Getting Real: The Maryland Healthcare Ethics Committee Network's COVID-19 Working Group Debriefs Lessons Learned.

Responding to a major pandemic and planning for allocation of scarce resources (ASR) under crisis standards of care requires coordination and cooperation across federal, state and local governments in tandem with the larger societal infrastructure. Maryland remains one of the few states with no state-endorsed ASR plan, despite having a plan published in 2017 that was informed by public forums across the state. In this article, we review strengths and weaknesses of Maryland's response to COVID-19 and the role of the Maryland Healthcare Ethics Committee Network (MHECN) in bridging gaps in the state's response to prepare health care facilities for potential implementation of ASR plans. Identified "lessons learned" include: Deliberative Democracy Provided a Strong Foundation for Maryland's ASR Framework; Community Consensus is Informative, Not Normative; Hearing Community Voices Has Inherent Value; Lack of Transparency & Political Leadership Gaps Generate a Fragmented Response; Pandemic Politics Requires Diplomacy & Persistence; Strong Leadership is Needed to Avoid Implementing ASR … And to Plan for ASR; An Effective Pandemic Response Requires Coordination and Information-Sharing Beyond the Acute Care Hospital; and The Ability to Correct Course is Crucial: Reconsidering No-visitor Policies.

Influence of Community and Culture in the Ethical Allocation of Scarce Medical Resources in a Pandemic Situation: Deliberative Democracy Study.

BACKGROUND: Stark gaps exist between projected health needs in a pandemic situation and the current capacity of health care and medical countermeasure systems. Existing pandemic ethics discussions have advocated to engage the public in scarcity dilemmas and attend the local contexts and cultural perspectives that shape responses to a global health threat. This public engagement study thus considers the role of community and culture in the ethical apportionment of scarce health resources, specifically ventilators, during an influenza pandemic. It builds upon a previous exploration of the values and preferences of Maryland residents regarding how a finite supply of mechanical ventilators ought to be allocated during a severe global outbreak of influenza. An important finding of this earlier research was that local history and place within the state engendered different ways of thinking about scarcity. OBJECTIVE: Given the intrastate variation in the themes expressed by Maryland participants, the project team sought to examine interstate differences by implementing the same protocol elsewhere to answer the following questions. Does variation in ethical frames of reference exist within different regions of the United States? What practical implications does evidence of sameness and difference possess for pandemic planners and policymakers at local and national levels? METHODS: Research using the same deliberative democracy process from the Maryland study was conducted in Central Texas in March 2018 among 30 diverse participants, half of whom identified as Hispanic or Latino. Deliberative democracy provides a moderated process through which community members can learn facts about a public policy matter from experts and explore their own and others' views. RESULTS: Participants proposed that by evenly distributing supplies of ventilators and applying clear eligibility criteria consistently, health authorities could enable fair allocation of scarce lifesaving equipment. The strong identification, attachment, and obligation of persons toward their nuclear and extended families emerged as a distinctive regional and ethnic core value that has practical implications for the substance, administration, and communication of allocation frameworks. CONCLUSIONS: Maryland and Central Texas residents expressed a common, overriding concern about the fairness of allocation decisions. Central Texas deliberants, however, more readily expounded upon family as a central consideration. In Central Texas, family is a principal, culturally inflected lens through which life and death matters are often viewed. Conveners of other pandemic-related public engagement exercises in the United States have advocated the benefits of transparency and inclusivity in developing an ethical allocation framework; this study demonstrates cultural competence as a further advantage.

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

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.

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.

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.

The community speaks: understanding ethical values in allocation of scarce lifesaving resources during disasters.

INTRODUCTION: Pandemic influenza or other crises causing mass respiratory failure could easily overwhelm current North American critical care capacity. This threat has generated large-scale federal, state, and local efforts to prepare for a public health disaster. Few, however, have systematically engaged the public regarding which values are most important in guiding decisions about how to allocate scarce healthcare resources during such crises. METHODS: The aims of this pilot study were (1) to test whether deliberative democratic methods could be used to promote engaged discussion about complex, ethically challenging healthcare-related policy issues and (2) to develop specific deliberative democratic procedures that could ultimately be used in a statewide process to inform a Maryland framework for allocating scarce healthcare resources during disasters. Using collaboratively developed focus group materials and multiple metrics for assessing outcomes, we held 5-hour pilot community meetings with a combined total of 68 community members in two locations in Maryland. The key outcomes used to assess the project were (1) the comprehensibility of the background materials and ethical principles, (2) the salience of the ethical principles, (3) the perceived usefulness of the discussions, (4) the degree to which participants' opinions evolved as a result of the discussions, and (5) the quality of participant engagement. RESULTS: Most participants were thoughtful, reflective, and invested in this pilot policy-informing process. Throughout the pilot process, changes were made to background materials, the verbal introduction, and pre- and post-surveys. Importantly, by holding pilot meetings in two distinct communities (an affluent suburb and inner city neighborhood), we discerned that participants' ethical reflections were framed in large part by their place-based life experiences. CONCLUSION: This pilot process, coupled with extensive feedback from participants, yielded a refined methodology suitable for wider-scale use and underscored the need for involvement of diverse communities in a statewide engagement process on this critical policy issue.

