An Analysis of After Action Reports From Texas Hurricanes in 2005 and 2017.

OBJECTIVE: To review and analyze After Action Reports from jurisdictions in Texas following Hurricanes Katrina and Rita in 2005 and Hurricane Harvey in 2017 in order to assess the utility of AARs as a quality improvement measurement tool. METHODS: The authors searched the Homeland Security Digital Library, the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange, and Google Scholar for any AARs that covered the response phase of at least one of the 3 hurricanes, mentioned the state of Texas, and suggested solutions to problems. The authors applied public health emergency management (PHEM) domains, as outlined by Rose et al, to frame the AAR analysis. AARs were coded by 2 reviewers independently, with a third acting as adjudicator. As an example, the problem statements in 2005 and 2017 AARs from 1 statewide agency were compared. RESULTS: Sixteen AARs met the inclusion criteria. There were 500 identified problem-solution sets mapped to a PHEM domain. The content was unevenly distributed, with most issues coming under PHEM 2: Policies, Plans, Procedures, and Partnerships at 45.2% in the 2005 hurricanes and 39.9% in 2017. AARs lacked consistent format and were often prepared by the response agencies themselves. Five consistent issues were raised in 2005 and again in 2017. These were volunteer management and credential verification, donations management, information sharing, appropriately identifying those requiring a medical needs shelter, and inadequate transportation to support evacuation. CONCLUSION: Because of the lack of objective data, inconsistent format, unevenly distributed content, and lack of adherence to any framework, AARs are fraught with shortcomings as a tool for PHEM. Inclusion of more objective reporting measures is urgently needed.

Strengths, weaknesses, opportunities, and threats that impact disaster health research.

OBJECTIVE: To characterize the strengths and weaknesses of the current status of disaster research evidence; and to identify potential interventions specific to the disciplines of medicine, public health, and social sciences. DESIGN: A mixed method study using nominal group technique and a strengths, weaknesses, opportunities, and threats (SWOT) analysis. PARTICIPANTS: Subject matter experts (SMEs) in the fields of medicine, public health, and social sciences who are engaged in disaster research. RESULTS: The nominal group technique achieved 100 percent response rate. After coding and analysis, ten distinct disaster research evidence themes were identified: awareness; evidence quality; funding; human resources; interdisciplinary studies; politics; research process; research topics; sectoral collaboration; and "other." Strengths in each area were limited but focused on quality and workforce pipeline. Weaknesses were limited funding and low research quality. Opportunities included improving methods and increased interdisciplinary collaboration. The threats most consistently identified were limited funding and political influences on disaster research funding. CONCLUSIONS: Disaster research experts from three disciplines identified a number of barriers and facilitators to improving disaster-related research. The limited, inconsistent, and episodic funding and the politics related to it were the greatest and most common barriers. This weakness needs to be strategically addressed to significantly advance the field of disaster research.

Characterizing the Current State of Training Courses Available to US Disaster Professionals.

OBJECTIVE: The objective of this study is to characterize US-based disaster training courses available to disaster response and disaster health professionals. Its purpose is to better inform policies and decision-making regarding workforce and professional development to improve performance. METHODS: Courses were identified from 4 inventories of courses: (1) National Library of Medicine Disaster Lit database; (2) TRAIN National Learning Network; (3) Federal Emergency Management Agency (FEMA) National Preparedness Course Catalog; and (4) Preparedness and Emergency Response Learning Centers. An online search used 30 disaster-related key words. Data included the course title, description, target audience, and delivery modality. Levels of learning, target capability, and function were categorized by 3 expert reviewers. Descriptive statistics were used. RESULTS: There were 3662 trainings: 2380 (65%) for professionals (53% for public health); 83% of the courses were distance learning, with 16% via classroom. Half of all trainings focused on 3 of 37 disaster capabilities and 38% of them were related to chemical, biological, radiological, nuclear, and explosives (CBRNE). The educational approach was knowledge-based for all courses and 99.6% imparted only lower levels of learning. CONCLUSION: Despite thousands of courses available, there remain significant gaps in target audience, subject matter content, educational approaches, and delivery modalities, particularly for health and public health professionals.

Equipping Public Spaces to Facilitate Rapid Point-of-Injury Hemorrhage Control After Mass Casualty.

