Minnesota flu line will speed antivirals to at-risk patients

Lisa Schnirring

Oct 21, 2009 (CIDRAP News) In a move designed to lighten the burden on emergency departments and clinics, Minnesota officials today unveiled a flu triage line staffed by nurses who can discuss symptoms with sick patients, suggest treatment steps, and prescribe an antiviral drug if the caller is in a high-risk category.

Minnesota Health Commissioner Sanne Magnan, MD, said today at a press conference, "By providing support and treatment over the phone, we hope this new service will allow our healthcare providers and facilities to focus on those people who need the most attention." Another benefit is keeping sick people from spreading the virus when they visit clinics and emergency departments, she said.

Magnan said one of the state's medical providers told her their calls have tripled because of patients with suspected flu infections.

Aaron DeVries, MD, a medical epidemiologist at the Minnesota Department of Health (MDH), told reporters, "The flu is stretching our healthcare system in new ways and we need new options."

Minnesota's flu line is the first in the country that has a statewide reach and can prescribe antivirals over the phone under standing orders from a physician. The service was developed through a public-private partnership that includes the MDH, the Minnesota Hospital Association, the Minnesota Council of Health Plans, healthcare providers, local health departments, and the Children's Physician Network. Its developers also received advice from others partners, including the US Centers for Disease Control and Prevention (CDC).

A round-the-clock service
The Children's Physician Network is spearheading flu line operations with 50 lines staffed by nurses around the clock, 7 days a week. Callers who have flu symptoms are connected to either a CPN nurse or, if they have health insurance, a nurse at a triage line operated by their health system.

For low-risk patients with mild illnesses, nurses are likely to suggest rest and fluids at home. Patients with more serious symptoms are urged to be evaluated at a clinic or hospital. Those who nurses believe to be at high risk, such as pregnant women and those with underlying health conditions, can receive an antiviral prescription, which is faxed to the patient's pharmacy. Antiviral medications for people who are uninsured will come out of the state's antiviral stockpile, officials said.

Magnan said the flu line was developed with a $2.5 million federal grant and that state officials won't know the total cost until they can get a fix on the line's usage. "But if we can keep people who need information out of doctor's offices, it won't take long for savings to accrue," she added.

Ruth Lynfield, MD, Minnesota's state epidemiologist, told CIDRAP News that the flu line offers the potential for patients to begin antiviral treatment sooner. Over the past few weeks, federal officials have voiced concerns about delays in antiviral treatment as a contributing factor in some of the more serious and fatal flu cases. Earlier this week the CDC sent a health alert network message urging clinicians not to depend on rapid tests for treatment decisions and to start antiviral treatment promptly in at-risk patients, without waiting for the results of more definitive tests.

Lynfield said the key to the successful development of the flu line was the phone triage expertise of the state's health system partners and having private partners that are very public health minded. "They had the flexibility to quickly ramp things up and they understand what the priority needs are," she said.

Janny Brust, director of community affairs and medical policy for the Minnesota Council of Health Plans, told CIDRAP News that private medical groups and state officials have been working on flu issues and emergency preparations for several years. "We already had those relationships," she said.

Health plans are interested in measures such as the flu line that can improve the quality of and access to care, she said. "Not everyone is knowledgeable about how to access healthcare," Brust said, adding that Minnesota's system has the potential to seamlessly connect people to all their different plans by calling one number.

Liability concern raised
Carl Schultz, MD, professor of emergency medicine at the University of California at Irvine, told CIDRAP News that a flu line like Minnesota's is a reasonable public health response that has the potential to reduce the burden on hospital emergency departments. Schultz also chairs the disaster preparedness and response committee of the American College of Emergency Physicians.

However, he said prescribing antivirals over the phone may raise liability issues. At today's press conference, Magnan said most actions of triage line workers, unless they are egregious, will be covered under the Public Readiness and Emergency Preparedness (PREP) Act, a federal law that provides liability protection for healthcare workers in public health emergencies and provides compensation to patients who are injured by countermeasures.

Schultz said emergency departments in the Irvine area are seeing an increasing number of flu cases but have not resorted to any surge plans. He said some California counties and some of its larger health systems have flu hotlines, but Minnesota's is the only one he knows of that covers the whole state and has the capacity to prescribe antivirals. "Minnesota has had a tradition of pulling together lots of different participants," he said.