Local Acts DESIGN AND IMPLEMENTATION OF A STATEWIDE INFLUENZA NURSE TRIAGE LINE IN RESPONSE TO PANDEMIC H1N1 INFLUENZA

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1 Locl Acts The 2009 H1N1 influenz pndemic creted demnd for helth-cre services tht mny helth-cre systems nd providers were unprepred to meet in timely wy. One stte used public-privte prtnership to ddress this incresed demnd for informtion nd services, including offering prescription for those whose symptoms wrrnted tretment with n ntivirl mediction. Spulding et l. describe how the Minnesot Deprtment of Helth worked with vriety of prtners, including the Minnesot Hospitl Assocition nd the Minnesot Council of Helth Plns, to estblish coordinted sttewide nurse trige line the Minnesot FluLine. This effort could serve s model for other locl public helth deprtments when rpid response to helth-cre thret is needed. Jnice Huy CAPT (Ret.), U.S. Public Helth Service DESIGN AND IMPLEMENTATION OF A STATEWIDE INFLUENZA NURSE TRIAGE LINE IN RESPONSE TO PANDEMIC H1N1 INFLUENZA Alicen B. Spulding, MPH Deborh Rdi, MBA, BSW Hether Mcleod, MSW Ruth Lynfield, MD Michelle Lrson, MPA Terri Hyduke, MA Peter Dehnel, MD Crig Acomb, MS Aron S. DeVries, MD, MPH The 2009 H1N1 influenz pndemic ws first identified in April nd rpidly spred worldwide. 2 In the northern hemisphere, first wve begn in April 2009, peking in June, followed by reltively low ctivity during July nd August. By September, H1N1 ctivity begn incresing once gin, t higher rtes thn in June, suggesting lrger wve of influenz ctivity hd begun. 3 Minnesot clinics reported experiencing very high numbers of ptients seeking cre, including those with influenz symptoms nd the worried-well, s in other prts of the United Sttes nd the world. 4 6 As more ill ptients sought in-person helth cre, there were more opportunities for influenz trnsmissions to occur within the crowded helth-cre system (HCS). Additionlly, some fcilities reported spot shortges nd low inventories of personl protective equipment, such s N95 msks nd surgicl msks. Rpid ccess to H1N1 ntivirl tretment becme incresingly problemtic in September Given the high number of people seeking cre, ptients were encountering delys in reching helth-cre providers, including ptients t incresed risk for severe disese who were dvised to receive n ntivirl prescription (e.g., those with underlying helth conditions, young children, nd pregnnt women). The uninsured nd underinsured encountered brriers due to the cost of helth-cre provider visit in ddition to the cost of n ntivirl if indicted. Complicting these concerns ws the possibility tht overuse nd misuse of ntivirls my led to oseltmivir resistnce, s ws observed in the circulting sesonl H1N1 influenz strin. The Minnesot Deprtment of Helth (MDH) developed multiple tools to support helth-cre providers. Informtion nd fct sheets on H1N1 disese ctivity, vccine vilbility, preventing illness, nd describing people t risk for more severe disese were developed nd distributed through unique MDH website. 7 Specific guidnce ws creted for HCSs on the use of ntivirl medictions, vccine distribution nd utiliztion, nd infection control in conjunction with the U.S. Centers for Disese Control nd Prevention (CDC). Additionlly, MDH prioritized the use of Minnesot cche ntivirl medictions for uninsured or underinsured ptients, nd for instnces when there ws disruption in the mrket supply. In September 2009, s influenz ctivity ws incresing in Minnesot, n HCS sought guidnce from MDH to ssist with options for the nticipted surge of people seeking helth cre. Nurse trige lines (NTLs) nd informtion lines hve been utilized by HCSs for routine ptient cre, with some jurisdictions utilizing informtion lines during the H1N1 pndemic It ws determined tht n NTL would be the most effective, rpidly deployed method of meeting the needs of the H1N1-ssocited helth-cre surge. A coordinted sttewide NTL system clled the MN FluLine (Minnesot FluLine) ws creted to ddress the following objectives: (1) decrese public confusion by providing ccurte informtion, 532

