Report: H1N1 phone triage lines informed, aided patients

Jun 4, 2012 (CIDRAP News) – Phone-based flu lines that operated during the 2009 H1N1 pandemic increased public flu knowledge, may have prevented unnecessary 911 calls and visits to health facilities, and eased access to antivirals when appropriate, a recent report found.

The report is from the Nurse Triage Project (NTP), which is assessing the feasibility of developing a national telephone triage model to reduce some of the burden on the US healthcare system during a severe flu pandemic.

The group released its initial findings recently in a report posted on the National Association of County and City Health Officials (NACCHO) Web site. Besides representative from NACCHO, NTP collaborators include experts from the Centers for Disease Control and Prevention (CDC), the Association of State and Territorial Health Officials (ASTHO), and several other stakeholders.

The phone triage study is part of a larger effort to improve antiviral distribution and dispensing based on lessons learned during the 2009 H1N1 pandemic, according to the report.

Nurse triage hotlines were one of the alternate antiviral distribution methods included in feedback from a public opinion panel released in a May 17 report from the Institute of Medicine. Members of the public who participated in the talks, held at three locations earlier this year, voiced confidence in specially trained phone line nurses, but worried that the systems could be overwhelmed in an emergency setting and that flu and other conditions would be difficult to diagnose without face-to-face interaction.

Investigators from ASTHO and NACCHO focused on public health affiliated flu lines staffed by nurses or other medical professionals that were designed to advise callers, triage sick patients, and prescribe antiviral medications over the phone.

Of eight flu lines that met the group's criteria, three were local health jurisdictions: New York City Department of Health and Mental Hygiene, Public Health Region IV in southwestern Washington state, and Public Health-Seattle and King County. Four were state health departments—Florida, Minnesota, Oregon, and New Jersey.

The eighth flu line included in the report is Rocky Mountain Poison and Drug Center (RMPDC), a Denver-based agency that is integrated with the local public health and healthcare system.

Case reports for the eight flu lines reflect three different approaches, including informational lines staffed by nonclinical workers, nurse triage lines that didn't provide antivirals, and nurse triage lined that prescribed antiviral medications over the phone.

Two of the flu lines—those in Minnesota and Public Health Region IV in Washington—included protocols and standing orders that allowed nurses to prescribe antivirals over the phone. Two others (RMPDC and Seattle/King County) were equipped to collect surveillance data, which gave public health officials real-time information to guide response activities.

For each of the eight triage lines, the investigators reported several details, such as when the system was launched, the structure of the triage design, how it was staffed, and usage statistics.

For example, Minnesota' system was a collaboration between the Minnesota Department of Health and 14 other health organizations, including health systems and insurance plans. The state epidemiologist was cleared to authorize antiviral dispensing to anyone who met the protocol's criteria. Minnesota's flu line fielded 27,391 calls. Of 6,160 unique callers, 38% were advised to see a health provider and 62% were urged to take home care measures. Antivirals were prescribed to 374 callers (6%).

Overall, the call volume for the eight flu lines totaled 116,357, of which 9% were evaluated by a registered nurse and 3.5% were given an antiviral prescription, according to the report.

Researchers found that the flu lines increased the public's knowledge about the pandemic virus, may have prevented unnecessary calls to the 911 systems and healthcare visits, and eased access to antivirals when appropriate, despite patients' insurance status and access to healthcare. They add that, by limiting visits to health facilities, it may also have helped prevent disease spread.

The investigators observed that flow charts, decision trees, and message scripts helped jurisdictions provide consistent information to callers, which could be updated and modified as response needs evolved. The components could be the building blocks of a national phone-based triage system for the next influenza pandemic, the group wrote.

Because resources, capacities, and capabilities vary by community, health officials should consider implementing a national flu line network that can be activated any time and provide around-the-clock service, the group recommended. They said a national system could help deliver a unified, consistent message and provide consistent standards and screening protocols.

The experts urged planners to examine laws and other gaps that would pose obstacles to launching an efficient public health response and identify mechanisms that would support an infrastructure for managing surges in call volumes across state boundaries.

The US poison control system could be a model for an infrastructure for supporting a national flu line, because all jurisdictions have at least one, they specialize in rapid, efficient phone consultations, are cost effective, and have plans in the works to extend across geographic boundaries and address mass events, conduct disease surveillance, and maintain integrated electronic medical records.

The authors emphasized that a national flu line is only part of a solution to increase access to antivirals.

"A national flu line must operate in concert with other efforts to improve distribution and dispensing of antiviral medications," they concluded. "A national flu line approach would support a high-quality, robust, and adaptable response to a future influenza pandemic."

See also:

May NACCHO report on flu information and triage lines (free log-in required)

May 18 CIDRAP News story "Public weighs in on pandemic antiviral distribution"

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