the patient post crisis. Also, a greater understanding of medication administration concepts should result, benefiting all patients.

References

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Academia, Culture, Health Care, Society

The Patient Perspective: Patient Safety

The Speak Up materials provided by The Joint Commission (2011a, 2011b) do a great service in succinctly illustrating the need to be educated about health care issues. Patients and their families have a unique perspective to understanding their (or, their family member’s) health (Vincent & Coulter, 2002). Although physicians, nurses, and allied health providers are responsible for providing quality care, it remains the domain of the patient to express uncertainty or provide additional information to guide the provider. Ultimately, the patient or surrogate decision-maker must provide consent for treatment and must do so with full understanding. There are times, however, that the scope of treatment is so drastic, emergent, or specialized that the patient may not have the facilities to gain a full understanding of care needing to be rendered (Vincent & Coulter, 2002). This is the exception.

In the case of Josie King (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004), which I elaborated on last week, Sorrel King, Josie’s mother, was educated about her daughter’s condition and spoke up as The Joint Commission recommends. Unfortunately, this case turned into tragedy not because Sorrel King did wrong but because the nurse disregarded her apprehension. This was tantamount to malpractice and no patient or family member could have prevented this, save for using force to physically prevent the administration of medicine. According to MacDonald (2009), there are nurses that believe “[patients] have no say and that medications are the domain of doctors, leaving the nurse and the patient to trust that the doctors would do the right thing” (p. 29).

Perhaps things were slightly different, however. As MacDonald (2009) explains, patient’s who are knowledgeable of their illness and take an active role in their health care decisions add another layer of safety, especially when considering medication action, reaction, and interaction. Medication prescription errors are numerous within health care, and as in the case of Josie King, improved communication between the physicians, nurses, and Sorrel King might have prevented Josie from being administered the narcotic and instead receiving the fluid she so desparately needed (Vincent & Coulter, 2002).

Health care should be patient-centric as it remains the responsibility of the patient to be educated about the care they receive and to provide consent for that care and treatment to be rendered. An uneducated patient does add risk, but sometimes this is unavoidable. It is in these instances that special care should be taken until a full medical history can be attained.

References

The Joint Commission. (2011a, March 7). Speak up: Prevent errors in your care [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up-prevent-errors-in-your-care-/

The Joint Commission. (2011b, April 5). Speak up: Prevent the spread of infection [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up–prevent-the-spread-of-infection/

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Macdonald, M. (2009). Pilot study: The role of the hospitalized patient in medication administration safety. Patient Safety & Quality Healthcare, 6(3), 28-31. Retrieved from http://www.psqh.com/

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Vincent, C. A. & Coulter, A. (2002). Patient safety: what about the patient? Quality & Safety in Health Care, 11(1), 76–80. doi:10.1136/qhc.11.1.76

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Academia, Health Care, Public Health

Comparing Hospital Care in My Area

Living in northeastern Connecticut, I find myself equidistant from two area hospitals. As a health care provider and consumer, I feel that it is important to choose the professionals who will provide my care based on fact. Websites created by the Joint Commission (2011) and the U.S. Department of Health and Human Services (HHS; 2011) prove to be a helpful repository of information regarding the safety and quality of care delivered by hospitals and practitioners across the country.

Using these two websites, I will compare the three closest hospitals to my zip code: 1) Day Kimball Hospital (10.3 mi), 2) Harrington Memorial Hospital (10.0 mi), and 3) Windham Community Memorial Hospital (21.7 mi). The mean distance from my home to these hospitals is 15.85 mi. with all three being acceptable by me in distance and time in the case of an emergency. Day Kimball Hospital (DKH; 2011) is a 104-bed acute care facility located in Putnam, Connecticut. Harrington Memorial Hospital (HMH; 2009) is a 114-bed acute care facility located in Southbridge, Massachusetts. Windham Community Memorial Hospital (WCMH; n.d.) is a 130-bed acute care facility located in Windham, Connecticut.

