Project EpiREADY

State: KY Type: Neither Year: 2016

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Located 15 miles south of Louisville, Kentucky, Bullitt County has seen a population expansion in recent years. In 2014, there were 77,955 people in Bullitt County, Kentucky, residing in 27,874 households. The majority of residents in 2014 self-identify as white (96.7%), followed by African American (1.1%). The median household income in 2013 was $54,836 (U.S. Census Bureau). Most residents work in industry, manufacturing, transportation and distribution. The ratio of primary care physicians to residents was 17:3 per 100,000 (Area Health Resources Files, 2011). The local health department provides many services to our residents and is best described by our mission statement, “to promote healthy lifestyles in Bullitt County through prevention and protection.” Our health department focuses on prevention and protection at the population health level to positively impact the lives of our citizens. One area of concern for our population is communicable disease transmission. Depending on the pathogen, communicable disease can spread quickly through our community, and one goal of the health department is to investigate all reported instances of these illnesses. In order to expedite this process, 902 KAR 2:020 (the state infectious disease reporting regulation) requires all healthcare providers to notify the local health department of the existence of certain diseases and conditions. Diseases requiring immediate, urgent, priority, routine or general notification are listed in the regulation to facilitate rapid public health action. While healthcare providers are aware of this regulation, reporting of these conditions continues to be inadequate. Health department personnel are often notified of suspect cases by commercial laboratories, opposed to local providers. This causes a significant delay in the investigation of these cases, increasing the chances of an outbreak. The Epi READY project has been developed by the health department as a multi-tiered plan to educate and engage community healthcare providers, with the following objectives: 1. Increase the quantity of communicable disease reports from local providers to better estimate the incidence of reportable diseases in our community2. Increase the quality of communicable disease reports from local providers to reduce the time required to launch the necessary investigation (as determined by the agent)3. Establish a two way communications pathway with each local provider for information sharing through personal meetings The Epi READY project was developed by the health department’s Epidemiologic Rapid Response Team (ERRT) and includes information on reportable conditions, including infectious agents and bioterrorism agents, lead exposure, animal bites, and tuberculosis. A table of reportable conditions based on requirements set forth by the Council of State and Territorial Epidemiologists (CSTE) case definitions is a highlight of this book. This table provides relevant information for each reportable condition, including laboratory tests needed for case classification. In regards to our objectives: 1. Quantity of Reports – In the pre-Epi READY period, between January 2013 and May 2014, the health department received 8 written reports. Following the Epi READY project, between June 2014 and November 2015, the health department received 19 reports, an increase of 137%. 2. Quality of Reports – In the pre-Epi READY period, between January 2013 and May 2014, the median number of correctly completed fields on paper reports was 20 of 24 fields (83.3%). Following the implementation of the Epi READY project, between June 2014 and November 2015, the median number of correctly completed fields on paper reports decreased to 19 of 24 fields (79.2%). This finding allowed us to identify a goal moving forward with the Epi READY project.3. Establish two-way communications pathway and develop and deliver a resource guidebook. This has been achieved and the health department now frequently receives calls from local providers to follow up on questions regarding reportable conditions and reporting procedures. Our manual provided our 24 hour contact information and in the Pre-Epi READY period, we received 8 afterhours calls regarding a reportable condition. In the post-Epi READY period, we received 5 afterhours calls regarding a reportable condition. An ERRT member met with local providers to deliver the manual in both a hardcopy and a digital copy. Over the course of several months in 2014, members of the ERRT visited 34 office locations, met with 73 unique providers, and distributed 57 copies of the Epi READY manual. The impact of this practice may not be felt yet. While the number of case reports has increased following the project, the number of correctly completed fields on reporting forms has slightly decreased. Additionally, the number of afterhours calls has decreased. However, the project has been successful in building relationships between the health department and our local providers.    
