Brian Schwartz

Emergencies and disasters impact population health. Despite the importance of upstream readiness, a persistent challenge for public health practitioners is defining what it means to be prepared. There is a knowledge gap in that existing frameworks lack consideration for complexity relevant to health systems and the emergency context. The objective of this study is to describe the essential elements of a resilient public health system and how the elements interact as a complex adaptive system. This study used a qualitative design employing the Structured Interview Matrix facilitation technique in six focus groups across Canada. Focus group participants were practitioners from public health and related sectors. Data collection generated qualitative data on the essential elements, and interactions between elements, for a resilient public health system. Data analysis employed qualitative content analysis and the lens of complexity theory to account for the complex nature of public health emergency preparedness (PHEP). The unit of study was the local/regional public health agency. Ethics and values were considered in the development of the framework. A total of 130 participants attended the six focus groups. Urban, urban-rural and rural regions from across Canada participated and focus group size ranged from 15 to 33 across the six sites. Eleven elements emerged from the data; these included one cross-cutting element (Governance and leadership) and 10 distinct but interlinked elements. The essential elements define a conceptual framework for PHEP. The framework was refined to ensure practice and policy relevance for local/regional public health agencies; the framework has ethics and values at its core. This framework describes the complexity of the system yet moves beyond description to use tenets of complexity to support building resilience. This applied public health framework for local/regional public health agencies is empirically-derived and theoretically-informed and represents a complex adaptive systems approach to upstream readiness for PHEP.

Given the steady rise of overdose morbidity and mortality in North America, and increasing frequency of sudden clusters of non-fatal and fatal overdoses in other jurisdictions, regional preparedness plans to respond effectively to clusters of overdoses may reduce the impact of such events on the population. On the 27th of February 2017 in Kingston, Ontario, KFL&A Public Health, in collaboration with public health partners, hosted a full-day workshop involving table-top exercises and discussions for service partners on how to prepare for, respond to, and manage a mass-casualty event secondary to opioid overdose in Southeastern Ontario. The workshop assisted in identifying the various challenges faced by service partners, provided an understanding of the roles and responsibilities of partner agencies, and helped to determine next steps in preparation to address a mass opioid overdose situation at the local level. This report suggests key roles and responsibilities of partners involved in responding to a mass-casualty event secondary to opioid overdose, recommendations to address the feedback and challenges raised throughout the workshop, and a protocol to help determine when to activate an Incident Management System (IMS).

Evidence to inform communication between emergency department clinicians and public health agencies is limited. In the context of diverse, emerging public health incidents, communication is urgent, as emergency department clinicians must implement recommendations to protect themselves and the public. The objectives of this study were to: explore current practices, barriers and facilitators at the local level for communicating public health guidance to emergency department clinicians in emerging public health incidents; and develop a framework that promotes effective communication of public health guidance to clinicians during emerging incidents. A qualitative study was conducted using semi-structured interviews with 26 key informants from emergency departments and public health agencies in Ontario, Canada. Data were analyzed inductively and the analytic approach was guided by concepts of complexity theory. Emergent themes corresponded to challenges and strategies for effective communication of public health guidance. Important challenges related to the coordination of communication across institutions and jurisdictions, and differences in work environments across sectors. Strategies for effective communication were identified as the development of partnerships and collaboration, attention to specific methods of communication used, and the importance of roles and relationship-building prior to an emerging public health incident. Following descriptive analysis, a framework was developed that consists of the following elements: 1) Anticipate; 2) Invest in building relationships and networks; 3) Establish liaison roles and redundancy; 4) Active communication; 5) Consider and respond to the target audience; 6) Leverage networks for coordination; and 7) Acknowledge and address uncertainty. The qualities inherent in local relationships cut across framework elements. This research indicates that relationships are central to effective communication between public health agencies and emergency department clinicians at the local level. Our framework which is grounded in qualitative evidence focuses on strategies to promote effective communication in the emerging public health incident setting and may be useful in informing practice.