General process of care measures account for best practices in medicine and health care. The Surgical Care Improvement Project has set goals preventing untoward cardiac effects during certain surgical procedures along with infection control measures. According to Health Compare (HHS, 2011), cumulative scores for each hospital based on general process of care measures in the Surgical Care Improvement Project are as follows: DKH=0.954, HMH=0.901, WCMH=0.935. Another general process measure aimed at providing the standard of care of heart attack victims is the Heart Attack or Chest Pain Process of Care. The cumulative scores for these reported measures are: DKH=0.967, HMH=0.973, WCMH=0.956. Another cardiac related measure is the heart failure process of care measure. The cumulative results are: DKH=0.950, HMH=0.873, WCMH=0.893. Pneumonia process of care measures are important to gauge the appropriateness of treatments provided to stave off further development of respiratory failure and sepsis, two highly conditions with increase mortality. The cumulative scores for the pneumonia process of care measures are: DKH=0.932, HMH=0.860, WCMH=0.955. The last general process of care measure reflects the adherence to best practices in treating and managing children’s asthma; however, none of the three hospitals provided data for any of the process measures of this category.

Along with process of care measures, outcome of care measures are also important as they reflect the ability of each hospital to manage the risks of mortality and morbidity in caring for their patients. Outcome measures are based on both death and readmission of heart attack, heart failure, and pneumonia patients. For all three hospitals, DKH, HMH, and WCMH, the cumulative results for outcome of care measures were not statistically different from than the national rates in all categories. Health Compare (HHS, 2011) reports these measures as such.

One final measure that I find important in choosing a hospital is the patient satisfaction scores. Cumulative scores of the Survey of Patients’ Hospital Experience allow us to compare the three hospitals: DKH=0.695, HMH=0.701, WCMH=0.677.

In ranking each of the three hospitals, I used an average of the cumulative scores for each hospital’s measure discussed above. The final score, according to the averages of the Hospital Compare (HHS, 2011) scores, is: DKH=0.900, HMH=0.862, WCMH=0.883; therefore, my first choice of hospitals, according to the data presented in Hospital Compare is DKH with WCMH being second and HMH third. According to this data, though, each of the three hospitals appears to be equitable with the others striving in some measures and faltering in others. This is also evidenced by Quality Check (The Joint Commission, 2011), which shows a graphic representation of the same overall data, National Quality Improvement Goals and the Surgical Care Improvement Project, used by HHS (2011). Quality Check (The Joint Commission, 2011) compares quality data with the target ranges of other hospitals.

According to Quality Check (The Joint Commission, 2011), DKH met all the target goals while exceeding the goals set for infection prevention. HMH failed to meet the pneumonia care goal, but met all other goals. HMH did not exceed any of the goals. WCMH failed to meet the heart failure care goal, but met all other goals. WCMH did not exceed any of the goals.

In considering the data from Hospital Compare (HHS, 2011) and Quality Check (The Joint Commission, 2011), it is clear that this data can be used by consumers to make more informed decisions regarding their health care. Though the methods in this paper might be questionable and simple, consumers may disregard some measures while favoring others, depending on their perception of what measures are important in judging the provision of the care that they might receive. Additionally, the data used for the comparisons, many times, accounted for a small patient population; however, each hospital serves comparable communities with comparable levels of service. This may be a consideration when performing scientific statistical analyses, but that would be beyond the scope of this paper.

The provision of health care must be ethical, just, and equitable. Allowing consumers access to data regarding the performance of hospitals in their area can provide additional insight to patients when choosing their health care provider.

References

Day Kimball Hospital. (2011). Sevices and locations: Day Kimball Hospital. Retrieved from http://www.daykimball.org/services-and-locations/day-kimball-hospital/

Harrington Memorial Hospital. (2009). About us: Harrington at a glance. Retrieved from http://www.harringtonhospital.org/about_us/harrington_at_a_glance

The Joint Commission. (2011). Quality check. Retrieved from http://www.qualitycheck.org/ consumer/searchQCR.aspx

U.S. Department of Health and Human Services. (2011). Hospital compare. Retrieved from http://www.hospitalcompare.hhs.gov/

Windham Community Memorial Hospital. (n.d.). CEO’s message. Retrieved from http://www.windhamhospital.org/wh.nsf/View/CEOsMessage

Criminal Justice, Emergency Management, Health Care, Politics, Public Health, Society

Bioweapons of Mass Destruction: Actual Use or Hoax

Weapons of mass destruction (WMDs) provide an alternative impact when compared to conventional weapons (e.g. artillery, firearms, blades and knives, batons, et al.). WMDs can be chemical, biological, radiological, nuclear, or explosive (CBRNE) in nature attacking the human body in manners not typical of conventional weapons (Cameron, Pate, McCauley, & DeFazio, 2000). WMDs can, therefore, have devastating effects on the preparedness of the health care system (Macintyre et al., 2000; Subbarao, Bond, Johnson, Hsu, & Wasser, 2006).

