Describe ways to demonstrate the core competencies described by James et al.
Describe hazard specific competencies for a hospital emergency manager.
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Disaster Medicine and Public Health
Preparedness: A Discipline
for All Health Professionals
James J. James, MD, DrPH, MHA; Georges C. Benjamin, MD, FACP;
Frederick M. Burkle Jr, MD, MPH, DTM, FAAP, FACEP; Kristine M. Gebbie, DrPH, RN;
Gabor Kelen, MD; Italo Subbarao, DO, MBA
ndividuals and populations exposed to natural and humancaused disasters confront myriad social, physical, psychological, environmental, and economic conditions that affect health.
Lessons learned from Hurricane Katrina (2005), the Haitian earthquake (2010), and other large-scale disasters consistently demonstrate that such events disproportionately affect the most vulnerable members of society, including children, elderly people,
and minority populations. Minimizing adverse health outcomes
requires cooperative efforts that cross traditional boundaries of
health specialties, professions, and nationalities. Health professionals are on the front lines when dealing with injury and disease every day, whether natural or man made.
vide a foundation for doctrine, education, training, and research
within the public health and health care sectors. (DMPHP includes all health professions and specialties, including but not limited to allied health, dentistry, emergency medical services, environmental health, epidemiology, hazardous materials response,
medicine, mental health, nursing, pharmacology, public health,
toxicology, and veterinary medicine.) Previous definitions have
been proposed, but despite their relevance, they have not achieved
widespread consensus. To distinguish DMPHP from other health
disciplines and professions, a modified definition is proposed that
recognizes the essential integration of clinical and public health
science and practice into the emergency response system:
There are a wide variety of disasters ranging from localized
events to large-scale public health emergencies. To respond
effectively, health professionals, regardless of specialty or area
of expertise, require a fundamental understanding of the disaster management system and the ways in which various healthrelated roles are integrated to protect health and respond to
disease or injury. In a disaster or public health emergency
(PHE), health professionals have an obligation to protect and
preserve the health, safety, and security of their patients, families, and communities, as well as themselves. All health disciplines should be knowledgeable about the range of illnesses
and injuries that may arise and how their particular expertise
facilitates effective response. In addition, all must be able to
recognize the general features of disasters and PHEs and be
knowledgeable about their impact on the population, how to
report a potential public health event, and where to access
pertinent information as required. Most disaster events are on
a scale that communities, whether in the developed or developing world, can manage well. Consequences are usually limited to direct injuries and deaths. In particular, large-scale
PHEs place unprecedented demands on the existing public
health infrastructure and system that may increase overall
morbidity and mortality. PHEs require an added degree of
coordination, cooperation, and collaboration between the
clinical workforce and public health authorities.
DMPHP is defined as the study and collaborative application
of sound scientific principles, practices, and standards by multiple health professions for the prevention, mitigation, management, and rehabilitation of injuries, illnesses, and other problems that affect the health, safety, and well-being of individuals
and communities in disasters and public health emergencies.
DEFINING THE KNOWLEDGE BASE FOR DISASTER
MEDICINE AND PUBLIC HEALTH PREPAREDNESS
It is recognized within the discipline of disaster medicine and public health preparedness (DMPHP) that there are distinct principles and practices across the health and social sciences that pro102
Disaster Medicine and Public Health Preparedness
Strong impetus for more focused attention to education, training, and research in DMPHP was provided by Homeland Security Presidential Directive 21 (HSPD-21)3 and 3 recent consensus reports.4-6 HSPD-21 specifically calls for the establishment of
a discipline that recognizes the unique principles in disasterrelated medicine and public health; provides a foundation for the
development and dissemination of doctrine, education, training, and research in this field; and better integrates private and
public entities into the disaster health system. As precedent for
this new discipline, HSPD-21 cites the evolution of the specialty
of emergency medicine due to recognition of the special considerations of emergency patient care. HSPD-21 endorses similar action directed to disaster-related public health and medicine, which
merits the establishment of a separate formal discipline.
Although DMPHP draws from multiple other fields, to be recognized and embraced as a distinct academic discipline, it must
be differentiated by its own unique and distinctive essentials. This
can be accomplished through description of an identifiable philosophy for the discipline, a sound conceptual framework, a unique
core body of knowledge, and acceptable methodological approaches for the pursuit and development of knowledge in the
field.7 Just as the discipline of biochemistry and its accompanying journals once evolved from the interests of individual exVOL. 4/NO. 2
©2010 American Medical Association. All rights reserved.
perts in organic chemistry, zoology, botany, and other fields, and
the discipline of genomics evolved from the interests of individual biochemists, geneticists, pharmacologists, and others, it is
envisioned that the discipline of DMPHP will evolve similarly,
in response to proper input and nurturing from experts with diverse clinical and public health backgrounds.8 DMPHP can be
seen as a “composite” discipline requiring integrated multidisciplinary study and research to meet its goals.
