The goals and objectives of our program are to plan and exercise a cross-jurisdictional emergency dispensing exercise among five local health departments, while delivering influenza vaccine to the public; to activate mutual aid among five local health departments in the service of providing an annual influenza and pneumonia vaccination clinic; to exercise emergency mass dispensing of vaccinations, using incident command, after-action evaluation, and improvement planning; and to provide flu vaccine to the residents of the five communities.
Mutual aid allowed clinical nurses to reconcile different nursing practices and to practice in other jurisdictions under the direction of another medical director. The regional clinic increased efficiency in delivering vaccines to general public by pooling the resources of five different jurisdictions. The regional clinic increased numbers of people vaccinated by publicizing in five communities.
Strong collaborative relationships have been built among the five health departments as a result of exercising mutual aid and working together on this intense project. With each successive year, there have been improvements in practice as each regional clinic builds on the improvement plan of the previous year. Each of the health directors, having had the opportunity to be incident commander over five communities, has increased confidence in his or her ability to fill the role.
Of primary interest is the opportunity to implement local public health mutual aid, which will be critical in a large-scale public health emergency or disaster. The practice also addresses the need to specifically exercise mass dispensing capabilities and to provide efficient annual flu immunization clinics. The adoption of a mutual aid agreement permits public health to operate in other communities; however, the actual practice of mutual aid is limited by the fact that public health events that require its activation are relatively infrequent. This practice allows communities to use the mutual aid agreement and work through the challenges of cross-jurisdictional collaboration in advance of a major public health event.
The five local health directors embarked on the first regional clinic in response to MDPH requirements for the development and exercise of emergency dispensing sites (while providing their annual flu clinics). However, the need for local public health mutual aid (the model practice) was determined by these health directors following the first regional clinic in 2005. At that early stage, each health department set up its own dispensing station, staffed by their own nurses, working under their own standing orders. Joint operations were hampered by the inability of clinical providers to work in a jurisdiction other than their own. The group worked with the Cambridge Advanced Practice Center (APC) to develop a mutual aid agreement. Each health department was then supported by the APC in presenting the mutual aid agreement to their respective local government.
In addition, the APC, based on other problems identified in the first regional clinics, developed an Emergency Dispensing Site Action Plan and other tools (pictogram signage and pocket communicator) to facilitate EDS operations. Exercising the mutual aid mechanism to provide a large-scale flu clinic allows the communities to actually share resources (human resources, translation, data, clinical supplies, vaccines, and other equipment). It also allows communities to strategize together about challenges, such as providing adequate care for people with mobility or mental health needs. This practice allows LHDs to effectively increase their capacity beyond what each department can handle on its own; and identify and address the challenges of cross-jurisdictional collaboration.
The participating health departments stated that they would not have had the necessary human resources to host a similarly sized clinic and that collaborating with their neighboring communities allowed them to provide vaccination to a large number of residents. Regional mutual aid agreements also allow the host community to establish clinical protocols and other procedures for providing services to the public, alleviating legal or technical concerns of the assisting communities. Mutual aid has typically been used by police and fire services but is very new to local public health. The need for a mutual aid agreement, already a CDC deliverable for public health preparedness funding, was verified during the early stages of the regional clinics and became a focus of the Cambridge APC. Collaboration, without a legal agreement, has not been adequate to allow health departments, particularly clinical staff, to provide services in another jurisdiction. This particular group of communities was the first in Massachusetts to work in the context of a mutual aid agreement (December 2006) and apply the principles of ICS to a large-scale immunization clinic. Previous attempts to share public health staff across jurisdictions were hampered by concerns about clinical liability and differing nursing practices.
Agency Community RolesFive LHDs were instrumental in identifying the issue and worked with the Cambridge APC in shaping and implementing the mutual aid agreement. The five LHDs first identified the need for a mechanism to allow mutual aid and a unified incident command system after their initial attempt to run a regional flu clinic. They were the first in Massachusetts, a home-rule state, to implement mutual aid in the delivery of a public health service. LHDs used the example of collaborative flu clinics as a supporting argument for adoption by their municipal governments of the public health mutual aid agreement. In the practice of an annual collaborative regional flu clinic, the LHDs engaged other municipal departments in the exercise of ICS. Partners include police, EMS, public works, schools, and information technology. Regional MRC volunteers and the Massachusetts Department of Public Health have also been invited into the process. Involving these stakeholders increases community support and improves the preparedness of all involved.
