Frontline Responders Research Articles

Working in the Emergency Department During a Virus Outbreak: Lessons from the Ebola Crisis

As the COVID-19 pandemic stretches public health systems around the world, the role of hospital emergency departments has never been more important. Whether people are acutely ill with symptoms from coronavirus or from other illnesses and injuries – such as heart attacks, strokes, or trauma accidents – citizens expect that the emergency department will be open and offer care. In this way, emergency departments function both as a place of medicine and as an institution that society has entrusted to accomplish normative values of ensuring citizens have access to essential services. Emergency doctors and nurses can be conceptualized as institutional custodians because they are the caretakers whose job it is to preserve this institution of healthcare. They help protect the human welfare, order, and stability of society through their everyday work in local emergency departments. As the coronavirus pandemic accelerates, the work of these institutional custodians becomes increasingly difficult as demand threatens to outstrip health system resources, and as more patients pose infection risks to frontline responders. How can institutional custodians in emergency departments stay the course during the coronavirus pandemic?

The timeline of information exchange: a service evaluation of London Ambulance Service NHS Trust's front line communication and emergency response to Exercise Unified Response.

Introduction:Exercise Unified Response, Europe’s largest major incident training exercise to date, provided a rich environment for the emergency services to test their multi-agency crisis response capabilities. Supported by the London Ambulance Service NHS Trust, this service evaluation examined London Ambulance Service NHS Trust front line communication and decision-making via body-worn camera footage.Methods:Twenty London Ambulance Service NHS Trust front line responders and evaluators were each equipped with a body-worn camera during Exercise Unified Response. The service evaluation aimed to: (a) produce timelines of the London Ambulance Service NHS Trust’s response in order to identify key events and actions during the ‘golden hour’ (the crucial first hour in the care of trauma patients), the proceedings of command meetings and the multi-agency response; and (b) develop recommendations for future training and evaluations.Results:The service evaluation identified that, within the golden hour, London Ambulance Service NHS Trust first responders rightly and rapidly declared the event a major incident, requested resources and assigned roles. Triage crews were tasked quickly, though it was identified that their efficiency may be further enhanced through more detailed triage briefings prior to entering the scene. The command meetings (led by the Metropolitan Police) lacked efficiency, and all agencies could make more effective use of the multi-agency shared radio network to address ongoing matters. Finally, London Fire Brigade and London Ambulance Service NHS Trust teams demonstrated clear communication and co-ordination towards casualty extraction.Conclusion:Successful multi-agency working requires clear communication, information sharing and timely command meetings. It is recommended that Joint Emergency Services Interoperability Principles multi-agency talk groups should be utilised more frequently and used to complete a joint METHANE report. In addition, training in areas such as communication skills and detailed briefings will enhance the front line response. Finally, body-worn cameras are shown to be an effective service evaluation tool, as a basis for promoting best practice as well as highlighting areas for future training and evaluations.

Designing Psychosocial Support for COVID-19 Frontline Responders in Pakistan: A Potentially Scalable Self-Help Plus Blueprint for LMICs

As part of its COVID emergency response, the Government of Pakistan’s Ministry of Planning, Development and Special Initiatives has promulgated its first ever Mental Health and Psychosocial Support (MHPSS) initiative. Supported by UNICEF, this initiative will be piloted in Pakistan’s federal capital in coordination with other government ministries. The core feature of this initiative is a web-based integrated system that provides MHPSS interventions at multiple levels, including psychosocial support to frontline responders. For this purpose, we developed a self-help tool, MyCare+, to help users assess and manage their own stress, and to consult a counsellor if needed. It is a comprehensive, evidence-driven, confidential application adapted to local needs and consolidates clinical data for further trend analysis. It is a practical, instructed self-guide for assessment and management of stress-related conditions in the field that is based on existing evidence, thus bridging a gap. Overall, the user feedback was positive for the English and Urdu versions of MyCare+, as they found the content relevant and helpful. More than 90% of users were able to follow the instructions and felt confident to use the tool. This article outlines a blueprint for developing this toolkit, which can be easily translated into regional languages and scaled up for supporting larger populations. Key implications for practice An evidence-driven, resource effective, potentially scalable solution is presented to support the frontline responders in the COVID-19 public health crisis in LMICs. A hybrid approach is followed that offers a self-help digital solution, supplemented by person to person contact with mental health professionals. The tool is designed to help conduct individual assessments and set personalised treatment goals to support frontline workers.

