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Tri-county Heatlh Department (TCHD)

State: CO Type: Model Practice Year: 2019

The goal of the effort was to ensure TCHD is cognizant of where it fits in the response structure during a radiation/nuclear disaster. It also ensures that partner agencies within the jurisdiction and at the state level understand what TCHD will do in a radiation/nuclear emergency incident, which should help render a more effective cross-disciplinary response. TCHD created long-term and short-term goals that were realistic. This helped to ensure that a thorough investigation into all aspects of such a response were explored, vetted, and exercised. To this end, a comprehensive research paper was written internally at TCHD, which then guided the planning process. After this initial step, TCHD then carried out stakeholder interviews to ascertain where partners were in their own agency/facility planning, what they could be expected to do, and what they could expect from their local health department. After a series of interviews with relevant stakeholders the preliminary Annex was written and amended internally. Subsequently, TCHD invited stakeholders to a series of meetings to workshop the plan and further amend the document as appropriate. When finalized, TCHD then conducted a series of trainings and exercises for both internal staff and external partner agencies. TCHD conducted its due diligence in order to understand where it fell into the response framework by working with both internal TCHD staff and collaborating with key external partners. Thus, after internal review, the Annex was brought to external partner agencies in order to validate its findings and reach a consensus in regards to responsibilities. The Annex was further validated by holding table top exercises internally and with external partners to find any gaps and further delineate operational responsibilities. Thus, the exercises we conducted with cross-jurisdictional partners throughout this process and once the Annex was finalized tested operationalization of this Annex and supported ongoing Annex refinement. Partners and stakeholders who operate within the TCHD jurisdiction who would be involved with interfacing with TCHD were included in interviews and trainings to include local and state emergency management, hospitals, behavioral health, coroners, EMS, fire, law enforcement, public health, ancillary care partners, volunteer groups, and other members of the Tri-County Healthcare Coalition. Partner agencies have been a part of this process from the earliest stages, with the exception of the initial internal research phase, to ensure harmonization of plans and to obtain cross-disciplinary buy-in and support. The entire process took approximately one year to complete. External stakeholders were critical in helping TCHD understand the macro-response that a radiation/nuclear disaster would entail. Partners were critical for understanding what jurisdictional, state, and national capabilities are available for such an incident. This helped to determine where TCHD fits in the overall response and what partner expectations exist for the agency's roles and responsibilities. Because this was a new planning effort for TCHD, it forged new partnerships with external agencies, including the Radiation Medical Reserve Corps (RMRC) and the University of Colorado Health (UCH) radiation physicists, which has now provided potential additional resources even during non-radiation/nuclear response planning and response efforts. TCHD regularly meets with partner agencies through meetings, trainings, and exercises that are conducted together. TCHD emergency preparedness and response planners are also expected to keep regular contact with partner agencies by attending partner agency meetings in order to gain a better understanding of how they operate on a day-to-day basis and during incident response. This regular contact helps TCHD and its partner agencies to further strengthen ties and create more familiarity with one another's capabilities, which is crucial in response operations and recovery. No costs were associated with this planning effort other than staff time both from TCHD and with partner agencies, thus all participation was in-kind.
To reiterate, TCHD's goal was to ensure that internal staff and external partners understood what TCHD would do during radiation/nuclear response by creating a response annex and training program. TCHD utilized qualitative data that was aimed at measuring the outcomes of the planning and training process. In creating the surveys, the agency put special emphasis on ascertaining whether respondents understood TCHD's role in a radiation/nuclear response, as well as external partner roles within the same operational framework. The results of the planning process yielded a viable Annex that can be used as a result of a radiation/nuclear disaster. The training process, as shown by survey responses, illustrates that partners understand how TCHD would fit into the response process, as well as their own roles, and were satisfied with the training and associated exercise provided to TCHD staff and the associated Tri-County Healthcare Coalition. The training and exercises were evaluated using qualitative metrics. Performance measures in such a context are hard to use as there is no concrete way of quantifying the efficacy of a training program outside of posing closed ended questions in which the respondent is either right or wrong. While care was used to not provide a survey that was simply a test of knowledge, questions that had a defined correct answer were incorporated to measure how well the training and exercise were received. This was supplemented with questions that was not only knowledge based but also part of operationalization of the Annex (i.e. do you know what you would do in a situation like the one presented?”). This evaluation was provided to both TCHD internal staff as well as cross-jurisdictional partners as represented in the Tri-County Healthcare Coalition. The primary data source was a TCHD administered survey of internal staff and external response partners. The data was collected by the TCHD Emergency Preparedness and Response (EPR) program. This was conducted using the suite of tools that Survey Monkey provides for data collection and analysis. There were no secondary data sources used as they were not applicable in this process. Taking into account that TCHD did not want to simply administer a test, a combination of questions that did not have a defined correct answer and ones that did were utilized. TCHD, wanting to evaluate if respondents had a firm grasp of what the health department would do during a radiation/nuclear event would do, used simple true/false and multiple choice questions to test if respondents knew what activities TCHD would be involved with in such a scenario, as well as asking if partners understood their associated roles in this type of incident. This meant that a binary right/wrong type of measure was used to evaluate the effectiveness of the training. Results were analyzed by looking at percentages of respondents who understood the material covered in the training and associated table top exercises as compared to those who responded incorrectly. Thirty-three members of the TCHD PHIMT staff were surveyed and 32 responded (96% actualized response rate). For example, 84% of internal staff respondents stated they now understood what their PHIMT section in the ICS organizational structure would do in a radiation/nuclear scenario. 