Anthrax Prophylaxis Streamlined Population Screening Form

State: CO Type: Model Practice Year: 2015

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Tri-County Health Department (TCHD) serves a very diverse population totaling approximately 1.3 million people  from its 11 offices across Adams, Arapahoe, and Douglas counties, making it the largest local health department in Colorado. The geography of this jurisdiction includes both densely populated areas and rural communities.  TCHD also provides support to neighboring Elbert County with a population of approximately 23,000 people and an additional 1,800 square miles of small communities and rural farmland. 

TCHD is a participant in the CDC’s Cities Readiness Initiative (CRI) program designed to enhance preparedness in the Country’s largest metropolitan statistical areas. With a limited nursing and physician staff, TCHD will need to rely heavily on volunteers and outside medical professionals to dispense prophylaxis to the entire population at 14 Points of Dispensing (PODs).  With such a large population possibly needing post-exposure prophylaxis in response to a wide-spread Anthrax release, and the requirement to prophylax the entire population within 72 hours of a known release, a simplistic and accurate tool for screening large numbers of people quickly and accurately was needed to meet these goals. Training for volunteers and staff on pre-identified forms will largely be done on a Just-In-Time (JIT) basis and need to be clear, concise, and straightforward.   

 The primary goal of this project was to create a fast, accurate, and easy to understand screening tool to be used during POD operations for the provision of prophylaxis. The objectives for this project (including a screening form and overlay tool) were that it should:

·         allow non-medical staff to quickly determine which pharmaceutical prophylaxis to dispense to patients and their family members

·         target only pertinent patient data in such a way to allow an overlay tool to isolate specific responses from the patient screening form

·         accommodate for the Head of Household (HoH) medication dispensing model as outlined by the CDC

The tool was created through a collaborative effort between Nursing and Emergency Preparedness and Response (EPR) staff at TCHD beginning February 2014. Once drafted, the form and overlay were tested internally by additional staff from both divisions and revised based on feedback several times between February and April 2014. After a final draft was completed, the form was shared with EPR staff from local public health agencies around the State and the Colorado Department of Public Health and Environment (CDPHE) for further testing. After finalization, the patient screening tool has been used and tested in several full-scale drills and training sessions, including the CDC Mass Antibiotic Dispensing (MAD) trainings. TCHD nurses reviewed each patient screening form after each of the exercises to test its accuracy, ease of use for non-medical volunteers, and its ability to speed up the process of screening and dispensing medications.

Following an extensive literature review, revision of several working versions of the tool, and input and feedback from medical and public health professionals across the Denver Metropolitan Area, TCHD has finalized a working model of the tool that could be used to rapidly screen a large population for Anthrax prophylaxis.

The tool has met all the goals and objectives it set out to accomplish, including rapid screening of a large population, ease of use for non-medical staff after a brief 10 minute Just In Time Training (JITT), and an accuracy rate of nearly 100% after reviews from full-scale exercises. TCHD was successful in the design of this patient screening tool because of teamwork, collaboration, and creativeness of all of its staff members involved with this project. TCHD collaborated with several internal divisions including Nursing, Emergency Preparedness and Response, and the TCHD Executive Director.  TCHD also solicited feedback to improve the form from members of other local health departments, members of the CDC, non-medical volunteer groups, and outside medical professionals.

Locally, the impact of this tool is a demonstrated decrease in the amount of time needed to screen people potentially exposed to CDC Category A agents like Anthrax.  Jurisdictions across the State have begun adopting this tool for their own use during POD operations as of October 2014. Using this standardized tool allows for interoperability for staff and resources across jurisdictions in the Denver metro area.  The potential impact of this practice could be national and possibly international as this tool could be utilized by any US territory that may receive assets from the Strategic National Stockpile (SNS) and the three standard medications within that cache to be used during a large scale Anthrax incident.

