Community Triage Centre for Influenza Assessment During Pandemics:

Simulation, Survey, and Administrative Data Research Studies

Pandemic influenza recurs at unpredictable intervals to cause great social disruption and economic losses. Invariably, a pandemic results in high morbidity and mortality increasing healthcare services demands that challenge healthcare delivery infrastructures and health human resources. In Alberta, Canada, 2.3 million of its 3.3 million residents (70%) may become infected with the influenza virus during the two waves that may last up to one year. In a moderately severe pandemic without any known effective vaccine or antiviral (WHO, 2005a), 825,000 (25%) of Alberta residents may become clinically ill. Four hundred and eighty thousand of Alberta residents (15%) may become ambulatory outpatients (four times above a normal influenza year). Seven thousand five hundred of Alberta residents (<1%) may become hospitalized (four times above normal). Two thousands (<1%) Alberta residents may die (eight times above normal).

Capital Health, one of nine Alberta’s Regional Health Authorities (RHAs), is the service center for 1.1 million residents in Edmonton and the surrounding urban and rural communities. It also acts as a referral centre for an additional half million residents in Central and Northern Alberta and the Northern Canadian territories. If the current processes of healthcare delivery for influenza treatment are maintained in a pandemic, the already overtaxed emergency departments (EDs) are likely to be overwhelmed. Patients who are 65 years of age and older with pre-existing respiratory or other chronic diseases will have a major impact (WHO, 2005b). Increasing surge capacity is, therefore, a vital component of pandemic influenza preparedness.

In order to prepare for a pandemic, Capital Health piloted a $1.8 million Community Triage Centre (CTC) project in February 2007, demonstrating the CTC to be a viable surge capacity option for EDs in an urban setting. The first of its kind in Canada, the three-week CTC pilot project was located in a parking lot adjacent to the Royal Alexandra Hospital (RAH) ED in Edmonton. The pilot project goals were to: 1) demonstrate the feasibility of physically deploying a CTC adjacent to an ED; 2) assess the acceptability, safety, and effectiveness of influenza-like-illness (ILI) clinical management within a CTC compared with usual care in an ED; and 3) test ILI-specific screening, triage and assessment tools that safely screen ambulatory patients and manage them in a CTC without the need for ED care.

Feedback from surveyed CTC patients, physicians, and staff respondents demonstrated satisfaction with the service provision and physical structure. Key learnings directly show many financial, operational, and patient or staff safety benefits of a CTC being located adjacent to an ED. They indirectly show that standardized CTCs may enhance staff deployment flexibility, avoiding the need for site specific training of staff and familiarizing them with the environment and equipment at each specific PICS facility. A critical question that remained unanswered during the three-week pilot project was the ability of the Portable Isolation Containment System (PICS) facility to care for the high patient volumes that are expected in an influenza pandemic. Staff recruitment and orientation, space limitation, and patient privacy were problematic during the pilot PICS deployment.

Capital Health now wishes to capitalize on the feedback and learnings from the CTC pilot project by proposing subsequent studies using administrative and chart data from Capital Health and Alberta Health and Wellness (AHW) to model surge capacity and rate limiting patient care processes through Monte Carlo simulations during and following a PICS deployment. Of particular interest is an assessment of follow-up care needs during an influenza pandemic. In addition, CTC investigators plan to survey family physicians, non-physician healthcare providers, and the public about pandemic planning using interactive and non-interactive web surveys. These surveys may facilitate public education and provide and precede forums for discussions of risk communication strategies and ethical issues surrounding pandemic management.

With Monte Carlo and risk communication modelling as well as e-surveys allowing rapid health information gathering, verification, integration, transfer, and dissemination (Ball MJ, 2001; Pace WD & Staton EW, 2005), the proposed activities may further evaluate a conceptual design and preliminary infrastructure development as well as human resources deployment and resources utilization. Administrative data studies on various ILI possibilities and probabilities helps CH plan for them in advance should they occur. The ensuing strengths of these activities are to come from cultivating educational interventions to enhance healthcare professionals’ participation, integration, and mobilization, while addressing important issues now to sustain healthcare services and resilient workplace dynamics in the future. Similarly, open communication, transparent decision-making, and reciprocity agreements among health establishments, all first-responders, and the public now may safeguard scarce health and health human resources as well as trust and cooperation later (Shultz et al.; Goldsand, 2007).

