COVID-19: Real-Time Policy Lessons From Alberta’s Acute and Primary Care Environments

Updated: July 28, 2020

Integrating the Social Sciences into Canada’s COVID-19 Response in Alberta, Canada

Leslie M, Fadaak R, Davies JM, et al. Integrating the social sciences into the COVID-19 response in Alberta, Canada. BMJ Global Health 2020;5:e002672.

Updated: December 4, 2020

North American Primary Care Research Group (NAPCRG) Annual Conference
November 20-24, 2020 | Virtual Meeting

Workshop: Deploying Tabletop Simulations to Improve Primary Care Preparedness for COVID-19
Presented by Johanna Blaak and Dr. Raad Fadaak, PhD.
Co-Authors: Dr. Myles Leslie, PhD; Dr. Jan Davies, MD; Dr. John Conly, MD; Dr. Jia Hu, MD; Dr. Lee Green, MD; Dr. Judy Seidel, PhD; Dr. Nelson Lee, MD; Nicole Pinto; Mazhabin Ferdous; Michelle Cheng.

Poster Presentation: Adapting Tabletop Simulations to Support Primary Care Teams in the COVID-19 Response
Presented by Johanna Blaak and Dr. Raad Fadaak, PhD.

Updated: January 28, 2021

Rapid conversion of an in-patient hospital unit to accommodate COVID-19: An interdisciplinary human factors, ethnography, and infection prevention and control approach

Fadaak R, Davies JM, Blaak MJ, et al. Rapid conversion of an in-patient hospital unit to accommodate COVID-19: An interdisciplinary human factors, ethnography, and infection prevention and control approach. PLoS ONE 16(1): e0245212. https://doi.org/10.1371/journal.pone.0245212

Updated: April 14, 2021

Virtual tabletop simulations for primary care pandemic preparedness and response

Blaak MJ, Fadaak R, Davies JM, et al. Virtual tabletop simulations for primary care pandemic preparedness and response. BMJ Simulation and Technology Enhanced Learning. Published Online First: 13 April 2021. doi: 10.1136/bmjstel-2020-000854.

Updated: July 23, 2021

Vaccine Hesitancy Guide

This online guide was developed with the support of primary care clinicians across Canada and is designed for their use. It amalgamates strategies for supporting better conversations with patients based on their vaccine hesitancy type.

The Vaccine Hesitancy Guide was featured in the following news coverage:

• Alberta primary-care physicians get vaccine hesitancy roadmap
• U of C vaccine hesitancy guide gives doctors facts for struggling patients
• Conversations regarding COVID vaccine hesitancy

Updated: May 9, 2020

Key Learnings & Recommendations for COVID-19 in Primary Care

Iterative findings from n=7 Tabletop Simulations. Tabletop simulations have been conducted in both rural and urban settings, ranging from Access clinics (designated COVID clinics), primary care clinics providing urgent care, and community based primary care clinics.

Iterative Key Learnings & Recommendations in document

Updated: May 8, 2020

Testimonials of Tabletop Simulation Exercises

These quotes were collected as part of follow-up ethnographic interviews:

“We were not sure what to expect when we agreed but once we got started we quickly realized how useful this was. Not only to recognize the things we were doing or had in place but to see areas that we could change”

Clinic Manager

“We put a lot of thought into process and setup of our clinic and the flow of patients through the clinic at the onset of COVID-19. We continually re-evaluated ourselves, as new information and updates became available. The simulation(s) with the W21 group helped us to go that “one step further”.

Physician member

“Eye opening and insightful! Good detailed and systematic review of our policies.”

Physician member

“Their feedback on how we could optimize things further, small items that we hadn’t considered that had potential to become big items during an emergency, and their availability for questions was truly invaluable.”

Physician member

“The floor plan format was a great aid to visually see how the flow will work, where people will go, and allowed us to reset or go back and think through it again. We came up with action items – things we need to implement and communicate with the rest of the team.”

PCN Nurse

“They are extremely up to date on all the IPC and PPE protocols and can integrate them into your clinic”

Physician member

“We included not just our entire staff, but also some emergency personnel from the community that we rely on (and who rely on us) in crisis situations. They were blown away by the level of consideration that goes into planning for a COVID+ or presumed COVID+ patient. They have committed to implementing some of the learning points into their responses as well.”