Ice, or freezing rain storms have the potential to affect human health and disrupt normal functioning of a community. The purpose of this study was to assess acute health impacts of an ice storm that occurred in December 2013 in Toronto, Ontario, Canada. Data on emergency department visits were obtained from the National Ambulatory Care Reporting System. Rates of visits in Toronto during the storm period (December 21, 2013 – January 1, 2014) were compared to rates occurring on the same dates in the previous five years (historical comparison) and compared to those in a major unaffected city, Ottawa, Ontario (geographic comparison). Overall visits and rates for three categories of interest (cardiac conditions, environmental causes and injuries) were assessed. Rate ratios were calculated using Poisson regression with population counts as an offset. Absolute counts of carbon monoxide poisoning were compared descriptively in a sub-analysis. During the 2013 storm period, there were 34 549 visits to EDs in Toronto (12.46 per 1000 population) compared with 10 794 visits in Ottawa (11.55 per 1000 population). When considering year and geography separately, rates of several types of ED visits were higher in the storm year than in previous years in both Toronto and Ottawa. Considering year and geography together, rates in the storm year were higher for overall ED visits (RR: 1.10, 95 % CI: 1.09-1.11) and for visits due to environmental causes (RR: 2.52, 95 % CI: 2.21-2.87) compared to previous years regardless of city. For injuries, visit rates were higher in the storm year in both Toronto and Ottawa, but the increase in Toronto was significantly greater than the increase in Ottawa, indicating a significant interaction between geography and year (RR: 1.23, 95 % CI: 1.16-1.30). This suggests that the main health impact of the 2013 Ice Storm was an increase in ED visits for injuries, while other increases could have been due to severe weather across Ontario at that time. This study is one of the first to use a population-level database and regression modeling of emergency visit codes to identify acute impacts resulting from ice storms.

Effective public health emergency preparedness and response systems are important in mitigating the impact of all-hazards emergencies on population health. The evidence base for public health emergency preparedness (PHEP) is weak, however, and previous reviews have noted a substantial proportion of anecdotal event reports. To investigate the body of research excluding the anecdotal reports and better understand primary and analytical research for PHEP, a scoping review was conducted with two objectives: first, to develop a thematic map focused on primary research; and second, to use this map to inform and guide an understanding of knowledge gaps relevant to research and practice in PHEP. A scoping review was conducted based on established methodology. Multiple databases of indexed and grey literature were searched based on concepts of public health, emergency, emergency management/preparedness and evaluation/evidence. Inclusion and exclusion criteria were applied iteratively. Primary research studies that were evidence-based or evaluative in nature were included in the final group of selected studies. Thematic analysis was conducted for this group. Stakeholder consultation was undertaken for the purpose of validating themes and identifying knowledge gaps. To accomplish this, a purposive sample of researchers and practicing professionals in PHEP or closely related fields was asked to complete an online survey and participate in an in-person meeting. Final themes and knowledge gaps were synthesized after stakeholder consultation. Database searching yielded 3015 citations and article selection resulted in a final group of 58 articles. A list of ten themes from this group of articles was disseminated to stakeholders with the survey questions. Survey findings resulted in four cross-cutting themes and twelve stand-alone themes. Several key knowledge gaps were identified in the following themes: attitudes and beliefs; collaboration and system integration; communication; quality improvement and performance standards; and resilience. Resilience emerged as both a gap and a cross-cutting theme. Additional cross-cutting themes included equity, gender considerations, and high risk or at-risk populations. In this scoping review of the literature enhanced by stakeholder consultation, key themes and knowledge gaps in the PHEP evidence base were identified which can be used to inform future practice-oriented research in PHEP.

