Nicole A. Errett

High Stakes and High Risk: A Focused Qualitative Review of Hazards During Cardiac Surgery

Cardiac surgery is a high-risk procedure performed by a multidisciplinary team using complex tools and technologies. Efforts to improve cardiac surgery safety have been ongoing for more than a decade, yet the literature provides little guidance regarding best practices for identifying errors and improving patient safety. This focused review of the literature was undertaken as part of the FOCUS initiative (Flawless Operative Cardiovascular Unified Systems), a multifaceted effort supported by the Society of Cardiovascular Anesthesiologists Foundation to identify hazards and develop evidence-based protocols to improve cardiac surgery safety. Hazards were defined as anything that posed a potential or real risk to the patient, including errors, near misses, and adverse events. Of the 1438 articles identified for title review, 390 underwent full abstract screening, and 69 underwent full article review, which in turn yielded 55 meeting the inclusion criteria for this review. Two key themes emerged. First, studies were predominantly reactive (responding to an event or report) instead of proactive (using prospective designs such as self-assessments and external reviewers, etc.) and very few tested interventions. Second, minor events were predictive of major problems: multiple, often minor, deviations from normal procedures caused a cascade effect, resulting in major distractions that ultimately led to major events. This review fills an important gap in the literature on cardiac surgery safety, that of systematically identifying and categorizing known hazards according to their primary systemic contributor (or contributors). We conclude with recommendations for improving patient outcomes by building a culture of safety, promoting transparency, standardizing training, increasing teamwork, and monitoring performance. Finally, there is an urgent need for studies that evaluate interventions to mitigate the inherent risks of cardiac surgery.

EPPM and willingness to respond: the role of risk and efficacy communication in strengthening public health emergency response systems.

This study examines the attitudinal impact of an Extended Parallel Process Model (EPPM)-based training curriculum on local public health department (LHD) workers’ willingness to respond to representative public health emergency scenarios. Data are from 71 U.S. LHDs in urban and rural settings across nine states. The study explores changes in response willingness and EPPM threat and efficacy appraisals between randomly assigned control versus intervention health departments, at baseline and 1 week post curriculum, through an EPPM-based survey/resurvey design. Levels of response willingness and emergency response-related attitudes/beliefs are measured. Analyses focus on two scenario categories that have appeared on a U.S. government list of scenarios of significant concern: a weather-related emergency and a radiological “dirty” bomb event (U.S. Department of Homeland Security, 2007). The greatest impact from the training intervention on response willingness was observed among LHD workers who had low levels of EPPM-related threat and efficacy perceptions at baseline. Self-efficacy and response efficacy and response willingness increased in intervention LHDs for both scenarios, with greater response willingness increases observed for the radiological “dirty” bomb terrorism scenario. Findings indicate the importance of building efficacy versus enhancing threat perceptions as a path toward greater response willingness, and suggest the potential applicability of such curricular interventions for boosting emergency response willingness among other cadres of health providers.

Safety Culture in Cardiac Surgical Teams: Data From Five Programs and National Surgical Comparison

BACKGROUND Little is known about safety culture in the area of cardiac surgery as compared with other types of surgery. The unique features of cardiac surgical teams may result in different perceptions of patient safety and patient safety culture. METHODS We measured and described safety culture in five cardiovascular surgical centers using the Hospital Survey on Patient Safety Culture, and compared the data with the Agency for Healthcare Research and Quality (AHRQ) 2010 comparative database in surgery and anesthesiology (all types). We reported mean scores, standard deviations, and percent positive responses for the two single-item measures and 12 patient safety climate dimensions in the Hospital Survey on Patient Safety Culture. RESULTS In the five cardiac surgical programs, the dimension of teamwork within hospital units had the highest positive score (74% positive responses), and the dimension of nonpunitive response to error had the lowest score (38% positive responses). Surgeons and support staff perceived better safety climate than nurses, perfusionists, and anesthesia practitioners. The cardiac surgery cohort reported more positive safety climate than the AHRQ all-type surgery cohort in four dimensions but lower frequency of reporting mistakes. The cardiac anesthesiology cohort scored lower on two dimensions compared with the AHRQ all-type anesthesiology cohort. CONCLUSIONS This study identifies patient safety areas for improvement in cardiac surgical teams in comparison with all-type surgical teams. We also found that different professional disciplines in cardiac surgical teams perceive patient safety differently.

A Threat- and Efficacy-Based Framework to Understand Confidence in Vaccines among the Public Health Workforce

The Extended Parallel Process Model (EPPM) is an established threat- and efficacy-based behavioral framework for understanding health behaviors in the face of uncertain risk. A growing body of research has applied this model to understand these behaviors among the public health workforce. In this manuscript, we aim to explore the application of this framework to the public health workforce, with a novel focus on their confidence in vaccines and perceptions of vaccine injury compensation mechanisms. We characterize specific connections between EPPM’s threat and efficacy dimensions and relevant vaccine policy frameworks and highlight how these connections can usefully inform training interventions for public health workers to enhance their confidence in these vaccine policy measures.

