Public Health Emergency Preparedness

Executive Summary

Objective and Directives

This report describes the development, testing, and implementation of a model to enable community health call centers, such as poison control centers, nurse advice lines, and other hotlines, to support home-management and shelter-in-place approaches in certain mass casualty or health emergency events. To guide call centers in adapting to accommodate such emergencies, we developed four specific products:

• A matrix of the Department of Homeland Security's 15 National Planning Scenarios with potential call center response capabilities specified (Appendix 1).
• For the four National Planning Scenarios for which call centers had the best capabilities, a detailed list of all the applicable capabilities (Appendix 2).
• Suggested elements for public health information and decision support hotlines. (Appendix 3).
• Four fully detailed interactive response applications that allow callers to use their touch-tone phones to automatically retrieve critical information during a public health emergency (Appendix 4).

These products were developed for the four specific planning scenarios but can be adapted to others as appropriate. Together, they cover the full range of capabilities that community health call centers can provide.

To develop these products, Denver Health responded to five specific directives. The results for each are summarized here.

Results and Recommendations

1. Establish an advisory panel of subject matter experts to supplement our expertise and provide assistance and guidance

We convened a national advisory panel of 13 subject matter experts with backgrounds and experience in fields that we considered crucial to community and national response planning as it relates to health call centers.

In addition, we invited representatives from several key Federal agencies to participate, including the Department of Health and Human Services, Department of Homeland Security, and Department of Transportation, as well as the American Red Cross. Panelists and agency representatives convened at three advisory panel meetings and the final presentation meeting in Washington, DC.

At these meetings, agency representatives educated the panel and core team members on the current Federal response efforts under way and how this project would best integrate with or support those efforts. The core team described the potential response capabilities that community health call centers could provide in responding to specific scenarios and proposed strategies and resources for assisting them in such responses. The expert panelists provided guidance on the development of the strategies and resources and helped refine them for the greatest utility and exportability.

2. Develop scenarios for mass health emergencies including chemical, biological, radiological, nuclear, and explosive (CBRNE) events and decide which ones provide the best opportunity for home-management/shelter-in-place strategies

We used the Department of Homeland Security's (DHS) National Planning Scenarios to ensure consistency with other preparedness and response efforts that are being developed. While these scenarios do not cover all possibilities for health emergencies, they do include a wide spectrum of disasters that communities could face. Though many other disaster scenarios have been developed, the DHS scenarios were developed with the participation of numerous Federal agencies.

We reviewed all 15 scenarios and determined which ones could benefit from use of the potential response capabilities of community health call centers. We then developed a matrix that lists each scenario, including expected casualties, infrastructure damage, evacuation/displacement of persons, sheltering, and victim care strategies. We focused development of our model on scenarios with the following characteristics:

• The community infrastructure was expected to remain intact so that call centers would be operable.
• Major public health outcomes would be involved.
• The scenario had the potential for many "worried well" (those with little or no injury who could overwhelm health care delivery systems), who could benefit from home management or sheltering in place.

We determined that four biological related scenarios (Biological Attack—Aerosol Anthrax, Biological Disease Outbreak—Pandemic Influenza, Biological Attack—Plague, and Biological Attack—Food Contamination) afforded the best opportunity to involve all potential response capabilities for community health call centers. Furthermore, our team and the panel believed that many response capabilities for biological incidents could also be used to address the response needs of chemical, radiological, and natural disasters. The broader application of health call center response capabilities to meet the needs of all 15 scenarios is discussed in this report.

3. Research existing models, protocols, and algorithms; develop and implement a scenario-based model using poison control centers, nurse call lines, and similar centers

We researched whether there were proven or experimental models for health call center responses to the four selected scenarios or any closely related scenarios. Searches of the published literature, public health practices, and Internet resources produced only limited results related to our objective. Many local and State public health department Web sites provide flu vaccination clinic information, searchable by city name or zip code. A few health departments also had telephone information hotlines that used either standard recorded messages or live agents to provide specific clinic locations or general influenza information. We did not locate any operating examples of interactive automated telephone-based systems for providing information to or collecting information from the public during health emergencies.