 

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Tri-County Health Department
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Anthrax Prophylaxis Streamlined Population Screening Form
Tri-County Health Department (TCHD) serves a very diverse population totaling approximately 1.3 million people  from its 11 offices across Adams, Arapahoe, and Douglas counties, making it the largest local health department in Colorado. The geography of this jurisdiction includes both densely populated areas and rural communities.  TCHD also provides support to neighboring Elbert County with a population of approximately 23,000 people and an additional 1,800 square miles of small communities and rural farmland.  TCHD is a participant in the CDC’s Cities Readiness Initiative (CRI) program designed to enhance preparedness in the Country’s largest metropolitan statistical areas. With a limited nursing and physician staff, TCHD will need to rely heavily on volunteers and outside medical professionals to dispense prophylaxis to the entire population at 14 Points of Dispensing (PODs).  With such a large population possibly needing post-exposure prophylaxis in response to a wide-spread Anthrax release, and the requirement to prophylax the entire population within 72 hours of a known release, a simplistic and accurate tool for screening large numbers of people quickly and accurately was needed to meet these goals. Training for volunteers and staff on pre-identified forms will largely be done on a Just-In-Time (JIT) basis and need to be clear, concise, and straightforward.     The primary goal of this project was to create a fast, accurate, and easy to understand screening tool to be used during POD operations for the provision of prophylaxis. The objectives for this project (including a screening form and overlay tool) were that it should: ·         allow non-medical staff to quickly determine which pharmaceutical prophylaxis to dispense to patients and their family members ·         target only pertinent patient data in such a way to allow an overlay tool to isolate specific responses from the patient screening form ·         accommodate for the Head of Household (HoH) medication dispensing model as outlined by the CDC The tool was created through a collaborative effort between Nursing and Emergency Preparedness and Response (EPR) staff at TCHD beginning February 2014. Once drafted, the form and overlay were tested internally by additional staff from both divisions and revised based on feedback several times between February and April 2014. After a final draft was completed, the form was shared with EPR staff from local public health agencies around the State and the Colorado Department of Public Health and Environment (CDPHE) for further testing. After finalization, the patient screening tool has been used and tested in several full-scale drills and training sessions, including the CDC Mass Antibiotic Dispensing (MAD) trainings. TCHD nurses reviewed each patient screening form after each of the exercises to test its accuracy, ease of use for non-medical volunteers, and its ability to speed up the process of screening and dispensing medications. Following an extensive literature review, revision of several working versions of the tool, and input and feedback from medical and public health professionals across the Denver Metropolitan Area, TCHD has finalized a working model of the tool that could be used to rapidly screen a large population for Anthrax prophylaxis. The tool has met all the goals and objectives it set out to accomplish, including rapid screening of a large population, ease of use for non-medical staff after a brief 10 minute Just In Time Training (JITT), and an accuracy rate of nearly 100% after reviews from full-scale exercises. TCHD was successful in the design of this patient screening tool because of teamwork, collaboration, and creativeness of all of its staff members involved with this project. TCHD collaborated with several internal divisions including Nursing, Emergency Preparedness and Response, and the TCHD Executive Director.  TCHD also solicited feedback to improve the form from members of other local health departments, members of the CDC, non-medical volunteer groups, and outside medical professionals. Locally, the impact of this tool is a demonstrated decrease in the amount of time needed to screen people potentially exposed to CDC Category A agents like Anthrax.  Jurisdictions across the State have begun adopting this tool for their own use during POD operations as of October 2014. Using this standardized tool allows for interoperability for staff and resources across jurisdictions in the Denver metro area.  The potential impact of this practice could be national and possibly international as this tool could be utilized by any US territory that may receive assets from the Strategic National Stockpile (SNS) and the three standard medications within that cache to be used during a large scale Anthrax incident.  
Statement of the problem/public health issue As a participant in the Cities Readiness Initiative (CRI) program, TCHD is required to demonstrate the ability to provide prophylaxis to the 1.3 million people within its jurisdiction within 72 hours. When faced with time constraints, the potential for medical contradictions, allergic reactions to medications, and other challenges, TCHD, and other CRI participants, have been actively searching for the best tool to streamline the patient screening process. TCHD, like most local public health agencies, has limited nursing and physician staff and would need to rely heavily on volunteers and outside medical professionals to dispense prophylaxis to the entire population at 14 Points of Dispensing (POD’s). After completing an exhaustive literature search for such a tool, and narrowing the results to best practices identified at five health departments in the United States, TCHD staff realized they would need to create a new patient screening form that worked in combination with an overlay tool that isolated specific patient responses to medical questions to achieve its objective of an accurate, easy to use, and rapid screening tool. What target population is affected by problem (please include relevant demographics) o What is target population size? TCHD’s population consists of three large Denver Metropolitan Area counties including Adams, Arapahoe, and Douglas Counties as well as supporting the neighboring Elbert County for emergency preparedness and response activities. The approximate combined population is 1.3 million men, women, and children.  