Hypothermia in prehospital polytrauma victims: an overlooked companion

Introduction Hypothermia is a common companion of polytrauma and poses a serious threat and significantly affects the outcome in terms of morbidity and mortality. The initial approach to trauma victims was based on aggressive fluid resuscitation to maintain adequate tissue perfusion. This was highly inadequate and in most circumstances quite harmful. The lethal triad eventually results in a predictable and irreversible progression toward death. Many polytrauma victims presenting to the emergency department are hypothermic. Hypothermia is defined as core body temperature less than 35°C. Heat loss typically occurs at a rate of 60–75 kcal/h by four different methods: radiation, conduction, evaporation, and convection. Hypothermia in patients with trauma is caused by a multitude of factors. It affects almost all organs and also the coagulation system. It is crucial to alleviate the possibility of the setting in of the lethal triad, which includes acidosis, hypothermia, and coagulopathy. Resuscitating a patient with trauma in a prehospital environment is a much difficult task, which requires knowledge that the recognition and prevention of the lethal triad is critical. Hemorrhage in trauma leads to acidosis, hypothermia, and coagulopathy. Hypothermia worsens acidosis, which in turn contributes to further coagulopathy. This causes further hemorrhage, setting off the deadly vicious cycle. Thus, frontline responders are an essential part of the trauma management system, and recognition and prevention of the hypothermia arm in the lethal triad is of utmost importance.

Mental Illness, Mental Disability, and the Exercise of Human Rights: Key Differences and Similarities According to Mental Health Administrators and Managers Within Brazil

This qualitative study identified the perception of administrators and managers of the interrelation between mental disability and mental illness. It investigated experiences in which these differences facilitated or impaired the exercise of fundamental rights by persons with mental illness in a city in the state of Sao Paulo, Brazil. From this perspective, it is important to discuss the exercise of human rights in mental health. It is a key issue for social work practitioners and service managers, who are often the frontline responders to individuals with mental illness. Data were collected through semi-structured interviews analyzed through Bardin’s content analysis technique. The following categories resulted from the analysis: clear perception of mental illness and mental disability definition and legislation; situations of fundamental rights fulfillment; and situations of disrespect of fundamental rights. Mental health managers noted the difficulties experienced when those with mental illness attempted to exercise their fundamental rights. Such attempts were often frustrating and fruitless. This situation is caused by the absence or limitation of a special legislation regarding fundamental rights of persons with mental illness in the country. In this context, the legislative power is primarily responsible for developing special acts and including them in general laws, especially considering the contributions of mental health legislation to a life with dignity for persons with mental illness.

Responding to the Ebola virus disease outbreak in DR Congo: when will we learn from Sierra Leone?

Responding to the Ebola virus disease outbreak in DR Congo: when will we learn from Sierra Leone?

RISE Up: Facilitating Frontline Responder Collaboration on Co-Occurring Child Welfare and Intimate Partner Violence Cases.

Intimate partner violence (IPV) services are necessary in numerous human service systems, requiring responders (e.g., victim services, law enforcement, social service providers) to collaborate with one another to best meet the needs of their respective clients. Child welfare workers, in particular, carry caseloads with a high prevalence of IPV, yet have reported significant barriers to successful collaboration with other responder roles, such as tension regarding who is the primary client (i.e., the IPV victim or the child). This study explores the qualitative responses of child welfare workers in Florida to understand their collaboration experiences, focusing specifically on their perceptions of facilitative factors of collaboration. Data were collected in Wave 4 of the Florida Study of Professionals for Safe Families, an ongoing longitudinal study of turnover among newly hired child welfare workers. Participants in child welfare and health and human services roles were asked to provide a response to the open-ended item: "What is most helpful in establishing strong collaborations with other responders on cases that involve intimate partner violence?" To better contextualize the results, the analytic sample was ultimately reduced to 526 child welfare workers currently employed in Florida who reported ever working on cases with IPV and provided a response to the open-ended item. Based on a thematic analysis, findings lend to a conceptual model of IPV collaboration among frontline workers that promotes institutional empathy through a cumulative building of communication, rapport, appreciation for teamwork, and consistent understanding of case processes: The Responder InStitutional Empathy (RISE) model of collaboration. Frontline worker efforts to improve collaboration would be bolstered by the accompanying efforts of leadership. The authors suggest increasing mechanisms to promote joint work between responder roles, such as cross-training and colocation.

