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In the event of a natural or man-made disaster involving large numbers of children, resources in the Southeastern U.S. are extremely limited. This article chronicles the efforts of the Alabama Department of Public Health, the Mississippi State Department of Health, and the South Central Center for Public Health Preparedness in conjunction with more than 40 organizations to develop a voluntary network of health-care providers, public health departments, volunteers, and emergency responders from Alabama, Florida, Louisiana, Mississippi, and Tennessee. The purpose of the Southeastern Regional Pediatric Disaster Surge Network (the Network) is to improve the pediatric preparedness response strategies of public health, emergency response, and pediatric providers in the event of large-scale emergencies or disasters that overwhelm local or state pediatric resources.
The planning and development of the Network is proceeding through three general phases—information sharing, mutual goal setting and collective action, and long-term formal linkages. In Phase 1, critical planning tasks to be undertaken in the development of the Network were identified. In Phase 2, the agencies developed a draft operational handbook that served as the basis for a formal memorandum of understanding. In Phase 3, participants will engage in exercises and evaluations that will further identify and work out logistical and operational details.
During the past five years, the South Central Center for Public Health Preparedness (SCCPHP) has worked in conjunction with the Alabama Department of Public Health (ADPH), the Mississippi State Department of Health (MSDH), and more than 40 agencies and institutions to improve the pediatric preparedness response strategies of public health, emergency responders, and pediatric providers in the Southeastern United States. Disasters such as Hurricane Katrina, the earthquakes in Haiti and Chile, and other emergencies have illustrated the need for a coordinated and collective response to the needs of children, as children are among the most vulnerable to injury, disease, and exploitation in any emergency.1 Immediate response is needed not only to ensure child survival and protection, but also to restore some sense of normalcy to the lives of children.
The Southeastern U.S. lacks pediatric surge capacity because of the relatively small number of pediatric facilities, limited public health resources, high rates of poverty, and other adverse factors specifically related to children. As a result, the ability to respond effectively to large-scale pediatric emergencies and disasters is often beyond the capacity and capability of a single organization, institution, or health department. The challenge of accommodating pediatric surge becomes more daunting given the increased number and consequences of large-scale disasters, and the number of agencies and organizations that must be organized, coordinated, and managed during a disaster response.2,3
Through their emergency and disaster experiences, ADPH, MSDH, and pediatric providers learned that traditional approaches and local health systems, by themselves, were not always effective in addressing the complex, multi-institutional, and multijurisdictional nature of regional pediatric surge.4–8 Further, they realized that the continuing challenges of limited pediatric resources and the unique physiological, mental, and social issues of children would require a focus on leading, organizing, and managing numerous government and private sector organizations to eliminate multiple chains of command, reduce duplicative efforts, and prevent agencies from working at cross purposes. Effective pediatric emergency and disaster response in the Southeast would require a collaborative network of agencies and organizations—a new type of organization called a high-reliability network (HRN).9
This article chronicles the efforts of more than 40 organizations to develop an HRN, specifically the Southeastern Regional Pediatric Disaster Surge Network (the Network), a voluntary network of health-care providers, public health departments, volunteers, and emergency responders from Alabama, Florida, Louisiana, Mississippi, and Tennessee. The purpose of the Network is to provide pediatric care and mutual aid at the time of an emergency or disaster.
Previous efforts by national and regional groups have illustrated methods for addressing surge capacity through general mutual aid agreements and limited emergency-response resources related to children.10 These efforts, however, are generally clinically focused, intrastate, and not specific to the Southeastern U.S. In contrast, Network organizers envisioned the solution to limited pediatric surge capacity as regional in nature and as a managerial and organizational issue rather than strictly clinical. Therefore, drawing upon the high-reliability organization (HRO) literature, Network partners attempted to create, maintain, and operate a collaborative, pediatric-surge HRN. The aim was to create a network that would (1) be highly reliable and (2) exhibit an extremely high degree of inter-organizational/agency collaboration. Additionally, this first-of-its-kind regional network would have to operate in cooperation with existing response systems as described in the National Response Framework.11
Organizations that operate successfully in uncertain settings where the potential for disasters is ever present but fewer disasters occur than are expected are termed HROs. Examples of HROs include power-grid dispatching centers, aircraft-carrier operations, air-traffic control systems, nuclear power generation, wildfire management, U.S. Army combat maneuver groups, high-density theme parks, prison inmate transport operations, and emergency medical treatment. The best of these organizations rarely fail, even though they encounter numerous unexpected events.