Physician member

“In the world of navigating virtual meetings and calls, this group has really mastered it using a very good and intuitive interactive whiteboard with zoom in the background. The whiteboard allows everyone to visualize a very detailed floor plan . . . to highlight some important blindspots with our flow”

Physician member

“That was really amazing – lots of great feedback and re-assurance that we were on the right track”

Physician member

Updated: May 8, 2020

Actionable Clinic-Oriented Support Responding to COVID-19 Pandemic in Primary Care

Background: Early conversations with Primary Care stakeholders identified a hunkering for actionable and concise recommendations for primary care clinics across the province. Infection Prevention Control (IPC) principles and well-developed practices in acute care, did not seem to seamlessly integrate within the primary care setting, and clinics were responsible for implementation and adaptation of these new protocols to work in their clinic. Our interdisciplinary team of Human Factors (HF), IPC, and Organizational Sociology (OS) worked with primary care leaders to deliver Tabletop Simulations. Tabletop simulations are a novel method developed by our team as an effective and efficient method for assessing and optimizing care environments, borrowing critical components from a variety of well-established techniques. Tabletop simulation exercises are a well-known method to assess public health preparedness (Dausey, Buehler, & Lurie, 2007), and to address appropriate responses in the healthcare system. HF tabletop evaluations are an alternative but proven technique in Healthcare Quality Improvement (QI) used to (re)design complex healthcare environments (AHS Human Factors, 2017). In addition, clinical simulations have been implemented as both effective educational exercises (Patterson, Blike, & Nadkarni, 2008) and system-based QI techniques (Dubé et al., 2019).

Methods: Tabletop simulations involve participants working through a series of scenarios using tokens on a floor plan. Participants are all key personnel within the clinic that are most likely to be involved in COVID-relevant care or patient management. The participants systematically go through the order of operations following the protocols they have put in place for (suspected) COVID-19 patients and, facilitated by a moderator, identify issues and opportunities for improvement within their clinic by using simulated scenarios.

As issues or unclarity in protocol comes up, the group will brainstorm and develop solutions that work for all participants (e.g., while some solutions work for physicians it needs to be acknowledged that this same solution might cause issues for other clinic staff). The moderator will ensure any solutions are in compliance with IPC guidelines and policies, by keeping up to date on current best practices and any remaining questions will be relayed back to IPC.

Findings: With currently seven completed tabletop simulations, with two in person and five virtually, we have provided detailed results and recommendations for each individual clinic. As well as identified key learnings more universally actionable in primary care settings, such as but not limited to;

• Patients who have symptoms of COVID-19 and/or Influenza-Like Illnesses (ILI), should be treated equally.
• Establish a consistent COVID-19/ILI notation system in your EMR.
• Clearly designate Exam Rooms where COVID-19 –confirmed patients will be seen.

Conclusion: We are confident we have developed a robust pilot method for delivering a range of expertise to primary care practices across the province, nation, and internationally. Feedback from those teams participating in our pilots are universally positive, with one medical director describing their simulation as “jawdropping” and another administrator describing their simulation as “practically helpful in ways I couldn’t imagine before we began.”

Updated: May 11, 2020

Blending Infection Prevention and Control and Human Factors teams: A new approach to managing the COVID-19 pandemic

Background: Traditionally, the management of pandemics and lesser outbreaks of disease in acute care facilities, has been the purview of specialists in Infection Prevention and Control (IPC). IPC clinicians include both doctors and nurses, and their roles include the development, implementation and audit of policy, best practices and guidelines; education of healthcare workers; and surveillance. Recently, there have been recommendations in the literature and practice to complement the work of IPC clinicians with Human Factors (HF) analyses. Indeed, this combination of expertise has been shown to enhance identification of important system factors in key aspects of donning and doffing Personal Protective Equipment (PPE) during simulations of patients with Ebola. Additionally, ethnographic expertise has been identified in the Quality Improvement (QI) and IPC literatures as a central resource in understanding and remediating the cultural and contextual challenges to achieving IPC compliance. We describe below some of the earliest steps in blending the domains of IPC, HF, and ethnography, as they were undertaken during the response to the COVID-19 pandemic in acute care facilities in Alberta, Canada. We outline the genesis and evolution of a mixed-methods QI participant action research platform to assist acute care clinicians as they dealt with the pandemic.

