Mary F. Moorhouse James I. Burns

1. Disease Surveillance and Response: Using surveys to iteratively hone questions for future research Mary F. Moorhouse James I. Burns NDMS Conference Dallas, Texas April 2004

2. Credentials Mary F. Moorhouse, BSN, RN, CRRN, LNC Nurse Consultant Nursing Author Forensic Nurse James I. Burns Systems Analyst S.A.I.C.

3. Objectives

4. Objectives 1. Discuss efficient use of RN resources to support a community-based response to patients with Influenza-like-illness (ILI) symptoms. 2. Discuss attitudes of nursing professionals regarding epidemics, isolation and quarantine. 3. Identify a mechanism for worried-well to receive timely support and clinical advice during an epidemic or bioterrorism incident. 

5. Historical Perspective

6. A 20th Century Perspective 100,000 dead from atomic bomb blast Hiroshima, Japan 1945 242,000 confirmed dead in earthquake Tangshan, China 1976 22,000,000 succumb to influenza pandemic Worldwide 1918-1919

7. Influenza • Influenza and its complications account for millions of temporary debilitating illnesses yearly in the USA. • Annually in the USA, there are more than 100,000 hospitalizations, and on average 35,000 deaths. Source: Medical Surveillance Monthly Report (MSMR)

8. Force Health Protection • In 2002, 1500 members of US armed forces were hospitalized for influenza and pneumonia. • 22,600 additional members of the armed forces were ambulatory with influenza and pneumonia. • At one time in 2002, 1.5 percent of our armed forces were incapacitated for some duration by influenza and pneumonia. MSMR: http://amsa.army.mil/1Msmr/2003/Figures_Tables/No6/Article1/table1.jpg

9. Infectious Diseases Nearing Elimination? • Historians in the next millennium may find that the 20th century’s greatest fallacy was the belief that infectious diseases were nearing elimination. The resultant complacency has actually increased the threat. Both naturally occurring and bioterrorist infectious disease agents hold an increasing potential to destabilize international security. Failure to recognize and accept this concept will lead to disaster. Source: “Addressing Emerging Infectious Disease Threats: A Strategic Plan for the Department of Defense” A study conducted by Global Emerging Infections System [GEIS] 1998 http://www.geis.ha.osd.mil/

10. Words of Wisdom “The threat of bio-terrorism is not going to disappear and new and emergent [infectious] agents are likewise going to be a fact of life…If we fail to muster the will to build the systems which are needed to detect and counter disease outbreaks in their early stages, we may look forward to another AIDS epidemic or perhaps it will be pandemic influenza or smallpox.” Source: D. A. Henderson “US Response to Possible Bio-terrorism” National Academy of Science 2 May 2000 http://www.hopkins-biodefense.org/

11. Improving Surveillance of an ILI Outbreak

12. Public Health Surveillance • The challenge is to distinguish between an Influenza outbreak and a bioterrorism attack. • A number of infectious diseases manifest themselves in patients with early symptoms similar to influenza. • A system to generate information for quick analysis should be developed.

13. Influenza-Like-Illness • Influenza-like illness is defined as having fever or feverishness plus at least 2 of the following symptoms: headache, myalgia, cough, or sore throat. Source: Arch Intern Med. 2000;160:3243-3247 http://archinte.ama-assn.org/issues/v160n21/abs/ioi00019.html

14. Potential data sources for timely and sensitive outbreak detection • Outpatient syndromes (EMS, ERs, ambulatory care, schools) • Intensive care syndromes (ARDS, encephalitis) • Unexplained deaths • Pharmaceuticals (OTC, prescription, antivirals, IND drugs) • Veterinary surveillance • Clinical and public health laboratories • Informal and formal clinician-based networks • Billing and insurance data Source: The Need for Improved Surveillance Systems for Rapid Detection of Emerging InfectionsJ.A. Pavlin et al. GEIS

15. The Key • Early indication of an infectious disease outbreak such as SARS, anthrax, or smallpox is the key to reducing loss of life. • The sooner the “infected person” can be encouraged to come forward and talk with a health professional, the better.