In response to increasing violent attacks, the Stop the Bleed campaign recommends that everyone have access to both personal and public bleeding-control kits. There are currently no guidelines about how many bleeding victims public sites should be equipped to treat during a mass casualty incident. We conducted a retrospective review of intentional mass casualty incidents, including shootings, stabbings, vehicle attacks, and bombings, to determine the typical number of people who might benefit from immediate hemorrhage control by a bystander before professional medical help arrives. On the basis of our analysis, we recommend that planners at public venues consider equipping their sites with supplies to treat a minimum of 20 bleeding victims during an intentional mass casualty incident.

Post-Mortem Evaluation of Potentially Survivable Hemorrhagic Death in a Civilian Population.

BACKGROUND: Although the survivability of military extremity hemorrhage is well documented, equivalent civilian data are limited. We analyzed statewide autopsy records in Maryland to determine the number of hemorrhagic deaths that might have been potentially survivable with prompt hemorrhage control. Similar analyses of battlefield deaths led to life-saving changes in military medical practice. STUDY DESIGN: This is a retrospective study of decedent records. The objective is to estimate the number of hemorrhagic deaths that might have been prevented by prompt placement of an extremity tourniquet. Maryland autopsy records from 2002 to 2016 were selected using the following search terms: amputation, arm/arms, avulsion, exsanguination, extremity/extremities, leg/legs. The records were analyzed by applying a checklist of previously developed military criteria to characterize deaths as potentially survivable or nonsurvivable with prompt use of a tourniquet. Suicides and decedents less than 18 years old were excluded. The study did not use information about living participants. Two expert reviewers independently evaluated and scored the death records. Deaths were classified as either potentially survivable or nonsurvivable. A third reviewer broke any ties. RESULTS: There were 288 full autopsy records included in the final analysis. Of the eligible decedents reviewed during the 14-year period, 124 of 288 had potentially survivable wounds; 164 had nonsurvivable wounds. CONCLUSIONS: Over the 14-year study interval, 124 Maryland decedents-an average of 9 per year-might have been saved with prompt placement of a tourniquet. If extrapolated, approximately 480 people in the US might be saved per year. These results provide evidence to support educating and equipping the public to provide bleeding control.

Brief, Web-based Education Improves Lay Rescuer Application of a Tourniquet to Control Life-threatening Bleeding.

OBJECTIVE: The objective was to determine whether brief, Web-based instruction several weeks prior to tourniquet application improves layperson success compared to utilizing just-in-time (JiT) instructions alone. BACKGROUND: Stop the Bleed is a campaign to educate laypeople to stop life-threatening hemorrhage. It is based on U.S. military experience with lifesaving tourniquet use. While previous research shows simple JiT instructions boost laypeople's success with tourniquet application, the optimal approach to educate the public is not yet known. METHODS: This is a prospective, nonblinded, randomized study. Layperson participants from the Washington, DC, area were randomized into: 1) an experimental group that received preexposure education using a website and 2) a control group that did not receive preexposure education. Both groups received JiT instructions. The primary outcome was the proportion of subjects that successfully applied a tourniquet to a simulated amputation. Secondary outcomes included mean time to application, mean placement position, ability to distinguish bleeding requiring a tourniquet from bleeding requiring direct pressure only, and self-reported comfort and willingness to apply a tourniquet. RESULTS: Participants in the preexposure group applied tourniquets successfully 75% of the time compared to 50% success for participants with JiT alone (p < 0.05, risk ratio = 1.48, 95% confidence interval = 1.21-1.82). Participants place tourniquets in a timely fashion, are willing to use them, and can recognize wounds requiring tourniquets. CONCLUSIONS: Brief, Web-based training, combined with JiT education, may help as many as 75% of laypeople properly apply a tourniquet. These findings suggest that this approach may help teach the public to Stop the Bleed.

Translating Battlefield Practices to Disaster Health.

We review aspects of the recently released National Academies of Sciences, Engineering, and Medicine report A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury most relevant to disaster health, particularly the concepts of focused empiricism and building a learning health system. The article references battlefield success utilizing these concepts and the emerging Disaster Research Response Program. We call upon disaster health researchers to apply the report's recommendations to their work. (Disaster Med Public Health Preparedness. 2017;11:510-511).

Innovations for Tomorrow: Summary of the 2016 Disaster Health Education Symposium.