The predominant language spoken in all four counties is English, followed secondly by Spanish. During a mass prophylaxis dispensing operation involving medication that can be dispensed and sent home, such as pills, TCHD would implement the Head of Household (HoH) model to limit the number of people arriving at a Point of Dispensing (POD).  The HoH model allows one responsible adult for each household to arrive at a POD, provide information for all family members for screening, and receive appropriate medication for all family members not excluded for specific reasons, without all family members being present. The target population served by this tool is both those providing the screening for potentially exposed people as well as those being served by the POD. What percentage did you reach? While TCHD has not had a need to use this tool for our entire population, short emergency exercises utilizing the tool have provided great confidence in being able to expand the use of this tool for the entire population. During the exercises in 2014 in which this screening form and overlay tool have been used , approximately 195 households were served, with approximately 536 patients in those households being screened. What has been done in the past to address the problem? In the past, TCHD, like other health departments across the US have relied heavily on medical providers screening every patient that comes through a Point of Dispensing (POD). With limited medical staff being available to offer prophylaxis to the entire population within 72 hours, the screening process can be slow. At times, this traditional model can actually cause added delay and barriers to accessing needed medication during a large scale incident requiring timely prophylaxis. TCHD’s prior screening tool was developed through a regional collaborative effort that was approved based upon the needs of the EPR planners many years ago.  However, the tool was tested during a full scale exercise last year in 2013 and was identified to be cumbersome, asked patient questions that did not pertain to medication decision making for such an emergency, and was confusing to POD staff and patients.  The old screening forms did not have a logical flow, did not combine pertinent information into sections to help the screener in making a medication choice for each patient, and often had many scratched out areas and re-written notes that were confusing to the dispensing station. The old screening forms were continually changing, and were based upon a very old screening form provided by the State health department. All of these complications added to the amount of time needed to accurately screen each patient. The old screening forms also collected data that had no weight in the decision making process of which antibiotic to dispense during an Anthrax exposure. Though geared towards patients quickly completing the form, the older screening form created more roadblocks for the patients and the screeners than it solved. Why is current/proposed practice better? TCHD has discovered through numerous drills and real world incidents and exercises, including vaccinations provided through POD’s during H1N1, that clients may wait in line for more then 10-15 minutes after completing their forms before they are screened and processed.  This new screening form is designed to have the patient help develop a medication code by answering yes and no questions by filling in a circle that has a number in each response. When the patient fills in the circle, it blacks out a number, and leaves the unanswered response number exposed. This number combination from the four questions correlates to a specific medication and is used by the screener to determine what medication to dispense. The new tool that TCHD created helps alleviate three significant problems that have been observed at each POD. The first problem is the time needed for the public to accurately complete the form and go through the screening process. The new form assists the patient waiting in line to help reduce screening time, by allowing them to answer simple yes and no questions to develop the four-digit numerical code used for decision making around medications.  The second problem addressed by this new screening tool is the challenge of determining the appropriate medication to be dispensed to individuals.  The accuracy of medication dispensing given to patients has increased following the introduction of this new screening tool by removing the need to sift through unnecessary medical information. The new screening tool focuses on six basic questions relating to medication allergies, as well as if the patient weighs less than 99 lbs, if the patient is pregnant, and if the patient has any type of renal disease. The third challenge observed during POD operations was the need to use limited medical staff to screen patients. The ease of use of the screening tool for medical and non-medical staff and volunteers has relieved a large staffing restriction for this role within a POD, freeing up technical experts to serve in other vital roles during a response. Is current practice innovative? How so/explain? This practice is innovative in that it has simplified and streamlined a crucial part of the process to provide life saving medications to large portions of the population and includes saving time, increasing accuracy, and preserving limited medical staff for more appropriate roles during response operations.  TCHD nursing staff identified a problem, researched the issue pertaining to other US health departments with the same goals and objectives, and found no tool available that would meet all of the objectives TCHD set out to solve.  TCHD nurses, working closely with emergency preparedness and response staff,  redesigned the patient screening form, removed questions and patient information that was not vital to the emergency mass prophylaxis process, and simplified the pharmacological decision making process. TCHD nurses have designed a tool that integrates nursing judgment about medication decisions into a tool that guides a non-medical volunteer to make decisions during an emergency to reduce morbidity and mortality. As far as TCHD research has discovered, such a practice has never been achieved for mass prophylaxis of an Anthrax release. New to the field of public health While screening tools at POD’s during a mass prophylaxis incident is not a new concept, the tool developed by TCHD to increase accuracy, speed, and ease of use is new to public health.  The screening form and complimenting overlay tool work in combination to offer a large population rapid, accurate medication dispensing with limited medical staff.  This has also been demonstrated and used by CDC in their Mass Antibiotic Dispensing (MAD) Training in a Denver Metro Area exercise in September 2014.  This form/overlay is available for review if needed in this application process.  