Methods: This description is part of the narrative of a CIHR-funded study, the Co-Principal Investigators of which are an IPC medical specialist and an Ethnographer, and in which HF expertise was to be specifically included alongside ethnographic observations and IPC evaluations. On March 10, 2020, an IPC clinician from an acute care study site contacted one of the study team HF experts with an offer to observe a simulation of a patient deteriorating with severe COVID-19 symptoms in the Emergency Department (ED). This invitation was the catalyst for what would become ongoing co-research combining the expertise and perspectives of IPC specialists, HF experts, and an ethnographer. Over the course of the next months of the pandemic and research activity, the individuals involved varied, but the composition of the co-research team consistently included all three forms of expertise. This participant action co-research team visited units in 3 different hospitals in a single health Zone in Alberta. After the initial ED co-visit, further observations included 1) a walk-though of a new area of the same hospital’s ED for patients with COVID-19/Influenza Like Illnesses (ILI); 2) participation in a team simulation on a High-Risk Obstetric Unit; 3) multiple walk-throughs of the same ED; 4) multiple walk-throughs of a COVID-19 Nursing Unit, recently converted from a post-operative orthopedic and general surgery Nursing Unit; 5) a walk-through of a designated COVID-19 Unit at a different hospital; and 6) a walk-though of a recently constructed COVID-19 tent, on site at a different hospital.

Findings/Contributions: Each of these co-research collaborations led to shared IPC, HF, and ethnographic findings and recommendations. For example, in the new ED COVID-19 Unit, IPC provided posters for how patients should physically distance and perform hand hygiene. The HF contribution recommended increasing the size of the messages on the posters for increased readability; to post them closer to where patients sat; and to add them to the overhead televisions in the patients’ waiting area. The ethnographic contribution provided background analyses of the inter and intra-professional hierarchies that were shaping responses to IPC protocols and HF recommendations. On the COVID-19 Unit at the second hospital, the IPC had placed a yellow-coloured sign showing where to hang a clean stethoscope in an Isolation room. HF recommended changing the sign’s colour to blue, thus implying the device was clean and ready to use. Ethnography recommended points of intervention that would join the disparate working groups and processes that had led to mismatches between the colours and the assumptions that they embedded.

Conclusions: Combining individuals with IPC, HF, and ethnographic expertise and experience has enriched efforts, in real time, to provide safer care for patients and safer working conditions for healthcare providers during the COVID-19 pandemic.

Updated: January 28, 2021

Foothills Medical Centre, Unit 64 (COVID-Designated); Human Factors and Ethnographic-Supported Redesign

This work was published in PLoS One.

Background: Formerly a post-operative unit, Unit 64 at the Foothills Medical Centre (FMC) was quickly repurposed to become a COVID-19 designated general medicine unit for the hospital. Based on walkthroughs and sustained unit observations, our team (Human Factors/ethnography) provided discrete recommendations to improve the layout, placement, and use of personal protective equipment (PPE) and other safety supports.

Methods: Our team initiated contact with the unit through Infection, Prevention, and Control (IP&C) leadership. We began by observing the unit and integrating our clinical ethnographer, who took initial observations of the floor layout and staff practices. Our Human Factors team then organized a visit that involved the unit manager, lead clinical nurse educator, and the ethnographer to do a walk-through of the space. Together, the HF and IP&C teams made significant safety recommendations and co-designed solutions that were presented to the staff in a floor huddle at the Nursing Station.

Findings/Contributions: Our Human Factors team made a number of critical safety observations regarding the placement of PPE for donning and doffing. The hallways were originally cluttered with PPE, such as clean gowns in bundles on chairs in charting areas. Additionally, donning and doffing equipment was often in close proximity (rather than being separated by 2 metres) on re-purposed patients’ bedside tables in the hallways, adding to the overcrowding. In addition, our HF/ethnography team observed a number of actual and potential contamination events related to housekeeping carts.

