基层突发公共卫生事件应急体系应对能力评估工具的开发、应用与评估模型的探索性研究
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摘要
2003年上半年突如其来的SARS爆发,给我国的公共卫生体制带来了前所未有的挑战。SARS疫情的蔓延,充分暴露了我国公共卫生事业发展滞后、应对突发公共卫生事件机制不健全、重大疫情信息监测报告网络不完善、应急救治能力不足、疾病预防控制工作薄弱等问题。因此,围绕公共卫生长期需求,构建适应我国国情的突发公共卫生事件应急处理机制和公共卫生的危机管理机制,已成为当前一个迫切需要解决的课题。
1、研究目的
通过现场调查(定性研究和定量研究相结合)和专家访谈相结合的研究方法,提出适合我国国情的突发公共卫生事件应急体系的评价体系和指标,构建应急体系能力评估模型。具体目标是:
(1)提出适合我国现有应急体系应对能力评价框架及指标体系;
(2)开发应急体系应对能力评估工具,构建应急能力评估模型
(3)描述我国基层应急体系应对能力建设现状
(4)评价现有应急体系的能力状况,提出改善能力、完善应急体系建设的策略与建议。
2.研究内容与方法
通过文献综述、专家咨询、专家论坛等定性研究的方式,构建系统评价我国突发公共卫生事件应急体系能力的评估框架和评估指标体系,并根据文献描述和专业知识,将定量的指标转化可以获得的评估问卷。
在全国范围内抽取不同经济状况的研究现场进行现场评估和应用。采用自行开发和设计的、经过信度和效度评价的评估工具了解能力建设现状,并在现场研究基础上,采用统计学方法探索能力评估模型。
定量收集的资料采用Epidata3.1双遍录入,使用SPSS11.0对资料进行统计学分析;定性研究的资料采用归纳的方法进行分析。
3.研究结果
3.1基层突发公共卫生事件应急体系能力评估工具的开发
突发公共卫生事件应急体系能力评估应该以县级基层单位的评估为起点和核心。基层突发公共卫生事件应急体系能力评估工具的开发应该立足于基层突发公共卫生事件应对体系中的业务技术部门,以机构为单位开展评估。基层突发公共卫生事件应急体系能力评估需涵盖保障能力、预警能力(识别与判断能力)、应急能力(应急处理、现场救治、救援、控制能力)和评估机制四个方面。
县级疾病预防控制中心和综合医院的评价工具包括①预案、规章制度、操作手册等文件、②监测与预警、③实验室检测、④应急队伍及专家库、⑤信息交流与发布、协调机制、⑥演练与培训、⑦应急处置能力和⑧储备八个维度,而乡镇卫生院则着重评估基本卫生服务、监测与预警、实验室检测和应急能力四个方面。县CDC、县医院以及乡镇卫生院的评估工具问卷分别包括了211、184和54个评估指标。
研究开发的问卷的内部一致性较高,总体评价系数均在0.95以上。除了CDC的“信息”维度的系数为0.5833外,其他维度的系数均大于0.6。在CDC和综合医院的问卷中分别有5个(62.15%)和7个(86.75%)的克朗巴赫系数α值在0.8以上。Spearman秩相关系数检验结果显示各调查问卷的维度之间的相关性较好。
3.2基层突发公共卫生事件应急体系能力建设现状
3.2.1疾病预防控制中心
调查的18家县级疾病预防控制中心(CDC)平均最大服务半径为81.36Km,平均在职职工61人,以卫生专业技术人员为主(79.8%),学历普遍较低(主要是中专及以下),而职称多为中级及初级。实验室工作人员占在岗职工总数的6.84%-25%不等。
调查地区的CDC均制定和颁布了突发公共卫生事件的应急预案,但是仅有25.00%的单位提供的预案满足《条例》的要求,预案涵盖的内容不全面,没有形成体系;研究地区完成了辖区内尤其是传染病的监测体系建设,有89.90%的机构对收集的资料开展流行病学描述性分析,有75.00%的机构可以开展趋势分析,有2家机构仅能在突发公共卫生事件发生时做简单的风险分析。监测信息迟报、漏报现象依然存在,传染病的及时率最低为4.23%,传染病漏报率最高达到27.10%不等。县级CDC的实验室还是主要以血液标本为主,开展ELISA、培养等工作。
各调查单位都设置了突发公共卫生事件应急管理部门,其中常设机构占66.67%,均能在突发事件发生时成立应急队伍,有66.67%的机构备有专家资源库。各单位针对重点传染病的各种能力包括监测、识别、应急处理等较强,但是针对原因不明疾病、化学物质中毒、放射物质泄露与伤害等突发公共卫生事件的能力较为薄弱。各单位工作人员对应对突发公共卫生事件的信心普遍不足,仅有30-40%的工作人员认为本单位具有相应的独立应对能力。
各单位均已建立了信息沟通、交流与信息发布的制度、长效的培训和演练机制,但是培训内容单一,局限在重点传染病上。
能力评分发现,监测与预警方面的得分较高(90.65),而储备的应答情况最差(49.14),不同经济状况地区不同维度得分差别无统计学意义。
3.2.2县综合医院
调查的17家县级综合医院中,专业技术人员(医生、护士和医技人员)约占医院总人数的82.30%(65.09-92.20%),平均医护比为1:1.06,有三分之二的医院病床处于超负荷状况。
县级综合医院都拥有预案、重点传染病、突发紧急状况的救助手册和紧急救援方案。有三分之一的医院设置了症状监测点,有83.33%的单位要求医生填写门诊日志。各单位均实现了传染病和突发公共卫生事件的网络直报,仅有71.40%的单位会定期分析收集的资料。
县医院能够成批收治主要传染病、常见疾病和重大食物中毒的患者,但是对于化学性物质引起的伤害、放射伤害以及自然灾害引起的各种疾患和伤害的救治能力有限,尚不能成批收治外伤患者;不同省份和地区之间,传染病应对能力不同;有15家医院(83.33%)建立了人力资源储备库,但是仅有1家(5.56%)医院储备了心理医生,2家医院(11.12%)储备了家庭护士;紧急状态下各医院的加床能力较弱,平均可以增加10.07%的病床;没有一家医院的实验室加入区域内的公共卫生实验室网络。