2 Locl Acts 533 consistent messging, nd ssistnce, including use of ntivirl medictions; (2 ) decrese the spred of disese by reducing the volume of sick individuls gthering in helth-cre settings; (3 ) reduce medicl surge on the HCS to ensure tht other priority medicl needs would continue to be met; nd (4 ) meet the needs of uninsured or underinsured ptients, nd those without esy ccess to helth cre. PROJECT DESCRIPTION MDH ws pproched by n HCS with the ide of estblishing coordinted, sttewide NTL system with single toll-free number for Minnesotns in September All HCSs with opertions in Minnesot tht hd n NTL were contcted to prticipte in this publicprivte prtnership. During series of teleconferences with 14 Minnesot-bsed public nd privte helth orgniztion prtners including the Minnesot Hospitl Assocition nd the Minnesot Council of Helth Plns nd one fce-to-fce meeting, the structure nd functions of the MN FluLine were estblished. MDH contrcted n NTL vendor to operte the MN FluLine toll-free number 24 hours per dy, seven dys per week. All nurses performing trige services by the vendor were licensed registered nurses (RNs). MDH creted single clinicl evlution lgorithm nd protocol for stnding orders bsed on CDC tretment nd prevention guidelines trgeting people with symptoms of influenz-like illness (ILI) nd those with exposure to someone with ILI. ILI ws defined s fever F nd cough or sore throt. A drft version of the protocol ws provided to the medicl directors of prtner NTLs for feedbck. The edited protocol ws dopted by ll prticipting HCS prtners nd dministered uniformly. Adpttion of the protocol to mke it comptible with the NTL s own electronic helth-cre record system ws llowed. Upon first clling the MN FluLine, ll cllers received stndrd messge with informtion on influenz. If the cller remined on the line to spek with the medicl screener but hd no symptoms, he or she ws referred to influenz informtion resources, such s generl informtion hotlines, United Wy 211, nd websites. To mintin continuity of cre, once screened, ll cllers ssocited with n HCS tht operted prticipting NTL were trnsferred from the toll-free number to their HCS NTL where the stndrdized protocol ws dministered. If the cller ws ffilited with helth orgniztion without n NTL, or if the cller reported not hving insurnce, the cll ws mintined by the contrct vendor of the MN FluLine, who dministered the stndrdized protocol. For ll clls mnged by the contrct NTL, contct informtion ws recorded by the medicl screener, nd the cller ws plced in queue for nurse to return the cll (Figure 1). Bsed on the stndrdized trige protocol dministered by the contrct NTL nd ll other prticipting NTLs, cllers with symptoms were recommended to one of the following dispositions: (1) continue cre t home, (2) contct helth-cre provider, (3) see helth-cre provider, (4 ) go to the emergency deprtment, or (5 ) cll 911 (Figure 2). If cllers were recommended to remin t home but were determined to be t incresed risk for severe ILI bsed on CDC tretment guidelines for treting ptients with helth conditions tht increse the risk for severe complictions of influenz, n ntivirl (oseltmivir) ws prescribed by the contrct NTL nurse. Prescriptions were phoned in to the cller s phrmcy of choice for people currently in Minnesot. Before the cll ws completed, ll cllers (except those who were recommended to go to the emergency deprtment or cll 911) were provided in-depth home cre informtion, infection prevention instructions, informtion on oseltmivir nd side effects if pproprite, nd informtion bout when to seek future cre for the illness. At the designted locl phrmcy, if the ptient hd insurnce nd there ws no mrket interruption in the supply, tretment course of oseltmivir ws dispensed, nd insurnce ws billed. If the ptient ws uninsured or underinsured, oseltmivir from pre-positioned stte cche ntivirls ws dispensed t no cost to the ptient or with n option of low-cost fee. MDH creted legl ssessment tht, long with the lgorithm nd protocol, explined the legl frmework of the MN FluLine. The order to dispense ntivirls vi protocol ws executed by the Stte Epidemiologist under uthority delegted by the Commissioner of Helth. As the contrct vendor for the MN FluLine ws cting on behlf of the stte of Minnesot, per Minnesot Sttutes 13.04, 12 ll cllers were provided privcy sttement before privte helth dt were collected. Prescribing vi protocol by RNs is llowed under MN Sttute Five weeks fter plnning ws initited, the MN FluLine begn opertions on October 21, MDH held press conference nnouncing its lunch, which ws highly ttended by locl medi, nd provided subsequent regulr interviews bsed on inquiries from sttewide medi outlets. Pid dvertisements were plced in specific lnguge medi outlets, nd MDH s influenz website 7 hd informtion on the MN FluLine positioned prominently on its min pge. The MN FluLine discontinued service on Mrch 31, 2010.