Depending on the pathogen, communicable disease can spread quickly through our community, and one goal of the health department is to investigate all reported instances of these illnesses. In order to expedite this process, 902 KAR 2:020 requires all healthcare providers to notify the local health department of the existence of certain diseases and conditions. Diseases requiring immediate, urgent, priority, routine or general notification are listed in the regulation to facilitate rapid public health action. While healthcare providers are aware of this regulation, reporting of these conditions continue to be inadequate. Health department personnel are often notified of suspect cases by commercial laboratories, opposed to local providers. This causes a significant delay in the investigation of these cases, increasing the chances of an outbreak. Our entire population, estimated at 77,955 in 2014, is at risk for some of these infectious agents. Young children, pregnant women, the elderly, and those with underlying conditions are at a heightened risk. It is difficult to determine the total number of residents that may benefit from visiting local providers with access to the Epi READY manual. Due to our proximity to Louisville, many of our residents travel out of county for care and these out of county providers have not received our manual. In the past, we have attempted to address this problem by contacting local providers via email, fax and phone and this has not helped to increase our reporting rates. The Epi READY manual will serve our providers and residents by providing a one stop shop reference manual on condition specifics (such as required lab testing) and reporting requirements in Kentucky. This will hopefully lead to prompt, detailed reporting from our providers and a quicker investigation on the part of the health department.          
The goal of Project Epi READY is to provide an awareness of reportable conditions to the various medical providers within the community and to improve communication and consistent reporting between providers and the local health department. Ultimately we hope to improve patient care and follow up with a more timely process utilizing a team approach to diagnosing and treating reportable conditions. Certain diseases and conditions are reportable to the local health department, per state regulations for healthcare providers. Receiving timely and accurate disease reports is an on-going issue, requiring constant follow-up by BCHD personnel. State regulations (KAR 902 02:020) require a provider or laboratory to report diagnoses or laboratory results to the local health department or the state Department for Public Health. This state regulation essentially defines the communicable disease stakeholders as every healthcare provider and laboratory in Bullitt County. When the LHD receives reports of conditions from Kentucky providers or laboratories, further follow up is usually necessary to determine whether or not the case meets the requirements for reporting the illness to the CDC. These requirements are set forth by the Council for State and Territorial Epidemiologists (CSTE) case definition. In order to best serve the community, we requested that each provider contact the Bullitt County Health Department directly. Health department representatives are available, even after hours, in order to provide direction on the given condition being reported. The purpose of the Epi READY resource guide is to provide recommended guidelines regarding appropriate reporting of those required conditions listed within this booklet. These guidelines are based on Kentucky Statutes and current Standards of Care. The goal is to provide an awareness of reportable conditions to the various medical providers within the community and to improve communication and consistent reporting between providers and the local health department. Ultimately we hope to improve patient care and follow up with a more timely process utilizing a team approach to diagnosing and treating reportable conditions. The Epi READY Reportable Conditions Resource Guide provides information relative to various reporting requirements including Tuberculosis, Lead, Animal Bites, and Food and Waterborne Outbreaks. The most valuable tool within the Resource Guide is the Table of Notifiable Conditions. This table, based primarily on requirements set forth by the Council for State and Territorial Epidemiologists (CSTE) case definitions, is cross-referenced with the Kentucky mandated reporting timeframe for ease of reference. The table is divided into three segments based on the timeline Kentucky has established for reporting the diseases for which surveillance is required. The first section includes conditions that should be reported within 24 hours and is denoted by a gray background. The second section contains all conditions that should be reported within 1 business day and is denoted by a pink background. Lastly, the third section includes conditions that should be reported within 5 business days and is denoted by a green background. Laboratory tests required for case classifications are included in the second column. The results of the tests included in this column (and only these tests) are what public health needs to fulfill the CDC’s requirement. Often, if a required lab is not completed a case is not included as a part of Kentucky’s disease surveillance. If possible, when laboratory tests are ordered to diagnose a patient please order the tests found in this column.The third and final column, entitled “Comments,” includes several pieces of information. Suggestions for exclusion from public contact, available immunizations, and other information may be listed for some of the conditions. Most importantly however, comments that describe the documentation that the Health Department requires to make case determinations are included in this column. In most cases, lab results alone are not sufficient to fulfill the case definition and further follow up is required to determine symptomology and diagnoses. These comments should act as a guide for what type of information should be gathered and then faxed when reporting a notifiable condition. If the health department receives all necessary documentation when a report is made, the surveillance system is much more efficient and time that can be devoted to patients is not wasted. (Below you will find an example a comment included and how to utilize the information)Comment: “Clinical presentation and laboratory confirmation is required for case determination,” Interpretation: Lab results and symptoms are needed for case classification Action: Complete a KY Reportable Disease Form (EPID 200). Be sure to include information in all relevant fields and fax to the Bullitt County Health Department along with any lab results.