县级医疗机构与卫生行政部门、上级医疗单位之间已经形成了良好的信息沟通和交流机制,但是与疾病预防控制中心、卫生监督所乃至辖区内其他医疗机构之间的信息共享机制不完善;各地建立了长效的培训和演练机制。
从县级综合医院不同维度得分情况来看,培训、监测与预警能力的应答情况较好,而储备的应答情况最差,分别为73.50、65.37和44.93分。
3.2.3乡镇卫生院
研究共计调查54所乡镇卫生院。乡镇卫生院卫生技术人员学历和职称普遍较低,基本以中专及以下学历、初级职称为主,分别占调查人数的67.69%和76.15%,基本没有本科以上学历和高级职称的人员。调查地区均建立了完善的计划免疫接种网络,实现了县-乡-村三级管理网络,“四苗”覆盖率均在90%以上。乡镇卫生院均建立了传染病信息管理系统,59.23%的乡镇卫生院实现了传染病网络直报。被调查的乡镇卫生院基本不具备突发公共卫生事件的急救能力。基础设施较差、人力资源匮乏、监测预警能力有限、监测网底脆弱等问题严重制约和影响着乡镇卫生院基本卫生服务以及应对能力的发展。
3.3应急能力评估模型的探索性研究
采用本研究现场收集的相关资料,使用因子分析的方法初步建立了基层应急能力的评估模型。研究发现,疾病预防控制中心、县级综合医院的综合能力主要由应急因子、识别因子和保障因子组成,计算公式为:F_(CDC)=0.608F_(应急)+0.242F_(识别)+0.15F_(保障)F_(hospital)=0.718F_(应急)+0.156F_(保障)+0.126F_(识别)
3.4应急能力发展对策研究
定性研究发现,我国已经初步建成了突发公共卫生事件应急体系的基本框架,但地区间和系统内发展不均衡、职能定位不明确、机制不健全的问题普遍存在。聚类研究发现,无论是医院还是疾病预防控制中心均可以归为四类,不同类别能力特点不同,中心位置分布不同,具体表现为(1)综合能力高且单项能力发展均衡,但是单一能力评价平平;(2)三个评价因子各有所长,分别表现为保障机制完善突出的、识别能力强、应急能力强三类。因而在地区能力发展策略制定的时候,应该优先解决能力评估中发现的问题和不足之处,提高基层突发公共卫生事件应急体系综合能力
4.结论
研究开发的能力评估工具包括了保障、预警(识别与判断能力)、应急(应急处理、现场救治、救援、控制能力)和评估机制四个层面,预案与规章制度、监测与预警、实验室检测、应急队伍及专家库、信息交流、发布与协调机制、演练与培训、应急处置能力和储备等八个维度,具有良好的信度和效度,可用于基层应急体系的能力评估。基层突发公共卫生事件应急体系综合应对能力综合反应在应急、识别和保障三个角度,这三个因子构成了基层综合能力三角模型。
我国目前已经基本形成了县-乡-村三级突发公共卫生事件监测网络,初步形成突发公共事件应急预案框架体系,大大提高处置突发事件、保障公共安全的能力。但是,卫生投入、人力资源、实验室仪器设备、监测网络建设情况等是影响基层突发公共卫生事件应急体系应对能力的主要影响因素,能力发展不均衡是各地普遍存在的问题。
基层单位在今后的能力发展中,应该重点关注能力评估后发现的薄弱环节。对于综合能力发展均衡的机构应该在保持现有优势的基础上稳固发展;对于保障机制落后的机构,应该建立和完善各种规章制度,强化应急机制的建设;对于识别能力落后的机构,应该在今后的资源配置中加大对实验室、监测网络的建设,在人才培养中应该进一步提高监测数据的分析和利用能力;对于应急能力薄弱的机构,应该通过培训、演练等方式提高应急队伍的应急意识和应急能力。
Background
The outbreak of severe acute respiratory syndrome(SARS),in the first 6 months in 2003,was not only a huge disaster to people's life and health,but also a heavy attack to China's economy,which disclosed the weakness of the public health system, including the poor infrastructures,scarce human resources and inadequate capacity. How to respond to public health emergencies swiftly and properly has become an unprecedented challenge to China's public health.An important lesson from SARS outbreak is that inadequate surveillance and response capacity can result in disease epidemic all over the country,and cause mass panics in communities,furthermore, endanger the national public health security.To meet the long-term needs of public health and social development of China,it is in urgency to establish a comprehensive response system and crisis management mechanism for public health emergencies.
