2014 Model Practices

Multi-Divisional Strike Teams for Surge Support

Tri-County Health Department

6162 S Willow Dr. Suite 100

Greenwood Village

Colorado

80111

720-200-1532

www.tchd.org

Taylor Jones

Disease Intervention Program Manager

tjones@tchd.org

Dr. John M Douglas

1,000,000-1,999,999

Tri-County Health Department (TCHD) is the largest local public health agency in the State of Colorado, serving approximately 1.3 million residents in Adams, Arapahoe, and Douglas Counties. TCHD has 11 offices across our three counties. TCHD is broken into six divisions and offices. These include Epidemiology, Planning, and Communication (EPC), Nutrition, Public Health Nursing (PHN), Environmental Health (EH), Emergency Preparedness and Response (EPR), and Administration. Colorado state law requires that public health agencies monitor, investigate, and control communicable diseases affecting the public’s health. The Colorado State Board of Health determines the conditions and diseases that are required to be reported to health departments. Physicians and laboratories notify state or local health departments of reportable disease cases within 24 hours or 7 days following diagnosis, depending on the disease. Health department employees then investigate these cases to identify risk factors and implement disease control measures. Most (but not all) reportable conditions are infectious diseases such as salmonellosis, Shiga toxin-producing Escherichia coli, and many others. Colorado state law also states that outbreaks due to any cause are reportable conditions and must be reported to the local or state health department within 24 hours of identification. In 2012, TCHD investigated 1254 cases of notifiable diseases. Of the 1254 case investigations, 514 were in Adams County, 499 were in Arapahoe County and 241 were in Douglas County. The same year TCHD conducted a total of 70 outbreak investigations throughout our 3 counties. TCHD’s Disease Intervention Specialist Team is responsible for investigation of reportable disease cases and infectious disease outbreaks occurring within TCHD’s jurisdiction. The team currently consists of a manager and 3.5 FTEs. Due to these limited resources, infectious disease outbreaks in TCHD’s jurisdiction have occasionally exceeded the capacity of the Disease Intervention Team to respond and/or precluded the timely completion of routine work. Limited employees , resources and funding is something that most local health departments are challenged with and they often find themselves struggling to investigate and manage large scale public health emergencies. This practice seeks to address the challenge of having limited resources but still being able to respond as an agency to public health emergencies. Furthermore, the practice is designed to provide surge support options for every size agency and will allow them to be prepared to respond to a public health emergency. This practice has three primary objectives: 1)Develop an organized approach to situations that exceed our day to day activities by having four strike teams trained at all times to increase surge capacity. 2)Build cross-divisional knowledge and confidence by maintaining six fully trained employees from Environmental Health, Nursing, Emergency Preparedness and Response, and Epidemiology, Planning and Communication (EPC) on each strike team. 3)Integrate the strike team into the Incident Command System (ICS) during a Public Health investigation. The strike teams are led by Disease Intervention Specialists housed in TCHD’s Epidemiology, Planning and Communication (EPC) division. This division is responsible for keeping employees trained on standard investigation protocols. Each strike team is comprised of the EPC lead and five other TCHD staff from Environmental Health, Nursing and Emergency Preparedness and Response. One key to the success of this approach was obtaining the support of each Division Director to allocate staffing for the strike teams. After the teams were established, EPC conducted an infectious disease training and team building exercise.

This developed trust and encouraged communication within the four teams. Each strike team is “activated” for a one month period every four months. This approach avoids placing any undue burden on any individual staff member. EPC hosts a quarterly meeting of the strike teams to review infectious disease follow up and practice outbreak management. After the first 4 months of activation, EPC provided an online evaluation of how each team member managed workload and competing priorities. EPC assessed the average number of large scale activations and routine case investigations to determine the impact strike team participation had on a team member’s workload. The overall feedback was that the participation was manageable and there was limited interference with routine work. The evaluation did provide feedback that resulted in changes to improve communication systems. Feedback from strike team members was that email was not always the most effective way for them to be contacted as many of them were out of the office doing field work. Strike team leaders therefore used email, voicemail, and text messaging to contact team members. Although this resulted in redundant methods of communication, contact with staff was ensured.