Rapid response to meningococcal disease cluster in Foya district, Lofa County, Liberia January to February 2018.

IntroductionEarly detection of disease outbreaks is paramount to averting associated morbidity and mortality. In January 2018, nine cases including four deaths associated with meningococcal disease were reported in three communities of Foya district, Lofa County, Liberia. Due to the porous borders between Lofa County and communities in neighboring Sierra Leone and Guinea, the possibility of epidemic spread of meningococcal disease could not be underestimated.MethodsThe county incidence management system (IMS) was activated that coordinated the response activities. Daily meetings were conducted to review response activities progress and challenges. The district rapid response team (DRRT) was the frontline responders. The case based investigation form; case line list and contacts list were used for data collection. A data base was established and analysed daily for action. Tablets Ciprofloxacin were given for chemoprophylaxis.ResultsSixty-seven percent (67%) of the cases were males and also 67% of the affected age range was 3 to 14 years and attending primary school. The attack rate was 7/1,000 population and case fatality rate was 44.4 % with majority of the deaths occurring within 24-48 hours of symptoms onset. Three of the cases tested positive for Neisseria Meningitidis sero-type W while six cases were Epi-linked. None of the cases had recent meningococcal vaccination and no health-worker infections were registered.ConclusionThis cluster of cases of meningococcal disease during the meningitis season in a country that is not traditionally part of the meningitis belt emphasized the need for strengthening surveillance, preparedness and response capacity to meningitis.

Insights from outside BJOG

Insights from outside BJOG

Evolutions in global epidemic and pandemic preparedness

The 21st century poses complex challenges for public health. Our planet is experiencing unprecedented levels of globalization, urbanization and mobility of its 7 billion inhabitants, many of whom live in poverty, conflict or are at risk of natural disasters and suffering from the effects of climate change. Infectious hazards, new and old, threaten the lives and well-being of billions of people across the globe. As the UN's specialized agency for health, WHO investigates around 300 disease outbreaks every year. But detecting and managing epidemic and pandemic-prone diseases is harder than ever. During the last two decades, several high profile disease outbreaks have had a profound effect on public health's response to epidemics and pandemics. Today, in sharp contrast to the last century, there is an expectation that we detect outbreaks faster and manage them better. The response to health emergencies today is vastly different from previous eras where containment was a pre-dominant strategy. Today, for any outbreak, we need to systematically use the combination of modern epidemiology utilizing the power of technology; new and easy-to -use field-based rapid diagnostic tools; clinical care even in the harshest of conditions, vaccines and other medical counter-measures, rapidly developing them if they don’t already exist; real-time training of front-line responders; and effective risk communication and community engagement. This new recognition that we need to marry the social aspects of epidemic and pandemic response with an ever stronger bio-medical response is changing the way disease outbreaks are being managed. Just in the last decade, lessons learnt from MERsCoV in Saudi Arabia and South Korea; Ebola in West Africa; Zika in South America; Yellow Fever in Angola and the Democratic republic of Congo, several ongoing outbreaks of Cholera and Diphtheria in Bangladesh have created the momentum to re-think disease outbreak management to prevent epidemics or pandemics. As the science of epidemic and pandemic diseases marches forward, and social science makes its presence increasingly felt, there is an effort to make the response operations more effective, particularly for large-scale epidemics. The introduction of Emergency Operations Centers (EOCs) in countries, and WHO's own reform establishing the use of an incident management system (IMS) have had an impact on how disease outbreaks are viewed and managed. As the current generation of public health experts and personnel, we will undoubtedly write the next chapter in how the epidemics and pandemics of the rest of the 21st century will be managed.

How emergency managers (mis?)interpret forecasts.

Emergency managers who work on floods and other weather-related hazards constitute critical frontline responders to disasters. Yet, while these professionals operate in a realm rife with uncertainty related to forecasts and other unknowns, the influence of uncertainty on their decision-making is poorly understood. Consequently, a national-level survey of county emergency managers in the United States was administered to examine how they interpret forecast information, using hypothetical climate, flood, and weather scenarios to simulate their responses to uncertain information. The study revealed that even emergency managers with substantial experience take decision shortcuts and make biased choices, just as do members of the general population. Their choices vary depending on such features as the format in which probabilistic forecasts are presented and whether outcomes are represented as gains or losses. In sum, forecast producers who consider these decision processes when developing and communicating forecasts could help to improve flood preparation and potentially reduce disaster losses.