Objective
The general objective of this study is to develop tailored assessment tool for public health emergency response system in China.Specifically,through field investigation and qualitative interviews
1.to create framework and indicators for the assessment of public health emergency response system using literature review,key informatics interview and theme forum;
2.to develop tailored tools and models for the assessment of public health emergency response system;
3.to apply the assessment tools for describing and understanding the capability of public health emergency response system in county level health facilities of rural China;
4.to identify the weaknesses and pitfalls of current public health emergency response system,and to provide policy recommendations for its improvement.
Methodology
Qualitative methods including literatures review,key informatics interview and experts' forum were applied to set up the framework of the assessment and index system for Public Health Emergency Response System,and to develop the assessment tools including questionnaires and interview guideline.
Field investigations using structured questionnaires were carried out to understand the current situation of Public Health Emergency Response System with regard to function,composition,infrastructure,capacity,and system assurance,etc.at county level.The questionnaires were designed specifically for this study,and the eliability and validity of the questionnaires were tested before field survey.National experts and health/public health professionals from local health bureau,center of disease control and prevention,county hospital,township hospital were interviewed during study period.Models for capacity evaluation were generated based on the data collected from the field investigation.
All the quantitative data were entered into the database created through Epi-data 3.1,and were analyzed with SPSS 11.0.Content analysis,with an inductive approach, was used in qualitative data analysis.
Results
1.The structure of the index system for public health emergency response system
The capability assessment set the county-level unit of the Public Health Emergency Response System as the starting point and target.The development of assessment tools had based on the duties,responsibilities and functions of each sector in the Public Health Emergency Response System in county.Data were collected from the responsible person in the relevant sections.The index system of capability assessment for county-level Public Health Emergency Response System had been designed to cover the system assurance,early warning(ability to identify and judge), emergency response(emergency,on-site treatment,rescue and control) and the mechanism of assessment.
For the center for disease control and prevention at county-level and county hospitals,the ccomprehensive assessment index system was constructed with eight dimensions,i.e.,(1) protocols,rules,regulations,operating manuals,(2) surveillance and alert,(3) laboratory confirmation,(4) emergency response team and experts,(5) information communication,dissemination and coordination,(6) training and drills,(7) rightness in action and(8) reserve.For the township-level hospitals,the index system was designed to focus on the capability of essential health care service,disease surveillance and early warning,laboratory testing,and response.The questionnaires for county CDC,county hospital and township-level hospitals consisted of 211,184 and 54 indicators respectively.
The internal consistency of each questionnaire was high and the overall Cronbach'sαcoefficients was higher than 0.95.Except for dimension of information communication and dissemination,Cronbach'sαcoefficient of other dimensions was higher than 0.60.For the questionnaire developed CDC and general hospitals,5 (62.15%) and 7(86.75%)Cronbach'sαcoefficients were higher than 0.8 respectively. Spearman correlation coefficients test showed that the correlation between dimensions of the questionnaire was also high.
3.Capability of the studied Public Health Emergency Response System
3.1 County CDC
Totally 18 county CDCs were be investigated of which the mean of maximum service distance was 81.36 km.The average number of employees of CDC was 61 with 79.8%being healthcare-related technicians.Majority of the employees had an education of secondary school,and did not have a chief or associate chief title.The proportion of the staff working in the laboratory varied from 6.84%to 25.00%.
All the sampled CDCs had developed and announced at least one Public Health Emergency Preparedness Plan in which only about 25%plans met the requirements of the "national regulation".However,these plans did not be well development since the structure of the plan was uncompleted and the coverage of the contents was incomprehensive.Although in the studied counties,a disease surveillance system has already been set up,the application of the data was limited.About 89.9%of the CDCs could do epidemiological description,and 75%could apply for trend analyses,but only two CDCs could do some kind of risk assessment when a public health emergency actually happened.There were the missed or delayed reports in surveillance,The promptness of infectious disease report could be low to 4.23%and the omission rates for infectious disease could be high to 27.10%in the sampled study sites.The main laboratore tests carried out in county CDC were bacterial culture and ELISA using blood samples.
All of the investigated counties had set up their own department of public health emergency management and 66.7%of them being standing bodies.It was found that the Public Health Emergency Response System at county level was able to organize emergency team.Of the 18 counties,12 had resource backup for experts.The system was strong in responding to major infectious disease emergencies,including surveillance,case identification,on-site handling,but weak to unknown disease, chemical poison,radioactive material leak and injury.Results from the interviews showed that public health staffs were not very much confident in the capability of response to public health emergency of their own health sectors.