Costs and ExpendituresStart-up and implementation costs for this program were covered under grant funds received per the State-CDC Preparedness Cooperative Agreement. Reusable equipment (e.g., radios, vests, signs, stands, caution tape, etc.), are essential logistical items that were purchased once. Establishing mutual aid agreements was an activity also supported by these funds. The estimated cost of each exercise is $1,500 plus in-kind contributions. Most dollars spent per exercise covers care and feeding of staff and volunteers (i.e., breakfast and lunch). Dollar expenditures have also included over-time compensation for security, traffic detail, transportation, and custodial services.
In-kind contributions include vaccine (provided by the state health department), health department staff, MRC volunteers, and renewable administrative and clinical supplies (e.g., forms, gloves, band-aids, etc.) that are provided by each department and pooled into a single operational cache prior to the exercise. The host department receives Medicare reimbursement for vaccine administration to eligible patients, which is then deposited in a revolving account maintained by one town and used the following year to cover exercise costs.
ImplementationIn 2005, Massachusetts LHDs (Arlington, Belmont, Brookline, Newton, and Watertown) came together to provide a single, coordinated flu clinic meant to practice for an emergency dispensing scenario. Coordinated clinic operations were difficult as each health department was bound by its own protocols. At least one LHD had been advised by its lawyers not to be involved with actual clinical services in another jurisdiction, out of concern for liability exposure. As a result, each department that was able to provide clinical services did so at its own table using its own standing orders, essentially offering several clinics in a shared space. The primary lesson from this experience was that a truly collaborative emergency dispensing operation would require a mechanism to allow mutual aid and a unified ICS.
The Cambridge Advanced Practice Center (APC) worked with the Massachusetts Department of Public Health (MDPH) and with the LHDs, to develop a mutual aid agreement into which all local departments could enter and which would provide legal protection to allow cross-jurisdictional clinical practice. The APC also developed an Emergency Dispensing Site Action Plan, which provides guidance for running a large-scale operation using the principles of ICS. In subsequent years, each of the five LHDs has served as host community for the annual regional flu clinic. The initial goal was to provide public health officials with hands-on experience working as a sub-region to implement an emergency dispensing operation, with special attention on ICS. Since that first clinic, the LHDs have successfully incorporated ICS. The host health director serves as incident commander; the other LHDs fill the command and general staff positions. Successive exercises have increased in scope and impact. The first of two clinics in 2006 provided 199 vaccinations, the second 673; in 2007, there were 777; and in 2008, 991 vaccines were provided in a period of two hours.
The after action report and improvement plan determines the focus and objectives of the subsequent clinic-exercise. Over the years they have established operational and clinical protocols; improved use of ICS; developed effective clinic flow aided by pictographic signage; incorporated MRC volunteers; increased access to vulnerable populations; and incorporated a behavioral health unit. This annual regional clinic has provided five LHDs with the opportunity to practice mutual aid in the delivery of a real service in a nonemergent situation. The collaboration has allowed the LHDs to work through the challenges of varying clinical practices and to identify areas of improvement for staff that do not work together regularly. It has provided real community benefit while training and exercising a critical function of local health department emergency response. Local health departments identify a mutually agreeable date and begin planning approximately two months in advance of the clinic.
Each community in Massachusetts has its own unique municipal structure, requiring individualized approaches to getting governing bodies to approve public health mutual aid. The local government liaison became more active in assisting other local health departments in their efforts to approve mutual aid. Local health officials became more articulate in advocating for adoption of public health mutual aid.
There is no question about the stakeholders’ commitment to perpetuate this practice because it clearly benefits all partners. Sub-regional collaboration for the annual exercise allows for the pooling together of essential resources, most notably staff and vaccine supplies. The participating health departments state that they do not have the necessary resources, human and other, to host a similarly sized clinic and serve such a large number of individuals. In 2004, one of these communities was required to respond to a very large Hepatitis A exposure.
Although neighboring health departments were eager to help, many were hampered by lack of mutual aid. These five local health departments, knowing that the possibility always exists for a similar situation in their own communities, are invested in maintaining the relationships and the ability to provide clinical services across jurisdictional lines. The partners in this annual exercise have pooled money from Medicaid reimbursements for provision of flu vaccine to use as ongoing support of the project. Additionally, periodically they receive small grants or local assistance for supplies and food.