Proficiency in DMPHP requires knowledge and skills beyond
those typically acquired in clinical and public health training
and practice, and must encompass unique competencies. The
delivery of optimal care in a disaster relies on both clinical and
public health expertise, and depends on a common understanding of each health professional’s role in the broader emergency
management system. To be considered proficient in DMPHP,
individuals must demonstrate common mastery of defined essentials in this field. Certain backgrounds (such as may be found
in subspecialties within medicine, public health, and nursing,
among others) may have further differentiated skills that can
be applied effectively in specific disaster events.
EMERGENCY MANAGEMENT ASPECTS OF DMPHP
To prepare for a disaster or PHE, health professionals should
learn the essential elements of community and institutional disaster plans, as well as federal and local incident command. Plans
should include assessment and characterization of surge capacity assets in the public and private health response sectors, and
the extent of their potential assistance in an emergency. Health
responders must be knowledgeable about institutional, community, and regional response systems and their respective roles
within those structures, including policies and procedures for
mobilizing and integrating civilian, military, and other response resources and assets. Health responders also require
knowledge of administrative regulations, safety and security issues, systems engineering, decontamination protocols, forensics, use of personal protective equipment, evacuation procedures, continuity planning, and utilization of public information
and communication networks.
CLINICAL ASPECTS OF DMPHP
In a disaster, clinicians should be prepared to apply and adapt
their usual practices and behaviors, as appropriate, to the recognition, diagnosis, triage, and treatment of seriously injured
or ill people, with limited situational awareness and resources.
They may be required to apply their accustomed clinical skill
set to the assessment and management of people of all ages under a variety of scenarios. At times, they may be called upon to
fill nonclinical response functions such as moving patients during a hospital evacuation. Although clinicians specializing in
DMPHP should have a universal core knowledge and skill set,
understanding the limitations of one’s individual clinical capabilities is equally important.
Clinicians and other health responders need to be familiar with
medical and mental health implications of the spectrum of diDisaster Medicine and Public Health Preparedness
sasters and PHEs and recognize that people may have been exposed to nonconventional agents as the source of unusual presentations. This requires competence in identifying the health
consequences and treatment of exposure to biological, chemical, radiological, nuclear, and incendiary agents. In a mass casualty situation, health system responders may need to take personal histories, conduct physical examinations, and manage
injured or ill people in potentially hazardous environments with
limited medical supplies and equipment while maintaining situational awareness. They should be prepared to follow appropriate diagnostic procedures to confirm or refute possible etiologies, and in some cases begin treatment based solely on
symptoms and signs. Implementation of safety and protection
principles to prevent harm to themselves and others is critical,
as is sensitivity to the diagnostic and treatment plans for psychological and behavioral as well as physical trauma.
All health responders should know the ethical and legal structures that govern response to disasters and PHEs, while maintaining the highest possible standards of care under extreme conditions. This encompasses their rights and responsibilities to
protect themselves and treat others (including those with potentially contagious diseases), with consideration of issues such
as professional liability, worker protection and compensation,
licensure, and privacy.
PUBLIC HEALTH ASPECTS OF DMPHP
There are many health system responders who are not clinicians that need to demonstrate proficiency in public health preparedness and response. Although they may not be involved
directly in casualty assessment and treatment, the work of these
responders is critical to meeting the health needs of affected
populations. Actions and interventions that must be considered following the onset of a disaster or PHE include health
monitoring and surveillance; outbreak investigation; isolation
and quarantine; population-based triage; mass sheltering and
feeding; vector control; environmental monitoring; ensuring
the safety of food and water supplies; responder and health care
worker protection; basic sanitation and hygiene; countermeasure stockpiling, distribution, and dispensing; and management of mass fatalities. This requires basic knowledge of descriptive and analytical epidemiology, laboratory science,
environmental and occupational health, infection control,
nutrition, effective communication practices and the social
Health professionals who have direct roles in disaster response
should be able to support surveillance efforts and explain the
rationale and procedures for case reporting. The basics of risk
communication and health messaging will be essential for communicating with affected individuals, their families, and the media regarding exposure risks and potential preventive measures. Finally, just like clinicians, public health responders should
know the moral, ethical, and legal issues that are relevant to
the management of affected populations and communities and
the basic legal framework for public health. They should be fa103
©2010 American Medical Association. All rights reserved.
miliar with ethical principles that underlie decision making in
disasters, such as those impacting allocation of scarce resources.
DEVELOPING CORE CURRICULA
AND TRAINING PROGRAMS IN DMPHP
Recent disasters and terrorist events have increased federal interest and attention for the integration of DMPHP into clinical and public health education. In 2006, passage of the
Pandemic and All-Hazards Preparedness Act (PAHPA; PL 109417) created important opportunities to build upon and standardize disaster preparedness education through various programs at the federal, state, and local levels.9 PAPHA called for
the development of integrated, interdisciplinary, and consistent public health and medical disaster response curricula, which
would be available to health professionals and health professional schools. Section 304 of the Act states that “the Secretary of Health and Human Services (HHS), in collaboration
with the Secretary of Defense, and in consultation with relevant public and private entities, shall develop core health and
medical response curricula and training by adapting applicable existing curricula and training programs to improve responses to public health emergencies.”