The function of information communication and exchange for public health emergency response had been well established not only within disease control and prevention system,but also betweeh CDCs and other health sectors.The regulations for information release were also set up in the study areas.Although the long-term rules for training and practicing had been developed,the content was constrained mainly for the major infectious diseases.
When measuring the capability of the system using score,the highest score was given to the capability of surveillance and early warning(90.65),and the lowest score was seen at capability of reserving(49.14 of 100).There was no significant difference in scores for each dimension between areas with different economic status.
3.2 County hospital
Of all the employees in the 17 investigated county hospitals,the average proportion of healthcare professionals was 82.30%varied from 65.09%to 92.20%. The mean ratio of doctors to nurses was 1 to 1.06.About two-third of the sampled hospitals had an over-use of hospital beds.
All the county general hospitals had contingency plans for public health emergencies,on-site treatment guideline for major infectious disease and other public health emergency events.One-third of the hospitals had set up symptom surveillance spot and 83.3%of the hospitals requested that the clinical physician should complete the log for outpatient visits,and registration for patients with major infectious diseases.All the county hospitals had installed internct-based infectious diseases surveillance and public health emergency reporting system.However,only 71.40%of the hospitals could analyze data regularly.
All the hospitals were able to respond to the emergencies in major infectious disease,regional priority disease and food poisoning,in terms of laboratory tests, medical personnel gathering and on-site rescue.However,the capacity for responding to emergencies due to chemical substances,radiation and natural disasters were not as good as to above events.The capacity for response to infectious disease varied between provinces.Overall,15 hospitals had established labor resources pool,of which only one(5.56%) had reserved for psychiatrist and two(11.12%) for family nurses.The possibility of providing extra hospital beds in emergency was low,at an average of 10%.None of the county hospital laboratories had joined the regional public health laboratory network.
The communication between county hospitals and local health bureau,and up-level hospitals were fine,actually much better than that between county hospital and CDC,health inspection,as well as other medical institutions.Long-term training and practicing mechanism had also been regulated in county hospitals.
With regard to dimentions,in county hospitals,the scores for dimention of trainging,surveillance and early warning,and reserve were 73.50,65.37and 44.93 respectively.
3.3 Township hospital
The employees had relatively poor education and low position title in all 54 township hospitals.Of them,67.69%and 76.15%had an education of secondary school and primary title respectively.The three-tier network from village to town to county for expanded planned immunization(EPI) had already been built in all the study sites with a coverage rate of 90%and higher for the EPI vaccines.All the township-level hospitals had had a infectious disease management system,however only 59.23%of these hospitals used internet based report.It was obvious that the township-level hospitals were weak in medical rescue for emergency.The main problems were poor infrastructure,insufficient human resources,and weak surveillance network.
4.Capacity assessment models
Based on the quantitative data collected in this study,capacity assessment models were established through factor analysis.Emergency,identification and protection,these 3 factors constitutes the triangular model to describe and evaluate the capability of county-level Public Health Emergency Response System.
F_(CDC)=0.608F_(emergency)+0.242F_(identification)+0.15F_(assureance)
F_(hospital)=0.718F_(emergency)+0.156F_(assurance)+0.126F_(identification)
5.Capacity development strategy
The basic framework of public health emergency response system had been built up in China.However,the unbalanced development between regions,the undefined and varied functions,unclear responsibilities of each sector,and uncompleted mechanism of the system were observed from both the qualitative interviews and quantitative investigations.Cluster analysis showed that both CDCs and county hospitals could be classified as four clusters with different capacity characters.The first is the units that had good integrated capacity,balanced score for all dimentions but each dimention is not outstanding,The other 3 clusters are the unites with special strengths in one or more dimentions Such as comprehensive in system composition, excellent in identification cases or evens,or strong capacity in on-site emergency handling.Therefore,it is of great importance to identify the problems and weaknesses of the system first when develop regional policies and strategies,to improve the general capability of the public health emergency response system.
Conclusion
The index system of capability for county-level Public Health Emergency Response System,developed by this study,covers the capability of system assurance, early warning(ability to identify and judge),emergency response(emergency,on-site treatment,rescue and control) and the mechanism of assessment,etc.The questionnaire consisted of eight dimensions including 1)plans,rules,regulations, operating manuals,2)surveillance and alert,3) laboratory testing,4) emergency team and experts,5)communication,dissemination,and coordination,6)training and drills, 7)capability of response and 8)reserve.The questionnaires are reliable and valid for public health emergency system at county level.
Emergency,identification and protection,these 3 factors constitutes the triangular model to describe and evaluate the capability of county-level Public Health Emergency Response System.
At present,the three-tier Public Health Emergency Response System has been available in rural counties of China with documented preparedness plan and basic function on responses to public health emergency,which to some extent can handle the emergencies and secure the publics.Nevertheless,the capability or function of the Public Health Emergency Response System is largely influenced by Public health budgets,human resources,laboratory equipment,and surveillance network.