Based on our walkthrough(s) and observations of the unit, our team recommended the following:

• Provide a single donning cart positioned between two single patient rooms, to minimize the overcrowding and spread of clean PPE along the unit hallways, and to further separate clean PPE from doffing spaces.
• Provide additional doffing garbage and ‘dirty’ linen hampers outside individual rooms to minimize clinicians walking in contaminated PPE to reach these bins. Ensure these bins are located to match the expected orientation (i.e., left versus right) for the clinician as he/she exits a patient’s room to doff PPE.
• Provide a dedicated ‘clean’ stethoscope in a tray located outside the rooms on donning carts. Contaminated stethoscopes should be placed into ‘dirty’ bins upon exiting patients’ rooms and double-wipe disinfected before being returned to the clean trays.
• Post an AHS-approved PPE doffing checklist on the inside of patients’rooms (backs of doors) so that they are accessible by clinicians for reference while doffing.
• Provide one or more dedicated specific housekeeping carts to the COVID-19 Unit. Ensure housekeeping staff do not store clean towels in the cart’s zippered storage pockets, to decrease the possibility of contamination with gloves/hands when cleaning.

Conclusions: With the support of Unit 64’s manager, clinical nurse educator, and staff, our recommendations were implemented within 24-48 hours. Clean PPE was clearly consolidated and separated from doffing areas. The result was a much more streamlined, less cluttered, and ultimately safer unit.

The Unit Managers and staff members other continued to express their appreciation for the interventions, including mentioning them in a recent retrospective of their transition from a surgical unit to a COVID-designated one:

Updated: June 25, 2020

Provision & Survey of Ear Savers/Mask Connectors

Authors: Anita Cisecki, Jan M. Davies, Raad Fadaak, and John M. Conly.

Background: The potential for spread from evolving cases of the infection from Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV2) requires that nurses and other healthcare providers in many jurisdictions wear a mask at all times – whether providing care directly to patients or working with colleagues, for example, discussing an order set or conducting a double-checking of a medication. This new requirement for in-hospital continuous wearing of masks contributed to shortages of regular surgical masks with ties and replacement with a new type of procedural/surgical mask. Instead of ties, the newly introduced mask has two elastic loops for attachment behind the ears. Although this type of mask is easy to don and doff, the loops can irritate the postauricular skin in some individuals. One option to counter the skin irritation was to use a plastic ear saver/mask connector (also known as a mask extender). This device, with several short protruding ‘legs’, is positioned horizontally on the back of the head, and over which the mask ear loops are clipped, theoretically removing any back-of-the ear pressure and irritation.

Methods: As part of a Quality Improvement study of face shields, we wanted to determine if ear saver/mask connectors functioned as suggested (utility) and how well they functioned (usability). We therefore undertook a Human Factors survey of users of (donated) samples of a specific, 3-D printed ear saver/mask connector (Surgical Mask strap Remix. https://www.thingiverse.com/thing:4249113 ). We chose to study use of the mask connectors by nurses working on a high-risk Labour and Delivery Unit in Calgary through a convenience sampling methodology. A utility/usability questionnaire was given to each of 11 nurses who accepted a donated device. Ten questionnaires were returned (n = 10). The devices studied were made of a rigid plastic and came with instructions to soften them in hot water, if necessary, to allow the connectors to conform to the shape of the user’s head.

Findings
Users: Participants had worked as nurses for an average of nearly 13 (1-36) years and on the Unit for an average of 10 (1-36) years. Eight nurses had long hair (e.g., worn in a ponytail), while two had medium (i.e., chin) length hair. Five nurses (50%) reported ear soreness/irritation with the new ear loop masks.

Utility: All but one nurse indicated that the mask connector functioned as designed, with nine nurses specifically indicating that ear soreness was reduced. However, some nurses found that while the extenders removed pressure from the backs of the ears, pressure was then distributed to the bridge of the nose, even when the mask loops were hooked over the outermost leg of the clip. The connectors worked well for nurses with longer hair (in a ponytail) but not for those with short hair.

