Local health department planning for a radiological emergency: an application of the AHP2 tool to emergency preparedness prioritization.

Every team responsible for managing an emergency might wish for the ability to predict the future, which would be based on situational awareness, past experience, and training under assumptions related to an emergency's complex situation and environment. Yet, situational awareness during an emergency is usually limited by a lack of resources for responding to an emergency and by the diversity of the stakeholders involved. As Danielsson and Ohlsson state: “An emergency is by definition a unique and unpredictable event, and it is seldom possible, even in retrospect, to assess what the outcome of an emergency response would have been if alternative measures had been followed. The only kind of normative models available to emergency response teams are tactical doctrines codified in manuals and guidelines.”1 Even these guidelines may lack adequate guidance for making good decisions, including a lack of resources and tools on how to make them. The U.S. Department of Homeland Security Target Capabilities List includes only “seven references to decision making, most of which involve planning for and coordinating the decision-making processes, and none of which involve elements for evaluating the ability to actually make decisions.”2,3 Also, the National Incident Management System focuses on planning for and coordinating decision making, but gives no explicit guidance on how to make a decision, especially by a team comprising people with varied priorities.4 Clearly, tools to help public health professionals undertake collaborative efforts to make effective decisions while responding to a complex emergency would be welcome. In fact, decision-making techniques do exist.5 The simplest technique and most broadly applied in government and industry is the Analytical Hierarchy Process (AHP), developed by Tomas Saaty at the University of Pittsburgh in the 1970s.6 The AHP is a multi-element decision analysis technique that involves structuring complex problems into a hierarchy of elements that influence the problem. Saaty compares the elements in pairs and employs an algorithm to sort them in order of importance in influencing the problem, then prioritizes the data to determine the best decision to solve the problem. The AHP technique is clear, methodical, nonpartisan, and transparent—characteristics that are suitable for high-stress, high-accountability fields such as emergency preparedness and response in public health. We developed an Internet-based, collaborative tool that we call All-Hazards Preparedness Squared (AHP2), which is especially designed for use in public health.7,8 It facilitates AHP-type analyses for a variety of stakeholders and provides a basis for analyzing their responses in ways that help prioritize key elements for preparedness and response to a public health emergency. It can also help a team evaluate specific potential actions and collaboratively determine the best decisions to meet the challenges of an emergency. Furthermore, it can be customized for each team member and distributed to all team members. For emergency preparedness and response, AHP2 can be used by a team to respond appropriately to a slow-moving emergency by prioritizing elements and resources in preparation for responding effectively to particular emergency scenarios. An example of an application of AHP2 for response might be the decision of when to close schools during an H1N1 epidemic, which involves the consideration of many elements and approaches to avoid unintended consequences (Personal communication, Harvey Kayman, University of California, Berkeley, June 2012).9 Our study, which was conducted in 2013, had two aims: (1) to test the AHP2 tool for its use in public health and (2) to present the results from an application of the tool to identify potential gaps in emergency preparedness by local health departments (LHDs) in California and Hawaii during a radiological emergency scenario resembling the Fukushima catastrophe. The participants revealed the challenges they might experience during a radiological emergency systematically through the use of the AHP2 tool. The specific radiological scenario we developed was the movement of a radioactive plume that was carried by wind across counties in California and Hawaii and that was tracked by local citizens' network of radiation monitors, whose members posted data on Facebook. Through this process, survey participants had the opportunity to reflect on the consequences of radiological contamination affecting their home counties and cities.