Weakness of the system recognized in this study should have huge impacts on the improvement of capability of the system.For the units having stronger integrated capability,balance should be maintained during the development of the whole system. For the units having poor assurance capability,legislations and preparedness should be the key component for further development.For the units having poor identification capability,more resources should be allocated to the surveillance network and laboratory,and capacity in data analysis and application should also be strengthened.For the units having poor response capacity,training and practicing are extremely important to enhance the awareness and accelerate the responses for public health emergencies.
1、研究目的
通过现场调查(定性研究和定量研究相结合)和专家访谈相结合的研究方法,提出适合我国国情的突发公共卫生事件应急体系的评价体系和指标,构建应急体系能力评估模型。具体目标是:
(1)提出适合我国现有应急体系应对能力评价框架及指标体系;
(2)开发应急体系应对能力评估工具,构建应急能力评估模型
(3)描述我国基层应急体系应对能力建设现状
(4)评价现有应急体系的能力状况,提出改善能力、完善应急体系建设的策略与建议。
2.研究内容与方法
通过文献综述、专家咨询、专家论坛等定性研究的方式,构建系统评价我国突发公共卫生事件应急体系能力的评估框架和评估指标体系,并根据文献描述和专业知识,将定量的指标转化可以获得的评估问卷。
在全国范围内抽取不同经济状况的研究现场进行现场评估和应用。采用自行开发和设计的、经过信度和效度评价的评估工具了解能力建设现状,并在现场研究基础上,采用统计学方法探索能力评估模型。
定量收集的资料采用Epidata3.1双遍录入,使用SPSS11.0对资料进行统计学分析;定性研究的资料采用归纳的方法进行分析。
3.研究结果
3.1基层突发公共卫生事件应急体系能力评估工具的开发
突发公共卫生事件应急体系能力评估应该以县级基层单位的评估为起点和核心。基层突发公共卫生事件应急体系能力评估工具的开发应该立足于基层突发公共卫生事件应对体系中的业务技术部门,以机构为单位开展评估。基层突发公共卫生事件应急体系能力评估需涵盖保障能力、预警能力(识别与判断能力)、应急能力(应急处理、现场救治、救援、控制能力)和评估机制四个方面。
县级疾病预防控制中心和综合医院的评价工具包括①预案、规章制度、操作手册等文件、②监测与预警、③实验室检测、④应急队伍及专家库、⑤信息交流与发布、协调机制、⑥演练与培训、⑦应急处置能力和⑧储备八个维度,而乡镇卫生院则着重评估基本卫生服务、监测与预警、实验室检测和应急能力四个方面。县CDC、县医院以及乡镇卫生院的评估工具问卷分别包括了211、184和54个评估指标。
研究开发的问卷的内部一致性较高,总体评价系数均在0.95以上。除了CDC的“信息”维度的系数为0.5833外,其他维度的系数均大于0.6。在CDC和综合医院的问卷中分别有5个(62.15%)和7个(86.75%)的克朗巴赫系数α值在0.8以上。Spearman秩相关系数检验结果显示各调查问卷的维度之间的相关性较好。
3.2基层突发公共卫生事件应急体系能力建设现状
3.2.1疾病预防控制中心
调查的18家县级疾病预防控制中心(CDC)平均最大服务半径为81.36Km,平均在职职工61人,以卫生专业技术人员为主(79.8%),学历普遍较低(主要是中专及以下),而职称多为中级及初级。实验室工作人员占在岗职工总数的6.84%-25%不等。
调查地区的CDC均制定和颁布了突发公共卫生事件的应急预案,但是仅有25.00%的单位提供的预案满足《条例》的要求,预案涵盖的内容不全面,没有形成体系;研究地区完成了辖区内尤其是传染病的监测体系建设,有89.90%的机构对收集的资料开展流行病学描述性分析,有75.00%的机构可以开展趋势分析,有2家机构仅能在突发公共卫生事件发生时做简单的风险分析。监测信息迟报、漏报现象依然存在,传染病的及时率最低为4.23%,传染病漏报率最高达到27.10%不等。县级CDC的实验室还是主要以血液标本为主,开展ELISA、培养等工作。
各调查单位都设置了突发公共卫生事件应急管理部门,其中常设机构占66.67%,均能在突发事件发生时成立应急队伍,有66.67%的机构备有专家资源库。各单位针对重点传染病的各种能力包括监测、识别、应急处理等较强,但是针对原因不明疾病、化学物质中毒、放射物质泄露与伤害等突发公共卫生事件的能力较为薄弱。各单位工作人员对应对突发公共卫生事件的信心普遍不足,仅有30-40%的工作人员认为本单位具有相应的独立应对能力。
各单位均已建立了信息沟通、交流与信息发布的制度、长效的培训和演练机制,但是培训内容单一,局限在重点传染病上。
能力评分发现,监测与预警方面的得分较高(90.65),而储备的应答情况最差(49.14),不同经济状况地区不同维度得分差别无统计学意义。
3.2.2县综合医院
调查的17家县级综合医院中,专业技术人员(医生、护士和医技人员)约占医院总人数的82.30%(65.09-92.20%),平均医护比为1:1.06,有三分之二的医院病床处于超负荷状况。
县级综合医院都拥有预案、重点传染病、突发紧急状况的救助手册和紧急救援方案。有三分之一的医院设置了症状监测点,有83.33%的单位要求医生填写门诊日志。各单位均实现了传染病和突发公共卫生事件的网络直报,仅有71.40%的单位会定期分析收集的资料。