Goal(s) and objectives of practice The primary goal of this project was to create a fast, accurate, and easy to understand screening tool to be used during Point of Dispensing (POD) operations for the provision of prophylaxis. The objectives for this project (including a screening form and overlay tool) were that it should: ·         Allow non-medical staff and volunteers to quickly determine which pharmaceutical prophylaxis to dispense to patients and their family members ·         Target only pertinent patient data in such a way to allow an overlay tool to isolate specific responses from the patient screening form ·         Increase accuracy of the medications being dispensed to an entire family using the Head of Household (HoH) model In the event of a large scale Anthrax exposure, the entire Denver Metropolitan area, and other US metropolitan areas, would require the same types of tools in order to quickly, efficiently, and accurately provide the appropriate medications to members of the public to mitigate Anthrax infections.   Keeping this in mind, TCHD created a tool that could be used within its own jurisdiction and throughout the nation to help standardize Anthrax prophylaxis, and ultimately streamline the process to save time, and most importantly, lives. What did you do to achieve the goals and objectives? In the past, TCHD, like other health departments across the US, have relied heavily on a medical provider screening each and every patient that comes through a Point of Dispensing (POD). With limited medical staff being available to offer prophylaxis to the entire population within the designated 72 hours, the screening process can be slow. At times, this traditional model can actually cause added delay and barriers to accessing needed medication during a large scale incident requiring timely prophylaxis. TCHD’s prior screening tool was cumbersome, asked patient questions that did not pertain to medication decision making for such an emergency, and was confusing to POD staff and patients.  The old screening forms did not have a logical flow, did not combine pertinent information into sections to help the screener in making a medication choice for each patient, and often had many scratched out areas and re-written notes that were confusing to the dispensing staff. All of these complications added to the amount of time needed to accurately screen each patient. The old screening forms also collected data that had no weight in the decision making process of which antibiotic to dispense during an Anthrax exposure, such as a patients’ age, what medications they were currently taking, and what their allergies to any medications were. Though geared towards patients quickly completing the form, the older screening form created more potential roadblocks for the public and the screeners than it solved. This new screening form and overlay tool is very innovative in that TCHD nursing staff took a problem, researched the issue pertaining to other US health departments with the same goals and objectives, and found no tool available that would meet all of the objectives TCHD set out to solve.  TCHD nurses redesigned the patient screening form, removing questions and patient information that was not vital to the emergency mass prophylaxis process.  The nurses found a way to develop a four-digit code that translated medication judgment into an overlay tool that could correlate the code with a specific medication to be dispensed without adding to the morbidity and mortality of the patient. As far as TCHD research has discovered, such a practice has never been achieved for mass prophylaxis due to an Anthrax release. Steps taken to implement the program The tool was created in collaboration between Nursing and Emergency Preparedness and Response (EPR) staff at TCHD in a multistep process. First, TCHD nursing staff reviewed the existing tool to specifically identify areas that were causing challenges or roadblocks for both screening staff and the public completing the form. Once these challenges were identified, a review was conducted to identify any existing tools from around the country that may appropriately address the challenges and meet the objectives for this project. As none were identified that addressed all challenges TCHD faced, TCHD nursing staff, working in coordination with EPR staff, drafted a tool using an overlay to meet the objectives of this project. The form and overlay were tested internally by additional staff from both collaborating divisions and revised based on feedback provided during debriefing sessions. To test the accuracy and efficiency of the tool and ease of use for non-medical staff following 5-10 minute Just- In-Time Training (JITT) sessions, TCHD first exercised it with seven of the agency’s designated emergency preparedness nurses. The nurses were given a 10 minute group training on how to use the overlay tool. Each nurse completed 5 patient screening forms with up to 10 mock-patients to represent a household and were then asked to screen each patient and determine which medication to dispense using the overlay tool.  