Considering an attack such as a mass contamination of the money supply, there are two possibilities: actual contamination and hoax contamination. In actual contamination, the epidemiology of illness will correspond with the travel of contaminated bills, reaching long distances in short periods of time (as evidenced by the website http://www.wheresgeorge.com). As the contaminated money travels from one consumer to the next (possibly also infecting adjacent bills, wallets, counter-tops, and register drawers), it will do so undetected until the incubation period lapses and the first wave of infected people begin presenting to health care facilities for treatment (presumably, with a difficult diagnosis – an uncommon pathogen). These people should be geographically dispersed so that identification of the terrorist act is yet to be made. Not until epidemiologists track the vector to the money supply will the threat be discovered. Once this occurs, the populace will be suspicious of money, causing an entirely different catastrophe, but the fear will be real.

On the other hand, if the attack is a hoax, there will be no incubation period or actual illness, yet psychogenic effects will be almost immediate, causing many people to seek medical care at once overburdening the health care system (MacIntyre et al., 2000). Arguably, this type of attack will be short-lived; however, the effects can be disastrous.

Regardless of the type of attack, whether actual or hoax, there will be a large, resource-intensive response from national, state, and local levels of government and the private sector (Walsh et al., 2012). This would place a strain on response resources and other infrastructure, such as health care as previously mentioned. In both instances, though, lives could be lost, also. With the real attack, many people could die from the disease, but if resources are taken away from other sick patients, they are at risk of dying also. This holds true for hoax attacks. As many healthy people flood emergency rooms with mysteriously fleeting symptoms, truly sick patients are not being managed efficiently and are put at serious risk.

Though the example attack might not be feasible for one reason or another, it is interesting to think of the many ways in which we as a nation are vulnerable. This leads to the question of how much we value our freedom vs. how many freedoms are we willing to give up in order to feel safe. I have decided that I value my freedom, the freedom that most foreign terrorists despise, so much that I am not willing to part with it to any extent. So long as we live free and without fear, the terrorists cannot win.

References

Cameron, G., Pate, J., McCauley, D., & DeFazio, L. (2000). 1999 WMD terrorism chronology: Incidents involving sub-national actors and chemical, biological, radiological, and nuclear materials. The Nonproliferation Review, 157-174. Retrieved from https://www.piersystem.com/clients/PIERdemo/ACF1D7.pdf

MacIntyre, A. G., Christopher, G. W., Eitzen, E., Gum, R., Weir, S., DeAtley, C., … Barbera, J. A. (2000). Weapons of mass destruction events with contaminated casualties: Effective planning for health care facilities. Journal of the American Medical Association, 283(2), 242-249. doi:10.1001/jama.283.2.242

Subbarao, I., Bond, W. F., Johnson, C., Hsu, E. B., & Wasser, T. E. (2006). Using innovative simulation modalities for civilian-based, chemical, biological, radiological, nuclear, and explosive training in the acute management of terrorist victims: a pilot study. Prehospital and Disaster Medicine, 21(4), 272-275. Retrieved from http://www.hopkins-cepar.org/downloads/publications/using_sim_modalities.pdf

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Academia, Clinical, Emergency Management, Emergency Medical Services, Health Care, Public Health, Society

Medical Error: The Josie King Story

Josie King’s story (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004) is heartbreaking, but the events told herein empowered Sorrel King, Josie’s mother, to take on a mission responsible for numerous patient care recommendations that have enhanced the safety of pediatric patients throughout the country. Josie King was only 18 months old when she climbed into a hot bath and suffered 1st and 2nd degree burns which led to her being admitted to Johns Hopkins pediatric intensive care unit (PICU). Within 10 days, Josie was released from the PICU and brought to the intermediate floor with all assurances that she was making a remarkable recovery and would be released home in a few days. Josie did not continue her remarkable recovery, however.

According to Sorrel King (Josie King Foundation, 2002), Josie began acting strangely, exhibiting extreme thirst and lethargy, after her central intravenous line had been removed. After much demanding by Sorrel, a medication was administered to Josie to counteract the narcotic analgesia she had been administered. Josie was also allowed to drink, which she did fervently. Josie, again, began recovering quickly. Unfortunately, the next day, a nurse administered methadone, a narcotic, to Josie as Sorrel told her that Josie was not supposed to have any narcotics… that the order had been removed. Josie became limp and the medical team had to rush to her aid. Josie was moved back up to the PICU and placed on life support, but it was fruitless. Josie died two days later and was taken off life support.

