This project provided a means for first responders to receive information at time of need on people in the community who were being monitored due to Ebola risk. A model is presented to share information, ensure confidentiality, and yet allow the first responder to be notified of a possible risk when responding to a call. This model can be used to assist in protecting first responders for other high consequence infectious diseases.
Tarrant County Public Health Department
First Responder Infectious Disease Notification Submitti
Overview: Brief description of LHD- location, demographics of population served in your community:Tarrant County Public Health (TCPH), located in Fort Worth Texas is the local health department serving Tarrant County, Texas. Tarrant County is located in the northern central portion of the State of Texas. Fort Worth is the county seat and is the seventeenth largest city in the United States. The 2013 Census Bureau reported Tarrant County’s demographics as White (50.1%), Hispanic (27.6%) and Black (15.9%). Per capita income in Tarrant County is $28,125.00 with 14.7% of residents at or below poverty level.
TCPH provides services to Tarrant County’s approximately 1.9 million residents and 41 incorporated municipalities. These services include health education, disease control, laboratory services, health screenings, and treatment, immunizations, and WIC. With a budget of approximately $60 million and a combined staff of 400 employees, TCPH is proudly established in 19 permanent locations with additional outreach sites to serve a diverse population. The total service area is the entire Tarrant County.
The Mission Statement for TCPH is “Safeguarding the Community’s Health”
Describe public health issue:An unexpected public health issue demanded immediate attention: the presence of the Ebola virus disease (EVD) in North Texas, and the management of the public health response to this “high consequence infectious disease”. Though there were numerous public health issues that came along with EVD, the need to communicate with first responders for emergency preparedness purposes became a critical priority. Specifically, there was an immediate need to share information about locations of (permanent or temporary) residence within Tarrant County where individuals under active EVD monitoring were located, so that first responders would be adequately prepared in the event of a call for assistance at the affected address.Goals and objectives of proposed practice:The goals and objectives of the practice included (1) identifying a trusted agent/responsible party in each jurisdiction or city to serve as a point of contact for relevant communications; (2) fully explaining the expectations and responsibilities of TCPH and the trusted agent; (3) communicating clearly with trusted agents about infectious disease monitoring activities in their city; (4) providing information to trusted agents efficiently; (5) protecting the confidentiality of affected individuals; (6) creating and maintaining a working partnership between relevant TCPH divisions and trusted agents , including their emergency management personnel, and (7) maintaining compliance with federal and state disclosure laws.How were practice implemented / activities?The practice was implemented by creating a planning team to anticipate the requirements of the notification process and utilizing existing County resources to gather information, identify the appropriate stakeholders, analyze the proposed practice and then put in into action.Results/ Outcomes (list process milestones and intended/actual outcomes and impacts.Were all of the objectives met?All of the objectives were met. TCPH was able to achieve results which met the intended goals of getting information to those who needed it, ensuring that they knew what to do (and what not to do) with that information, and carrying out the practice in a way that protected the privacy of the affected individuals.What specific factors led to the success of this practice?Many factors led to the success of this practice:• Intensive and immediate planning, with the involvement and collaboration of numerous subject-matter-experts within the County’s organizational structure. Stakeholders included members of County Administration, Emergency Management, Public Health officials, and legal counsel.• The support and authority of the County Judge and Administrator.• Highly coordinated communications with City Managers and Emergency Management personnel throughout the County• Good plan design• Focus on the confidentiality of the overall process and the security of data
Public Health impact of practice:With effective incident management on the part of TCPH and its collaborative partnerships with municipalities, 1st responders were protected along with the public’s safety. Additionally this incident management leads to: effective training for personnel, education for the public about methodologies for prevention and protection as they relate to infectious disease containment. Lessons learned also provided insight into expanding networks to increase preventive measures for the public’s safety.
Responsiveness and Innovation:On September 30, 2014 a Liberian man who had flown to Texas was diagnosed with Ebola at Texas Health Presbyterian Dallas hospital. While unprecedented in the United States, the diagnosis of an Ebola patient triggered the “usual” initiation of disease-monitoring protocols just as any other notifiable condition would. The Epidemiology staff at TCPH worked under intense pressure to investigate and interview contacts, communicate to schools and employers, submit to numerous news interviews, prepare educational materials, and respond to the public in an environment where general misinformation and public hysteria was common.