During the past 20 years, there has been considerable research on HROs and the strategies they pursue in addressing complex, large-scale logistical problems and in avoiding accidents and cascading events that would otherwise result in significant losses.12–19 Although various authors have listed an array of characteristics of HROs, three primary characteristics are most often cited:
HROs have been studied extensively; however, the lessons learned in managing HROs have not been systematically applied to the management and operation of multiple government and private sector organization networks required to respond to large-scale disasters. These lessons focus on the network organization, management, and leadership.
The Network organizers understood that a network could not be expected to adopt HRO attributes overnight. Rather, the Network would have to incorporate HRO characteristics as interagency collaboration and the Network itself developed. Figure 1 shows the three phases of the collaborative network developmental process.21 Phase 1 is termed “exchange network” because it is the period during which the members of the network exchange information, usually through interpersonal interactions among members. In Phase 2, members form “action networks” in which agencies collaborate to establish mutual goals and take collective action. In short, action network members engage in projects and network development, and establish goals to be achieved by a set of undertakings that involve assignment of tasks and accompanying accountability. Phase 3, “systemic network,” sees the formulation and exchange of formal documents creating formal agreements among network members.
In an effort to create an effective HRN to address a specialized emergency and preparedness need within the region, ADPH and MSDH partnered with SCCPHP to sponsor the creation of the Network. This voluntary Network representing health-care providers, public health departments, volunteers, and emergency responders from five states will serve as a source for pediatric resources in the event of an emergency or disaster in any one or all of the five states. When there is no emergency or disaster, SCCPHP maintains the Network and coordinates its activities.
For the purposes of the Network, a pediatric emergency or disaster is defined as an overwhelming incident that exceeds the effective response capability or resources of impacted pediatric health-care facilities. An incident of this magnitude will almost always involve a broad range of health-care providers and emergency responders from a variety of jurisdictions. Only a broad systems solution such as an HRN can deal with patient surge issues of such magnitude.
During a response to an emergency, the Network will operate within the prescriptions of the National Response Framework11 as a resource for operational support through an Emergency Operations Center (EOC) appropriate for the incident.22 In essence, the local incident command will request support from a state EOC and, if appropriate, from one state EOC to another state EOC. The visibility of Network resources will be through the Essential Support Function 8 (Public Health and Medical Services [ESF 8]22) representative at the state-level EOC. During a response that involves a gubernatorial or Presidential declaration of emergency, the sharing of resources across state boundaries will be governed by the Emergency Management Assistance Compact (EMAC) enacted by Congress and approved by all states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands.23 For emergencies that are not of sufficient scale to achieve a declaration of emergency, resource sharing will be achieved through mutual aid understandings separate from EMAC.24 The Network will function with a memorandum of understanding (MOU) signed by all Network participants and additional mutual aid agreements that exist among many of the Network participants.
In planning and developing the Network, we had an advantage compared with efforts to develop other types of networks. This advantage concerned the nature of the participants and the agreement to aggressively seek what “we did not know.” Because the Network comprised health-care institutions, the individuals involved possessed a similar type of training and experience (e.g., physicians, nurses, and health administrators). As the management scholar Henry Mintzberg observed, such participants can be more easily coordinated because they possess a “standardization of skills,” which they acquired through comparatively similar training.25 In addition, the participants understood the ultimate goals of effectiveness and reliability (doing the right things) as well as the reality of efficiency (doing things right) as they applied to the Network. Therefore, they understood the big picture and were insistent on developing the Network with people who understood the nature of emergency response. In addition, participants insisted on maintaining the individual autonomy of each participating organization, but willingly committed to yielding to the common goal of Network effectiveness and reliability.
The planning and development of the Network is proceeding though three general phases—information sharing, mutual goal setting and collective action, and long-term formal linkages, as introduced in Figure 1. This model, drawn from the interagency collaboration literature, was adopted by SCCPHP to provide developmental guidance and to serve as a format for documentation of Network activities. Figure 2 shows the three phases of Network development, the actual and proposed associated activities of the Network, and HRO characteristics that will aid in moving the Network to an HRN. Figure 2 can serve as a starting point or model for those wanting to develop a broad collaborative network.