Data analysis was done using Epi Info 7.0 using paper reports from local providers maintained by the health department. The primary paper report that was analyzed was the default EPID 200 form, provided by the Kentucky Department for Public Health for providers to report conditions to the local health department. This document was also provided to local providers in the Epi READY manual. In regards to our objectives: 1. Increase the quantity of communicable disease reports from local providers to better estimate the incidence of reportable diseases in our community – In the pre-Epi READY period, between January 2013 and May 2014, the health department received 8 written reports. Following the Epi READY project, between June 2014 and November 2015, the health department received 19 reports, an increase of 137%. 2. Increase the quality of communicable disease reports from local providers to reduce the time required to launch the necessary investigation (as determined by the agent)– In the pre-Epi READY period, between January 2013 and May 2014, the median number of correctly completed fields on paper reports was 20 of 24 fields (83.3%). Following the implementation of the Epi READY project, between June 2014 and November 2015, the median number of correctly completed fields on paper reports decreased to 19 of 24 fields (79.2%). This finding allowed us to identify a goal moving forward with the Epi READY project. 3. Establish two-way communications pathway and develop and deliver a resource guidebook. This has been achieved and the health department now frequently receives calls from local providers to follow up on questions regarding conditions and reporting procedures. At the health department, our afterhour’s answering service provides reports on calls received when the health department is closed. These reports were analyzed during the pre-Epi READY period, between January 2013 and May 2014, and 8 calls were received by the answering service relating to reportable conditions in the manual. Four of these calls (50%) were reporting a dog bite or rabies post-exposure prophylaxis; two of the calls (25%) were reporting cases of tuberculosis; one report (12.5%) of a foodborne illness and one report (12.5%) of a case of pertussis. In the post-Epi READY period, between June 2014 and November 2015, 5 calls were received by the answering service relating to reportable conditions in the manual. Four of these calls (80%) were reporting a dog bite or rabies post-exposure prophylaxis and one call (20%) was a report of a possible case of chikungunya. The health department saw a decrease in the number of after hour reports from 8 calls to 5 calls, a 37.5% decrease. However, it is important to note that the number of calls is dependent on the number of reportable conditions. Additionally, an ERRT member met with local providers to deliver the manual in both a hardcopy and a digital copy. Over the course of several months in 2014, members of the ERRT visited 34 office locations, met with 73 unique providers, and distributed 57 copies of the Epi READY manual. Local providers now have a point of contact at the health department to direct any questions or concerns to.          
The initial investment to establish this program was substantial. However, with the required time and production of materials completed, continual maintenance is straight-forward. The primary commitment to sustainability will be in maintaining accurate information. The health department will continuously evaluate the accuracy of the content, from both a legal and medical standpoint. As changes occur, it is imperative the health department share the most current information with all guidebook holders to ensure the integrity of the program. The Epi READY Reportable Conditions Resource Guide was developed in such a manner to allow easy updating of one page or one section. Up-to-date contact information for each healthcare provider must be maintained to ensure all stakeholders are receiving any correspondence distributed. The health department routinely uses the “blast fax” to share appropriate information with providers and the database maintained continuously. An improvement plan was developed from feedback and includes:1. Updates as often as necessary to ensure accuracy of information will be an ongoing process by Epi staff, as well as maintenance of contact information. The 24/7 contact list will be tested annually.2. The BCHD Quality Improvement Team will meet annually to evaluate the manual and the process for effectiveness.  
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