Higher Education Crises: Training New Professionals for Crisis Management

With events such as natural disasters and active shooters occurring on college campuses, crisis management has become a required function of higher education administrators. Training and planning efforts are often limited to senior level leaders who will manage the campus response in a large-scale incident. Yet small-scale incidents are more likely to occur, placing new professionals in the role of frontline responders without adequate training. This qualitative study shares administrator experiences with crisis situations and what they recommend for inclusion in training new professionals to respond.

The Impact of First Responder Turnout and Curb-to-care Intervals on Survival From Out-of-hospital Cardiac Arrest: DeRuyter NP, Husain S, Yin L, et al. Resuscitation. 2017;113:51-55

Out of hospital cardiac arrest (OHCA) is a significant cause of death in the United States with 300,000 people dying annually. Emergency Medical Services (EMS) providers are the front-line responders who treat out of hospital cardiac arrest and the time from collapse to initial cardiopulmonary resuscitation (CPR) and defibrillation has been shown to influence the likelihood of survival.

The Mission to Stop Ebola: Lessons for UN Crisis Response

The Ebola outbreak of 2014–2016 was a fast-moving, multidimensional emergency that presented unprecedented challenges for the multilateral system. In response to the outbreak in Guinea, Liberia, and Sierra Leone, the UN established the first-ever emergency health mission, the UN Mission for Ebola Emergency Response (UNMEER). UNMEER is an important case study of how the UN, with member-state support, can provide a whole-of-system response through coordination, partnership, and creative use of existing tools. This report, therefore, asks three questions about this groundbreaking mission: was it needed, was it properly structured, and did it deliver? In answering these questions, it offers eight broad lessons for UN crisis response: - A sequenced approach and flexible mandate allow for better responses to unanticipated challenges. - Effective responses draw upon the full range of UN tools and implementing partners based on the principle of comparative advantage, but they must take into account the challenge of integrating distinct organizational cultures. - Flexible and predictable funding is critical for rapidly scaling up responses to multidimensional crises. - Local engagement with key stakeholders during the peak of a crisis enhances long-term effectiveness. - A system-wide communications strategy, bolstered by strong communications capacity in the field, is required from the outset. - High-level coordination and oversight can provide flexibility and quick reaction. - Close proximity to frontline responders and the site of the crisis enhances field coordination. - A regional office can improve coordination across borders, but it must be joined with a strategy to account for the specificity of national and local contexts.

Monitoring RhoGTPase Activity in Leukocytes Using Classic "Pull-Down" Assays.

Inflammation is a complex process involving the contribution of leukocytes and blood vessels, which collectively aim to restore homeostasis following injury to the body. Leukocytes are essential front-line responders to infectious or noninfectious injury and can be deployed within minutes of sensing damage. A typical inflammatory response leads to the exit of circulating leukocytes into the surrounding extravascular space, which follows a series of increasingly adhesive events - collectively termed the "multistep adhesion cascade." The Ras homology (Rho) family of small GTPases (RhoGTPases) are intracellular proteins involved in translating extracellular signals into cellular behavior, such as adhesion and migration. This chapter focuses on how to prepare, perform, and monitor RhoGTPase activation assays using classic pull-down assays. Although this chapter focuses on RhoGTPase signaling downstream of L-selectin clustering, the methods outlined here can be applied to analyzing RhoGTPase activity in response to stimulating other surface receptors.

Activation of the Innate Immune Receptors: Guardians of the Micro Galaxy : Activation and Functions of the Innate Immune Receptors.

The families of innate immune receptors are the frontline responders to danger. These superheroes of the host immune systems populate innate immune cells, surveying the extracellular environment and the intracellular endolysosomal compartments and cytosol for exogenous and endogenous danger signals. As a collective the innate immune receptors recognise a wide array of stimuli, and in response they initiate specific signalling pathways leading to activation of transcriptional or proteolytic pathways and the production of inflammatory molecules to destroy foreign pathogens and/or resolve tissue injury. In this review, I will give an overview of the innate immune system and the activation and effector functions of the families of receptors it comprises. Current key concepts will be described throughout, including innate immune memory, formation of innate immune receptor signalosomes, inflammasome formation and pyroptosis, methods of extrinsic cell communication and examples of receptor cooperation. Finally, several open questions and future directions in the field of innate immunity will be presented and discussed.