We found published reports describing the use of call center capabilities for responding to health events relative to the four biological scenarios of interest:

• An influenza hotline conducted a vaccination survey during an influenza season with a vaccine shortage. The hotline addressed questions from the public regarding vaccine availability, groups most at risk, and symptoms in order to reduce inquiries to physician offices and local health departments. The authors suggested that State health departments consider a hotline to educate the public regarding influenza vaccination and to follow up with callers who were advised to receive vaccination to improve compliance.
• A health department in Canada provided SARS information to the public through a hotline and supported the management of more than 10,000 individuals placed in quarantine, mainly in their own homes. The hotline required more than 200 health department staff to support its operations over a 3-month period.
• A health department in the United States used videophones to monitor suspected SARS cases and their close contacts. Afterwards, the equipment was used to monitor patients with active and latent tuberculosis.
• Health officials in Taiwan quarantined more than 130,000 people, mostly in their homes, for 10 to 14 days to prevent the transmission of SARS. Management of those in quarantine consisted of daily visits or telephone calls to review the person's current health status, including temperature recordings and symptoms.
• Four populations (Hong Kong, Taiwan, Singapore, and the United States) were surveyed about attitudes regarding the use of preventive measures to control the spread of a contagious disease. Support for any preventative measure decreased significantly if the condition of arrest for refusing to comply was added. The most favored methods of monitoring quarantine compliance were daily visits from health officials and periodic telephone calls. In the United States, the majority of respondents favored home quarantine for themselves and their families.

These reports suggest that using the telephone to provide information and support disease control measures such as home quarantine would likely be favorably received by the public and would assist public health agencies in the management of such efforts. Indeed, our experiences in operating a health call center that provides poison and drug information and nurse triage recommendations suggest that the public will seek out such community resources during health emergencies. We developed the Health Emergency Line for the Public (HELP) program to provide information and decision support to the public related to health events in Colorado.

In this report, we provide the HELP model blueprint so that other health call centers can consider developing these response capabilities. We also present health call-center-based information tools that use technology to better handle surges in demand, such as an Interactive Response (IR) system that allows callers to use their touch-tone phone to automatically retrieve information.

We focused the resource development on five health call center response capabilities: health information, disease/injury surveillance, triage/decision support, quarantine/isolation support, and outpatient drug information/adverse event reporting. We did not address the mental health assistance/referral capability as a specific health call center component, but included suggestions to reduce community anxiety and panic in the resources and strategies that we developed for the other five response capabilities. We assessed each response capability for: significance, applicability to scenarios, current examples, range of support technology, and staffing required. We then proposed resources and strategies for each capability.

Health Information. Use of health call centers could greatly augment mass risk communication messages and help to alleviate surges to health care systems. Our experience and that of others has shown that incidents generating public concern usually require robust mass risk communication strategies coupled with hotlines or other forums to assist those with further needs. Providing health information is applicable for all National Planning Scenarios; however, the best association of health call center expertise and community need is for: Aerosolized Anthrax, Pandemic Influenza Outbreak, Plague Outbreak, and Food Contamination.

We developed an instructional guide for community health call centers to develop a health information capability consistent with that of the HELP program (Go to Appendix 3, Suggested Elements for Public Health Information and Decision Support Hotlines). We describe the components that we found to be essential for developing a standardized response capability. These components provide us with the platform onto which additional capabilities could be added to support outpatient health care and monitoring during public health emergencies. This response model for public health events includes providing consistent, accurate information, collecting and maintaining structured data to characterize events and responses, and developing capability and capacity to adapt to other public health emergencies.

We also developed two applications for providing automated information to callers, especially important in events that could generate call volumes that surpass call center staff ability to answer calls. These two applications were developed for use with an IR system to allow callers to use their touch-tone phone to retrieve information. One IR application allows callers to get zip code-specific messages and was developed specifically for finding point-of-dispensing (POD) locations to get medications during an event requiring community prophylaxis. The Cities Readiness Initiative program of the Centers for Disease Control and Prevention (CDC) recommends POD mechanism development as a key element of readiness. The other IR application allows callers to navigate through a library of Frequently Asked Questions (FAQs) to retrieve information relative to their concern. Both applications ensure consistent and accurate information delivery: the same information is provided to every caller, every time.