Tri-County Health Department (TCHD) is the largest local health department in Colorado, serving an ethnically and socioeconomically diverse population of approximately 1.3 million. TCHD’s jurisdiction includes Adams, Arapahoe, and Douglas Counties in the greater Denver metropolitan area. Colorado state law requires that public health agencies monitor, investigate, and control communicable diseases affecting the public’s health. The Colorado State Board of Health determines the conditions and diseases that are required to be reported to health departments. Physicians and laboratories notify state or local health departments of reportable disease cases within 24 hours or 7 days following diagnosis, depending on the disease. Health department employees then investigate these cases to identify risk factors and implement disease control measures. Most (but not all) reportable conditions are infectious diseases such as salmonellosis, Shiga toxin-producing Escherichia coli, and many others. Colorado state law also states that outbreaks due to any cause are reportable conditions and must be reported to the local or state health department within 24 hours of identification. TCHD’s Disease Intervention Team is responsible for investigation of reportable disease cases and infectious disease outbreaks occurring within TCHD’s jurisdiction. The team currently consists of a manager and 3.5 FTEs. Due to these limited resources, infectious disease outbreaks in TCHD’s jurisdiction have occasionally exceeded the capacity of the Disease Intervention Team to respond and/or precluded the timely completion of routine work. TCHD’s population at the time of the 2010 census was 1,299,071 people. Half (643,740; 50%) were male. Among the total, 997,303 (77%) were white, 75,122 (6%) were African-American, 55,724 (4%) were Asian, 11,462 (1%) were American Indian or Alaska Natives, 1,923 (<1%) were Native Hawaiian or Pacific Islanders, 108,270 (8%) were of other descent, and 49,267 (4%) self-identified as multiracial. Nearly one quarter (294,792; 23%) were Hispanic or Latino. There were 100,264 (8%) people younger than 5 years and 98,877 (8%) older than 65 years; these two age groups are at increased risk of complications associated with reportable enteric infections. Because investigation of reportable disease cases and outbreaks is intended to prevent disease in people who would otherwise become ill, the percentage of the population reached cannot be determined. In the past, TCHD’s Disease Intervention Program has recruited colleagues from other parts of the agency to assist with reportable disease case and outbreak investigation when needed on an ad hoc basis. This was very disruptive to staff routine work and often staff who were recruited were not as current on their outbreak response training as would have been helpful. Scheduled activation of a trained group of team members is better because: •Team members can plan for additional work during their activation periods •Team members maintain competency in case investigation because they are engaged regularly •Including participants from different TCHD divisions promotes teamwork and cooperation •Multiple teams can be activated at once in large-scale outbreaks or emergent situations Multiple schools of public health have developed Graduate Student Epidemiology Response Programs (GSERPs), which recruit and place public health students in state and local health departments to assist with outbreak investigations and other short-term applied public health projects (1). The DeKalb County, Georgia Board of Health was awarded a Promising Practice in 2006 for its Student Outreach and Response Team (SORT), which was formed to address the issue of providing surge capacity for outbreaks, bioterrorism events, and other public health emergencies.

To our knowledge, this is the first description of our approach, which involves recruiting and cross-training employees from other divisions within the same agency to promote surge capacity. Our practice is a creative use of an existing practice: the development of GSERP by schools of public health. The use of GSERPs is described in the literature in the following references: 1.Centers for Public Health Preparedness. Graduate Student Epidemiology Response Programs at Centers for Public Health Preparedness: At A Glance. Available at: http://preparedness.asph.org/perlc/documents/GSRP_AAG.pdf. Accessed October 22, 2013. 2.Horney JA, Davis MK, Ricchetti-Masterson KL, MacDonald PD. Fueling the Public Health Workforce Pipeline Through Student Surge Capacity Response Teams. Public Health Rep 2011;126(3):441-446. 3.Montealegre JR, Koers EM, Bryson RS, Murray KO. An Innovative Public Health Preparedness Training Program for Graduate Students. Public Health Rep 2010;125(Suppl 5):70-77. 4.MacDonald PD, Davis MK, Horney JA. Review of the UNC Team Epi-Aid Graduate Student Epidemiology Response Program Six Years After Implementation. Public Health Rep 2010;125(6):916-922. 5.Pogreba-Brown K, Harris RB, Stewart JS, et al. Outbreak Investigation Partnerships: Utilizing a Student Response Team in Public Health Responses. Public Health Rep 2010;125(6):916-922. 6.Gebbie EN, Morse SS, Hanson H, et al. Training for and Maintaining Public Health Surge Capacity: A Program for Disease Outbreak Investigation by Student Volunteers. Public Health Rep 2007;122(1):127-133.

Food Safety

Goal(s) and objectives of practice 1.Develop an organized approach to situations that exceed our day to day activities by having four strike teams trained at all times to increase surge capacity. 2.Build cross-divisional knowledge and confidence by maintaining six fully trained staff from Environmental Health, Nursing, Emergency Preparedness and Response, and Epidemiology, Planning and Communication (EPC) on each strike team. 3.Integrate the strike team into the Incident Command System (ICS) during a Public Health investigation. Tri-County Health Department routinely investigates cases and outbreaks of communicable disease in a variety of settings including restaurants, schools, and child care and health care facilities. When these community partners experience an outbreak they expect that the health department conduct their investigation efficiently with minimal impact on the day-to-day business and provide guidance to prevent further transmission of the disease. In order to achieve this, the strike team model was developed to increase surge capacity, build cross-divisional knowledge and confidence in outbreak investigations, and integrate ICS during these investigations. As mentioned above, each strike team has multi-disciplinary representation from four disciplines including disease control, environmental health (EH), nursing and emergency preparedness and response (EPR). One key to the success of the model was obtaining the support of the division directors to allocate what was estimated to be a limited amount of staff time to the effort. Strike team members were trained in case investigations prior to their month of activation. Case investigation assignments were based on the strike team member’s expertise. EH and EPR staff were trained on routine enteric case investigations. While nursing staff were also trained on enteric case investigations, they were also trained to investigate hepatitis A, and pertussis; hepatitis A and pertussis case investigations may involve chemoprophylaxis which is a procedure with which nursing staff are more experienced. The practice emphasizes fostering collaboration among internal stakeholders by providing continued opportunities for staff from PHN, EPR, and EH to get more involved with communicable disease activities and strengthen their disease investigation skills. Once assigned to different strike teams, each team is activated on a rotating monthly schedule for routine communicable disease case investigations. These case investigations do not include weekend or evening calls, and the team members’ regular work duties take precedence. Furthermore, community partners benefit from the cross-divisional surge capacity because outbreak investigations can be investigated in a timely fashion. Because employees are selected from within our agency, there are no start up or in-kind costs associated with this practice. This is a cost effective approach to unitizing agency resources to be prepared when a response is needed.

