Chapter 4. Results

AHRQ assigned us five primary tasks to develop this model for adapting community health call centers to support outpatient health care and monitoring in a major health care crisis. We anticipate that this model will integrate with other community efforts by a variety of response agencies to address the specific needs of the public in certain health emergency scenarios. The goal of this project is to provide community health call centers with a tested model for responding to a health emergency and the resources to help inform and support the public.

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 (Table 1) that met at three advisory panel meetings held in Washington, DC. Panelists had backgrounds and experience in:

• Public health and epidemiology.
• Emergency preparedness planning, responses, and exercises.
• Emergency call center services.
• Nurse advice/triage and health decision algorithms.
• Poison control centers and medical toxicology.
• Health informatics.
• Data and voice technology.
• Victim services and mental health counseling.
• Risk communication.
• Law and public policy.

The panelists represented agencies and fields that were considered crucial to community and national response planning as it relates to community health call centers. They helped in reviewing our objectives, selecting appropriate disaster scenarios, and reviewing concepts for model and application development. Once application prototypes were developed, the panel reviewed exercise results and provided suggestions for improvement and exportability.

In addition, we invited representatives from several key Federal agencies and the American Red Cross to participate in panel meetings and the final presentation (Table 2). These representatives educated the panel and core team members about other Federal response efforts underway and how this project would best be able to integrate or support those projects. Agency representatives are listed in the table below.

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 National Planning Scenarios to assure consistency with other preparedness and response efforts.¹⁴ These 15 scenarios do not cover all possibilities for health emergencies; however, they do include a wide spectrum of disasters that communities could face. Although other potential disaster scenarios have been used for response planning, these 15 have been developed in a very structured manner and with participation of numerous Federal agencies. Using these scenarios will provide a common framework for sharing best practices and strategies.

We reviewed all 15 scenarios and determined the ones that could best benefit from the potential response capabilities of community health call centers. The six response capabilities that were assessed include:

• Health information.
• Disease surveillance.
• Triage/decision support.
• Quarantine/isolation support.
• Outpatient drug information/adverse event reporting.
• Mental health assistance/referral.

We developed a matrix that lists each scenario and the expected casualties, infrastructure damage, and evacuations/displaced persons as presented in the executive summary for that scenario (Go to Appendix 1). We also provided the recommendations for evacuations, sheltering, and victim care strategies from the activated mission areas listed in the document. We determined which of the six potential response capabilities would be appropriate or practical for community health call centers to provide in each scenario. Each capability was then graded based on our experiences and the anticipated response needs of a community during such a disaster scenario using the following scale:

• Capabilities that correspond best with expertise of health call centers and the expected response needs of a community.
• Other capabilities that correspond with the expertise of health call centers and the expected response needs of a community.
• Capabilities that may exist in health call centers though there may not be the response need in a community.
• Capabilities that health call centers would need to refer to more appropriate resources within a community.
• Capabilities that are not well-suited to community needs for this scenario.
• Primarily a community response capability with which health call centers would need to integrate.

The scenario matrix indicates that a health call center's capability to provide health information most frequently corresponds with the expected response needs of a community. The strongest association for this call center capability and community need occurs with the biological scenarios. However, providing health information would also be of benefit in almost all scenarios: nuclear, radiological, chemical, and natural disasters. For the remaining five call center response capabilities, the strongest associations with perceived community needs seem to correspond best with the biological scenarios. Conversely, a technologically centered cyber attack seems the "weakest" scenario for benefiting from most of the response capabilities of a health call center.

Therefore, we decided to focus our model development on the biological scenarios since they involve large health impacts, have the potential for many "worried well," and could benefit from home management of illness and sheltering in place strategies, and because community infrastructure could be expected to remain intact so that call centers would likely be able to operate. We determined, in conjunction with the advisory panel, that four of the biological scenarios afford the best opportunity to involve most of the potential response capabilities for community health call centers:

• Biological attack—aerosol anthrax.
• Biological disease outbreak—pandemic influenza.
• Biological attack—plague.
• Biological attack—food contamination.

In addition, we developed potential health call center capabilities for each of the four selected National Planning Scenarios (Appendix 2), which provide specific suggestions for each of the six health call center response capabilities. This document can assist call centers and public health agencies in determining the expected health needs for each scenario and selecting those for which they may want to plan.

This is not to imply that health call centers could not play an important role in responses to other scenarios, but rather that developing tools related to the response needs of these biological scenarios afforded the greatest potential for success. As the scenario matrix suggests, the resultant applications and response strategies could then be assessed for applicability or modification to address the response needs of other scenarios. For example, a surveillance application for influenza or plague reports could be adjusted to capture chemical or radiological agent illness reports.