The Institute of Medicine (2001) published six dimensions of health care: safety, effectiveness, patient-centered, timeliness, efficiency, and equality. In Josie’s case, the care was not delivered efficiently, effectively, safely, or in a patient- or family-centered fashion. The overuse of narcotics in Josie’s case was certainly not effective or safe. Additionally, withholding fluids and allowing her to become dehydrated was detrimental to her recovery, which was neither safe nor effective. As Josie exhibited extreme thirst, her symptoms were dismissed, which does not follow patient-centeredness. Moreso, when the nurse administered the narcotic to Josie despite the pleadings of her mother, it demonstrated a lack of family-centered care, safety (in that, the order should have been double checked), efficacy (further demonstrating overuse of narcotic analgesia), and efficiency, as medication orders were either unclearly written or removed.

This story is clearly a demonstration that mistakes can happen at even the best of hospitals.

References

Institute of Medicine. (2001, July). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ New Tool To Fight Lawsuits: Saying ‘I’m Sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Emergency Management, Emergency Medical Services, Health Care, Politics, Public Health, Society

Critical Incident Response Plans

The possibility of a large-scale event threatening the health and safety of a large number of residents in Connecticut is sizable. Emergency response plans (ERPs) need to be in place to address concerns including epidemic/pandemic disease, the intentional or accidental release of a hazardous material, contamination of the food and/or water supply, and other incidents that might threaten the 3.4 million residents and could result in mass casualties. For this reason, the State of Connecticut Department of Public Health (DPH; 2005) has developed an ERP to guide the department in the event of a catastrophic threat the lives and safety of the residents of Connecticut. Additionally, the State of Connecticut has developed a State Response Framework, much like the National Response Framework, in order to allow for a modulation of an incident from a local level to a state or federal level (State of Connecticut, Department of Homeland Security, 2010; U.S. Department of Homeland Security, 2008). The ability of an incident response to grow and shrink as an incident dictates follows the natural progression of incidents starting and ending locally, whether involving state or local responses at any time during the response (Walsh et al., 2012).

The ERP (DPH, 2005) that guides the DPH allows for representation in the state EOC while forming a modular incident management team (IMT) to staff the DPH emergency command center. The DPH IMT is designed not only to support the state EOC when activated, but also supports the various local incident commands as a public health and medical service resource. In keeping with the modular aspects of the incident command philosophies and the state and national response framework, the DPS ERP becomes a valuable resource for both initiating a response to a significant threat to the public health and safety and allows for an expert resource when other incidents of magnitude, but not necessarily public health in nature, require or benefit from the availability of public health experts.

One criticism I do have, however, is that the plan (DPH, 2005) does not address the provision of emergency medical services (EMS). For some time, there has been much confusion as to where EMS falls in the realm of emergency service functions. EMS, for many jurisdictions, is a function of the fire department and may fall under the direction of ESF #4, firefighting, especially as many EMTs and paramedics are cross-trained to fight fire. However, ambulances are not firefighting apparatus. As ambulances do transport the ill and injured, perhaps EMS falls to ESF #1, transportation. This is unlikely, though, as the primary need is not the transportation provided but the care rendered. Public health and medical services, ESF #8, seems to me to be the logical category for EMS to fall under, but EMS has an expanded role that also fits ESFs #9, #10 & #13 (search & rescue, oil & hazmat response, and public safety & security, respectively), as well as the aforementioned ESFs #1 and 4. This lack of initial categorization may allow flexibility in the deployment of EMS personnel and equipment, but it could also lead to ineffective deployment strategies resulting in a shortage of EMS in one area and overutilization in another.

References

State of Connecticut, Department of Homeland Security. (2010, October). State response framework. Retrieved from http://www.ct.gov/demhs/lib/demhs/telecommunications/ct_state_response_framework_v1_oct_10.pdf

State of Connecticut, Department of Public Health. (2005, September). Public health emergency response plan: Emergency Support Function #8 Public health and medical services. Retrieved from http://www.ct.gov/ctfluwatch/lib/ctfluwatch/pherp.pdf

U.S. Department of Homeland Security. (2008, January). National response framework. Retrieved from http://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Emergency Management, Emergency Medical Services, Health Care, Politics

Emergency Operations Center Leadership

The emergency operations center (EOC) is a decentralized and secure place for senior management officials to maintain operational awareness when confronted with a large scale events or disasters (Walsh et al., 2012). Although these events or disasters may dictate the use of local incident commands at various emergencies throughout an area, the EOC allows an incident management team to direct the overall response effort while maintaining complete situational awareness. This allows for increased interoperability and the availability of resources and a centralized planning and intelligence effort (Walsh et al., 2012). During a multi-state event, a joint field office (JFO) might serve as the primary EOC to support other EOCs that have been activated.