In early 2005, a conference hosted by the Children's Hospital of Alabama and convened by SCCPHP was held for regional pediatric providers, public health representatives, and other responders to address the lack of pediatric surge capacity. As shown in Figure 2, in the meeting, critical pre-event planning tasks were identified that would have to be undertaken in the development of a regional pediatric medical surge network, including network organization planning, financial agreement planning, and operational/medical staff protocol planning.8 The critical planning tasks identified by the working group are shown in Figure 3.
In October 2008, ADPH contacted SCCPHP regarding a U.S. Department of Homeland Security grant to improve emergency preparedness in Alabama, specifically to advance the planning of the pediatric surge network and create a functioning HRN. The centerpiece of the project was a series of participatory meetings of pediatric-preparedness stakeholders to formalize a regional pediatric disaster surge network using a modified Delphi methodology.26,27
The project plan consisted of five Phase 2 stages (Figure 2):
The Planning Steering Committee comprised 11 members (two from MSDH, one from the University of Mississippi School of Medicine, four from ADPH, and four from SCCPHP). The Planning Steering Committee met three times via teleconference to review progress in the recruitment of participants for the face-to-face workshops and to establish a schedule and agenda for the workshops.
The first workshop, in March 2009, is best described as a “proof of concept” exercise. SCCPHP investigators outlined the project, reviewed the project plan, and facilitated the first information-gathering exercise in the subject areas of (1) network coordination, (2) finance, (3) medical staff/personnel, (4) operations, (5) planning, (6) logistics, and (7) public information. The information collected during the workshop became the input for the first draft of the Network Handbook, developed by SCCPHP.
Prior to the second workshop, SCCPHP distributed the draft Network Handbook to attendees of the first workshop and those who had registered for the second workshop. The draft had six sections: (1) introduction, (2) purpose, (3) network activation, (4) operations and logistics, (5) medical staff and personnel development, and (6) finance. In preparation for the second workshop, SCCPHP investigators developed a list of topics and worksheets to gather data about the topics. The 38 participants were organized into six workgroups to collect data on the first 12 topics shown in Figure 4. The workgroups presented their findings in a plenary session, with the SCCPHP investigators serving as facilitators. Before the second workshop concluded, data were collected on each of the 12 topics.
Using the data, SCCPHP investigators expanded the draft of the Network Handbook and distributed it to all previous workshop attendees and third workshop registrants. The third workshop was designed similarly to the second workshop and, in addition, there was a plenary session to review and edit the draft of the Network Handbook. The workgroups were assigned topics 13 through 19 from Figure 4, with topics 17 through 19 combined into one topic dealing with network financing.
In the workshop, the issue was raised as to whether Network efforts were duplicating plans previously developed by the state emergency management agencies. A consensus was reached that pediatric-focused resources were neither well-defined nor well-represented in the response processes coordinated by the emergency agencies. Therefore, it was also established that the Network would be represented in the participating states' EOCs by state public health agencies that fill the ESF 8 “seat” in the EOC during disaster response activations.
A Handbook Editing Committee was formed from participants in the third workshop plus others from the previous workshops nominated by the project's sponsors. The formation of the Handbook Editing Committee was a major breakthrough in the fourth workshop meeting, not only in the contents of the Network Handbook, but also, and more importantly, in the ownership of the process. To this point, the Network Handbook and the organizational direction of the project had been largely “owned” by the SCCPHP investigators, who argued that as long as the project was not led by the representatives of the Network partners, it would be more difficult, and likely impossible, to bring it to fruition. During the meeting of the Handbook Editing Committee, ownership was transferred from the SCCPHP investigators to the Network participants. In addition, it was concluded that participating institutions, at best, would only commit to broad participation and to provide pediatric resources to the “best of their ability” in a formal Network agreement. Detailed and specific procedures for credentialing, patient transfer, and financing could not always be anticipated, and regulations varied considerably from state to state. Network participants would not commit to an agreement that could jeopardize their own operation or potentially incur crippling financial costs.