Our assessment also suggested that, while mental health assistance and referral is a capability that all scenarios would likely need, it is primarily a community response capability in which health call centers would play a supportive role. Therefore, we did not specifically develop an application for this capability but instead considered how to incorporate sensitivity to community emotions, stress, and anxiety that a major disaster will exacerbate.

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

To better develop our community health call center model and tools, we first researched available information on existing models, protocols, and algorithms for community communication strategies related to the four biological scenarios.

In the fall of 2005, we searched PubMed® (medical and scientific literature), www.Google.com (Internet), and http://www.cdc.gov/ (public health practice and guidance) Web sites to locate information. We used subject keywords (biological attack, disease outbreak, anthrax, aerosol anthrax, inhalation anthrax, plague, pneumonic plague, influenza, pandemic influenza, food contamination) in combination with each of these focusing keywords (surveillance, triage, quarantine, isolation, mental health, prophylaxis, side effects, adverse events, clinical algorithms). Results from these searches were reviewed to find existing models of call center strategies for community communication and support.

The searches revealed only limited results related to model development. We did, for example, identify many city and State public health department Web sites providing influenza vaccination clinic information that were searchable by using either city name or zip code (California¹⁵, Minnesota¹⁶, Georgia¹⁷, Massachusetts¹⁸). A few included a telephone information hotline as well (San Diego¹⁹, Oregon²⁰). We did not locate any States using interactive automated telephone-based systems, but some did have either noninteractive recorded messages or a person on the line providing specific clinic location or general influenza information. Some Web sites simply forwarded the user to the CDC Web site for general influenza information.

A report by Cartter et al. described the Connecticut influenza hotline and how it conducted a vaccination survey during the 2004-2005 influenza season when there was a vaccine shortage. The hotline addressed questions from the public regarding vaccine availability, which groups were most at risk, and influenza symptoms in order to reduce inquires to physicians 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 in order to improve compliance.²¹

A few reports were related to severe acute respiratory syndrome (SARS) surveillance strategies using telephones or call centers:

• Toronto Public Health, in addition to providing SARS information to the public through their hotline, also used this resource to support the management of 13,291 individuals who were placed in quarantine, mainly in their own homes. Of that number only 0.1 percent were issued an enforceable quarantine order after initial noncompliance.²
• Kuhles reported using videophones to monitor seven suspected SARS cases and their close contacts. Afterwards, the videophones were used to monitor patients with active and latent tuberculosis. The videophones enabled local health department staff to visually assess the patient's condition during each call.²²
• Lee et al. reported on the experience in Taiwan of using quarantine to prevent transmission of SARS. From late February to mid June 2003, more than 131,000 people were placed in quarantine for 10 to 14 days; most were placed in home quarantine during the months of April and May. Management of those in quarantine consisted of daily visits or telephone calls to review the person's health status including temperature recordings and symptoms. The quarantine was considered very successful with only 0.2 percent fined for violation of quarantine rules.²³
• Blendon et al. reported results of a survey conducted in four populations (Hong Kong, Taiwan, Singapore, and the United States) concerning attitudes about quarantine in a public health emergency. Respondents were asked if they supported the use of three preventive measures to control the spread of a contagious disease: requiring everyone to wear a mask in public, requiring everyone to have their temperature taken to screen for illness before entering public places, and quarantining people suspected of having been exposed to the disease. The percentage of people favoring any measures in any population ranged from 44 percent to 99 percent; the highest mean favorable response occurred for quarantine. However, support for all measures decreased significantly if the condition of arrest for refusing to comply was added. Respondents were also asked about their preferences for monitoring compliance during quarantine and were most in favor of a daily visit from a health official followed by periodic telephone calls. The least favored methods of monitoring were more intrusive measures such as periodic video screening, electronic bracelets, and stationed guards. In the U.S., more than 70 percent of respondents favored home quarantine for themselves and their family as opposed to a separate facility.²⁴

These results suggested to us that using the telephone to provide information and support disease control measures like home quarantine would likely be favorably received by the public and would assist public health agencies in the management of such efforts. We therefore proceeded with the use of the HELP model as a platform for a wide range of call center based health information strategies on which we could explore the use of an Interactive Response (IR) system to automate certain of those functions to better handle surges.

We developed tools for the five response capabilities mentioned earlier:

• Health information.
• Disease/injury surveillance.
• Triage/decision support.
• Quarantine/isolation support.
• Outpatient drug information/adverse event reporting.