Afterward, the nurses spent a significant amount of time scrutinizing the details of the form without using the tool to make sure they arrived at the same decision to dispense the proper medication to the patient. Several weeks after this internal exercise, TCHD partnered with a retirement community, who were eager to test their closed POD emergency response plans and processes using their retired medical and non-medical volunteers. In this exercise, 125 mock-households were created, totaling 256 patients being screened. The screening forms were completed on-site by volunteers willing to act as mock-patients and volunteers were encouraged to create complex medical situations for the forms. These challenges included incomplete forms and conflicting answers . Following the success of this exercise, the form was presented to the State Health Department (CDPHE) and other local health departments and emergency preparedness and response partners for additional feedback and testing. Several minor recommendations were identified and incorporated into the form over several weeks.  Two months after this, the form was used as a creative solution by CDPHE and the CDC Mass Antibiotic Dispensing (MAD) training. TCHD nurses reviewed each patient screening form after the exercises to continue to monitor for accuracy, ease of use for non-medical volunteers, and its ability to speed up the process of screening and dispensing medications. What was the timeframe for the practice From the decision to begin exploring new options for a POD screening tool, until the point where the tool was ready to be mass produced for use in all 14 TCHD Points of Dispensing (PODs), approximately six months passed from Jan through June 2014.  The tool has now been recommended for use statewide in Colorado. Were other stakeholders involved? What was their role in the planning and implementation process? What does the LHD do to foster collaboration with community stakeholders? Describe  the relationship(s) and how it furthers the practice goal(s) Collaboration with other health departments, healthcare providers, and volunteers was vital to ensuring TCHD met its goals of creating an accurate and easy to use tool to provide medications to people rapidly.  TCHD actively sought out people from across local and state public health agencies and people with clinical and non-clinical experience to provide feedback during the development of this tool. Agencies that helped test and provide feedback on this tool included TCHD nursing, medical, clerical and administrative staff, TCHD EPR staff, partners from several local health departments, the CDPHE Office of Emergency Preparedness and Response, the CDC MAD training team and participants, and the Heritage Eagle Bend retirement community volunteers. These volunteers and professionals helped TCHD assess what information was vital in making a decision for which medication to be dispensed. Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Else, provide an estimate of start-up costs/ budget breakdown. The only costs involved in developing this tool were staff time for research, assessment, planning, designing, testing, and evaluation.  After the tool was finalized, there were costs for the overlay tool to be printed onto hard plastic so the patient screening form can easily slide into the tool.  The cost for each of these hard-plastic tools was:_$21 - $23 per item and is dependent on the volume being printed.  
What did you find out? To what extent were your objectives achieved? Please re-state your objectives from the methodology section. The primary goal of this project was to create a fast, accurate, and easy to understand screening tool to be used during Point of Dispensing (POD) operations for the provision of prophylaxis. The objectives for this project (including a screening form and overlay tool) were that it should: ·         Allow non-medical staff to quickly determine which pharmaceutical prophylaxis to dispense to patients and their family members, ·         Target only pertinent patient data in such a way to allow an overlay tool to isolate specific responses from the patient screening form, ·         Increase accuracy of the medications being dispensed to an entire family using the  Head of Household (HoH) model. We discovered, through several different drafts of the form, that not every scenario can be planned for, but the majority of patient situations could be dealt with in a very streamlined and rapid manner.  TCHD nurses decided to include only questions that determined which medication a patient needed to prevent a fatal Anthrax infection.  Many hours of debate and analysis went into determining which questions must be asked and those that the nursing staff would like to be asked. With limited room on the patient screening form, only questions that must be asked were included. This meant the removal of asking a patients age, if patients had hepatic problems, possibly affecting how they metabolized the medication, and even what medications patients were taking, to prevent medication interactions.  These questions were removed because they did not affect the immediate need to be medicated to prevent a deadly Anthrax infection. It was decided that patients with hepatic problems would need follow-up with their healthcare provider, but they would initially need to start prophylaxis to prevent death from a possible Anthrax exposure.  Patient ages did not matter compared to the importance in knowing their weight, for example a person who may be 80 years old, but weighs less than 99lbs is important.  It was also determined that medication interactions may be possible, but when weighing the consequences of not prophylaxing, which can include death, it was determined that medication would be provided to these individuals with guidance to follow-up with their healthcare provider after receiving medications at the POD. Did you evaluate your practice? Intervention evaluation has been done continually while making changes and improving the form after feedback from specific presentations and drills.  In total, 195 households with approximately 536 patients were screened over the course of the various exercises conducted.  The largest exercise during which this tool was used involved screening 125 households containing 256 mock-patients in an exercise where all stations within a POD were performed.  