Usability: On a Visual Analogue Scale of 1-5, ease of use of the connectors averaged 3.2 (1.25-5). Two nurses had no difficulty using the device while two found the mask was pulled too tightly to the face. Another nurse developed a headache from the pull of the mask. Six nurses had difficulty removing their masks when doffing Personal Protective Equipment (PPE), with the device catching in glasses and hair being pulled out of whatever was holding it back, e.g., a hair clip. This difficulty resulted in strands of hair dangling, with potential contamination of the hair against the front of the mask. Five nurses noted potential or actual self-contamination as a concern, with three recommending design, size and material changes. 

Conclusions: Within the context of Infection Prevention and Control, and the reported difficulty of removal of masks during doffing of PPE, there is a potential for self-contamination with these devices. We know from our previous simulation study of preparation for Ebola (Human Factors Evaluation of Simulated Ebola Virus Disease Patient Scenarios: System Factors Associated with Donning and Doffing During Triage, Treatment and Transport.) that healthcare workers are more likely to become contaminated during doffing than at other times. Since our study of the mask connectors, we also noted that many nurses opted to wear cotton ‘scrub-style’ caps or headbands with buttons, on which to hook the masks. Although our study was small and only included nursing staff on a single unit, based on our observations, we recommend that the plastic back-of-the-head style of mask connectors should be used only for ‘physical or social distancing’, such as when nurses are working at the Nursing Station or on breaks, rather than when providing care to COVID-19 patients. Mask connectors should not be used with N95 masks, because of potential interference with their fit, and not when providing care to patients in isolation.

Acknowledgement: The Authors acknowledge the contributions of the nurses who participated in this survey and the individuals who made and donated the ear savers/mask.

Updated: May 11, 2020

Understanding and Improving Interactions with Novel Protocols and Governance Mechanisms between Healthcare Professionals during the COVID-19 Pandemic

Background: The COVID-19 pandemic response has seen major changes to operations in acute care facilities worldwide. A wide range of novel protocols and governance structures have ushered these changes into effect. In Alberta, Canada, efforts to adapt hospitals have included changes to protocols that shape care delivery processes, as well as the invocation of temporary emergency governance mechanisms at health zone and hospital levels. These changes to process and authority have emerged simultaneously with public health measures, Infection Prevention and Control (IPC) guidelines, and emergency management plans. In this highly fluid context and in the absence of definitive answers, acute care clinicians are engaging in significant and creative interpretations of novel protocols. These interpretations, or efforts to make meaning, reflect pre-existing culture (values) and context (rules) which may be more, or less, well matched to the ‘new normal’ introduced by the pandemic. In this participant-action research we set out to study and assist clinicians as they deploy their existing cultural values and contextual knowledge to parse and implement the changes in their workplace.

Participant-Action Research Questions: Our central research question sought to understand how clinicians were interacting with novel protocols and governance mechanisms. Our central integrated Knowledge Transfer (iKT) goal was to inform clinicians about, and so improve their interactions with those same novel protocols and governance mechanisms.

Methods: In the period beginning on 10 MAR 2020 we began conducting a continuous documentary analysis of public health measures and IPC guidelines for acute care facilities. This analysis was supplemented with ethnographic observations of one of Alberta’s Zone Emergency Operations Command (ZEOC) activities and hospital-based Incident Command Post (ICP) activities at acute care facilities inside the same Zone. ZEOC calls were monitored live, or listened to as recordings. ICP activities were observed first hand, through email contact, or through key informant interviews. In-person ethnographic observations were conducted in 6 units (Emergency Departments, Intensive Care Units, and designated COVID-19 wards) within 3 hospitals in the Zone. These in-person observations focused on understanding on how culture and context were shaping the interpretations of, and communication patterns of clinical, administrative, and housekeeping staff. The observations also included a participant-action component, with the ethnographer assisting staff by supplementing their contextual knowledge of emergent protocols and command processes at the ICP and ZEOC levels.

Findings: Protocols for ensuring that COVID-19+ patients were transported within the hospitals in a manner that maximized their safety and minimized the risk of infection to staff were the subject of significant attention and interpretation. The interpretive work involved in creating new transport protocols sometimes spanned units within hospital sites, or even across hospital sites. A novel protocol developed by one group might be shared via the ZEOC, IPC, or informal networks to other sites intra or extra-murally. At other times, the diffusion or clarification of a novel protocol relied on the participant-action orientation of the ethnographer as he provided insights on current guidelines or command structures.