The disciplines of paramedicine and emergency medicine have evolved synchronously over the past four decades, linked by emergency physicians with expertise in prehospital care. Ambulance offload delay (OD) is an inevitable consequence of emergency department overcrowding (EDOC) and compromises the care of the patient on the ambulance stretcher in the emergency department (ED), as well as paramedic emergency medical service response in the community. Efforts to define transfer of care from paramedics to ED staff with a view to reducing offload time have met with resistance from both sides with different agendas. These include the need to return paramedics to serve the community versus the lack of ED capacity to manage the patient. Innovative solutions to other system issues, such as rapid access to trauma teams, reducing door-to-needle time, and improving throughput in the ED to reduce EDOC, have been achieved by involving all stakeholders in an integrative thinking process. Only by addressing this issue in a similar integrative process will solutions to OD be realized.

Emergency medical technicians (EMTs) and paramedics experience critical incidents which evoke distress and impaired functioning but it is unknown which aspects of incidents contribute to their impact. We sought to determine these specific characteristics by developing an inventory of critical incident characteristics and testing their relationship to protracted recovery from acute stress, and subsequent emotional symptoms. EMT/paramedics (n = 223) completed a retrospective survey of reactions to an index critical incident, and current depressive, posttraumatic and burnout symptoms. Thirty-six potential event characteristics were evaluated; 22 were associated with peritraumatic distress and were retained. We assigned inventory items to one of three domains: situational, systemic or personal characteristics. We tested the relationships between (a) endorsing any domain item and (b) outcomes of the critical incident (peritraumatic dissociation, recovery from components of the Acute Stress Reaction and depressive, posttraumatic, and burnout symptoms). Analyses were repeated for the number of items endorsed. Personal and situational characteristics were most frequently endorsed. The personal domain had the strongest associations, particularly with peritraumatic dissociation, prolonged distressing feelings, and current posttraumatic symptoms. The situational domain was associated with peritraumatic dissociation, prolonged social withdrawal, and current posttraumatic symptoms. The systemic domain was associated with peritraumatic dissociation and prolonged irritability. Endorsing multiple characteristics was related to peritraumatic, acute stress, and current posttraumatic symptoms. Relationships with outcome variables were as strong for a 14-item inventory (situational and personal characteristics only) as the 22-item inventory. Emotional sequelae are associated most strongly with EMT/paramedics’ personal experience, and least with systemic characteristics. A14-item inventory identifies critical incident characteristics associated with emotional sequelae. This may be helpful in tailoring recovery support to individual provider needs.

A standard of prehospital care for patients presenting with ST-segment elevation myocardial infarction (STEMI) includes prehospital 12-lead and advance Emergency Department notification or prehospital bypass to percutaneous coronary intervention centres. Implementation of either care strategies is variable across communities and neither may exist in some communities. The main objective is to compare prehospital care strategies for time to treatment and survival outcomes as well as cost effectiveness. PREDICT is a multicentre, prospective population-based cohort study of all chest pain patients 18 years or older presenting within 30 mins to 6 hours of symptom onset and treated with nitroglycerin, transported by paramedics in a number of different urban and rural regions in Ontario. The primary objective of this study is to compare the proportion of study subjects who receive reperfusion within the target door-to-reperfusion times in subjects obtained after four prehospital strategies: 12-lead ECG and advance emergency department (ED) notification or 3-lead ECG monitoring and alert to dispatch prior to hospital arrival; either with or without the opportunity to bypass to a PCI centre. We anticipate four challenges to successful study implementation and have developed strategies for each: 1) diversity in the interpretation of the ethical and privacy issues across 47 research ethics boards/commiittees covering 71 hospitals, 2) remote oversight of data guardian abstraction, 3) timeliness of implementation, and 4) potential interference in the study by concurrent technological advances. Research ethics approvals from academic centres were obtained initially and submitted to non academic centre applications. Data guardians were trained by a single investigator and data entry is informed by a detailed data dictionary including variable definitions and abstraction instrucations and subjected to error and logic checks. Quality oversight provided by a single investigator. The window of the trial in each community has been confirmed with the basehospital medical director to correspond to the planned technological advances of the system of care. We hope this comparative analysis across treatment strategies for clinical outcomes and cost will provide sufficient evidence to implement the superior strategy across all communities and improve outcomes for all STEMI patients. ClinicalTrials.gov: NCT00747656