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.

Participatory public health systems research: value of community involvement in a study series in mental health emergency preparedness.

BACKGROUND: Concerns have arisen over recent years about the absence of empirically derived evidence on which to base policy and practice in the public health system, in general, and to meet the challenge of public health emergency preparedness, in particular. Related issues include the challenge of disaster-caused, behavioral health surge, and the frequent exclusion of populations from studies that the research is meant to aid. OBJECTIVE: To characterize the contributions of nonacademic collaborators to a series of projects validating a set of interventions to enhance capacity and competency of public mental health preparedness planning and response. SETTING(S): Urban, suburban, and rural communities of the state of Maryland and rural communities of the state of Iowa. PARTICIPANTS: Study partners and participants (both of this project and the studies examined) were representatives of academic health centers (AHCs), local health departments (LHDs), and faith-based organizations (FBOs) and their communities. PROCEDURES: A multiple-project, case study analysis was conducted, that is, four research projects implemented by the authors from 2005 through 2011 to determine the types and impact of contributions made by nonacademic collaborators to those projects. The analysis involved reviewing research records, conceptualizing contributions (and providing examples) for government, faith, and (nonacademic) institutional collaborators. RESULTS: Ten areas were identified where partners made valuable contributions to the study series; these "value-areas" were as follows: 1) leadership and management of the projects; 2) formulation and refinement of research topics, aims, etc; 3) recruitment and retention of participants; 4) design and enhancement of interventions; 5) delivery of interventions; 6) collection, analysis, and interpretation of data; 7) dissemination of findings; 8) ensuring sustainability of faith/government preparedness planning relationships; 9) optimizing scalability and portability of the model; and 10) facilitating translational impact of study findings. CONCLUSIONS: Systems-based partnerships among academic, faith, and government entities offer an especially promising infrastructure for conducting participatory public health systems research in domestic emergency preparedness and response.

Community capacity-building in disaster mental health resilience: a pilot study of an academic/faith partnership model.

We describe an academic/faith partnership approach for enhancing the capacity of communities to resist or rebound from the impact of terrorism and other mass casualty events. Representatives of several academic health centers (AHCs) collaborated with leaders of urban Christian-, Jewish-, and Muslim faith-based organizations (FBOs) to design, deliver, and preliminarily evaluate a train-the-trainer approach to enhancing individual competencies in the provision of psychological first aid and in disaster planning for their respective communities. Evidence of partner commitment to, and full participation in, project implementation responsibilities confirmed the feasibility of the overall AHC/FBO collaborative model, and individual post-training, self-report data on perceived effectiveness of the program indicated that the majority of community trainees evaluated the interventions as having significantly increased their: (a) knowledge of disaster mental health concepts; (b) skills (self-efficacy) as providers of psychological first aid and bereavement support services, and (c) (with somewhat less confidence because of module brevity) capabilities of leading disaster preparedness planning efforts within their communities. Notwithstanding the limitations of such early-phase research in ensuring internal and external validity of the interventions, the findings, particularly when combined with those of earlier and subsequent work, support the rationale for continuing to refine this participatory approach to fostering community disaster mental health resilience, and to promoting the translational impact of the model. An especially important (recent) example of the latter is the formal recognition by local and state health departments of program-trained lay volunteers as a vital resource in the continuum of government assets for public health emergency preparedness planning and response.

Assessment of psychological preparedness and emergency response willingness of local public health department and hospital workers.

This study sought to investigate the relationship between psychologically-related attitudes/beliefs toward public health emergency response among local health department (LHD) and hospital workers and their willingness to respond to a pandemic influenza emergency scenario and a radiological 'dirty' bomb scenario, to inform workforce resilience-building interventions. LHD and hospital workers participated in a survey based on an established threat- and efficacy-oriented behavioral model (the extended parallel process model) that focused on collection of the aforementioned attitudes, beliefs, and self-reported response willingness. Odds ratios associating psychologically-related attitudes and beliefs with self-reported response willingness were computed Perceived levels of psychological preparedness and support were shown to impact response willingness, with more pronounced effects in the radiological 'dirty' bomb scenario. Compared to those who did not perceive themselves to be psychologically prepared, those who did perceive themselves as prepared had higher odds of self-reported response willingness. The relationship of these perceptions and self-reported willingness to respond in all contexts, both scenarios, and both cohorts was influenced by perceived self-efficacy andperceived family preparedness.

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.

Characterizing public health emergency perceptions and influential modifiers of willingness to respond among pediatric healthcare staff.