Sharing information with first responders about their possible exposures to a communicable disease by the public health department is not new in Texas. State law prescribes procedures for public health to share limited confidential information with a responder when an exposure has occurred – procedures that are used after an exposure. The objective of this project was to ensure responders were informed of the possible presence of a disease before an exposure would occur and allow for appropriate additional infection control measures. The need to disclose information to emergency managers and city officials as part of the project in response to the EVD issue presented new challenges and extraordinary teamwork.
We identified our target population as first responders, in general. This included police, emergency personnel, fire departments, and the city officials responsible for their management. In Tarrant County, there are 37 cities with various emergency response agencies (police, fire, EMS) and 2 county agencies which service unincorporated areas. A few of the smaller incorporated areas of the County share resources with larger cities.
In the planning and initial communication phase of the practice, we reached the entire target population. A series of closed-to-the-public conference calls were executed, whereby the contact information was shared with City Managers and Emergency Managers for participation in the calls. At the beginning of each conference, we “called roll” to determine the participants. Some cities had multiple participants on each call, and others delegated one person to participate in the calls. Each of the incorporated areas and county agencies were involved in at least one occurrence of the conference calls to share information. The typical agenda for the conference calls included an update or statement from the Public Health Director, relevant information from the Public Health Chief Epidemiologist, information on communication and privacy from the Compliance Officer, and a block of time for fielding and responding to questions from participants. The conference calls and the information shared throughout the process were well received by participants.
The first EVD monitoring notices were delivered to designated trusted agents in cities on October 17, 2014. In all, nine (9) cities were contacted on the first day of the practice with specific information about an address in their city where a person was being actively monitored for Ebola. Each day, as the contact list grew, more notices were delivered. Over the course of the next year, this practice was maintained consistently. In total, nineteen (19) different trusted agents received notifications at least once.
In this manner, TCPH reached 49.7% of the original target population with actual notifications of EVD monitoring and 100% of the responders who served the areas where people with risk for developing Ebola Virus Disease resided. In the past, the need to share information infections status information with first responders has been the result of an exposure that may have occurred. A first responder who has an exposure and needs to know the infection status of a source patient notifies the health department via an affidavit describing the exposure. The exposure is reviewed by the health authority who determines if an exposure occurred and, when needed, issues an order to the source patient to be tested. Results from the tests are given to the health department for communication to the first responder agency. This system, while useful in addressing occupation exposures, does not address prevention of exposure to a high consequence disease.
EMS personnel called to respond to assist a person with an infectious disease generally found out about the disease after the response. This resulted in a reactive measure to mitigate the harm of exposure.
The current practice is far superior for many reasons. The focus is on prevention and preparation. In creating a model that allows for the deliberate sharing of information to response agencies before a call for service is placed, we provide an avenue for first responders to have knowledge about the health condition of a potential patient, or potential exposure to infectious disease at a location before they even arrive.
This knowledge allows for a proactive approach to delivering service to individuals at the affected location. Additionally, the model established for EVD notifications can be repurposed for other outbreaks or unplanned emergency notifications.
This is an innovative practice. The presence of the Ebola virus in the United States was unprecedented. The response to the presence of the virus had not been planned for, created or tested. Tarrant County immediately responded to the need to act by pooling resources and developing a whole response protocol that would meet our established objectives.
The ability to disclose protected information to others in the event of an emergency is written into the communicable disease chapter in Texas medical privacy law. However, there was no frame of reference for how a Public Health Authority is permitted to respond to an Ebola crisis. The planning team assembled to craft a response and create this new practice researched state and federal law, and applied the guidance of the U.S. Department of Health and Human Services for Public Health purposes.
We created a process that, to our knowledge, was new to the field of public health in the scope of preparations and communications related to the Ebola virus, and applicable to other high consequence infectious diseases.
The practice is not evidence based.