Though the applications were developed for use with an IR system, they could be used without such technology. The call flows, decision trees, and message scripts could be used to guide call center staff in how to handle calls or could be used with other technology such as recordings and announcements to assist call center staff in managing higher call volumes. The POD application could be modified to provide any information based on zip codes, such as in evacuations, sheltering in place, snow cancellations, or mass vaccinations.

Disease/Injury Surveillance. Call centers that collect any health data could contribute to surveillance systems to quantify illness/injury (situational awareness) or to detect sentinel events or emerging health threats. Some health call centers may already analyze their own data to characterize their patient populations, while others may not realize the value of their data as it relates to a public health agency's need for disease and injury surveillance. The National Planning Scenario with the best association between health call center expertise and community need for disease/injury surveillance was the Pandemic Influenza Outbreak scenario, though almost all of the other scenarios could benefit from using call centers to capture health data for disease or injury surveillance.

For example, the American Association of Poison Control Centers contributes to disease surveillance by transmitting data related to toxic substance exposures to the CDC's BioSense program. That program is an initiative to develop a national biosurveillance capability that seeks to improve the Nation's capabilities for disease detection, monitoring, and real-time situational awareness through access to existing data resources.

Appendix 3, Suggested Elements for Public Health Information and Decision Support Hotlines, discusses structured data collection and public health partnering for developing disease/injury surveillance capabilities. The POD and FAQ applications, besides providing health information, also can collect data that could be useful in surveillance, such as the zip codes entered by callers seeking information.

Triage/Decision Support. Health call centers can assist with triage and decision support for health concerns and can alleviate surges to health care facilities, thereby reducing unnecessary hospital visits and associated health care costs. The National Planning Scenario with the best association between health call center expertise and community need for this capability was the Pandemic Influenza Outbreak scenario. However, almost all of the other scenarios could benefit from using call centers to assist with the triage and management of disease or injury, especially in preventing the "worried well" from overwhelming health care facilities.

Current examples of this capability include poison control centers that triage poisoning and provide exposure management support, and nurse advice lines that triage symptoms and provide symptom/disease management support. Both call center types provide such services with licensed clinical professionals on a daily basis, and this strengthens their credibility with the public. Research has shown that such centers reduce health care costs by preventing unnecessary emergency department visits and hospital admissions. Therefore, using these trusted call centers in health emergency situations should result in the same efficiencies and cost effective outcomes.

The HELP program does not use clinicians but provides disease and symptom information for the caller to use in making decisions for their own health care. Such an approach reduces the need to have clinicians—a finite resource that will be in high demand during any health emergency—on staff. For normal daily operations, trained information providers deliver scripted information and refer callers requiring exposure, symptom, or injury triage, as well as management support, to appropriate resources such as a poison center, nurse advice line, or health care provider. Using information providers to handle most public information needs prevents unnecessary calls to clinician-staffed lines so that they can continue to handle medical triage and management support calls.

Communities should consider the clinical recommendations they would use in the event of a major health emergency, such as pandemic influenza, that severely affects the health care delivery system. The health care delivery system and health care providers need to consider how they would handle a surge of sick patients in the face of increased demands on limited health care resources. A health call center needs to ensure that its recommendations are consistent with those of the rest of the health care delivery system and its health care providers.

Quarantine and Isolation Support. Health call centers are well suited to assist with monitoring or contacting those in quarantine and isolation, especially if they have appropriate guidance and resources. Research indicates public support for quarantine to control disease and for monitoring the status of those in quarantine by telephone. The two National Planning Scenarios involving infectious diseases (Pandemic Influenza Outbreak and Plague Outbreak) would potentially require the use of quarantine and isolation as disease control measures and could benefit from using call centers to support such measures. Future SARS and other infectious disease outbreaks would require planning and response capabilities similar to those for the influenza and plague scenarios.