Within the EOC, there are a number of leaders and managers responsible for ensuring an effective response strategy for the emergency that is being faced. One of these leaders is the Area Command Logistics Section Chief (or, “Log Chief”). The Log Chief is responsible for procuring and otherwise acquiring the facilities and personnel to support the response initiative. This includes “resources from off-incident locations […] providing facilities, transportation, supplies, equipment maintenance and fuel, food services, communications and information technology support, and emergency responder medical services, including innoculations” (Walsh et al., 2012, p. 60).

In response to an impending an ice storm in Austin, Texas, in 2003, the city’s EOC was activated 24 hours in advance of the storm. One of the crucial area command members activated was the Log Chief. The Log Chief ensured that redundant communications facilities were available as power outages were interferring with some established communications equipment. The Log Chief also ensured that there was food available for delivery to each small-scale incident as it developed. This was important as the available resources were deployed, there was a lack of available manpower during shift change, so feeding hungry crews was a priority. The Log Chief, on this incident, had many other important functions, but as a responder working in these adverse conditions, it was most important for me to be fed and have solid communications in the event I was to be one of the motorists sliding off the road.

References

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Emergency Management, Emergency Medical Services, Health Care, Politics, Public Health

The National Incident Management System

The National Response Framework (NRF) is an evolution of a series of national readiness plans that have been adapted to handle various emergencies at the national level (Walsh et al., 2012). According to Walsh et al. (2012), the federal government developed a response plan to guide the efforts and deployable assets in the event of any emergency that overwhelmed local and state capabilities. The first of these plans was developed in 1992, called the Federal Response Plan (FRP), and proved ineffective when implemented during a hurricane response in Miami, Florida, primarily due to a lack of familiarity and a focus on federal efforts instead of local scalability.

At the time the FRP was in effect, many fire departments across the country were adopting a modular system of incident management referred to as the incident command system (ICS). Early in its inception, ICS was not standard between the various departments, but as the federal government began to improve upon the FRP, developing the National Response Plan (NRP) with a focus towards incorporating and standardizing ICS, the various fire departments began to refer to the federal government implementation of ICS which promoted its standardization. The NRP was created in 2004 to answer concerns that were outlined in Presidential directives HSPD-5, HSPD-8, and discussions regarding the recent terror attacks on September 11, 2001, and the federal response to Hurricane Katrina. The NRP, in addition to standardizing ICS, addressed the roles of each level of government (local, state, and federal), non-governmental disaster aid organizations, and private business (U.S. Department of Homeland Security, 2004; Walsh et al., 2012). This growth, evolution, and adaptation of ICS within the NRP grew into a further adaptation of a comprehensive incident management system, now known as the national incident management system (NIMS) which allows for implementation at each level of government, within business, and with each private citizen (U.S. Department of Homeland Security, 2008a, 2008b; Walsh et al., 2012). This scalability also allows for increased modulation by either increasing the scope of a response or decreasing it as needed. In 2008, the U.S. Department of Homeland Security (2008a), understanding the shortcomings of the NRP and the promise of NIMS, further refined the response guidelines while using NIMS principles to develop the National Response Framework (NRF; U.S. Department of Homeland Security, 2008a, 2008b; Walsh et al., 2012). Both NIMS and the NRF share the foundation principle that most incidents start and end at the local level and are best managed by local interests (U.S. Department of Homeland Security, 2008a; Walsh et al., 2012).

This was evident during the 2008 hurricane season. As a contractor under Emergency Support Function #8 – Public Health and Medical Services Annex – I was part of the largest single mobilization of emergency medical services in history. Although we could have taken over jurisdiction from the clearly overwhelmed local government (as might have occurred under the FRP), we continually offered our assistance and only responded when requested. This allowed for a more focused response with rapid demobilization and remobilization when confronted with a second and third hurricane that threatened another region. This effort was appreciated by the local emergency managers who not only learned from the event but also adapted their local response plans to include variations of significant mobilizations of each of the emergency support functions.
The continued development of the response plans, incident management systems, and command structures and systems is a testament of the government’s ability and readiness to assist in the event of an emergency, but it is also a testament to the understanding of self-reliance.