This practice may address the “CDC Winnable Battle” for healthcare-associated infections. By communicating in advance to first responders, EMS workers gain the opportunity to adequately prepare for treating patients or their contacts, thereby reducing the risk of transmission.The expenses attributed to this new practice were minimal. In addition to the usual office supplies needed to generate letters and deliver them confidentially, there were increased mileage expenses due to travel and delivery to trusted agents.
LHD and Community Collaboration and Implementation StrategyThe goals and objectives of the First Responder Infectious Disease Notification practice included:1. Identifying a trusted agent/responsible party in each jurisdiction or city to serve as a point of contact for relevant communications2. Fully explaining the expectations and responsibilities of TCPH and the trusted agent3. Communicating clearly with trusted agents about infectious disease monitoring activities in their city4. Providing information to trusted agents efficiently5. Protecting the confidentiality of affected individuals6. Creating and maintaining a working partnership between relevant TCPH divisions and trusted agents , including their emergency management personnel7. Maintaining compliance with federal and state disclosure laws
To achieve the goals and objectives of the practice, TCPH partnered with other County departments to form a planning team that would thoroughly evaluate the critical steps in implementing a working plan designed for immediate action and efficacy.TCPH utilized the Emergency Management staff and leveraged their existing relationships with response agencies and stakeholders in cities and towns countywide. These experts provided specific knowledge about the computer aided dispatch (CAD) systems used in each city, and provided valuable information about how they did or did not work together. We also considered the impact of mutual aid agreements in place and the affect that notification would or should have on neighboring cities.Existing relationships with the City Managers and Administrators were of critical importance. The City Manager became the “default” trusted agent in most jurisdictions, unless they appointed another responsible official to serve as the first point of contact. Through the Tarrant County Administrator’s office, communications were directed to City Managers, inviting them to an invitation-only conference call, wherein Tarrant County would reveal this new practice and solicit feedback from cities, including their first response staff. The City Managers shared these communications with their EMS Coordinators, Fire Chiefs, Chiefs of Police and other designees directly affected by the practice. From the beginning, Tarrant County invited the input of community leaders and communicated directly with them.Tarrant County’s legal team provided invaluable advice for the written communication pieces which would be distributed to trusted agents and also to the individuals being monitored for Ebola. The importance placed on maintaining compliance with disclosure laws cannot be underestimated. We were determined to launch the practice without fanfare from the media or unnecessary attention from the public, but with reliability to our city partners and a commitment to privacy for the human beings potentially exposed to Ebola. The team of attorneys we worked with helped research, refine, and approve the tools used to implement the practice, and which are still in use today.The practice incorporates a multi-agency workflow that begins with the CDC, and runs through the State Department of Health to the Local Health Department and then to the affected city as a notification letter. The letter to first responders is routed through a central point of contact (the “trusted agent”). This person(s) would take responsibility for receiving the letter from TCPH about the address where a person(s) under EVD monitoring was housed. TCPH reports the address only to the trusted agent. No other information about the individual, their risk level, the number of monitored individuals at the location, the country of origin, or other detail was given.The communication was issued in the form of a physical letter, complete with instructions on how the information about the address is to be used and how it is not to be used. The notification letter was hand-delivered to the trusted agent in a sealed confidential envelope, with a signature required as acceptance of responsibility for each letter.The trusted agent was responsible to initiate the practices established in their organization for response purposes. In general, TCPH instructed the city to enter a non-searchable flag into the dispatch system(s) used for emergency calls, so that an alert would be present only when/if a call for service was placed for an address under active monitoring. The alert would instruct dispatch workers to contact the Public Health Department’s 24-hour phone number for instructions. This number is consistently assigned to an Epidemiology staff member, who would provide instructions for first responders en route to a monitored address.Because each city has their own unique organization structure, with or without mutual aid agreements, with a single dispatch system or with multiple systems, we asked that each trusted agent determine their own response protocol and performance measures. The trusted agent became responsible for protecting the confidential information disclosed to them in the letter at the time of receipt.The process for receiving and confirming information about the individuals to be monitored is shown below as a process map. This initial step includes collaboration between the divisions of Epidemiology, Geographical Information Systems, and Compliance within TCPH.
