A key lesson from the Thunderstorm Asthma emergency is the importance of setting the right strategic objective to create a 'unity of effort' across the multiple agencies involved in the response. This was the most important contribution a central leadership body could make under the circumstances. Here we examine this question further.
The thunderstorm created a mass casualty event that stretched 000 call takers, the ambulance service, and hospital emergency departments to the full, with thousands of patients presenting with breathing difficulties. A good account of the incident is available from the Inspector General For Emergency Management (IGEM) Report here.
Each of the main agencies responded by mobilising their full capacity, including a surge capability, in order to meet the demands of the situation. In addition, an Incident Management Team was established to lead and coordinate the response at an inter-agency level, as set out in the State Health Emergency Response Plan (SHERP). Our question here is - what did this IMT have to contribute, given every agency was already going flat out ?
The answer of course is - 'to provide strategic leadership', but what does this mean in practice ? A look at the HCD Framework provides us with an indication -
If we examine briefly each of the elements within the Framework we get the following picture.
Situational Awareness - each agency had an idea of their own immediate position, the emergency department of a hospital for example knew how many patients were waiting for treatment at their location. The challenge was to collate and disseminate an overall perspective of the incident to assist on-scene managers and decision makers with the decisions they had to take - whether to divert ambulances for example.
Organisational Inputs - this includes the drawing on memorandums of understanding to bring in additional resources, such as from the private sector.. This was done quite effectively.
Situation Understanding - this was a major challenge, as a thunderstorm asthma event was unprecedented on this scale and it took some time before a clear idea of the nature and scale of the incident emerged. This could only be done at a central level, on the basis of an overview of all the information coming in.
Desirable Outcomes - Setting overall objectives to allow on scene decision makers to set immediate priorities and goals, and also to determine whether they were getting on top of the situation or required additional resources. More on this below.
Decision Making - Here we have the IMT's own decision making less in mind than that of its subordinates, setting these up for success rather than failure. This follows directly from the previous point on objectives setting.
Consequences - This is where the strategic component can be seen most clearly. The surge capacity could only be sustained for a short period of time, 24-48 hours at most. If the incident looked likely to continue or even escalate beyond that period, urgent steps needed to be taken to prepare for that contingency.
All of these functions were critical, but in this incident one stands out - the setting of a strategic objective to pull the entire response together, to create a unity of effort across all agencies, align the allocation of scarce resources, and shape decision making at all levels. This could be done through a single concept - TRIAGE.
In this diagram, taking from Avoiding Catastrophe's training module in Incident Management based on this event, we see this single overarching objective from four perspectives - what it meant for casualty management, for overall incident control, and for response agencies both pre-hospital and hospital.
The benefit of this single strategic objective lay in its ability to shape DECISION MAKING at all levels. For casualties it facilitated a self-triage process, with directions on where to get an appropriate level of assistance, for the IMT in tracking how the response was going overall and where available resources should be sent, and for agencies on who to send further along the chain - 000 takers on who needed an ambulance, ambulance crews on who to transport to hospital, emergency departments on who treat first.
The key principle lay in the idea that those who really needed treatment received it, which meant filtering out those that didn't. This was the critical challenge, and the most important performance indicator as to how well the response was being been conducted. One of the best examples of this was the role of community pharmacies, and their association, who stayed open late on the first evening and offered thousands of patients suffering breathing difficulties with another option from calling an ambulance. They also coordinated the distribution of asthma puffers once stocks started running low.
Triage is a well-established principle in mass casualty incident management, so this is not a novel suggestion. What is instructive from this case is the way it highlights how a single overarching objective can play an organising role across a complex, multiagency incident. Finding such a principle is not always easy, but if one is available, then deploying it in this manner is a critical function on the part of the leadership team in overall charge of the response.
This article runs alongside Avoiding Catastrophe's training program in Incident and Emergency Management. For more information about this training, and how it might apply in your context, contact us at editor@avoidingcatastrophe.com