In 2007, HSPD-21 called for federal interagency action and cooperation to ensure that core public health and medical curricula and training developed pursuant to PAHPA address the
needs to improve individual, family, and institutional public health
and medical preparedness and to develop a mechanism to coordinate public health and medical disaster preparedness and response core curricula and training across executive departments
and agencies, to ensure standardization and commonality of knowledge, procedures, and terms of reference within the federal government that also can be communicated to state and local government entities, academia, and the private sector.
To lead federal efforts for the development and delivery of core
curricula and training related to medicine and public health
in disasters, HSPD-21 specifically calls for the establishment
of an academic joint program for disaster medicine and public
health, housed at a National Center for Disaster Medicine and
Public Health, at the Uniformed Services University of the
Health Sciences. The HHS and Department of Defense are required to carry out respective civilian and military missions
within this program. In 2009, federal directives aimed at education and training in disaster medicine and public health began to be addressed by the Federal Education and Training Interagency Group. The Group, as authorized under PAHPA,
serves as a coordinating body for the delineation of core competencies and education and training standards across federal
departments and agencies, as well as state and local government entities, academia, and the private sector in relation to
public health emergency and disaster response. The primary
charge of this group is to identify and implement a national strategy for the education and training of health professionals in disaster-related medicine and public health. The recently re104
Disaster Medicine and Public Health Preparedness
leased National Health Security Strategy further emphasizes the
importance of professional training, competencies, and standards to help ensure the attainment and maintenance of proficiency by the disaster response workforce.10
In 2009, the American Medical Association (AMA) House of
Delegates adopted policy calling for formal education and training in DMPHP to be incorporated in all medical school and
residency programs.11 This initiative includes integration of core
curricula and training programs to provide a consistent learning experience for physicians-in-training and other students in
the health professions. Such training requires consensus on competencies and learning objectives to ensure that course content is based on a well-defined and testable body of knowledge, skill set, and methodology.
To prepare health professionals to respond appropriately and
to assist professional schools and continuing education programs to meet this challenge, various organizations and universities have developed competencies for health professionals and other emergency responders.12-20 To date, many of these
efforts have been limited primarily to individual specialties or
targeted professionals. This has resulted in a lack of definitional uniformity across professions with respect to education,
training, and best practices, thus limiting the establishment of
DMPHP at an operational level. To better integrate competencies across all health specialties and professions, a consensusbased educational framework and competency set was published from which educators could devise learning objectives
and curricula in DMPHP that are tailored to the needs of all
health professionals.21 The framework includes the delineation of 7 core learning domains and 19 core competencies
(Table), as well as 73 specific subcompetencies targeted at 3
broad health personnel categories. A learning matrix also was
developed to allow disaster health educators and accreditation
entities to incorporate the competencies at any desired proficiency level.
The DMPHP educational framework identifies 3 broad, yet distinct, personnel categories to encompass all health professionals:
informed workers/students, practitioners, and leaders. Personnel
are expected to perform at different levels of proficiency depending on their experience, professional role, level of education, or
job function across the core competencies and subcompetencies.
The framework allows for all health professions to be represented in each category, and recognizes the diversity of expected
job functions and educational requirements for each health profession involved in disaster prevention, mitigation, response, and
recovery. The health personnel categories establish increasing standards for each core competency. The proposed competency set
and educational framework were endorsed by the National Disaster Life Support Education Consortium in May 2008. (The Consortium is an unincorporated association jointly sponsored by the
AMA and National Disaster Life Support Foundation, Inc, convened by the AMA. It consists of 75 professional organizations
and distinguished individuals with interest and expertise in diVOL. 4/NO. 2
©2010 American Medical Association. All rights reserved.
saster medicine and public health preparedness, as well as experts in professional education and curriculum development, all
of whom participate on a voluntary basis.)
Although this vision has been endorsed by many, the implementation is not clear. Decisions about exactly which competencies form the common core for all members of all professions considered to be health professions have not been made.
Work that is under way to meet the PAHPA mandate for public health education, for example, does not presume that all public health workers will possess the skills to diagnose individual
patient conditions or initiate individual therapies. Similarly,
it is unlikely that all licensed physicians and nurses will be expected to have the skills to diagnose and mitigate contamination of a municipal water supply. All of these need a common
base that is respectful of all contributions to health and maximizes the efficiency of the health contribution to community
readiness, response, and recovery. The DMPHP educational
framework provides the best effort to date to facilitate decisions about how best to proceed.
If DMPHP is to be a recognized discipline, then a core standard curriculum must be defined and mastery demonstrated by
all who wish to be acknowledged as proficient or “specialist”
in this field. Anything less perpetuates the insular “silo” approach that continues today. Specific subcompetencies appropriate for public health practitioners, or certain medical and
nursing practitioners, must be considered in addition to the core
competencies, however they are defined.
BUILDING THE DMPHP RESEARCH BASE
The effects of conven …
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