Telephones were used to monitor those in quarantine in the SARS outbreaks in Toronto and Taiwan, and less than one percent of those in quarantine developed symptoms or were noncompliant. Simply having a staff person contacting those in quarantine can attain this response capability, but larger numbers of people in quarantine will require more automated approaches for monitoring health status and compliance. We developed a Quarantine/Isolation (QI) Monitoring Application (Go to Appendix 4, Developing an Interactive Response Tool) that uses an IR system and frees staff to handle only those needing further attention, such as those developing symptoms or those who did not answer earlier calls. Since most in quarantine should require only periodic monitoring, automating much of that with the QI Monitoring Application could be of great utility.

The QI Monitoring Application automatically places calls to individuals in home quarantine to assess their current health status and reports on those that don't answer so that further followup can be conducted. The application is part of an IR system that can initiate up to 12,000 calls in a ten-hour period. Though this application was developed for use with an IR system, it could be used without such technology. The call flows, decision trees, and message scripts could be used to guide call center staff in handling calls in a structured manner. The application could be adapted to other scenarios that might require contacting individuals by telephone for sheltering in place strategies. We recommend that public health agencies develop referral protocols and guidance for call center staff in handling situations in which a quarantined individual needs food, medication, or financial assistance.

Outpatient Drug Information/Adverse Event Reporting. The CDC's Cities Readiness Initiative program requires that participating cities prepare plans for mass prophylaxis with Strategic National Stockpile assets. Depending on exposure, this program could result in thousands to millions of people being dispensed antibiotic medications. Health call centers can support these efforts by providing information about the incident and the supplied medications, as well as by collecting any potential adverse event reports. The two National Planning Scenarios involving agents that would be treated with antibiotics are Aerosolized Anthrax and Plague Outbreak, but other scenarios that involve either mass vaccinations (Pandemic Influenza Outbreak), wide-scale use of medications for treating radiation exposure (Nuclear Detonation, Radiological Dispersal Devices), or Food Contamination may also require this response capability.

Examples of health call centers providing this capability include the HELP program collecting adverse event information regarding smallpox vaccinations, many drug information centers collecting information for the Food and Drug Administration's (FDA) MedWatch reporting program, and poison control centers handling drug identification calls.

We have developed an application that would support mass prophylaxis with antibiotic drugs using an IR system. The Drug Identification (DI) Application assists callers in identifying dispensed drugs, provides information on how to take them, and describes potential adverse reactions. This would allow public health agencies to concentrate on operating mass dispensing sites and health care providers to care for those that develop illness. Though this application was developed for use with an IR system, it could be used without such technology to guide call center staff in how to handle these calls. The application could be adapted to other scenarios that might require mass administration of medications or vaccinations and provision of relevant information.

MentalHealth Assistance/Referral. Health call centers providing health information and support will help relieve anxiety and stress among the public, especially since many such centers are known and trusted resources within communities. All 15 of the National Planning Scenarios will likely result in varying degrees of community fear, panic, anxiety, and depression. Countless suicide prevention and counseling hotlines currently exist and are run by trained mental health staff. The National Suicide Prevention Lifeline provides a 24-hour toll-free service that routes callers to crisis centers across the country. Additionally, nurse advice lines are capable of handling patients with depression, and poison control centers regularly receive suicide and intentional harm calls. Health call center staff can be trained to identify callers that may benefit from a referral to community mental health resources.

4. Develop a mechanism to test and evaluate the model with a local exercise

The HELP model has been tested over 3 years of daily operations and in response to several major health events. The HELP model has made it possible for us to provide consistent, accurate, and up-to-date information during bioterrorism exercises and public health emergencies in partnership with the Colorado Department of Public Health and Environment. The HELP program provides a model for disseminating and collecting information that, to date, has involved handling more than 75,000 calls related to several major health events, including West Nile virus (WNV) and influenza outbreaks. The public's demand for information during these events has required us to develop better strategies for delivering such services with limited staffing resources.

