Patient Movement, En-Route Care, and Decontamination in Arctic Conditions: Engineering the System for Safe Control and Coordination.

INTRODUCTION: Increasing interest in the Arctic demands that the Department of War be prepared for Cold Region Expeditionary Medical Operations (CREMO). Central to CREMO is the En-Route Care and Patient Movement (ERC/PM) system providing life-saving interventions. In addition, the Arctic is not immune to Chemical, Biological, Radiological, and Nuclear (CBRN) threats. Current doctrine, however, has limited integration of ERC/PM and decontamination systems. This study is the first to apply a novel hazard analysis, System-Theoretic Process Analysis extended for Coordination (STPA-Coordination) to engineer safe ERC/PM and decontamination systems, mitigating and removing identified risks. MATERIALS AND METHODS: The study used STPA-Coordination to model and analyze the ERC/PM system in CREMO and CBRN conditions. According to Leveson and Thomas (2018), STPA is a 4-step process. Step 1 identifies stakeholder losses and system-level hazards. Step 2 graphically models the system showing control, feedback, and coordination relationships. Step 3 uncovers hazardous control actions. Finally, Step 4 finds loss scenarios for why the hazardous controls or unsafe behaviors occurred. As Johnson (2017) describes, STPA-Coordination provides additional guidance to develop Step 2 and find coordination-related loss scenarios in Step 4. RESULTS: The paper highlights STPA-Coordination results from analysis of 16 unsafe control actions and 53 loss scenarios, which delivered 49 unique safety recommendations. The Top 5 recommendations are in the paper. The research also created a Triage Decision Matrix to assist in prioritizing the 49 recommendations, which allocated the recommendations based on Triage category and trauma event size. An inherent limitation in this study is the ability to refute the results. To mitigate, the authors incorporated feedback from medical and decontamination experts, which provided a form of results validation. CONCLUSIONS: In addition to the safety recommendations, the study provides a system-theoretic framework to engineer safe control and coordination into similar Military Health systems.