While the intended 2007/2008 CTC pilot project has a broad application with the larger context of overall public health emergency planning, it has several challenges that are beyond the control of the researchers. ILI patients that are to become subjects in several studies may exhibit symptoms that are not solely due to influenza viral infections. Their incubation and communicability of the circulating influenza may be substantially different from those of the pandemic influenza. There may be inadequate patients to describe children under five years of age, compared to children between 5 and 16 years of age. The same situation may exist for pregnant women, compared to other adult women between 15 and 50 years of age. Also, ILI symptom coding has not previously been validated in administrative records. For these reasons, there is a need to verify these codes in order to explore omissions, such as heart failure presentations, which were not noted in the past CTC pilot study.

Moreover, the initial CTC deployment may not include all treatments required for definitive care. Relevant patients will be encouraged to participate in the CTC pilot with the benefits of decreased waiting times from presentation to a preliminary or final diagnosis. Deployment may result in a shift of ILI cases from other nearby EDs, as all urban EDs within Edmonton are within a 15 min driving distance of each other. Comparisons with urban Calgary EDs and without the presence of a CTC at any ED during an identical period are to be made. With respect to Monte Carlo simulation of influenza pandemic conditions, it does not require that influenza viral infection is the cause of ILI symptoms. In the future, computer simulation or standardized patient drill may be considered for testing protocols for rapid response times needed with large patient volumes.

Project Team

This CTC project has the financial, administrative, and/or operational support of Capital Health senior executives, Alberta Health and Wellness, Capital Health iCare, University of Alberta, City of Edmonton, Capital Health Emergency Preparedness Director, and City of Edmonton Emergency Preparedness Director.

Proposed Research

The following table and text describe the intended research activities for the 2007/2008 CTC project.

2007/2008 CTC Pilot Project Research Objectives, Hypotheses, and Requirements

Objective / Hypothesis / Requirements
1. To identify the surge capacity of the CTC from patient screening to discharge, using live actors simulating scripted patient scenarios. / Surge capacity can be determined using estimated range of arrival to discharge times, varying complexity of cases with corresponding level of healthcare needs, e.g. antivirals, laboratory testing, treatment, referral to ED, post-discharge follow-up. / PICS facility
Consumables
Core process
Patient protocols
Clinical charts
Ethnographic data
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Clinical staff
Support service staff
Script writers
Patient actors,
Ethnographic observers
2. To identify the rate limiting critical points for screening and triage of ILI patients at a CTC deployed near an urban ED using computer models simulating various conditions. / Simulations of patients presenting to an ED for all causes can successfully predict the rate limiting critical points for screening and triage of ILI patients at a CTC established nearby. Simulations can assess the ability to add increased services (nasopharyngeal specimen, assessment for antiviral eligibility and treatment, ability to deliver increasing levels of care) / Monte Carlo model
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Programmer/
data analyst
Graduate assistant
3. To ascertain the effects of a brief closing of the Northeast Community Health Centre (NECHC) ED on adjacent ED patient volumes. / A closure of North East Medical Center during Sept/Oct 2007 did not result in increased ED patient volumes in nearby Capital Health EDs / AHW administrative data
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Data analyst
4 To describe subsequent secondary ED and community physician visits for discharged ED ILI patients
5. To compare the rates of subsequent secondary ED and community physician visits among ILI patients with co-morbidities (diabetes, heart failure, COPD, asthma) and/or lower socioeconomic status (SES) with those of their counterparts without co-morbidities and/or higher SES. / Urban ED visits in metro Alberta by ILI patients result in subsequent secondary ED and physician visits by discharged patients. Subsequent ED and physician visits in discharged ED ILI patients increase in frequency as overall ER volumes increase. Subsequent hospital admissions of ED ILI patients decrease in frequency as overall ER volumes and hospital occupancy increases. Urban ED ILI patients (transfers from nursing home, the elderly) with co-morbidities (diabetes, heart failure, COPD, asthma) and/or lower SES have more subsequent secondary ED and physician visits compared with the other discharged ED ILI patients. / Administrative data
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Data analyst
6. To follow-up discharged ED ILI patients and measure their rates of subsequent ED and community physician visits. / Discharge ED ILI patients can be successfully contacted by telephone or can access online Capital Health ILI self-management information for assessment of resolving ILI symptoms. Such patients return to ED and physician offices less often than concurrent controls in the same and other urban EDs. / ILI self-management information
ED discharge and diagnostic data
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Web/survey developer
Data analyst
7. To measure adherence to respiratory etiquette in ED waiting areas during the annual influenza season. / Patients in ED waiting areas during the annual influenza season do not adhere to respiratory etiquette. / Ethnographic data
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Ethnographic observer
Data analyst
8. To assess the effectiveness of point-of-care (POC) testing for ILI in an ED with an increase in ILI cases in defining a community ILI outbreak / ED POC testing for ILI during times of excess presentations can result in identifying influenza and non influenza communicable diseases community outbreaks. / POC test for ILI
ED administrative data
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Data analyst
9. To describe ILI cases by age group using school laboratory reports, school absenteeism reports, physician visit claims, ED visits, outbreak notifications, and sentinel physician notifications / ILI disease burden by age group, temporal variation, residence location, and reporting source (ED, physician visits, school absenteeism reports, laboratory isolates, outbreak notifications) can be compared to the sentinel community physician notifications in tandem / Administrative data
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Data analyst
10. To assess the influenza pandemic preparedness of local family physicians. / A web enabled survey of key informant family physicians can assess pandemic preparedness readiness. / Web survey
Advertisement
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Web/survey developer
Data analyst
11. To assess the influenza pandemic preparedness of local public health nurses. / A web enabled survey of key informant nurses can assess pandemic preparedness readiness. / Web survey
Advertisement
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Web/survey developer
Data analyst
12. To test a two-way communication platform for public health emergencies with community residents. / An online two-way communication system for public health emergencies can be used by the public wishing to be more proactive in influenza pandemic preparedness planning. / Web survey
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Web/survey developer
Data analyst
13. To develop a risk communication strategy by studying the role of the public in public health emergencies. / Lack of model of individual action and responsibility during a public health crisis prevents in-depth evaluation of event-specific crisis risk communication efforts and their effectiveness / Risk communication model
Focus groups
Course compensation
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Risk communication
specialist
Graduate assistant
14. To establish an expedited ethical review process for health research that can be activated during a public health emergency based upon predetermined ethical guidelines. / A process for ethical review during a public health emergency can be established. / Consulting ethicist