This section will review each response capability and propose scenario-based strategies for using community health call centers, including:

• Significance of the response capability.
• Applicability of the capability to the National Planning Scenarios.
• Current examples of the capability.
• Range of technology to support the capability.
• Staffing required to deliver the capability.
• Our proposed resources and strategies for the capability.

Health Information

Significance. Use of health call centers could greatly augment mass risk communication messages and help alleviate surges to health care systems. Our experience and that of others has shown that incidents that generate public concern usually require robust mass risk communication coupled with hotlines or other forums to assist those with further needs.⁵

Scenarios. Of the 15 National Planning Scenarios, we identified applicability for this health information capability in all scenarios, with the best association of health call center expertise and community need for Aerosolized Anthrax, Pandemic Influenza Outbreak, Plague Outbreak, and Food Contamination.

Current Examples. Current examples of health information capabilities include those provided by poison control centers, nurse advice lines, drug information centers, many public health agency hotlines (often single issue focused or developed ad hoc to address a certain event), and our HELP program.

Technology. Basic telephone technology is required to provide health information capability and could consist of a single phone line with a recording or a live agent. Accommodating larger call volumes requires additional phone lines, a telephone switch that can support simultaneous announcements, automated call distribution, call management software, and even additional equipment, such as an IR system to allow callers to retrieve information by voice or by touch-tone entries. The HEALTH model report describes much of the technology that an advanced call center that expects to handle significant call volume should consider.⁵

Staffing. Delivering health information requires trained information providers—individuals who have been trained in customer service, operating telephones and other equipment, and the topical content. Clinicians are not required (and would be overqualified) for this capability unless a call center is being considered for providing assessment or management of a caller's health concern or medical condition.

Proposed Resources. Appendix 3, Suggested Elements for Public Health Information and Decision Support Hotlines, offers instructions that a community health call center can use to develop health information capabilities that are similar to the HELP program. The model describes the essential components for developing a standardized response capability and provided us with the platform onto which additional capabilities could be added to support outpatient health care and monitoring during public health emergencies. This model for responding to public health events includes providing consistent and accurate information, collecting and maintaining structured data to characterize events and responses, and developing capability and capacity to adapt to other public health emergencies.

Issues that are important to the creation of standardized responses are call-handling procedures, call center infrastructure/technology issues, creation of toll-free lines with up-to-date recordings, integration of related Web sites, training for information providers, defining referral procedures, quality control and quality assurance practices for maintaining consistent and accurate information delivery and reporting protocols.

We strongly urge a call center attempting to provide health information during an emergency to do so in cooperation with the public health authority that is, by statute, responsible for coordinating health and medical services in response to public health and medical care needs following a major disaster or emergency. Coordination with the health authority will help ensure overall consistency with other response measures. Figure 3 shows the process that we used to draft, review, and approve health information content. The messages on various health topics in some of the applications in this report were developed in concert with State health department epidemiologists. They should not be viewed as absolutes, and any call center planning to use the message contents should first have them reviewed by its own public health agency.

We have developed two applications for providing automated information to callers, which is especially important in events that could generate increased call volumes that surpass a call center's staffing capacity. The two applications were developed for use with an IR system so that callers can retrieve information using a touch-tone phone. Both ensure consistent and accurate information delivery: the same information is provided to every caller, every time. These applications are summarized below and described fully in Appendix 4, Developing an Interactive Response Tool.

POD Application. The CDC's Cities Readiness Initiative program (http://www.bt.cdc.gov/cri/) recommends Points of Dispensing as a key element of readiness and response. This IR application will provide inbound callers with locations for drug dispensing sites in their county based on the caller's zip code. The caller can choose between English and Spanish. The application also can provide an individual message for each zip code within a county to allow for relaying customized information. Finally, the application can report on how many callers select each message option.

FAQ Library Application. The FAQ Library Application can disseminate health department-approved, up-to-date, consistent, and accurate information to the public and health care providers. This IR application allows callers to navigate through a library of FAQs to retrieve information relative to their concern. Callers can choose to speak to an information provider. The information providers use the same FAQs to answer caller questions. The application provides reports on how many callers selected each message option and on the zip codes entered. An initial bulletin announcement can be activated to provide emergency or seasonal information prior to callers being prompted for their zip code.