县医院能够成批收治主要传染病、常见疾病和重大食物中毒的患者,但是对于化学性物质引起的伤害、放射伤害以及自然灾害引起的各种疾患和伤害的救治能力有限,尚不能成批收治外伤患者;不同省份和地区之间,传染病应对能力不同;有15家医院(83.33%)建立了人力资源储备库,但是仅有1家(5.56%)医院储备了心理医生,2家医院(11.12%)储备了家庭护士;紧急状态下各医院的加床能力较弱,平均可以增加10.07%的病床;没有一家医院的实验室加入区域内的公共卫生实验室网络。
县级医疗机构与卫生行政部门、上级医疗单位之间已经形成了良好的信息沟通和交流机制,但是与疾病预防控制中心、卫生监督所乃至辖区内其他医疗机构之间的信息共享机制不完善;各地建立了长效的培训和演练机制。
从县级综合医院不同维度得分情况来看,培训、监测与预警能力的应答情况较好,而储备的应答情况最差,分别为73.50、65.37和44.93分。
3.2.3乡镇卫生院
研究共计调查54所乡镇卫生院。乡镇卫生院卫生技术人员学历和职称普遍较低,基本以中专及以下学历、初级职称为主,分别占调查人数的67.69%和76.15%,基本没有本科以上学历和高级职称的人员。调查地区均建立了完善的计划免疫接种网络,实现了县-乡-村三级管理网络,“四苗”覆盖率均在90%以上。乡镇卫生院均建立了传染病信息管理系统,59.23%的乡镇卫生院实现了传染病网络直报。被调查的乡镇卫生院基本不具备突发公共卫生事件的急救能力。基础设施较差、人力资源匮乏、监测预警能力有限、监测网底脆弱等问题严重制约和影响着乡镇卫生院基本卫生服务以及应对能力的发展。
3.3应急能力评估模型的探索性研究
采用本研究现场收集的相关资料,使用因子分析的方法初步建立了基层应急能力的评估模型。研究发现,疾病预防控制中心、县级综合医院的综合能力主要由应急因子、识别因子和保障因子组成,计算公式为:F_(CDC)=0.608F_(应急)+0.242F_(识别)+0.15F_(保障)F_(hospital)=0.718F_(应急)+0.156F_(保障)+0.126F_(识别)
3.4应急能力发展对策研究
定性研究发现,我国已经初步建成了突发公共卫生事件应急体系的基本框架,但地区间和系统内发展不均衡、职能定位不明确、机制不健全的问题普遍存在。聚类研究发现,无论是医院还是疾病预防控制中心均可以归为四类,不同类别能力特点不同,中心位置分布不同,具体表现为(1)综合能力高且单项能力发展均衡,但是单一能力评价平平;(2)三个评价因子各有所长,分别表现为保障机制完善突出的、识别能力强、应急能力强三类。因而在地区能力发展策略制定的时候,应该优先解决能力评估中发现的问题和不足之处,提高基层突发公共卫生事件应急体系综合能力
4.结论
研究开发的能力评估工具包括了保障、预警(识别与判断能力)、应急(应急处理、现场救治、救援、控制能力)和评估机制四个层面,预案与规章制度、监测与预警、实验室检测、应急队伍及专家库、信息交流、发布与协调机制、演练与培训、应急处置能力和储备等八个维度,具有良好的信度和效度,可用于基层应急体系的能力评估。基层突发公共卫生事件应急体系综合应对能力综合反应在应急、识别和保障三个角度,这三个因子构成了基层综合能力三角模型。
我国目前已经基本形成了县-乡-村三级突发公共卫生事件监测网络,初步形成突发公共事件应急预案框架体系,大大提高处置突发事件、保障公共安全的能力。但是,卫生投入、人力资源、实验室仪器设备、监测网络建设情况等是影响基层突发公共卫生事件应急体系应对能力的主要影响因素,能力发展不均衡是各地普遍存在的问题。
基层单位在今后的能力发展中,应该重点关注能力评估后发现的薄弱环节。对于综合能力发展均衡的机构应该在保持现有优势的基础上稳固发展;对于保障机制落后的机构,应该建立和完善各种规章制度,强化应急机制的建设;对于识别能力落后的机构,应该在今后的资源配置中加大对实验室、监测网络的建设,在人才培养中应该进一步提高监测数据的分析和利用能力;对于应急能力薄弱的机构,应该通过培训、演练等方式提高应急队伍的应急意识和应急能力。
Background
The outbreak of severe acute respiratory syndrome(SARS),in the first 6 months in 2003,was not only a huge disaster to people's life and health,but also a heavy attack to China's economy,which disclosed the weakness of the public health system, including the poor infrastructures,scarce human resources and inadequate capacity. How to respond to public health emergencies swiftly and properly has become an unprecedented challenge to China's public health.An important lesson from SARS outbreak is that inadequate surveillance and response capacity can result in disease epidemic all over the country,and cause mass panics in communities,furthermore, endanger the national public health security.To meet the long-term needs of public health and social development of China,it is in urgency to establish a comprehensive response system and crisis management mechanism for public health emergencies.