3 534 Locl Acts Figure 1. MN FluLine system design A sttewide nurse trige line responding to 2009 H1N1 influenz in Minnesot providing clinicl evlution, referrl to pproprite level of cre bsed on symptoms, infection prevention recommendtions, nd n ntivirl prescription when indicted MN 5 Minnesot MDH 5 Minnesot Deprtment of Helth CDC 5 Centers for Disese Control nd Prevention Myo 5 Myo Clinic ILI 5 influenz-like illness The totl number of clls to the toll-free number ws bsed on telephone compny dt. The NTL contrct provider collected dt on the number of clls evluted by the medicl screener, the number of clls referred to the prtner NTL, nd the demogrphics nd disposition of clls for cllers with ILI or exposed to someone with ILI. Surveillnce for hospitlized cses of lbortory-confirmed influenz ws conducted sttewide by MDH during the time frme of the MN FluLine s implementtion. 3 Minnesot county popultion dt used to clculte cll rtes were bsed on the U.S. Census Bureu s 2009 intercensl estimtes. 14 RESULTS From October 21, 2009, to Mrch 31, 2010, the MN FluLine received 27,391 clls (Figure 3). There ws n initil overwhelming response following the lunch of the MN FluLine, with more thn 9,000 clls in the first 10 dys of service. The mjority of clls (56%) occurred during the month of October, with demnd tpering off during subsequent weeks corresponding to decresing number of hospitliztions due to H1N1 (Figure 4). The MN FluLine ws initited the sme week the number of hospitliztions peked in Minnesot.

4 Locl Acts 535 Figure 2. MN FluLine disposition design A sttewide nurse trige line responding to 2009 H1N1 influenz in Minnesot providing clinicl evlution, referrl to pproprite level of cre bsed on symptoms, infection prevention recommendtions, nd n ntivirl prescription when indicted MN 5 Minnesot MDH 5 Minnesot Deprtment of Helth MD 5 medicl doctor ED 5 emergency deprtment RN 5 registered nurse Of the cllers, 6,094 voluntrily ended their cll fter hering the stndrd messge with informtion on H1N1 nd relted resources, leving totl of 21,297 cllers evluted by the medicl screener. Of those cllers, 13,958 (66%) reported ILI symptoms or exposure to someone with ILI, nd 7,339 (34%) reported not hving ILI or exposure to someone with ILI nd were referred to generl H1N1 informtion resources. Of those reporting ILI symptoms or exposure to someone with ILI symptoms bsed on the medicl screener dt, 3,691 were informtion-only, non-flu-relted, or duplicte clls; 3,799 were trnsferred to prtner HCS with n NTL for protocol dministrtion; nd 6,468 were mnged by the MN FluLine contrct provider. After excluding dditionl duplictes, non-flu-relted, nd informtion-only clls bsed on NTL nurse dt, totl of 6,160 unique cllers (22% of ll cllers) were triged by the NTL contrct provider. Of those cllers, 5,949 (97%) completed the MN FluLine nurse protocol (Figure 3). There ws n pproximtely even distribution of clls by dy, with 24% of clls occurring on Sturdy or Sundy. The men length of cll to the MN FluLine ws 13 minutes, with rnge of 0 70 minutes. MN FluLine

5 536 Locl Acts Figure 3. Flowchrt of ll MN FluLine cllers: Minnesot, October 2009 Mrch 2010 A sttewide nurse trige line responding to 2009 H1N1 influenz in Minnesot providing clinicl evlution, referrl to pproprite level of cre bsed on symptoms, infection prevention recommendtions, nd n ntivirl prescription when indicted MN 5 Minnesot ILI 5 influenz-like illness NTL 5 nurse trige line