How Co-Developed Are Community and Academic Partnerships?

The world-renowned resources of Johns Hopkins Hospital (JHH) in Baltimore, Maryland, stand in marked contrast with the surrounding impoverished neighborhoods. Community-based organizations (CBOs) are critical frontline responders to residents' needs. Baltimore CONNECT, an academic-community partnership, co-developed an intervention to strengthen connections between CBOs and between CBOs and the health care system. To understand how members of an academic- community partnership define the act of "co-development" and share perceptions of barriers, facilitators, and ways to measure it. We conducted semistructured interviews with 15 community partners, academic partners, and external stakeholders. Partners conceptualized co-development as a fluid and evolving process that is the outcome of shared decision making. This exploration revealed nuances within partnership dynamics, including motivations for participation, underlying incentives, partnership equality, balance of power, and trust and relation building. We present insights that can be used by academic researchers and community leaders looking to co-develop interventions to improve health in urban communities domestically and internationally.JHH in Baltimore, Maryland, is one of the most highly regarded hospitals in the United States. However, its institutional resources stand in marked contrast with those available to the impoverished neighborhoods that surround it. Many have called for JHH to play a greater role in the surrounding community, where it serves as a leading source of health care.

Identifying weaknesses in national health emergency response skills and techniques with emergency responders: A cross-sectional study from China.

To identify the weakest skill areas perceived by participants among key skills highly demanded during emergencies and to explore factors influencing the self-rated overall skill proficiency of public health emergency responders. The participants were selected by a multistage, stratified cluster sampling method in Heilongjiang CDC to complete questionnaires that assessed their perceptions of health emergency response skills and techniques. A final sample of 1,740 staff members was obtained and analyzed. The 5 top skill deficiency areas perceived by participants were field epidemiologic investigation, personal protection, effective nuclear and radioactive response as well as psychological interventio (for these two areas gain the equal score), and risk assessment. The logistic regression revealed personal protective skills as the most important factor contributing to the self-rated overall skill proficiency of public health emergency responders, followed by field epidemiologic investigation skills. More attention should be given to emergency response skill training and education programs. Major obstacles hindering the promotion of key skills and techniques among front-line emergency responders should be addressed urgently. Continuous efforts should be made to remove the financial, technical, and resource obstacles to improve public health emergency response capacity.

Producing Interdisciplinary Competent Professionals: Integrating One Health Core Competencies into the Veterinary Curriculum at the University of Rwanda.

Infectious diseases of grave concern to human health are emerging from wildlife and livestock populations in multiple regions of the world. Responding effectively to these emerging pandemics requires engagement of multidisciplinary groups of professionals. Using a One Health approach, One Health Central and Eastern Africa (OHCEA), a network of seven schools of public health and seven veterinary schools, with the support of the United States Agency for International Development (USAID), has engaged in curriculum review with the aim of building the skills of multidisciplinary groups of professionals to improve their capacity to respond to emerging infectious diseases. Through stakeholder analysis and curriculum development workshops, the University of Rwanda's School of Veterinary Medicine, in association with Tufts University, revised its curriculum to incorporate One Health competencies to be better prepared to respond to any infectious disease outbreak in Africa. The revised curriculum aimed to build cross-sectoral skills and knowledge; transform students' ways of thinking about infectious disease outbreak response; link human, veterinary, and wildlife health training opportunities; and strengthen community frontline responder training. Eight different disciplines engaged in the curriculum review process: Veterinary Medicine, Livestock Production, Wildlife and Aquatic Resources, Environmental Health and Epidemiology, Communication Technology, Engineering, Agriculture, and Public Health. One Health competencies such as communication, collaboration, leadership, and advocacy were added to the new curriculum, helping ensure that each professional be appropriately equipped with skills to recognize and respond effectively to any emerging infections.

Singapore Success: New Model Helps Forecast Dengue Outbreaks.

The island city-state of Singapore reported a record 2,441 cases of dengue fever in January 2016, 1 triggered by all-time-high temperatures in the preceding weeks. 2 , 3 Singapore is a potential hotbed for the widespread disease thanks to its tropical climate and highly urbanized environment. But it’s also a leader in mitigating the spread of dengue virus through an advanced mosquito control program, 4 aided in the past 3 years by a sophisticated model to forecast dengue outbreaks. 5