References

U.S. Department of Homeland Security. (2004, December). National response plan. Washington, DC: Author.

U.S. Department of Homeland Security. (2008a, January). National response framework. Washington, DC: Author.

U.S. Department of Homeland Security. (2008b, December). National incident management system. Washington, DC: Author.

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Academia, Emergency Management, Health Care, Public Health, Society

Public Health Risks in the 21st Century

Within the next 30 years, I foresee a significant public health risk of viral pandemic, a concern outlined in the recently published CISIS commission report (Fallon & Gayle, 2010). According to many, the next significant pandemic to be a global threat will occur anytime between now and 70 years (Gostin, 2004; Monto, Comanor, Shay, & Thompson, 2006; Ravilious, 2005; Smil, 2008; Tapper, 2006; Taubenberger, Morens, & Fauci, 2007). Although many scientists have their focus on influenza as the most probable for pandemic exposure, other novel virii, such as SARS, HIV, et al., have the facets to make them just as potentially significant (Gostin, 2004; Smil, 2008; Tapper, 2006). Regardless of the particular pathogen, history has shown pandemics to create and environment of negative net effects to humanity. According to Billings (1997) and Ravilious (2005), the Spanish influenza pandemic of 1918, caused by a mutated avian flu strain, claimed between 20-million and 40-million lives in a single year (Monto et al., 2006; Taubenberger et al., 2007). Spreading quickly along major international trade routes, the Spanish flu infected many servicemen returning from duty at the end of World War I. As these infected servicemen returned and celebrated the armistice in crowds of people, a severe strain on the public health system in the United States was unknowingly developing. Considering the hypervirilence and increased mortality (2.5%, compared to the typical 0.1%) caused by the 1918 Spaish flu, the world’s economy was in turmoil (Billings, 1997). As most of the American workforce was recently embroiled in overseas combat duty, upon their return they must now face the possibility of infection, an inability to work, and possible death.

Monto et al. (2006) outline a useful model of surveillance techniques that would not only be useful in detecting and improving response to influenza outbreaks, but it would certainly help to detect any new significant diseases that could be a public health risk and threaten a population or society. Additionally, Taubenberger et al. (2007) focuses on learning the biology of the influenza virus to predict the possibility of outbreak and, thus, pandemic potential. Coupling these two approaches makes sense to both identify potential pathogens and use surveillance techniques to track and direct responses to mitigate actual outbreaks as they occur. These efforts, however, should be directed by an organization that values independant operation, impartiality, neutrality, and universality, just a few of the principles of the Red Cross and Red Crescent movements (International Federation of Red Cross and Red Crescent Societies, 2010). Adoption of these principles will allow valuable health information to flow freely to other entities positioned to respond appropriately without regard to local politics, ensuring a just and equitable solution to help to mitigate the potential for great harm.

References

Billings, M. (1997/2005). The influenza pandemic of 1918. Retrieved from http://virus.stanford.edu/uda/

Fallon, W. J. & Gayle, H. D. (2010). Report of the CISIS commission on smart global health policy: A healthier, safer and more prosperous world. Washington, DC: Center for Strategic & International Studies.

Gostin, L. O. (2004). Pandemic influenza: Public health preparedness for the next global health emergency. The Journal of Law, Medicine & Ethics, 32(4), 565-573. doi:10.1111/j.1748-720X.2004.tb01962.x

International Federation of Red Cross and Red Crescent Societies. (2010, July). Haiti: From sustaining lives to sustainable solutions – the challenge of sanitation. Geneva, Switzerland: Author.

Monto, A. S., Comanor, L., Shay, D. K., & Thompson, W. W. (2006). Epidemiology of pandemic influenza: use of surveillance and modeling for pandemic preparedness. Journal of Infectious Diseases, 194(Suppl. 2), S92-S97. doi:10.1086/507559

Ravilious, K. (2005, April 14). What a way to go. The Guardian. Retrieved from http://www.guardian.co.uk/science/2005/apr/14/research.science2

Smil, V. (2008). Global catastrophes and trends: the next fifty years. Cambridge, MA: The MIT Press.

Tapper, M. L. (2006). Emerging viral diseases and infectious disease risks. Haemophilia, 12(Suppl. 1), 3–7. doi:10.1111/j.1365-2516.2006.01194.x

Taubenberger, J. K., Morens, D. M., & Fauci, A. S. (2007). The next influenza pandemic: Can it be predicted? Journal of the American Medical Association, 297(18), 2025–2027. doi:10.1001/jama.297.18.2025.