Participants attending the fourth workshop identified the need for and created two task forces. The Common Systems and Acronyms Task Force met via teleconference and focused on identifying systems that exist in each state to monitor the hospital resources and to define the variations of common acronyms used in the various partner states. The Resource Typing Task Force focused on defining pediatric-focused resources that can be added to the Federal Emergency Management Agency's Public Health and Medical Services resource definitions.28,29 The pediatric resources defined by the Resource Typing Task Force included physicians (e.g., general pediatrician, pediatric critical care, and anesthesiologist), registered nurses, respiratory therapists, mental health professionals, social workers, pharmacists, and paramedics, among others.
Workshops 5 through 7 featured reports from the Common Systems and Acronyms Task Force and the Resource Typing Task Force. Additionally, Network development had reached a point at which further development and movement to Phase 3 (Figure 2) would not be possible without executive-level commitment by the participating institutions. Therefore, drawing upon the Network Handbook, an MOU was drafted, edited, and submitted to key Network participants for vetting, final revisions, and signatures.
In addition, during workshop 7 it was recognized that the activities associated with day-to-day maintenance of the Network (e.g., maintaining Network participant points-of-contact information, convening Network participants, and planning and conducting exercises and drills) would have to be the responsibility of one organization that could keep it as a high priority. SCCPHP accepted this responsibility as it fit with the Center's fundamental mission and goals. Successful completion and signing of the MOU by Network participants and the establishment of the SCCPHP to facilitate Network maintenance would signify the end of Phase 2 and the beginning of Phase 3 of Network development.
As of this writing, the Network has entered Phase 3 of Network development (Figure 2). The final phase of Network development will engage participants in exercises and evaluations of the Network. Through these activities, additional logistical details will be identified and integrated into the Network Handbook. An important challenge confronting Network participants is to test the effectiveness of the conversion from a virtual to an actual operating Network. To date, all efforts have centered on organizing and developing the guidelines for implementing the Network, but the effectiveness of the effort has not been evaluated.
An important element of Network maintenance is the design, delivery, and evaluation of drills and exercises. Drills are scheduled quarterly for the purpose of verifying the Network Participant Primary-Point-of-Contact (Primary POC) list. The drill will involve the SCCPHP placing a telephone call and sending an e-mail message to every Primary POC and recording whether the contact is successful. A log of these drills will be maintained and reported regularly at each Network conference. On an annual basis, the Network will conduct at least two Homeland Security Exercise and Evaluation Program (HSEEP) compliant exercises.30 Both discussion-based and field exercises will be conducted. The exercises may be broad in scope to evaluate the integration and coordination of many aspects of the Network, or they may be functional to evaluate a particular function—e.g., an interstate request for support during a non-declared emergency.
The exercises will be robust in nature and incorporate the three suggestions of Bullard and colleagues:31
(a) ensure that legal issues are considered in the development and conduct of state and local legal preparedness exercises; (b) identify and promote awareness of key legal and operational issues and challenges faced by healthcare providers and facilities in an emergency; and (c) test healthcare provider and facility emergency response plans to ensure effectiveness and integration with other local emergency preparedness efforts.31
An important part of the HSEEP process is the detailed documentation of exercises in the form of planning documents and the writing of after-action reports and improvement plans (AAR/IPs). The AAR/IPs will be used to improve Network performance and to identify training and educational needs.
The Network participants engaged in a series of meetings from 2005 throughout 2010 to develop a voluntary pediatric surge network. Details have culminated in the development of a Network Handbook and broad MOU outlining the essential character of the Network. Although testing and evaluating the effectiveness of the Network remains the primary challenge, plans are in place to test the proposed system.
Development of the Network has been an interesting and often challenging process, and we learned some important lessons that will be of benefit for future Network development projects.
Exercises and subsequent evaluation of the Network will yield new insights into the development and operation of regional mutual aid networks. However, the real test of the Network will come in an actual emergency or disaster. If the initial reality test for the Network comes in the form of a localized emergency that impacts only one or relatively few participants, the Network is expected to function as envisioned. The ultimate test of the Network will be in an actual widespread emergency where all participants will face a difficult choice—should we look out for our own self-interest or participate altruistically as members of the Network? We think the Network will be collaborative and highly reliable and the relationships established through its development will provide vital regional pediatric surge capacity.
This project is partially funded by the Centers for Disease Control and Prevention through the South Central Center for Public Health Preparedness, the Alabama Department of Public Health, and the Mississippi State Department of Health.