OBJECTIVES: The aim of this study was to characterize the public health emergency perceptions and willingness to respond (WTR) of hospital-based pediatric staff and to use these findings to propose a methodology for developing an institution-specific training package to improve response willingness. METHODS: A prospective anonymous web-based survey was conducted at the Johns Hopkins Hospital, including the 180-bed Johns Hopkins Children's Center, between January and March 2009. In this survey, participants' attitudes/beliefs regarding emergency response to a pandemic influenza and a radiological dispersal device (RDD or "dirty bomb") event were assessed. RESULTS: Of the 1,620 eligible pediatric staff 246 replies (15.2 percent response rate) were received, compared with an overall staff response rate of 18.4 percent. Characteristics of respondent demographics and professions were similar to those of overall hospital staff. Self-reported WTR was greater for a pandemic influenza than for an RDD event if required (84.6 percent vs 75.1 percent), and if asked, but not required (74.4 percent vs 64.5 percent). The majority of pediatric staff were not confident in their safety at work (pandemic influenza: 51.8 percent and RDD: 76.6 percent), were far less likely to respond if personal protective equipment was unavailable (pandemic influenza: 33.5 percent and RDD: 21.6percent), and wanted furtherpre-event preparation and training (pandemic influenza: 89.6 percent and RDD: 82.6 percent). The following six distinct perceived attitudes / beliefs were identified as having institution-specific high impact on response willingness: colleague response, skill mastery, safety getting to work, safety at work, ability to perform duties, and individual response efficacy. CONCLUSIONS: Children represent a uniquely vulnerable population in public health emergencies, and pediatric hospital staff accordingly represent a vital subset of responders distinguished by specialized education, training, clinical skills, and disaster competencies. Even though the majority of pediatric hospital staff report WTR, nearly 15 percent for a pandemic influenza emergency and 25 percent for an RDD event would not respond if required. Other institutions can apply the methodology used here to identify particularly influential response willingness modifiers for pediatric care providers. These insights can inform customized preparedness training for pediatric healthcare workers, through identification of high-impact attitudes/beliefs, and training initiatives focused on addressing these modifiers.

Characterizing hospital workers' willingness to report to duty in an influenza pandemic through threat- and efficacy-based assessment.

BACKGROUND: Hospital-based providers' willingness to report to work during an influenza pandemic is a critical yet under-studied phenomenon. Witte's Extended Parallel Process Model (EPPM) has been shown to be useful for understanding adaptive behavior of public health workers to an unknown risk, and thus offers a framework for examining scenario-specific willingness to respond among hospital staff. METHODS: We administered an anonymous online EPPM-based survey about attitudes/beliefs toward emergency response, to all 18,612 employees of the Johns Hopkins Hospital from January to March 2009. Surveys were completed by 3426 employees (18.4%), approximately one third of whom were health professionals. RESULTS: Demographic and professional distribution of respondents was similar to all hospital staff. Overall, more than one-in-four (28%) hospital workers indicated they were not willing to respond to an influenza pandemic scenario if asked but not required to do so. Only an additional 10% were willing if required. One-third (32%) of participants reported they would be unwilling to respond in the event of a more severe pandemic influenza scenario. These response rates were consistent across different departments, and were one-third lower among nurses as compared with physicians. Respondents who were hesitant to agree to work additional hours when required were 17 times less likely to respond during a pandemic if asked. Sixty percent of the workers perceived their peers as likely to report to work in such an emergency, and were ten times more likely than others to do so themselves. Hospital employees with a perception of high efficacy had 5.8 times higher declared rates of willingness to respond to an influenza pandemic. CONCLUSIONS: Significant gaps exist in hospital workers' willingness to respond, and the EPPM is a useful framework to assess these gaps. Several attitudinal indicators can help to identify hospital employees unlikely to respond. The findings point to certain hospital-based communication and training strategies to boost employees' response willingness, including promoting pre-event plans for home-based dependents; ensuring adequate supplies of personal protective equipment, vaccines and antiviral drugs for all hospital employees; and establishing a subjective norm of awareness and preparedness.

The tower of ivory meets the house of worship: psychological first aid training for the faith community.

Clergy and laity have been a traditional source of support for people striving to cope with everyday tragedies, but not all faith leaders have the specialized knowledge required for the challenges of mental health ministry in the aftermath of widespread trauma and mass casualty events. On the other hand, some mental health professionals have acquired high levels of expertise in the field of disaster mental health but, because of their limited numbers, cannot be of direct help to large numbers of disaster survivors when such events are broad in scale. The authors have addressed the problem of scalability of post-disaster crisis mental health services by establishing an academic/faith partnershipforpsychological first aid training. The curriculum was piloted with 500 members of the faith community in Baltimore City and other areas of Maryland. The training program is seen as a prototype of specialized first-responder training that can be built upon to enhance and extend the roles of spiritual communities in public health emergencies, and thereby augment the continuum of deployable resources available to local and state health departments.

Academic psychiatry and health care reform: strategic initiatives for sustaining the clinical mission.

Health care reform has posed special challenges for departments of psychiatry in academic medical centers. This report describes one department's strategic responses to a marketplace with high penetration by managed care and provides examples of the kinds of faculty concerns that can arise when major departmental reorganizations are attempted. The department's successful adaptation to a radically altered professional environment is attributed to the following five initiatives: vertical integration and diversification of clinical programs, service line management, outcomes measurement, regional network development, and institutional managed care partnerships Although the authors did not design their adaptive efforts as a research study, they offer objective data to support their conclusion that the viability of their overall clinical enterprise has been sustained despite an external environment inhospitable to academic psychiatry.