Understanding the Impacts of Maritime Disruption Transportation to Hospital-Based Acute Health Care Supplies and Personnel in Coastal and Geographically Isolated Communities

OBJECTIVE This study aimed to identify maritime transportation disruption impacts on available health care supplies and workers necessary to deliver hospital-based acute health care in geographically isolated communities post-disaster. METHODS Semi-structured interviews were conducted with 25 key informants knowledgeable about the hospital-based acute health care supply chain and workforce emergency management plans and procedures in 2 coastal communities in British Columbia. These locations were accessed primarily through maritime transportation, including one urban center and one smaller, more remote community. Interview transcriptions were thematically analyzed. RESULTS Critical vulnerabilities to hospital-based acute health care delivery due to a maritime transportation disruption identified include lack of information about the existing supply chain, lack of formal plans and agreements, and limited local supply storage and workforce capacity. Measures to decrease vulnerability and enhance system capacity can be fostered to enhance acute health care system resilience for these and other geographically isolated communities. CONCLUSIONS A maritime transportation disruption has the potential to impact the availability of hospital-based health care supplies and health care personnel necessary to deliver acute health care in coastal communities post-disaster. Multisector engagement is required to address complex interdependencies and competing priorities in emergency response. Additional research and public-private collaboration is necessary to quantify potential impacts of maritime transportation disruption on the acute health care system. (Disaster Med Public Health Preparedness. 2018;page 1 of 9).

The use of exercises to enhance and assess interlocal collaboration in preparedness: A qualitative analysis

INTRODUCTION Interlocal collaboration, or collaboration among neighboring independent municipalities, has been generally accepted as an emergency preparedness strategy. In the absence of large-scale disasters, emergency preparedness exercises may serve to test the effectiveness of interlocal collaboration on emergency preparedness. However, the use of emergency preparedness exercises to enhance or assess interlocal collaboration, or its impact on preparedness, requires additional empirical exploration. HYPOTHESIS/PROBLEM This exploratory study aims to understand the perspectives of key informants (KIs) with broad knowledge of the history, goals, and implementation of the Urban Area Security Initiative (UASI) program, as well as knowledge of interlocal collaboration exercises conducted as part of the UASI program, about the role of exercises in improving and assessing interlocal collaboration for emergency preparedness. METHOD In early 2014, 28 KIs were interviewed during 24 semistructured interviews. Interviews were recorded and analyzed to identify key themes related to emergency preparedness exercises and the enhancement and assessment of interlocal collaboration. RESULTS KIs perceived exercises to enhance interlocal collaboration in preparedness by promoting regional, interlocal: risk assessment; emergency plan testing and operationalization; relationship development; support for regional plans and operational structures; capability delivery practice; best practice sharing across interlocal collaborations; and engagement of elected or senior leadership in interlocal preparedness endeavors. Exercise participants, scenarios, administration, formats, and assessment strategies to promote interlocal collaboration were identified. CONCLUSIONS Seven distinct mechanisms by which exercises can enhance interlocal collaboration that can be used to guide future research and policy development were identified. The format, scenario, participation, and administration of emergency preparedness exercises can be tailored to enhance collaboration.

Regional Collaboration Among Urban Area Security Initiative Regions: Results of the Johns Hopkins Urban Area Survey

Regional collaboration has been identified as a potential facilitator of public health preparedness efforts. The Urban Area Security Initiative (UASI) grant program, administered by the Federal Emergency Management Agency (FEMA) since 2003, has provided 64 high-risk metropolitan areas funding to enhance their regional preparedness capabilities. This study describes informal and formal regional collaboration infrastructure, as well as regional collaboration-related activities and assessment methods, in FFY2010 UASI regions. A cross-sectional online survey was administered via Survey Monkey from September through December 2013. Points of contact from FFY2010 funded UASI metropolitan areas completed the survey, with a response rate of 77.8% (n=49). Summary statistics were calculated to describe the current informal and formal regional collaboration infrastructure. Additionally, the cross-sectional survey collected rates of agreement with 8 collaborative preparedness statements at 3 time points. The survey found that UASI regions are engaging in collaborative activities and investments to build capabilities, with most collaboration occurring in the prevention, protection, and response mission areas. Collaborative relationships in preparedness among emergency managers and municipal chief executive officers improved during the FFY2010 UASI performance period compared to the pre-UASI award period, with lasting effects. The majority of UASI regions reported conducting independent assessments of capabilities and their measurement at the UASI region level. Urban areas that received a FFY2010 UASI grant award are engaging in collaborative activities and have established interjurisdictional relationships in preparedness. The use of grant funds to encourage collaboration in preparedness has the potential to leverage limited resources and promote informed investments.

Interlocal collaboration and emergency preparedness: a qualitative analysis of the impact of the Urban Area Security Initiative program.

OBJECTIVE Horizontal intergovernmental coordination, or interlocal collaboration, is an ongoing strategy to enhance public health emergency preparedness in the United States. This study aims to understand the impact of interlocal collaboration on emergency preparedness, and how the Urban Area Security Initiative (UASI) program, a federally administered grant program to promote regional preparedness capability development, has influenced perceptions of this relationship. DESIGN Semistructured interviews were conducted and recorded in early 2014. Transcribed data were coded and iteratively analyzed. A purposive and snowball sampling strategy was used. SETTING Interviews were conducted in person or by phone. PARTICIPANTS Twenty-eight key informants were interviewed during 24 interviews. Individuals were selected as key informants due to their knowledge of a UASI region(s) and its governance structures, investment strategies, and challenges, as well as knowledge of the UASI program&s history and goals. MAIN OUTCOME MEASURE(S) Interviews were used to identify, describe, and characterize perceptions of interlocal collaboration, national emergency preparedness, and the UASI grant. RESULTS Impacts, challenges, incentives, facilitators, and disadvantages to interlocal collaboration were identified. Interlocal collaboration was found to impact preparedness by promoting the perceived dissolution of geopolitical boundaries; developing self-reliant regions; developing regional capabilities; promoting regional risk identification; and creating an appreciation of interlocal collaboration importance. The UASI program was thought to have a profound and unique impact on the development of interlocal collaboration infrastructure and on national preparedness. CONCLUSIONS Interlocal collaborations contribute to overall national preparedness. Grant programs, such as the UASI, can incentivize and foster interlocal collaboration in preparedness.