Academia, Health Care, Public Health

A Novel Approach to Combat Heart Disease

According to Hansson (2005), cardiovascular disease is fast becoming the number one killer in the world among in developing countries and the Western world, due mainly to the correlation of increased rates of obesity and diabetes (Haffner, Lehto, Rönnemaa, Pyörälä, & Laakso, 1998; Miller, 2011; Willer et al., 2008). The goal of eradicating heart disease by the end of the twentieth century has been missed as cardiovascular disease is still responsible for 38% of deaths in North America. There has been much research over the last three decades regarding correlations between cardiovascular disease, obesity, and diabetes. Miller et al. (2011) identifies, based on the current literature, a number of metabolic syndromes in which elevated triglyceride levels are responsible for significantly increasing the risk of cardiovascular disease and the risk of death from a cardiac event.

Risk factors for cardiovascular disease, including smoking, hypercholesterolemia, and diabetes, which have positive predictive value for CVD, include a positive family history, hypertension, male gender, and age (Haffner, Lehto, Rönnemaa, Pyörälä, & Laakso, 1998; Hansson, 2005; Koliaki, 2011).

Demographically, according to NHANES 1999-2008 (as cited in Miller, 2011), Mexican American men (50 to 59 years old, 58.8%) are at the greatest risk with the highest prevalence of elevated triglyceride levels ( 150 mg/dL) followed by (in order of decreasing prevalence) Mexican American women ( 70 years old, 50.5%), non-Hispanic White men (60 to 69 years old, 43.6%), non-Hispanic White women (60 to 69 years old, 42.2%), non-Hispanic Black men (40 to 49 years old, 30.4%), and non-Hispanic Black women (60 to 69 years old, 25.3%).

Haffner et al. (1998) describe the importance of lowering cholesterol levels in those with diabetes mellitus type II as they both contribute to increases in mortality and morbidity from cardiovascular disease; therefore, efforts should be focused on identifying risks to heart health starting at age 30 with concomitant risk factors of diabetes or dyslipidemia, or any combination of two or more identified risk factors. More specific screening should begin at age 40 with Mexican American males and all other demographics suffering from any one of the secondary risk-factors, and at age 50 with all other ethnic demographics, regardless of the presence of risk-factors.

Specific screening for the at-risk population should include diagnostic percutaneous transthoracic coronary angiography (PTCA) and angioplasty, if needed. PTCA is a method of introducing a catheter through an artery to the coronary arteries of the heart, guided by radiology, to diagnose specific narrowing of these vessels, at which time a repair (angioplasty) can proceed immediately. PTCA, according to Koliaki et al. (2011), is the gold standard of diagnosing the presence and degree of atherosclerotic CVD. Currently, the standard for initiating PTCA requires a more acute presentation, typically complaints of chest pain or some other cardiac related illness. However, the proven safety and efficacy of PTCA may allow it to be used more as a screening tool as well as a primary coronary intervention in acute cases.

Utilizing the diffusions of innovations model of behavior change, public health entities can provide specific information to encourage interventional cardiologists to employ this technique as a focused CVD screening tool for at-risk populations (“Culture and health,” 2012). Adoption, however, is conditional on remuneration; therefore, a public health task force at the national level should investigate the potential for spending versus savings, and if significant, should disseminate the information to third-party payors (heath insurance providers, etc.) to ensure coverage when required. Additionally, grassroots efforts should be two-pronged, focusing on both the affected communities and the physicians most likely to contact the at-risk community. For the at-risk community, using mass-media, the message should simply be to discuss your risk with your physician, stop smoking, eat healthy, and exercise. The message, itself, needs to be conveyed in an effective manner, however. For the physicians, using mass-mailing and professional development campaigns, the message needs to more complex outlining risk versus reward, cost-effectiveness, and the potential for impacting a growing trend of heart-related death and disability. The American Heart Association has a proven track record of effective mass-media campaigns as well as professional development programs. So long as PTCA can be considered as an effective and cost-saving screening tool, the American Heart Association should certainly be involved in sending the message out.

Like with the proliferation of television advertisement of pharmaceuticals, using diffusions of innovations, we can get the heart-healthy message to the communities that would most benefit and the providers who can facilitate appropriate and novel screening and treatment techniques. We have already failed to eradicate CVD by the turn of the century, but if we think outside the box and develop novel approaches to consider, we may still have a chance at effectively lowering the incidence and prevalence of CVD in the years to come.

