Howard S. Gwon

Characterizing Hospital Workers' Willingness to Respond to a Radiological Event

Introduction Terrorist use of a radiological dispersal device (RDD, or “dirty bomb”), which combines a conventional explosive device with radiological materials, is among the National Planning Scenarios of the United States government. Understanding employee willingness to respond is critical for planning experts. Previous research has demonstrated that perception of threat and efficacy is key in the assessing willingness to respond to a RDD event. Methods An anonymous online survey was used to evaluate the willingness of hospital employees to respond to a RDD event. Agreement with a series of belief statements was assessed, following a methodology validated in previous work. The survey was available online to all 18,612 employees of the Johns Hopkins Hospital from January to March 2009. Results Surveys were completed by 3426 employees (18.4%), whose demographic distribution was similar to overall hospital staff. 39% of hospital workers were not willing to respond to a RDD scenario if asked but not required to do so. Only 11% more were willing if required. Workers who were hesitant to agree to work additional hours when required were 20 times less likely to report during a RDD emergency. Respondents who perceived their peers as likely to report to work in a RDD emergency were 17 times more likely to respond during a RDD event if asked. Only 27.9% of the hospital employees with a perception of low efficacy declared willingness to respond to a severe RDD event. Perception of threat had little impact on willingness to respond among hospital workers. Conclusions Radiological scenarios such as RDDs are among the most dreaded emergency events yet studied. Several attitudinal indicators can help to identify hospital employees unlikely to respond. These risk-perception modifiers must then be addressed through training to enable effective hospital response to a RDD event.

The Creation of a Biocontainment Unit at a Tertiary Care Hospital. The Johns Hopkins Medicine Experience.

In response to the 2014-2015 Ebola virus disease outbreak in West Africa, Johns Hopkins Medicine created a biocontainment unit to care for patients infected with Ebola virus and other high-consequence pathogens. The unit team examined published literature and guidelines, visited two existing U.S. biocontainment units, and contacted national and international experts to inform the design of the physical structure and patient care activities of the unit. The resulting four-bed unit allows for unidirectional flow of providers and materials and has ample space for donning and doffing personal protective equipment. The air-handling system allows treatment of diseases spread by contact, droplet, or airborne routes of transmission. An onsite laboratory and an autoclave waste management system minimize the transport of infectious materials out of the unit. The unit is staffed by self-selected nurses, providers, and support staff with pediatric and adult capabilities. A telecommunications system allows other providers and family members to interact with patients and staff remotely. A full-time nurse educator is responsible for staff training, including quarterly exercises and competency assessment in the donning and doffing of personal protective equipment. The creation of the Johns Hopkins Biocontainment Unit required the highest level of multidisciplinary collaboration. When not used for clinical care and training, the unit will be a site for research and innovation in highly infectious diseases. The lessons learned from the design process can inform a new research agenda focused on the care of patients in a biocontainment environment.

Guided preparedness planning with lay communities: enhancing capacity of rural emergency response through a systems-based partnership

INTRODUCTION Community disaster preparedness plans, particularly those with content that would mitigate the effects of psychological trauma on vulnerable rural populations, are often nonexistent or underdeveloped. The purpose of the study was to develop and evaluate a model of disaster mental health preparedness planning involving a partnership among three, key stakeholders in the public health system. METHODS A one-group, post-test, quasi-experimental design was used to assess outcomes as a function of an intervention designated Guided Preparedness Planning (GPP). The setting was the eastern-, northern-, and mid-shore region of the state of Maryland. Partner participants were four local health departments (LHDs), 100 faith-based organizations (FBOs), and one academic health center (AHC)-the latter, collaborating entities of the Johns Hopkins University and the Johns Hopkins Health System. Individual participants were 178 community residents recruited from counties of the above-referenced geographic area. Effectiveness of GPP was based on post-intervention assessments of trainee knowledge, skills, and attitudes supportive of community disaster mental health planning. Inferences about the practicability (feasibility) of the model were drawn from pre-defined criteria for partner readiness, willingness, and ability to participate in the project. Additional aims of the study were to determine if LHD leaders would be willing and able to generate post-project strategies to perpetuate project-initiated government/faith planning alliances (sustainability), and to develop portable methods and materials to enhance model application and impact in other health jurisdictions (scalability). RESULTS The majority (95%) of the 178 lay citizens receiving the GPP intervention and submitting complete evaluations reported that planning-supportive objectives had been achieved. Moreover, all criteria for inferring model feasibility, sustainability, and scalability were met. CONCLUSIONS Within the span of a six-month period, LHDs, FBOs, and AHCs can work effectively to plan, implement, and evaluate what appears to be an effective, practical, and durable model of capacity building for public mental health emergency planning.

Scarce Resource Allocation During Disasters: A Mixed-Method Community Engagement Study

Background During a catastrophe, health‐care providers may face difficult questions regarding who will receive limited life‐saving resources. The ethical principles that should guide decision‐making have been considered by expert panels but have not been well explored with the public or front‐line clinicians. The objective of this study was to characterize the public’s values regarding how scarce mechanical ventilators should be allocated during an influenza pandemic, with the ultimate goal of informing a statewide scare resource allocation framework. Methods Adopting deliberative democracy practices, we conducted 15 half‐day community engagement forums with the general public and health‐related professionals. Small group discussions of six potential guiding ethical principles were led by trained facilitators. The forums consisted exclusively of either members of the general public or health‐related or disaster response professionals and were convened in a variety of meeting places across the state of Maryland. Primary data sources were predeliberation and postdeliberation surveys and the notes from small group deliberations compiled by trained note takers. Results Three hundred twenty‐four individuals participated in 15 forums. Participants indicated a preference for prioritizing short‐term and long‐term survival, but they indicated that these should not be the only factors driving decision‐making during a crisis. Qualitative analysis identified 10 major themes that emerged. Many, but not all, themes were consistent with previously issued recommendations. The most important difference related to withholding vs withdrawing ventilator support. Conclusions The values expressed by the public and front‐line clinicians sometimes diverge from expert guidance in important ways. Awareness of these differences should inform policy making.

Too Many Patients…A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters

&NA; The threat of a catastrophic public health emergency causing life‐threatening illness or injury on a massive scale has prompted extensive federal, state, and local preparedness efforts. Modeling studies suggest that an influenza pandemic similar to that of 1918 would require ICU and mechanical ventilation capacity that is significantly greater than what is available. Several groups have published recommendations for allocating life‐support measures during a public health emergency. Because there are multiple ethically permissible approaches to allocating scarce life‐sustaining resources and because the public will bear the consequences of these decisions, knowledge of public perspectives and moral points of reference on these issues is critical. Here we describe a critical care disaster resource allocation framework developed following a statewide community engagement process in Maryland. It is intended to assist hospitals and public health agencies in their independent and coordinated response to an officially declared catastrophic health emergency in which demand for mechanical ventilators exceeds the capabilities of all surge response efforts and in which there has been an executive order to implement scarce resource allocation procedures. The framework, built on a basic scoring system with modifications for specific considerations, also creates an opportunity for the legal community to review existing laws and liability protections in light of a specific disaster response process.