1.  To identify the surge capacity of the CTC starting from patient screening to discharge, using live actors simulating scripted patient scenerios.

And

2.  To identify the rate limiting critical points for screening and triage of ILI patients at a CTC deployed near an urban ED, using computer models simulating various conditions.

An evaluation of the 2006/2007 CTC core process examined patient transit times. It was found that patient arrival to discharge time was 48.79 min on average. The range and SD were between 16 and 102 min and +27.23 min, respectively. The transit times at each of screening, triaging, registration, assessment, diagnosis, treatment, and discharge planning stages averaged 1.38 min, 6.09 min, 5.32 min, 37.52 min, and 48.79 min (CH, 2007a). Because these averaged CTC transit times were derived from a small patient volume and high patient to staff ratio, it would be highly unlikely that these transit times remain unchanged during an influenza pandemic. Each Capital Health ED would likely see 500 to 700 patients per day (CDC, 2004; Ferguson NM, 2006), all expecting the highest level of care possible.

The investigators propose using live and computer simulations in the 2007/2008 CTC pilot project in order to assess clinical variations of patient presentations and allow predictions of surge capacity and rate limiting critical points in a CTC. The objectives of the simulations are to: 1) Advance current CTC design to protect the acute care infrastructure and processes that ensure business continuity of all essential health service delivery; 2) Determine a flow process that maximizes CTC capacity and efficiency in managing patients with pandemic influenza; 3) Observe and document screening of simulated patients who are assigned to be either “assumed infective” or “assumed non-infective” with pandemic influenza, as a virus can be transmitted prior to the patient experiencing symptoms; 4) Observe and document triage and assessment of simulated patients based upon their acuity presentation or “how sick they are” and “how urgent is their healthcare needs;” 5 ) Identify the most suitable geographic location for a CTC in the City of Edmonton and the greatest distance from an ED without compromising the CTC’s ability to decant the pressure of ILI patients from the acute care centre; and 6) Investigate possible early treatment plan with antiviral medication for patients who present symptoms within 24-48 hr of onset.