In an effort to enhance education, training, and learning in the disaster health community, the National Center for Disaster Medicine and Public Health (NCDMPH) gathered experts from around the nation in Bethesda, Maryland, on September 8, 2016, for the 2016 Disaster Health Education Symposium: Innovations for Tomorrow. This article summarizes key themes presented during the disaster health symposium including innovations in the following areas: training and education that saves lives, practice, teaching, sharing knowledge, and our communities. This summary article provides thematic content for those unable to attend. Please visit http://ncdmph.usuhs.edu/ for more information. (Disaster Med Public Health Preparedness. 2017;11:160-162).

Proposing a Framework for Mobile Applications in Disaster Health Learning.

Mobile applications, or apps, have gained widespread use with the advent of modern smartphone technologies. Previous research has been conducted in the use of mobile devices for learning. However, there is decidedly less research into the use of mobile apps for health learning (eg, patient self-monitoring, medical student learning). This deficiency in research on using apps in a learning context is especially severe in the disaster health field. The objectives of this article were to provide an overview of the current state of disaster health apps being used for learning, to situate the use of apps in a health learning context, and to adapt a learning framework for the use of mobile apps in the disaster health field. A systematic literature review was conducted by using the PRISMA checklist, and peer-reviewed articles found through the PubMed and CINAHL databases were examined. This resulted in 107 nonduplicative articles, which underwent a 3-phase review, culminating in a final selection of 17 articles. While several learning models were identified, none were sufficient as an app learning framework for the field. Therefore, we propose a learning framework to inform the use of mobile apps in disaster health learning. (Disaster Med Public Health Preparedness. 2017;11:487-495).

From Leaders, For Leaders: Advice From the Lived Experience of Leaders in Community Health Sector Disaster Recovery After Hurricanes Irene and Sandy.

OBJECTIVE: Hurricanes Sandy and Irene damaged and destroyed homes, businesses, and infrastructure, and recovery after these storms took years. The goal of this article was to learn from the lived experience of local-level decision-makers actively involved in the long-term disaster recovery process after Hurricanes Irene and Sandy. Respondents provided professional recommendations, based on their experience, to assist other organizations in preparing for, responding to, and recovering from disasters. METHODS: Semi-structured interviews were conducted with professionals actively involved in recovery from Hurricane Irene or Hurricane Sandy in 5 different communities. Transcripts were qualitatively analyzed. RESULTS: Respondents' advice fell into 5 main categories: planning and evaluation, education and training, fundraising and donations management, building relationships, and disaster behavioral health. CONCLUSIONS: The lived experience of those in disaster recovery can provide guidance for planning, education, and training both within and outside their communities in order to better respond to and recover from future disasters. These data help to facilitate a community of practice by compiling and sharing the lived experience of leaders who experienced large-scale disasters, and the outcomes of this analysis help to show what areas of planning require special attention in the phases of preparedness, response, and recovery. (Disaster Med Public Health Preparedness. 2016;10:623-630).

Qualitative Assessment of a Novel Efficacy-Focused Training Intervention for Public Health Workers in Disaster Recovery.

OBJECTIVE: We trained local public health workers on disaster recovery roles and responsibilities by using a novel curriculum based on a threat and efficacy framework and a training-of-trainers approach. This study used qualitative data to assess changes in perceptions of efficacy toward Hurricane Sandy recovery and willingness to participate in future disaster recoveries. METHODS: Purposive and snowball sampling were used to select trainers and trainees from participating local public health departments in jurisdictions impacted by Hurricane Sandy in October 2012. Two focus groups totaling 29 local public health workers were held in April and May of 2015. Focus group participants discussed the content and quality of the curriculum, training logistics, and their willingness to engage in future disaster recovery efforts. RESULTS: The training curriculum improved participants' understanding of and confidence in their disaster recovery work and related roles within their agencies (self-efficacy); increased their individual- and agency-level sense of role-importance in disaster recovery (response-efficacy); and enhanced their sense of their agencies' effective functioning in disaster recovery. Participants suggested further training customization and inclusion of other recovery agencies. CONCLUSION: Threat- and efficacy-based disaster recovery trainings show potential to increase public health workers' sense of efficacy and willingness to participate in recovery efforts. (Disaster Med Public Health Preparedness. 2016;10:615-622).

Delivering Flexible Education and Training to Health Professionals: Caring for Older Adults in Disasters.