6 Locl Acts 537 Figure 4. Hospitlized, PCR-confirmed 2009 H1N1 cses nd clls to the MN FluLine : Minnesot, September 2009 Februry 2010 A sttewide nurse trige line responding to 2009 H1N1 influenz in Minnesot providing clinicl evlution, referrl to pproprite level of cre bsed on symptoms, infection prevention recommendtions, nd n ntivirl prescription when indicted PCR 5 polymerse chin rection MN 5 Minnesot ptients rnged in ge from 26 dys to 96 yers; 35% of ptients were younger thn 10 yers of ge, nd the verge ge ws 26 yers. The mjority of ptients were femle (58%). The mjority of cllers were clling on behlf of someone else (56%). Among the 88% of cllers who reported their insurnce sttus, 14% reported no insurnce coverge (dt not shown in Figures). Eighty-eight percent (n55,445) of cllers reported they were currently locted in Minnesot. Clls were received from 86 of Minnesot s 87 counties, nd mp of cll rtes by county shows tht the highest cll rtes per cpit were from rurl res (Figure 5). Bsed on 5,445 Minnesotns clling the MN FluLine, pproximtely one of every 1,000 Minnesotns utilized the service. Of the 5,949 cllers who received disposition from the NTL contrct provider, 2,666 (45%) were recommended to self/home cre, 1,292 (22%) were instructed to see helth-cre provider, 875 (15%) were instructed to visit n emergency deprtment, 497 (8%) were instructed to cll their helth-cre provider, 488 (8%) were provided informtion or dvice only, 122 (2%) were instructed to cll 911, nd eight (,1%) were given n other disposition. Six percent (n5374) were prescribed oseltmivir by the NTL contrct provider bsed on the protocol, of which 161 received dult dosing nd 213 received peditric dosing. Oseltmivir prescription rtes for Minnesotns were highest in rurl counties, similr to MN FluLine cll rtes by county (dt not shown in Figures). Of those who received disposition, 3,659 cllers (13% of ll totl cllers) received recommendtion tht did not involve seeking in-person helth cre. Including the 7,339 cllers who contcted the MN FluLine but did not hve symptoms of influenz (Figure 3), up to 10,998 in-person helth-cre encounters my hve been prevented by the MN FluLine.

7 538 Locl Acts Figure 5. MN FluLine cll rtes per 10,000 popultion, by county: Minnesot, October 2009 Mrch 2010 A sttewide nurse trige line responding to 2009 H1N1 influenz in Minnesot providing clinicl evlution, referrl to pproprite level of cre bsed on symptoms, infection prevention recommendtions, nd n ntivirl prescription when indicted MN 5 Minnesot

8 Locl Acts 539 DISCUSSION The pndemic due to 2009 H1N1 hd significnt impct on our society, with yers of life lost comprble with pndemics in 1957 nd During the H1N1 pndemic, CDC recommended tht helth-cre providers consider using telephone contct to reduce delys in tretment ccess 16 nd lter published report describing how to develop nd implement n NTL s mens of ddressing popultion needs during pndemic. 17 The MN FluLine ws sttewide NTL tht ws developed in five weeks nd begn service t the pek of 2009 H1N1 ctivity during lte October in Minnesot, mitigting some of the pndemic s impct on the helth-cre community. Although other orgniztions utilized telephone lines during the 2009 H1N1 pndemic, 8 10 the MN FluLine ws, to our knowledge, the only sttewide NTL implemented specificlly to respond to the public helth thret of 2009 H1N1 nd to offer prescription for n ntivirl if indicted. It hd mjor impct on the Minnesot popultion nd the helth-cre community, with one in every 1,000 Minnesotns ccessing the MN FluLine during its opertion. Mny ptients were children nd were from rurl res with more limited helth-cre ccess. The frequency of cllers who were uninsured (14%) ws bout 1.5 times the percentge of uninsured Minnesotns in 2009 (9.1%). 18 The even distribution of clls by dy emphsizes the importnce of hving services such s the MN FluLine vilble seven dys per week. Mny of the chllenges tht occurred during the 2009 H1N1 pndemic were solved by creting publicprivte prtnership tht included MDH, n existing highly experienced telephone nurse trige cll center, nd the stte s lrgest helth-cre plns with NTLs. Prior to this process, there ws no coordintion or forml communiction between HCS trige lines, nd very few provided ntivirl mediction per nurse protocol. This intervention ws specificlly designed to reduce the burden on medicl providers by triging ptients nd providing dvice or ntivirls s indicted. Criticl to this intervention ws its design nd implementtion in only five weeks. While other res of the country lso hd NTL in response to H1N1, 10 the MN FluLine ws stffed by nurses utilizing stndrdized protocol, who were ble to prescribe ntivirls nd rech lrge percentge of people living in the stte. There re mny benefits to the use of telephone consulttions s response to public helth thret. They offer the bility to quickly stndrdize nd updte informtion, provide sfety net for uninsured nd underinsured popultions, decrese the exposure rte both for ill people nd worried-well people seeking inperson cre, nd provide informtion nd emotionl support to people who re concerned bout illness. NTLs re lso beneficil in tht they reduce strin on the HCS, offer high levels of ptient stisfction, nd serve s sfe, efficient, nd cost-effective method of informtion dissemintion Benefits cn lso be seen in reduced trvel costs, reduced time wy from school/work, nd reduced childcre expenses. 17 Limittions There were severl limittions in the design nd implementtion of the MN FluLine. The service ws so overwhelmingly busy in the first week tht dditionl infrstructure, including phone lines nd utomted systems, were needed to meet the demnd. Initilly, there ws lso some confusion in communiction bout the MN FluLine s to whether or not person needed insurnce to be ble to cll. Although this confusion ws quickly clrified in MDH communictions, it is possible tht some people without insurnce did not ttempt to ccess the MN FluLine. Becuse cllers could repetedly ccess this service nd were not ssigned unique identifier when they clled, it is possible tht there were repet cllers in our dt. However, repet cllers my represent chnge in the sttus of the ptient. In this regrd, ech chnge in sttus could represent n instnce where the cller would hve sought in-person helth cre. It is lso possible tht people used the line for non-flu-relted clls, therefore incurring costs tht should not hve been covered by this MDH service. Finlly, n priori collection of performnce mesures would likely hve improved the types of dt collected nd would hve provided greter clrity to our estimtion of the MN FluLine s impct. It ws our experience tht using currently operting, experienced NTL ws vitl to the rpid implementtion of the MN FluLine. Utilizing direct trnsfers from the contrct NTL to other prticipting NTLs ws lso importnt in mintining communiction between the NTL nd the cller s helth-cre provider. Additionlly, ccurte nticiption of cller volume could optimize the initil success but, s we experienced, cn be difficult to predict. NTLs cn be powerful tools in responding to public helth emergencies, nd future prepredness plnning should include their use. CONCLUSION This public-privte prtnership leverged public helth nd nurse trige expertise utilizing the existing telecommunictions infrstructure to rpidly implement focused nd efficient helth-cre delivery system