One strategy is to use initial announcements to relay the information most requested by callers to reduce their need to speak with staff. On average, 60 percent of callers listen to the recorded information and terminate the call, indicating that their concern was addressed with the announcement. This has remained fairly constant for a range of health events over the last 3 years. Additionally, recordings of other frequently requested information can be cycled to potentially answer callers' questions while they are waiting to speak to staff.

Many callers may get the information they require from those messages and no longer need to wait for assistance. This ensures that staff is assisting those that could not be helped easily by other means. Recordings can also refer callers to other information sources, such as the Internet, that they may opt to explore instead of waiting in queue. By reviewing the concerns of callers speaking with staff, managers can determine if additional information should be added to the initial announcement or queue messages, or disseminated by the media or other sources in hopes of meeting demand without call center staff involvement.

The challenges we have encountered with surges in demand for HELP have led us to produce applications to better assist in providing information and supporting caller needs during health emergencies. Using technology such as an Interactive Response (IR) system has further improved our capacity for handling high call volumes. We have developed and tested four IR applications that we believe other community health call centers can use, as well:

• Quarantine/Isolation (QI) Monitoring
• Point of Dispensing (POD) Locations
• Drug Identification (DI)
• Frequently Asked Question (FAQ) Library

A prototype version of the QI Monitoring Application was tested in a rural user group (N=12) in conjunction with an influenza vaccination exercise in October 2005. The prototype application was revised to reflect many of the user suggestions. The revised and more fully developed QI Monitoring Application, along with the other three applications, were evaluated in an exercise in May 2006 in an urban user group (N=96) consisting primarily of local health personnel from 10 counties. The goal of the second exercise was to test the ability of the four IR applications either to initiate contact and determine health status of those in quarantine (QI Monitoring) or to effectively communicate key information to users calling into the four applications.

We met our overall exercise objectives, and we obtained excellent feedback to help us improve the tested applications. We also obtained important information on user acceptance of these IR applications. Although evaluations for all four applications were mostly favorable, it was apparent the FAQ Library application seemed more acceptable than the DI application, perhaps because the latter concerned medications that callers were asked to take.

The comments and evaluations of these applications should also help Public Information Officers in determining which ones may be acceptable for different events and in developing messaging strategies for those events. These results also suggest areas for potential community outreach efforts for public health agencies to create a more informed public. One lesson learned is that the applications will be only as good as the information that is developed for them and the means by which that information is provided to the public.

5. Prepare a final report and recommendations

This final report describes in detail areas described above: the model, the scenarios where the model could be used effectively at various levels of response, and a comparison of the model to other existing models. A brief summary of recommendations follows.

To help the public make informed decisions and care for themselves during severe health events, such as disaster scenarios, we must plan ahead to develop strategies that will minimize or alleviate surge on health care delivery systems and accommodate those most in need. Helping community health call centers develop response capabilities through the models and applications in this report can increase their ability to support the public.

We believe, as determined, in conjunction with the advisory panel, that the four biological scenarios from the Department of Homeland Security National Planning Scenarios described above afford the best opportunity to involve most of the potential response capabilities for community health call centers.

The target audiences for the proposed scenario-specific models and applications are community health call centers that are established and trusted community resources, including:

• Poison control centers.
• Nurse advice lines.
• Drug information centers.
• Health agency hotlines.
• Local/State/Federal public health agencies.

The resources that we have developed to support outpatient health care and monitoring during health emergencies with limited staffing will allow other health call centers to meet the challenges of surges in demand related to health events. These resources will provide the public with self-service support so that persons can make appropriate informed decisions about their health concerns. The basic call center infrastructure and essential elements of the HELP program are needed to support such strategies.

The HELP Models Interactive Response Tool and its four applications proposed in this report are not sole components but part of a comprehensive public information strategy that includes the use of mass media and community health call centers to support self-care, monitoring, appropriate referrals, situational awareness, and disease outbreak management and control.

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