Although these applications were both 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 without technology to guide call center staff in how to handle calls and what information to provide. Or these applications could be used with other technology such as recordings and announcements to assist call center staff in managing higher call volumes. Both applications could be adapted to other scenarios than those for which they were originally designed. The POD application could be modified to provide any information to be delivered based on a zip code designation for such events as evacuations, sheltering in place, snow cancellations, or mass vaccinations. The FAQ application could have any topics loaded into it for callers to retrieve.

Disease/Injury Surveillance

Significance. Call centers that collect any health data could contribute to surveillance systems for reporting illness/injury (situational awareness), for detection of sentinel events, or for emerging health threats. Some health call centers may already analyze their own data to characterize their patient populations or to identify health issues as they emerge. Others may not realize the value of their data as it relates to a public health agency's need for disease and injury surveillance.

Scenarios. Of the 15 National Planning Scenarios, the one with the best association between health call center expertise and community need for this capability was Pandemic Influenza Outbreak, though almost all the other scenarios could benefit from using call centers to capture health data related to disease or injury surveillance.

Current Examples. A current example of a health call center contributing to disease surveillance is the HELP program and its experiences in identifying sentinel events such as hantavirus and tuberculosis cases, as well as supplying weekly geo-coded data on self-reported cases of influenza/pneumonia, mold exposures, and WNV-related dead bird reports.

The American Association of Poison Control Centers also transmits data related to toxic substance exposures to the CDC's BioSense program (http://www.cdc.gov/biosense/files/BioSense_Overview_Handout9-06.pdf; PDF Help), whose objective is to improve the Nation's capabilities for disease detection, monitoring, and real-time situational awareness through access to existing data from health care organizations across the country.

Some individual poison centers²⁵ and nurse advice lines²⁶ have also analyzed their data as part of syndromic surveillance programs. Drug information centers that collect information on adverse drug events related to medical products contribute data to the Food and Drug Administration's (FDA) MedWatch reporting program (http://www.fda.gov/medwatch/).

Technology. Besides the call center technology mentioned previously for providing health information capability, a data collection system would be required for a disease and injury surveillance capability. Such data collection systems could range from forms or databases in software applications such as Microsoft Excel and Access that are designed to capture specific data to more advanced data collection applications that are marketed to health call centers for managing their operations. Statistical analysis capabilities would require the use of commercial software applications such as Microsoft Excel, SAS, or SPSS. Call centers could perform analysis themselves, or they could provide the data to public health or other agencies for analysis.

Staffing. In addition to information providers who are trained to collect data, statisticians and/or data analysts would be needed to perform and interpret analyses.

Proposed Resources. Appendix 3, Suggested Elements for Public Health Information and Decision Support Hotlines, discusses structured data collection and public health partnering for developing disease surveillance capabilities. The POD and FAQ library IR applications described above that provide health information also can collect zip code data that could be useful in surveillance, such as which zip codes are entered for callers seeking information related to WNV in humans or for callers seeking antibiotic medication dispensing locations.

Triage/Decision Support

Significance. Health call centers can assist with triage and decision support for health concerns. These support services can alleviate surges to health care facilities and thereby reduce associated health care costs that occur with hospital visits.

Scenarios. Of the 15 National Planning Scenarios, the Pandemic Influenza Outbreak had the best association between health call center expertise and community need. However, almost all 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. Current examples of call center capabilities with triage and decision support 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. The fact that these call center types provide services by licensed professionals (nurses, pharmacists, physicians) lends public credibility to the capabilities. Research has shown that a nurse advice line can affect patient behavior and facilitate the most appropriate use of health care resources.¹⁰

Poison control centers save an estimated $6.50 for every dollar invested in their operation.²⁷ By preventing unnecessary emergency department visits and hospital admissions through poisoning management support and consultations, they reduce use of expensive diagnostic testing, inappropriate use of antidotes, and lengthy hospital admissions. Therefore, using these same call centers in health emergency situations should result in the same efficiencies and cost effectiveness outcomes.

The HELP program does not normally provide symptom, disease, or exposure management and, therefore, does not need to be staffed by clinicians. It does, however, provide disease and symptom information that supports the public in making informed decisions about their health care. For normal daily operations, HELP is staffed with trained information providers who 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 a health care provider.

Another value of the HELP program providing health information to the public in an emergency event is preventing unnecessary calls to clinician-staffed lines and allowing them to appropriately handle medical triage and management support calls. However, the HELP program could be staffed with clinicians to provide triage or symptom management support for an emergency event, if needed. An example of this occurred when clinicians were needed to support a statewide smallpox vaccination program.²⁸

Technology. In addition to the call center technology and the data collection systems mentioned previously, clinicians require proven and stable software programs. These programs should be secure and HIPPA-compliant, and they should include embedded triage and decision support algorithms; support for the necessary health, medical, and drug information; and appropriate documentation and storage of collected data, recommendations, and information. For information providers solely providing information that supports the caller in making an informed decision about their health concerns, the same call documentation is appropriate and beneficial. Call recording is essential, as it ensures quality assurance and quality control, supports staff training, and serves as a durable record of call content.