From the time patients entered the POD to the time they exited with their medication, the average time it took to complete the paperwork, screen and dispense medication was 5 minutes per household. Of all the forms that were screened during this exercise, 100% of the patients received the correct antibiotics based upon individual allergies and contraindications. Agencies that helped test and provide feedback on this tool include TCHD nursing, medical, clerical and administrative staff, TCHD EPR staff, staff from multiple local health departments, the CDPHE Office of Emergency Preparedness and Response, the CDC MAD training team and participants, and the Heritage Eagle Bend retirement community volunteers.  These volunteers and professionals helped TCHD assess and evaluate what information was vital in making a decision for which medication to be dispensed. List any primary data sources, who collected the data, and how (if applicable) Data collection was accomplished by making the testing of this form a specific objective in a POD exercise.  TCHD EPR collected the data during the exercise.  Analysis included feedback from training, evaluating use of the form during the exercise, analyzing the documentation on each form and recording the time each patient took from greeting to receiving medication (dispensing throughput).    List any secondary data sources used (if applicable) None List performance measures used. Include process and outcome measures as appropriate. The screening form and overlay tool were used in several exercises where a HoH model was used with a total of 536 patients representing 195 households.  The accuracy of the antibiotics dispensed after each exercise proved to be 100% accurate.  One of the exercises measured the amount of time it took patients to go through the POD from completing the paperwork, to the time they were handed their medications and exited the building.  In this exercise, it took an average of 5 minutes per person (125 households with 256 patients total). The ease of use of the form came from providing a single 10 minute just in time training (JITT) to all users of the form, and all users were able to then complete screening on all mock patients with relative ease and minimal questions.  During all exercises, three antibiotics that are contained in the federally maintained SNS were represented as possible choices to be dispensed. Describe how results were analyzed Time results were analyzed by the EPR staff along with reviews of the screening forms.  At the time the patient was given a screening form, the time was recorded, and again recorded when they were handed medication and exited the POD. TCHD nurses reviewed each patient screening form after each of the exercises to ensure the proper medication was dispensed based upon the patient’s responses to the screening questions. Ease of use results were reported during the debriefings conducted after each exercise.  While some screeners were reluctant to trust the tool in the beginning, after 5-10 patients were initially screened, the screeners gained speed and confidence in using the tool and reported how easy it was to use after the exercise was completed. Were any modifications made to the practice as a result of the data findings? The screening form was a fluid document that underwent many changes after evaluation from several drills, and feedback was provided by other health departments and outside professionals and volunteers.  
Lessons learned in relation to practice  TCHD learned several lessons from creating this intervention that will help us in future practices.  The first lesson learned was we need to only collect data we plan on measuring or tracking. We no longer collect information not relevant to decision-making, especially when there is a declared emergency/disaster and time is critical because of the large population impacted and timely needs for mass prophylaxis.  The second lesson learned was that in an emergency, like many other health departments, TCHD will not have enough medically trained staff to screen and take care of patients. Practices and tools that maximize the effectiveness and efficiency of these providers and their skills will help save time and lives. Lessons learned in relation to partner collaboration (if applicable) TCHD learned that it can be difficult to change healthcare practitioners’ thoughts and habits during emergencies.  Healthcare providers are used to screening and evaluating all patients in-depth before providing medication. In an emergency, this will not be practical when we are trying to save lives and this tool helps non-medical staff and volunteers make medication decisions. TCHD initially met significant resistance internally as well as externally with healthcare providers who disagreed with this approach. However, once this template was created and tested, both internal and external partners recognize the value of this new tool.  Ultimately TCHD relied on the rationale that non-essential time spent evaluating patients meant more lives lost. In other words, the faster THCD could determine which medications a patient can take in a relatively safe manner, given the high morbidity and mortality of not receiving post-exposure treatment after exposure to Anthrax, the more people that would live through such a crisis. Did you do a cost/benefit analysis? If so, describe. No.  Is there sufficient stakeholder commitment to sustain the practice? TCHD has committed to producing the overlay screening tools to use in such an incident, and has committed to printing thousands of the patient screening forms if an Anthrax prophylaxis POD were needed. The State of Colorado just recently recommended the adoption of the tool statewide and to date three other LHDs have committed to adopting the screening tool.  All departments are negotiating sharing the costs of mass producing the forms and overlays. Describe sustainability plans This project is sustainable in that it is a standardized tool in almost any scenario requiring antibiotic prophylaxis. The tool itself does not require any updates or maintenance as long as sufficient copies are on hand in the aftermath of an incident.  This is sustainable as long as the three types of antibiotics in the SNS remain the primary drugs used during an Anthrax incident response.  In addition, the tool could likely be easily modified in the event of new antimicrobial recommendations.  
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