Objective
The general objective of this study is to develop tailored assessment tool for public health emergency response system in China.Specifically,through field investigation and qualitative interviews
1.to create framework and indicators for the assessment of public health emergency response system using literature review,key informatics interview and theme forum;
2.to develop tailored tools and models for the assessment of public health emergency response system;
3.to apply the assessment tools for describing and understanding the capability of public health emergency response system in county level health facilities of rural China;
4.to identify the weaknesses and pitfalls of current public health emergency response system,and to provide policy recommendations for its improvement.
Methodology
Qualitative methods including literatures review,key informatics interview and experts' forum were applied to set up the framework of the assessment and index system for Public Health Emergency Response System,and to develop the assessment tools including questionnaires and interview guideline.
Field investigations using structured questionnaires were carried out to understand the current situation of Public Health Emergency Response System with regard to function,composition,infrastructure,capacity,and system assurance,etc.at county level.The questionnaires were designed specifically for this study,and the eliability and validity of the questionnaires were tested before field survey.National experts and health/public health professionals from local health bureau,center of disease control and prevention,county hospital,township hospital were interviewed during study period.Models for capacity evaluation were generated based on the data collected from the field investigation.
All the quantitative data were entered into the database created through Epi-data 3.1,and were analyzed with SPSS 11.0.Content analysis,with an inductive approach, was used in qualitative data analysis.
Results
1.The structure of the index system for public health emergency response system
The capability assessment set the county-level unit of the Public Health Emergency Response System as the starting point and target.The development of assessment tools had based on the duties,responsibilities and functions of each sector in the Public Health Emergency Response System in county.Data were collected from the responsible person in the relevant sections.The index system of capability assessment for county-level Public Health Emergency Response System had been designed to cover the system assurance,early warning(ability to identify and judge), emergency response(emergency,on-site treatment,rescue and control) and the mechanism of assessment.
For the center for disease control and prevention at county-level and county hospitals,the ccomprehensive assessment index system was constructed with eight dimensions,i.e.,(1) protocols,rules,regulations,operating manuals,(2) surveillance and alert,(3) laboratory confirmation,(4) emergency response team and experts,(5) information communication,dissemination and coordination,(6) training and drills,(7) rightness in action and(8) reserve.For the township-level hospitals,the index system was designed to focus on the capability of essential health care service,disease surveillance and early warning,laboratory testing,and response.The questionnaires for county CDC,county hospital and township-level hospitals consisted of 211,184 and 54 indicators respectively.
The internal consistency of each questionnaire was high and the overall Cronbach'sαcoefficients was higher than 0.95.Except for dimension of information communication and dissemination,Cronbach'sαcoefficient of other dimensions was higher than 0.60.For the questionnaire developed CDC and general hospitals,5 (62.15%) and 7(86.75%)Cronbach'sαcoefficients were higher than 0.8 respectively. Spearman correlation coefficients test showed that the correlation between dimensions of the questionnaire was also high.
3.Capability of the studied Public Health Emergency Response System
3.1 County CDC
Totally 18 county CDCs were be investigated of which the mean of maximum service distance was 81.36 km.The average number of employees of CDC was 61 with 79.8%being healthcare-related technicians.Majority of the employees had an education of secondary school,and did not have a chief or associate chief title.The proportion of the staff working in the laboratory varied from 6.84%to 25.00%.
All the sampled CDCs had developed and announced at least one Public Health Emergency Preparedness Plan in which only about 25%plans met the requirements of the "national regulation".However,these plans did not be well development since the structure of the plan was uncompleted and the coverage of the contents was incomprehensive.Although in the studied counties,a disease surveillance system has already been set up,the application of the data was limited.About 89.9%of the CDCs could do epidemiological description,and 75%could apply for trend analyses,but only two CDCs could do some kind of risk assessment when a public health emergency actually happened.There were the missed or delayed reports in surveillance,The promptness of infectious disease report could be low to 4.23%and the omission rates for infectious disease could be high to 27.10%in the sampled study sites.The main laboratore tests carried out in county CDC were bacterial culture and ELISA using blood samples.
All of the investigated counties had set up their own department of public health emergency management and 66.7%of them being standing bodies.It was found that the Public Health Emergency Response System at county level was able to organize emergency team.Of the 18 counties,12 had resource backup for experts.The system was strong in responding to major infectious disease emergencies,including surveillance,case identification,on-site handling,but weak to unknown disease, chemical poison,radioactive material leak and injury.Results from the interviews showed that public health staffs were not very much confident in the capability of response to public health emergency of their own health sectors.
The function of information communication and exchange for public health emergency response had been well established not only within disease control and prevention system,but also betweeh CDCs and other health sectors.The regulations for information release were also set up in the study areas.Although the long-term rules for training and practicing had been developed,the content was constrained mainly for the major infectious diseases.