Staffing. Depending on the service provided, trained information providers and/or clinicians such as nurses, pharmacists, physicians, nurse practitioners, or physician assistants may be needed to staff the call center.

Proposed Resources. We are not proposing a specific resource beyond the delivery of health information by information providers to allow callers to make the most appropriate decision for their health concerns. However, we are suggesting that communities consider the clinical recommendations they would use in the event of a major health emergency that severely impacts the health care delivery system, such as pandemic influenza (Table 3).

A community may need to adjust standards of care in its planning for handling the increased patient demands from a pandemic or severe influenza outbreak. For more information, review the AHRQ publication, Mass Medical Care with Scarce Resources: A Community Planning Guide (http://www.ahrq.gov/research/mce/). Health care delivery systems and health care providers need to consider how they would handle increased volumes of sick patients, many of whom will not necessarily benefit from direct evaluations, in the face of increased demands on limited health care resources.

A health call center would need to ensure that its recommendations to callers were consistent with those of the rest of the health care delivery system and its health care providers. The following example includes some information that a call center may consider using as part of a home care management strategy.

Information for Patients. The language presented here is meant to be a discussion starter for communities to begin planning for handling the increased patient demands that could result from a pandemic or severe influenza outbreak. This language is not meant to be used as presented but rather, should be used by health care providers to strategize how they would handle increased volumes of sick patients, many of whom will not necessarily benefit from direct evaluations in the face of increased demands on limited health care resources. As part of such a strategy, clinical care algorithm dispositions may need to be reviewed and potentially revised.

• Influenza is a viral illness that causes muscle aches and pains, as well as respiratory symptoms ranging from cough, fever, and sore throat to severe respiratory distress.
• Almost everyone has experienced influenza at some point in their lives; it is most likely to occur in the winter when viruses are more easily spread from person to person.
• The human strain of avian influenza is expected to result in more people having severe respiratory symptoms than is usual for other types of influenza.
• Just as with other types of influenza, there is not any specific treatment available.
• In most cases, rest, fluids, and over-the-counter medications that help to lessen your symptoms are all that is needed.

"You have indicated that you have some of the symptoms of influenza but are not experiencing the most severe symptom, respiratory distress or breathing difficulty. That is very good. It is likely that your symptoms will not worsen, and home care will be all that is required. Because there is no specific treatment for influenza, medical care is only a benefit for those who are in severe respiratory distress and require assistance in breathing. Therefore, unless you are having substantial difficulty in breathing, there will be no benefit in going to the hospital or the doctor's office. Another advantage of staying home is that you avoid the spread of influenza that occurs in these settings. You could be exposed to influenza or, if you have influenza, you may expose others to the disease."

Home health care measures should include:

• Rest. (Help your body's immune system to fight off the flu by getting lots of rest.)
• Fluids. (Drink plenty of fluids to keep hydrated.)
• Over-the-counter medicine. (Pain relievers, decongestants, and fever reducers can help lessen many influenza symptoms and give you some relief.)
• Temperature. (Monitor your temperature periodically.)
• Food. (Your body needs food to replenish the energy used to fight off influenza.)

Monitor yourself. (If any of these symptoms occur, contact us or seek medical care):

• Shortness of breath or difficulty breathing.
• Confusion or seizures.
• Inability to retain fluids and keep hydrated.

If your health status changes, you can always call us back to be re-evaluated and get further recommendations.

As an example, Figure 4 contains a listing of possible patient dispositions that clinical care algorithm software programs can recommend when used by nurse advice lines. Many of these recommendations are conservative and tend to refer patients to health care providers for in-person clinical evaluation. This conservative approach helps to assure that potentially significant medical conditions receive the appropriate diagnostic testing and clinical followup.

However, in a severe health emergency such as pandemic influenza, community health care resources could be overwhelmed and require more judicious use of limited health care resources. In such a scenario, alternative dispositions and recommendations may be needed, especially those supporting home care management, if appropriate, to help alleviate demands on the health care delivery system. Another consideration is directing patients with non-influenza signs and symptoms to specific facilities to reduce the potential for disease spread among patients.

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