16. Survey Says…

17. Two informal surveys • A survey of telephone nursing healthcare information or triage centers. • A survey of registered nurses.

18. Survey of RN Call Centers • The first survey was conducted to better understand how data might be gathered to predict an ILI outbreak and develop a timely response to screen and treat influenza or similar epidemics.

19. RN Call Centers • Interviews were conducted with 3 types of RN call-in healthcare resource centers based in Colorado: • County Public Health Department • Corporate multi-site healthcare facility • Provider based telephone answering and triage service

20. Public Health Department • Population served—500,000, all ages • Hours of operation—8 to 5pm, 5 days per week • Telephone calls— up to 100 per day • Contacts not logged unless relating to reportable diseases such as TB • Specific healthcare recommendations avoided

21. Corporate Call Center/Help Line • Population served—over 3 million, all ages • Hours of operation—24 hours day/7 days week • Telephone calls average 270 per day • Contacts logged in computer database • Triage of symptoms determines specific healthcare recommendations provided

22. Provider Based Service • Population served—patients of 400+ healthcare providers across Colorado, all ages • Hours of operation—24 hours day/7 days week • Telephone calls approximately 500 per day • Contacts logged in computer database • Triage of symptoms determines specific healthcare recommendations and prescriptions provided based on standard protocols

23. Leveraging Existing RN Call Centers to Detect an ILI Outbreak Within 24 Hours

24. Goals • Improve the standard of care for a large number of patients presenting with ILI symptoms. • Develop a model for the efficient use of healthcare resources using RN support for a community-based response and attention to the worried-well during a naturally occurring epidemic or a bioterrorism attack.

25. Nimble Response • Nursing based telephone triage call centers can provide information useful to the early detection of Influenza, SARS, West Nile, Smallpox and Anthrax outbreaks, while promoting timely intervention and reduction of public anxiety.

26. Telephone Triage by RNs • RNs trained to Triage ILI (TILI) calls can screen the client and refer them for further follow-up.  • Follow up with individuals will provide an accurate map of the outbreak pattern as it develops.

27. Home Visits-Rapid Testing • Referrals for RN home visit could be made for assessment and performance of rapid diagnostic test to clarify diagnosis. • Information would be provided to a primary healthcare provider for prescription needs. • Additional healthcare information would be reviewed with patient/family

28. The Next Question • In order to provide home visit support, would RNs be willing to expose themselves to potentially serious infectious diseases?

29. Survey of RNs • A second survey was conducted to identify the attitudes of nursing professionals regarding epidemics, isolation and quarantine for the purpose of supporting a community-based response.

30. Isolation & Quarantine • Two common public health strategies that aim to protect the public by preventing exposure to infected or potentially infected individuals. • Both isolation and quarantine may be conducted on a voluntary basis or compelled on a mandatory basis through legal authority.

31. CDC Definitions • Isolation refers to the separation of people who have a specific infectious illness from healthy people and the restriction of their movement to stop the spread of that illness. • Quarantine, in contrast, generally refers to the separation and restriction of movement of people who are not yet ill, but who have been exposed to an infectious agent and are therefore potentially infectious.

32. Isolation & Quarantine Survey • A convenience sample of registered nurses from throughout the State of Colorado were provided a self-administered questionnaire. • Of 112 potential participants, 91 questionnaires were returned.  • The purpose was to gauge the nursing profession’s understanding and concerns regarding the voluntary and mandatory use of isolation and quarantine.  

33. Findings

34. Survey Findings • Educational preparation: • ADN/Diploma 13% BSN 29% MSN 51% PhD 7% Other 4% • Work setting: • Acute care 23% Clinic/Office 15% Education 14% Public/Community health 13% Hospice 4% Other 22% and Retired 5%

35. Survey Findings • The participants were directed to reflect on the recent SARS outbreak when considering their responses to the questions. • 89% of the nurses had gone to work at some time feeling ill—51% had a fever. • 66% were concerned about being contagious to coworkers; 49% concerned about exposure to patients or clients.