The National Center for Disaster Medicine and Public Health (NCDMPH), in collaboration with over 20 subject matter experts, created a competency-based curriculum titled Caring for Older Adults in Disasters: A Curriculum for Health Professionals. Educators and trainers of health professionals are the target audience for this curriculum. The curriculum was designed to provide breadth of content yet flexibility for trainers to tailor lessons, or select particular lessons, for the needs of their learners and organizations. The curriculum covers conditions present in the older adult population that may affect their disaster preparedness, response, and recovery; issues related to specific types of disasters; considerations for the care of older adults throughout the disaster cycle; topics related to specific settings in which older adults receive care; and ethical and legal considerations. An excerpt of the final capstone lesson is included. These capstone activities can be used in conjunction with the curriculum or as part of stand-alone preparedness training. This article describes the development process, elements of each lesson, the content covered, and options for use of the curriculum in education and training for health professionals. The curriculum is freely available online at the NCDMPH website at http://ncdmph.usuhs.edu (Disaster Med Public Health Preparedness. 2016;10:633-637).

Attitudinal Determinants of Local Public Health Workers' Participation in Hurricane Sandy Recovery Activities.

Local health departments play a critical role in short-, intermediate-, and long-term recovery activities after a public health emergency. However, research has not explored attitudinal determinants of health department workers' participation in the recovery phase following a disaster. Accordingly, this qualitative investigation aims to understand perceived facilitators and barriers to performing recovery-related activities following Hurricane Sandy among local health department workers. In January 2014, 2 focus groups were conducted in geographically representative clusters of local health departments affected by Hurricane Sandy (1 cluster in Maryland and 1 cluster in New Jersey). Focus groups were recorded, transcribed verbatim, and analyzed to qualitatively assess attitudes toward Hurricane Sandy recovery activities. This analysis identified 5 major thematic categories as facilitators and barriers to participation in recovery activities: training, safety, family preparedness, policies and planning, and efficacy. Systems that support engagement of health department personnel in recovery activities may endeavor to develop and communicate intra- and interjurisdictional policies that minimize barriers in these areas. Development and implementation of evidence-informed curricular interventions that explain recovery roles may also increase local health department worker motivation to participate in recovery activities.

Applying a Behavioral Model Framework for Disaster Recovery Research in Local Public Health Agencies: A Conceptual Approach.

The local public health agency (LPHA) workforce is at the center of the public health emergency preparedness system and is integral to locally driven disaster recovery efforts. Throughout the disaster recovery period, LPHAs have a primary responsibility for community health and are responsible for a large number of health services. In the face of decreasing preparedness funding and increasing frequency and severity of disasters, LPHAs continue to provide essential disaster life cycle services to their communities. However, little is known about the confidence that LPHA workers have in performing disaster recovery-related duties. To date, there is no widely used instrument to measure LPHA workers' sense of efficacy, nor is there an educational intervention designed specifically to bolster disaster recovery-phase efficacy perceptions. Here, we describe the important role of the LPHA workforce in disaster recovery and the operational- and efficacy-related research gaps inherent in today's disaster recovery practices. We then propose a behavioral framework that can be used to examine LPHA workers' disaster recovery perceptions and suggest a research agenda to enhance LPHA workforce disaster recovery efficacy through an evidence-informed educational intervention.

Building health care system capacity to respond to disasters: successes and challenges of disaster preparedness health care coalitions.

INTRODUCTION: This research aimed to learn from the experiences of leaders of well-developed, disaster preparedness-focused health care coalitions (HCCs), both the challenges and the successes, for the purposes of identifying common areas for improvement and sharing "promising practices." HYPOTHESIS/PROBLEM: Little data have been collected regarding the successes and challenges of disaster preparedness-focused HCCs in augmenting health care system preparedness for disasters. METHODS: Semi-structured interviews were conducted with a sample of nine HCC leaders. Transcripts were analyzed qualitatively. RESULTS: The commonly noted benefits of HCCs were: community-wide and regional partnership building, providing an impartial forum for capacity building, sharing of education and training opportunities, staff- and resource-sharing, incentivizing the participation of clinical partners in preparedness activities, better communication with the public, and the ability to surge. Frequently noted challenges included: stakeholder engagement, staffing, funding, rural needs, cross-border partnerships, education and training, and grant requirements. Promising practices addressed: stakeholder engagement, communicating value and purpose, simplifying processes, formalizing connections, and incentivizing participation. CONCLUSIONS: Strengthening HCCs and their underlying systems could lead to improved national resilience to disasters. However, despite many successes, coalition leaders are faced with obstacles that may preclude optimal system functioning. Additional research could: provide further insight regarding the benefit of HCCs to local communities, uncover obstacles that prohibit local disaster-response capacity building, and identify opportunities for an improved system capacity to respond to, and recover from, disasters.