100% of PHIMT members that responded to the survey correctly understood that TCHD would not be the lead agency is such a scenario and 77% correctly answered that the radiation/nuclear Annex helped the agency understand where it fits into the overall response framework. One hundred and thirty members of Tri-County Healthcare Coalition (HCC) Chapter partners were surveyed and 56 responded (43% actualized response rate). In analyzing the results of the Tri-County HCC Chapter survey, 82% of external partner respondents correctly identified TCHD as being the lead Emergency Support Function (ESF) #8 agency in a radiation/nuclear disaster. Seventy-five percent of respondents understood that while TCHD would offer guidance to healthcare providers in dealing with patients, clinical decisions would be left to providers themselves. It is important to note that no single respondent was told if they passed or failed the survey in any academic type terms. This survey was utilized and allowed for TCHD to evaluate itself by analyzing if a majority of respondents answered questions correctly or incorrectly. This helped TCHD to better understand which concepts were clear and which may need further refinement during future trainings on this area of focus. The survey data is being used as an evaluation tool for the agency to use to design better trainings and exercises for the future and refine any outstanding questions/concerns as related to the Annex. No modifications were made to the practice as a result of the findings. Most of the data has yielded results that lead the EPR program to believe that the training and exercise followed an appropriate pace, format, and level for those included in the training and exercise. While there were some questions that showed respondents did not fully understand a particular data point (e.g., 58% of respondents could not properly identify that an improvised nuclear device (IND) is a military grade weapon), they were not indicative of a widespread trend that would be worrisome for the agency. Instead, the survey results further solidified the EPR program's approach to including external partners from incipient stages of planning to enhance operationalization in a response. Additional future Annex refinements, trainings, and exercises will be conducted as per the agencies routine maintenance schedule.
TCHD has learned a great deal from this planning, training and exercise experience. The first lesson learned was that during the entire planning cycle it is important to have all relevant stakeholders present. This helps to strengthen partnerships, bring in new resources that may be available, leverage existing resources, and gain stakeholder buy-in and support. It also helps entities to draw statutory and capability based boundaries which is important in response operations. The second lesson learned was that plans and annexes must be exercised in a timely fashion. While training is an ongoing activity that needs to be done periodically, when a plan/annex has been newly written, it important to identify major gaps at an early stage. This helps to ensure that a document is accurate and reflective of internal and external capabilities at the onset. This is in stark contrast to a plan/annex that has been established and then must be completely overhauled to reflect new realities based on lack of partner integration, which is far more time intensive. A third lesson learned is that both internal and external training and exercising is important in identifying gaps and creating synergy amongst various agencies, which is important in creating trust and streamlining response efforts. Partners and stakeholders believed that the agency's radiation/nuclear planning was an important undertaking that they fully supported and were critical in helping TCHD understand the larger response to a radiation/nuclear incident that such an impactful and large disaster would entail. Partner agencies were key informants in regards to understanding what jurisdictional, state, and national capabilities are available for a radiation/nuclear incident. This collaborative information exchange helped to determine where TCHD would optimally fit in the overall response framework and what partner agency expectations, roles, and responsibilities include. Because this planning effort was based around a very new scenario for TCHD, it helped create new partnerships with external agencies, which now provides additional resources that can also be utilized during traditional public health response efforts. The proactive engagement demonstrated by both TCHD and its partner agencies was essential in facilitating productive meetings and well executed exercises. A cost/benefit analysis was not done as it was not applicable. TCHD found that there was significant partner commitment to sustain this planning effort. Partners included in the process from the beginning and part of the larger response framework are committed to the upkeep of both this Annex and the associated capabilities relevant during response to an incident with a radiation/nuclear component. Additional areas to support operationalization of this Annex related to partner roles/responsibilities are now being explored as a result of this collaborative effort. As an example, the local Radiation Medical Reserve Corps is now initiating work with TCHD and other key partners regarding community reception center planning as a result of this Annex and planning around nuclear/radiation incidents in general. Additionally, CDPHE is considering how they may prepare an associated plan related to this type of incident. The document will be sustained as part of the annual Public Health Emergency Operations Plan maintenance schedule involving internal, external, and subject matter expert reviews, trainings, and exercises to identify needed improvements and for the incorporation of new data or relevant response information.
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