36. Survey Findings • Five scenarios were posed to the participants: • If there was a SARS outbreak in your work setting but you felt you were not directly exposed would you agree to voluntarily quarantine in place—that is in the hospital/health facility—rather than return to your family? Yes 54% No 44% • If you had close contact with an individual in the community suspected of having SARS would you voluntarily refrain from working for 10 days? Yes 86% No10% Would you if you had no sick time/personal leave benefits to cover your salary? Yes 64% No 24%

37. Survey Findings • If a local care center was quarantined but lacked adequate staffing would you be willing to enter the facility to provide patient care? Yes 54% No 36% • If the facility where you are employed was quarantined but lacked adequate staffing would you be willing to enter the facility to provide patient care? Yes 73% No 18% • As part of a community epidemic surveillance response, would you be willing to make home visits to perform a nursing assessment and rapid diagnostic test in order to limit exposure of potentially infectious individuals in emergency departments or clinic/office waiting rooms? Yes 74% No 19%

38. What Does This Tell Us • Nurses sometime go to work when ill. • 86% would voluntarily isolate themselves if exposed to a serious infectious disease. This drops to 64% if salary is impacted. • Nurses are more likely to voluntarily enter a quarantined facility to provide care if they are already employed there—73% versus 54% for a facility were they are not employed.

39. More Importantly • 74% of the nurses surveyed would be willing to make home visits to perform nursing assessments and rapid diagnostic testing as part of a community epidemic surveillance response.

40. Maximizing Healthcare Resources • A mechanism is required to reduce unnecessary office/clinic, emergency department, or home visits • The needs of the worried-well for timely triage, pertinent information and appropriate healthcare options must be addressed

41. A Final Point Be Prepared

42. Future Surveys • We have developed an “ILI Self-Assessment” that could be used to ease the concerns of the worried-well during an outbreak.

43. ILI Self-Assessment: Six Quick Questions • Do you have a fever? • Do you have a cough? • Do you have a sore throat? • Do you have body aches and chills? • Do you have shortness of breath? • When did these symptoms begin?

44. 1-800 FLU LINE • Anyone with a touch tone phone could call an 800 number and take the ILI survey. • Based on the individual’s responses to the ILI self-assessment, the individual could be referred to appropriate healthcare resources. • Responses could be tallied and provide early warning of an outbreak.

45. Thank You

46. Contacting Us • Mary F. Moorhouse, RN Nurse Consultant (719) 475-7378 tntrnmary@adelphia.net • James I. Burns Systems Analyst (858) 270-2444 jimburns777@aol.com

47. Acknowledgements • W. J. Bergs Requirements Analyst Science Applications International Corporation • R. J. Coullahan, CEM Manager, Readiness & Response Division Science Applications International Corporation • A. W. Crosby, Ph.D. Professor Emeritus, The University of Texas at Austin • D. A. Henderson, M.D., M.P.H. The Johns Hopkins Center for Civilian Biodefense Studies • R. Koch Koch Business Services • M. J. Markley, RN Science Applications International Corporation • A. C. Murr, RN, BSN, LNC Telephone Triage Nurse • J. Pavlin, MD, MPH, Major, USA Global Emerging Infections Surveillance & Response system, WRAIR • J. Siegel, MD Chief Medical Informatician, Atlas Public Health

48. Additional Materials:TILI System Design Goals

49. TILI System Design Goals • 1) Reduce the annual number of deaths in the US from influenza and relatedcomplications. • 2) Reduce the number of influenza related hospitalizations. • 3) Reduce the number of patients presenting to emergency rooms and urgent care solely for treatment of ILI.

50. TILI System Design Goals • 4) Reduce the number of days of lost productivity from influenza. • 5) Regard 280 million Americans as resources and contributors. (Encourage prompt voluntary screening of ILI complaints and aggressive treatment of influenza when appropriate)