As the monitoring period expires, a separate notice is delivered to the trusted agent to require removal of the alert flag from the dispatch system. A confirmation step is included in the flag removal process, ensuring that TCPH receives verification from the trusted agent that the address is no longer flagged for alert in the dispatch system. The internal process for confirming and documenting the end of the monitoring period for an individual, including the notification to the affected city is shown in the process map below:
Removal Flow Chart
Evaluation:What did you find out? It is extremely important to convene key community stakeholders, county elected officials and other leadership along with TCPH staff very early in any high profile developing situation. Here are key points to consider with the assembled team:o Legal issues related to information distributiono Communication Action Plan ( type of communication, chain of custody for communication, etc.,o Timeline for communicationo Roles of all involved with accountability areasTo what extent were your objectives achieved? All of our objectives below were achieved. This served as an effective model for TCPH to keep key community stakeholders, elected officials and first responders informed of the developing situation. TCPH then shared this practice with other local health departments in Texas who were struggling with ways to cope with similar issues.
Please re-state your objectives from the methodology section:1. Identifying a trusted agent/responsible party in each jurisdiction or city to serve as a point of contact for relevant communications2. Fully explaining the expectations and responsibilities of TCPH and the trusted agent; 3. Communicating clearly with trusted agents about infectious disease monitoring activities in their city; 4. Providing information to trusted agents efficiently; 5. Protecting the confidentiality of affected individuals; 6. Creating and maintaining a working partnership between relevant TCPH divisions and trusted agents , including their emergency management personnel, 7. To maintain compliance with federal and state disclosure laws.Did you evaluate your practice? TCPH requested and received feedback from a few of the trusted agents involved in the practice. TCPH asked for an informal evaluation from city partners that had been involved in all stages of the practice. We found that city partners were appreciative of the efforts taken to execute the practice with courtesy and respect toward their responsibilities as city officials. One respondent described the immediate aftermath of the Ebola diagnosis as hysteria, and noted that the TCPH practice accomplished the establishment of a “chain of custody” once the information was delivered to them. The TCPH provided structure to a community of first responders “scrambling” to ensure the safety of their personnel.
TCPH is proud that our target population confirms the successful delivery of the objectives of the practice.
The government jurisdictions and agencies in Tarrant County who employ responders are committed to the health and of their workforce. The transportation by ambulance of the first U.S. diagnosed Ebola case in the Fall of 2014 caused a large amount of anxiety among first responders as commonly applied infection control measures to most patients were viewed as inadequate for patients with Ebola Virus Disease. This project was an answer to the responder’s need to know of possible Ebola risk so they could take additional infection control measures, while balancing a person’s right to privacy. The motive for responders to receive information will remain to address not only Ebola but also other high consequence infectious diseases.
Lessons learned in relation to practice• In over one year since project implementation, no breach of information has been reported. Emergency Medical Service Agencies are accustomed to handling and protecting confidential information. • Communications about people with possible risk of developing Ebola occurred only during business hours when the trusted agents at each jurisdiction were available. This did sometimes cause a delay in delivering the notices and getting addresses into the computer aided dispatch when an at-risk person arrived during a holiday or weekend.• Availability of public health personnel, in this case epidemiologists, around the clock to answer calls from emergency dispatch concerning a flagged address was necessary to the success of the project. Availability of personnel for public health emergency response has been an ongoing activity since the health preparedness funds were awarded in in 2002 and is now part of public health culture. • Secure communications, such as encrypted email messages reduced the public health staff time as compared to hand delivering notifications to each jurisdiction. Costs Once trusted agents were identified and agreements were in place with the dispatching jurisdictions for sharing of specific information and secure communications established, costs were low and entailed minimal staff time.
• Is there sufficient stakeholder commitment to sustain the practice?
During the last session of the Texas Legislature, House Bill 2646 bill was passed and signed into law giving explicit authority to public health departments in the state to release information to responder agencies for people who are being monitored for a communicable disease. Rules to implement the law are being written by the Texas Department of State Health Services using the Tarrant County model as input.