Objective 1: Create an organized approach to situations that exceeded our day to day activities by having four strike teams trained at all times to increase surge capacity Performance Measures: Was the strike team created in an organized fashion? Did the strike team provide surge capacity to disease control? Data Source: Outcome evaluation includes qualitative feedback from strike team participants about the organization and organizational sustainability of the strike teams. The evaluation came from a qualitative analysis of the structure of the strike teams during the process of their creation, as well as after a four month pilot. Primary sources reported on the organization and sustainability of the structure. After the pilot, disease control provided an outcome evaluation through qualitative feedback about whether the strike team structure increased surge capacity. Evaluation: Since their inception, the strike teams have had a standardized number of participants and have included representation from the following divisions: EPC, PHN, EH, and EPR. EPC is the strike team lead which provides clear roles and obvious contact persons for everyone on the teams. Quarterly strike team meetings during which feedback from participants is invited has not resulted in any criticisms about the organization structure. Having one team activated for each calendar month and keeping the four teams on a constantly rotating schedule ensures there are always members activated to assist with disease control work. Since the strike teams have been created there has only been one gap in strike team activation. This gap in coverage occurred after the 4 month pilot and allowed EPC to evaluate objectives and performance measures. Finally, everyone who joins a strike team is asked to sign a membership agreement acknowledging their participation in the team. This ensures that expectations for participation are clear; ensuring the surge capacity is there when needed.

Objective 2: Build cross-divisional knowledge and confidence by maintaining six fully trained staff from Environmental Health, Nursing, Emergency Preparedness and Response, and Epidemiology, Planning and Communication (EPC) on each strike team. Performance Measure: Do the majority of strike team members feel they have the knowledge and confidence to conduct infectious disease interviews? Since their creation, were the strike teams consistently fully staffed with representation from each division? Data: A survey monkey (online survey tool) created by the Disease Intervention Program Manager was sent to all members of the strike teams after a four month pilot. Evaluation: The creation of the strike teams put at least one person from each division on every team, and for the duration of the strike teams we were able to maintain full participation. After the trial period, strike team members who followed up on a case were asked if they felt “properly trained” and 100% (12 of 12) answered yes. Strike team members who assisted with an outbreak were asked if they felt “properly trained” and 100% (8 of 8) answered yes.

Objective 3: Integrate the strike teams into the incident command system (ICS) during a Public Health investigation. Performance Measure: Was the strike team successfully integrated into the ICS? Data: Qualitative feedback attained from a “hot wash” with participants was used to assess whether the strike team could be organized into the ICS, and whether this provides a better public health response to a large scale investigation. Evaluation Results: Fortuitously, just one day after the initial training of the new strike teams, a large scale E. coli outbreak at a detention facility necessitated a larger response than an individual strike team could manage so all four teams were activated. Soon after activation, the need for a more organized response became apparent, and ICS was utilized. While the ICS provided much needed organization, it was noted that it should have been implemented sooner to provide structure from the beginning instead of waiting until the response exceeded our capacity. However, once implemented, the ICS did enable all the work to be completed in a timely and organized manner. The strike teams, despite being trained only one day prior to the actual outbreak notification, conducted 261 interviews in three days proving that the strike team organized into the ICS is a successful model for outbreak investigation. Additional feedback from the “hot wash” indicated that the need for the immediate creation of an organization chart for command and general staff positions to make it easier to delineate tasks. Although there has not been another event necessitating the strike team implement the ICS, all lessons learned are summarized in the after action report to refer to and improve our response to the next event.

The Executive Management Team at TCHD has expressed their interest in maintaining and supporting the concept of the strike teams. The structure and organization is well defined with team members consisting of existing staff from 4 divisions so it does not cost TCHD additional funds to support the strike team. It was obvious to TCHD how valuable the existence of the team was when immediately after the initial strike team training, we had a large scale outbreak of E. coli at a local jail, and 261 inmates were interviewed in less than 3 days. Prior to the creation of the strike teams, there would have been significantly fewer trained staff to participate in interviewing inmates which would have significantly prolonged the investigation. The strike team staff members were surveyed resulting in positive feedback despite the additional workload, and the overall feedback was that it was not a huge time commitment. However, the contribution to the agency’s response capacity is significant, far exceeding the minimal time commitment for staff.

Workforce Development

Infectious Disease

Food Safety

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