When measuring the capability of the system using score,the highest score was given to the capability of surveillance and early warning(90.65),and the lowest score was seen at capability of reserving(49.14 of 100).There was no significant difference in scores for each dimension between areas with different economic status.
3.2 County hospital
Of all the employees in the 17 investigated county hospitals,the average proportion of healthcare professionals was 82.30%varied from 65.09%to 92.20%. The mean ratio of doctors to nurses was 1 to 1.06.About two-third of the sampled hospitals had an over-use of hospital beds.
All the county general hospitals had contingency plans for public health emergencies,on-site treatment guideline for major infectious disease and other public health emergency events.One-third of the hospitals had set up symptom surveillance spot and 83.3%of the hospitals requested that the clinical physician should complete the log for outpatient visits,and registration for patients with major infectious diseases.All the county hospitals had installed internct-based infectious diseases surveillance and public health emergency reporting system.However,only 71.40%of the hospitals could analyze data regularly.
All the hospitals were able to respond to the emergencies in major infectious disease,regional priority disease and food poisoning,in terms of laboratory tests, medical personnel gathering and on-site rescue.However,the capacity for responding to emergencies due to chemical substances,radiation and natural disasters were not as good as to above events.The capacity for response to infectious disease varied between provinces.Overall,15 hospitals had established labor resources pool,of which only one(5.56%) had reserved for psychiatrist and two(11.12%) for family nurses.The possibility of providing extra hospital beds in emergency was low,at an average of 10%.None of the county hospital laboratories had joined the regional public health laboratory network.
The communication between county hospitals and local health bureau,and up-level hospitals were fine,actually much better than that between county hospital and CDC,health inspection,as well as other medical institutions.Long-term training and practicing mechanism had also been regulated in county hospitals.
With regard to dimentions,in county hospitals,the scores for dimention of trainging,surveillance and early warning,and reserve were 73.50,65.37and 44.93 respectively.
3.3 Township hospital
The employees had relatively poor education and low position title in all 54 township hospitals.Of them,67.69%and 76.15%had an education of secondary school and primary title respectively.The three-tier network from village to town to county for expanded planned immunization(EPI) had already been built in all the study sites with a coverage rate of 90%and higher for the EPI vaccines.All the township-level hospitals had had a infectious disease management system,however only 59.23%of these hospitals used internet based report.It was obvious that the township-level hospitals were weak in medical rescue for emergency.The main problems were poor infrastructure,insufficient human resources,and weak surveillance network.
4.Capacity assessment models
Based on the quantitative data collected in this study,capacity assessment models were established through factor analysis.Emergency,identification and protection,these 3 factors constitutes the triangular model to describe and evaluate the capability of county-level Public Health Emergency Response System.
F_(CDC)=0.608F_(emergency)+0.242F_(identification)+0.15F_(assureance)
F_(hospital)=0.718F_(emergency)+0.156F_(assurance)+0.126F_(identification)
5.Capacity development strategy
The basic framework of public health emergency response system had been built up in China.However,the unbalanced development between regions,the undefined and varied functions,unclear responsibilities of each sector,and uncompleted mechanism of the system were observed from both the qualitative interviews and quantitative investigations.Cluster analysis showed that both CDCs and county hospitals could be classified as four clusters with different capacity characters.The first is the units that had good integrated capacity,balanced score for all dimentions but each dimention is not outstanding,The other 3 clusters are the unites with special strengths in one or more dimentions Such as comprehensive in system composition, excellent in identification cases or evens,or strong capacity in on-site emergency handling.Therefore,it is of great importance to identify the problems and weaknesses of the system first when develop regional policies and strategies,to improve the general capability of the public health emergency response system.
Conclusion
The index system of capability for county-level Public Health Emergency Response System,developed by this study,covers the capability of system assurance, early warning(ability to identify and judge),emergency response(emergency,on-site treatment,rescue and control) and the mechanism of assessment,etc.The questionnaire consisted of eight dimensions including 1)plans,rules,regulations, operating manuals,2)surveillance and alert,3) laboratory testing,4) emergency team and experts,5)communication,dissemination,and coordination,6)training and drills, 7)capability of response and 8)reserve.The questionnaires are reliable and valid for public health emergency system at county level.
Emergency,identification and protection,these 3 factors constitutes the triangular model to describe and evaluate the capability of county-level Public Health Emergency Response System.
At present,the three-tier Public Health Emergency Response System has been available in rural counties of China with documented preparedness plan and basic function on responses to public health emergency,which to some extent can handle the emergencies and secure the publics.Nevertheless,the capability or function of the Public Health Emergency Response System is largely influenced by Public health budgets,human resources,laboratory equipment,and surveillance network.
Weakness of the system recognized in this study should have huge impacts on the improvement of capability of the system.For the units having stronger integrated capability,balance should be maintained during the development of the whole system. For the units having poor assurance capability,legislations and preparedness should be the key component for further development.For the units having poor identification capability,more resources should be allocated to the surveillance network and laboratory,and capacity in data analysis and application should also be strengthened.For the units having poor response capacity,training and practicing are extremely important to enhance the awareness and accelerate the responses for public health emergencies.
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