References

Culture and health. (2012). Public health and global essentials (Custom ed.; pp. 213-226). Sudbury, MA: Jones & Bartlett.

Haffner, S. M., Lehto, S., Rönnemaa, T., Pyörälä, K., & Laakso, M. (1998). Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. New England Journal of Medicine, 339(4), 229-234. doi:10.1056/NEJM199807233390404

Hansson, G. K. (2005). Inflammation, atherosclerosis, and coronary artery disease. New England Journal of Medicine, 352(16), 1685-1695. doi:10.1056/NEJMra043430

Koliaki, C., Sanidas, E., Dalianis, N., Panagiotakos, D., Papadopoulos, D., Votteas, V., & Katsilambros, N. (2011). Relationship between established cardiovascular risk factors and specific coronary angiographic findings in a large cohort of Greek catheterized patients. Angiology, 62(1), 74-80. doi:10.1177/0003319710370960

Miller, M., Stone, N. J., Ballantyne, C., Bittner, V., Criqui, M. H., Henry N. Ginsberg, H. N., … Council on the Kidney in Cardiovascular Disease (2011). Triglycerides and cardiovascular disease: A scientific statement from the American Heart Association. Circulation, 123(20), 2292-2333. doi:10.1161/CIR.0b013e3182160726

Willer, C. J., Sanna, S., Jackson, A. U., Scuteri, A., Bonnycastle, L. L., Clarke, R., … Abecasis, G. R. (2008). Newly identified loci that influence lipid concentrations and risk of coronary artery disease. Nature, 40(2), 161-169. doi:10.1038/ng.76

Appendix

P.E.R.I. Problem Identification

The health problem I have identified is cardiovascular disease (CVD). According to Hansson (2005), CVD was expected to be significantly reduced or eliminated by the turn of the century; however, cardiovascular disease remains one of the leading cause of death globally with a rise in obesity and diabetes incidence (Willer et al., 2008). The two primary factors contributing to CVD are thought to be hypercholesterolemia, or high cholesterol levels in the blood, and hypertension, or high blood pressure, and although Koliaki et al. (2011) shows no predictive value between obesity and CVD, there remains a strong correlation between obesity and diabetes (Haffner, Lehto, Rönnemaa, Pyörälä, & Laakso, 1998; Hansson, 2005). A better look at the emerging literature might provide insight as to why attempts to control cholesterol and blood pressure have largely failed to eradicate CVD.

Koliaki et al. (2011) contend that smoking, hypercholesterolemia, and diabetes have positive predictive value for CVD while a positive family history, hypertension, male gender, and age, though predictive, are significantly less specific. Considering the causative risk factors and admitting the difficulty in changing age, family history, and gender, altering smoking status, cholesterol levels, and severity of diabetes and blood pressure have all been shown to decrease the risk of CVD. However, like genetic factors such as family history and gender, researchers are finding difficulty in controlling cholesterol levels effectively in many patients, especially those with concommitant diabetes mellitus (Haffner et al., 1998; Willer, 2008). However, statin-type cholesterol-lowering medications appear to have other protective effects than merely lowering cholesterol (Hansson, 2005).

In order to combat the growing concern of cardiovascular disease and, ultimately, the increasing mortality from the same, the American Heart Association (AHA) has published a scientific statement paper regarding the latest literature and research (Miller et al., 2011). AHA has taken the lead in cardiovascular health and strives to promote best practices based on the available evidence. By promoting AHA’s position using mass-mailing campaigns to physicians practicing in primary care, emergency, cardiology, and endocrinology, we can be assured that the right message is being disseminated rapidly to those most inclined to intervene. As more physicans in the identified roles adopt the latest evidence-based practice, more at-risk patients can be screened for CVD and the contributing factors. As screening paradigms become more focused, more of the at-risk population will be identified sooner which will allow for earlier intervention decreasing overall mortality and morbidity from CVD.

P cardiovascular disease
E Causes: DM, type II; dyslipidemia (hypercholesterolemia); smoking; diet; exercise; gender; age
Burden: increasing mortality and morbidity globally
R Diabetes mellitus screening and control, HTN screening and control, statin-type medication prescription, PTCA screening recommendations, smoking cessation
I AHA position, public health mailing campaign, cadre of physician groups