Conclusions: Further investigation is required to determine the conditions that underpin the un-assisted diffusion of novel protocols in acute care at a time of pandemic response.

Updated: May 8, 2020

Working as Conduits Across the Health System During the COVID Response

Background: The COVID-19 pandemic response has seen major changes to operations in acute care facilities worldwide. These include the reconfiguration of space and the re-tasking of personnel to accommodate anticipated or actual volumes of patients, and emergent Infection Prevention and Control (IPC) standards. In Alberta, Canada, novel COVID-19+ wards have been created inside and on the grounds of existing hospital facilities. As these reconfigured spaces have emerged and healthcare workers have been re-tasked, culture and context have provided guideposts for understanding and implementing the changes. In this participant-action research we set out to study and assist clinicians as they deployed their existing cultural and contextual experiences to make sense of their re-tasked work and reconfigured workplace.

Participant-Action Research Questions: Our central research question focused on understanding how acute care clinicians were using cultural and contextual resources to adapt. Our central integrated Knowledge Transfer (iKT) goal was to support clinicians in dealing with the changes by providing them with Human Factors (HF) and IPC feedback.

Methods: In the period beginning on 10 MAR 2020 an inter-disciplinary team with ethnographic, HF, and IPC expertise began field work in X units of Y hospitals in one of Alberta’s health Zones. Conducting in-person observations the team simultaneously focused on: 1) understanding on how culture and context were shaping interpretations of, and communication patters around, re-tasking and reconfiguration (ethnography); 2) providing feedback on the usability, safety, and sustainability of re-tasked and re-configured practices (HF); and 3) providing feedback on how to deliver care while minimizing the risk of infection (IPC).

Findings: Re-tasked clinicians working in reconfigured spaces were open to, and interested in, the combination of ethnographic, HF, and IPC expertise as they interpreted their new normal. Key iKT interventions here focused on cleaning techniques, the appropriate use of Personal Protective Equipment, the re-organization of spaces and processes to improve safety and efficiency while lowering the risk of infection, and acceptance of the new normal as a state that changed cultural as well as contextual parameters.

Conclusions: Further research is required to understand if and how these learnings might be packaged and scaled so that re-tasked clinicians working in reconfigured spaces can more efficiently and effectively adapt to emerging conditions in a pandemic.

Updated: May 11, 2020

Development of Educational Materials for Obstetric Care During the COVID-19 Pandemic

Background: Despite the COVID-19 pandemic, obstetric patients continue to present for care as they always have. For these patients’ care providers, this has meant rethinking and redefining how care is delivered, including where, by whom and, specific to COVID-19, with what Personal Protective Equipment (PPE) and Infection Prevention and Control (IPC) considerations. In addition, in most other parts of the hospital, COVID-19 patients are cared for on separate units from non-COVID-19 patients. However, Labour & Delivery (L&D) has been required to keep COVID-19 and non-COVID-19 patients on the Unit, which provides a unique challenge to ensure the safety of non-COVID-19 patients. The exercise of redefining care has therefore needed to consider care of the mother (and partner), baby, and care providers, as well as other patients.

Methods: To do so, we assembled a multidisciplinary team with the aim of producing a document detailing all requirements, following the journey of a patient from the community, through entry to the hospital with its initial screening for COVID-19, to the return home. The team included representatives from Obstetricians, Nurses, Anesthesiologists, Anesthesia Respiratory Therapists, Neonatal Intensive Care Nurses, IPC, Human Factors, Housekeeping and Security. An initial meeting was held, in situ on the Labour & Delivery Unit, tracing the patient’s path. This meeting functioned as a simulation, with a team member taking the role of the patient, and as a Human Factors cognitive walk-through and task analysis. One Obstetrician and the Clinical Nurse Educators undertook to develop a document, from notes taken during the simulation, which was then circulated to a core group of participants. Changes were made and another in situ meeting held. This process was repeated twice more, with multiple changes made to the document. Also included were descriptions of deviations from the ‘normal’ path of labour and vaginal delivery, such as the need for neonatal resuscitation, Caesarean Section, and medical deterioration requiring transfer to the Intensive Care Unit. Once the document was developed, it was used as the ‘shooting script’ for a video, to supplement the educational materials.

