Telephone triage and treatment protocol

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University of Wisconsin-Madison (UWM), with more than 42,000 students, experienced a surge of H1N1 cases in fall 2009. The University Health Services (UHS) clinic is normally staffed by an on-call clinician on Labor Day, yet the flood of phone calls from sick and worried students overwhelmed the one staff member. Due to the rush of calls, the clinic was compelled to open with the assistance of physicians who volunteered to begin screening and treating students before the semester began. For many ill students, "it was their first time away from home, they got really sick really quickly, and they needed a lot of guidance on how to take care of themselves," said Cheryle Sickels, UHS Primary Care Nurse Manager.

In response to the overwhelming number of sick and concerned students, UHS began a telephone triage and treatment program. Staff developed triage and treatment protocols that followed CDC guidelines on whether ill students should be seen for urgent care at the clinic or continue self care at home. UHS clinicians also wrote a template for determining which students should receive antiviral prophylaxis, although all students requiring prophylaxis were asked to be seen in the clinic. Staffing needs required that six primary care nurses were removed from direct patient care and placed on the phone to advise ill students, along with a nurse recruited from the Women's Health Clinic. It was important that the phone staff did not change throughout the course of the pandemic, because extensive training was required to ensure that nurses could easily follow and understand the daily changes in CDC guidelines.

UHS had significant support in its efforts to track and follow CDC guidelines in the form of a campus epidemiologist. Craig Roberts, a Physician Assistant and Epidemiologist at UHS, monitored CDC guidelines related to treatment, prophylaxis, and laboratory testing. He wrote and issued guidance explaining CDC guidelines to clinic staff, thus keeping them apprised of frequent changes and additions to national policy and assuring that all clinicians on staff were following the same protocol. He also issued a printed document called the Influenza Update Letter every day to inform UHS staff about the number of triage calls handled on the previous day, new CDC guidelines, and requirements for submitting potential H1N1 samples for testing.

The campus epidemiologist also assisted with monitoring H1N1 cases that were triaged over the phone and/or treated at the clinic. Careful monitoring allowed the clinic to be able to conduct follow-up calls with ill students to ensure that they were recovering and had the information they needed to take care of themselves. Initially, the triage phone line experienced approximately 100 calls per day, and 75 percent of these calls were related to H1N1 symptoms. The templates that nurses used to triage students were designed so that information could easily be entered in to UHS' electronic health record system.

Communicating with students, parents, and on-campus organizations played a large part in assuring that triaged students received appropriate follow-up care. Ill students who were told that they did not require care in the clinic received texts with tips on how to care for themselves in their homes or residence halls. The UHS communications department also worked closely with residence halls and housing services to set up isolation rooms for ill students, disseminate materials on hand hygiene and cough etiquette, and address parent concerns about students who could not return home. The UWM police department also facilitated an e-mail address to which faculty, staff, parents, and students could submit questions and receive answers from providers, emergency management personnel, the campus epidemiologist, or the UHS director. A common question came from parents who were worried about out-of-state students living in private residence halls. UHS provided triage, follow-up treatment, and advice to these students, yet was unable to require the use of isolation rooms in privately owned dorms.

Young adults were particularly vulnerable to the H1N1 virus, and UWM tried to counter this vulnerability by instituting systems to care for its large student population. The phone triage and treatment system not only efficiently funneled students through UHS; it also ensured that students received proper care in the days following their phone calls and advocated for their treatment and academic needs. At the request of UHS, the UWM chancellor wrote a letter to faculty and staff, asking them to excuse ill students from class without a doctor's note. With the assistance of the police department, UHS ensured that pharmacies around campus maintained their stock of fever-reducing medications and disposable thermometers for students who needed to monitor and treat their illness. Through the use of on-campus collaborations, UWM was able to design a triage and treatment plan that met the varied, on-going needs of ill and anxious students.

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