9 540 Locl Acts bsed on stndrd protocol nd sttewide ntivirl prescribing. The MN FluLine ws implemented t the time of gretest need in Minnesot, reched mny rurl nd uninsured Minnesotns, nd my hve prevented nerly 11,000 in-person helth-cre encounters. An ctivity such s the MN FluLine could be rpidly initited to respond to multiple helth-cre threts, such s emerging infectious disese outbreks or bioterrorism threts, or to provide helth-cre ccess following nturl disster. The uthors thnk Snne Mgnn, Richrd Dnil, Kristen Ehresmnn, Dwn Ginzl, Aggie Leitheiser, Ctherine Lexu, Crig Morin, Dve Orren, Kevin Sell, nd Megn Thompson, ll with the Minnesot Deprtment of Helth (MDH); Ptsy Stinchfield with Children s Hospitls nd Clinics of Minnesot; Alex Kllen nd John Jernign with the Centers for Disese Control nd Prevention (CDC); Blue Cross nd Blue Shield of Minnesot; Children s Physicin Network; Firview Helth Service; HelthPrtners; Myo Clinic; Medic; Metropolitn Helth Pln; OptumHelth; Prk Nicollet Helth Services; Prime West Helth; UCre; nd United Wy 211. Finncil support for the opertion of the MN FluLine ws provided by the CDC Public Helth Emergency Response Grnt (1H75TP000348). Alicen B. Spulding is doctorl cndidte in Epidemiology t the University of Minnesot School of Public Helth, Division of Epidemiology nd Community Helth in Minnepolis, Minnesot, nd former progrm evlution nlyst t MDH in St. Pul, Minnesot. Deborh Rdi is Eduction, Exercises, nd Plnning Unit Supervisor of the Office of Emergency Prepredness; Ruth Lynfield is Stte Epidemiologist; Michelle Lrson is Deputy Director of Sttewide Helth Improvement Inititives; Crig Acomb is Assistnt Commissioner; nd Aron DeVries is Medicl Director, Infectious Disese Epidemiology, Prevention, nd Control Division; ll with MDH in St. Pul. Hether Mcleod is Director, Nurse Trige Services; Terri Hyduke is Chief Executive Officer; nd Peter Dehnel is Medicl Director; ll with the Children s Physicin Network in Minnepolis. Address correspondence to: Aron S. DeVries, MD, MPH, Minnesot Deprtment of Helth, 625 Robert St. N, St. Pul, MN 55164; tel ; fx ; e-mil <ron.devries@ stte.mn.us>. The views expressed in this rticle re those of the uthors nd do not necessrily represent the views of CDC. This work ws exempt from Institutionl Review Bord pprovl Assocition of Schools of Public Helth REFERENCES 1. 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