Findings/Contributions: Development of the document was facilitated by an algorithm produced by an obstetric resident. In contrast, the overall process of detailing care was complicated by rapid, ongoing changes to PPE requirements, which were sometimes in conflict, depending on the source. Towards the end of the project, PPE requirements and other IPC recommendations stabilized, facilitating final editing of all three products. These were essentially completed one month after the first meeting, with another week for finalization of minor details. The materials were then distributed throughout the hospital, for access by all individuals and departments that help provide care for expectant mothers and their babies. Since then, the materials have become invaluable teaching tools, particularly since all midwifery patients in the city were directed to the FMC, along with the patients, nurses and physicians from one of the other hospitals, which closed its obstetric unit.

Conclusions: Development of educational materials such as these requires a team effort, focused on the patient’s journey.

Updated: June 26, 2020

Emergency Response ‘Trading Zones’: A qualitative case-study of Zonal Emergency Operations Centres in Alberta, Canada

Background: Early in Alberta, Canada’s COVID-19 pandemic response, an Incident Management System (IMS) was activated as part of an AHS organizational disaster management approach. As a response to the public health emergency, the IMS created an additional nested hierarchy of pandemic responders across the existing health system. A key feature of the IMS was the activation and establishment of regional level “Zone Emergency Operations Centres” (ZEOCs). The ZEOCs brought together a diverse group of health system and community-based stakeholders to respond to the pandemic, disseminating provincial level information and policy while dealing with local implementation issues. The ZEOCs enrolled experts from across their regions to create “incident management teams”, which were rapidly tasked with coordinating and collaborating to mitigate and respond to COVID-19. Understanding the value that the ZEOCs added and how they functioned in the context of a public health emergency is central to improving future pandemic preparedness.

Methods: Our team of qualitative social science researchers deployed as part of a rapid response grant to study and assist the communication, interpretation, and implementation of policy during the pandemic in Alberta.  We have conducted in-situ observations and semi-structured interviews in organizations across the province’s public health, acute and primary care, and social services sectors.  Our observations have included monitoring the Calgary ZEOC’s update calls and interviews with ZEOC members.  As such we are taking the Calgary ZEOC (CZEOC) as a case study of functionality and added value in the context of the pandemic.

Findings: In the period from March to the end of May, 2020, the CZEOC functioned largely as a ‘trading zone’ in which a broad range of experts and practitioners could interact and collaborate.  The ‘trading zone’ concept was originally developed to describe processes of coordinating ‘action and belief’ amongst radically different scientific disciplines. As a trading zone, the CZEOC brought clinical, administrative, operational, and community-based stakeholders together – representing radically different domains of expertise – to “hammer out…local coordination despite vast global differences” (Galison 1997:783). The CZEOC – like other ZEOCs activated across the province’s 5 health zones – functioned as a place to mediate competing priorities, negotiate diverse bodies of knowledge, and coordinate various interests during the response. In many cases, this required the effective translation of knowledge and problems between different expert groups, each of which was focused on responding to the local problems that emerged in the course of the pandemic. These challenges included managing site-based outbreaks in urban and semi-rural communities, coordinating changes in the provision of care, preparing the acute care system for surge operations, adapting to changing guidelines, and implementing new policies related to the COVID response.  Where these challenges might only have received local thought and solutions, the CZEOC facilitated the development of new regional norms of practice, new regional languages of collaboration, and helped to consolidate the interest and focal attention of varied experts. As a ‘trading zone’, the Calgary ZEOC coordinated expert activity and helped stabilize a set of priorities even amongst groups who had very different clinical, operational, or administrative mandates or priorities.

Conclusions: The CZEOC was a critical component of Alberta’s broader pandemic-activated IMS, which produced novel mechanisms of exchange that not only maintained the continuity of communication across vastly different domains of engaged experts, but gave rise to truly regional discussions and information sharing. Examined as a trading zone, the CZEOC functioned effectively and added significant value to Alberta’s pandemic response. Lessons for creating and facilitating ZEOC-like structures as part of emergency responses – and the communications challenges these structures address –  should be explored further.