The World Health Organization Raises the Alert
On the 12th of April 2009, Mexico responded to the WHO’s request for verification of an outbreak of acute respiratory illness (ARI) in the small community of La Gloria, Veracruz. By the end of April cases of severe respiratory infection had occurred in Mexico City and the first two cases were reported in the United States. On April 22nd, based on advice from the Public Health Agency of Canada (PHAC), Assistance Services Group began to track callers with respiratory symptoms who had a recent history of travel to Mexico.
On April 26th the PHAC advised Canadians that there had been six laboratory confirmed cases of H1N1 influenza, two in British Columbia and four from Nova Scotia. Tele-Care 811 based surveillance of calls and symptoms related to H1N1 began on April 28th and continued with daily and then weekly reports by postal code, community and health zone until the end of December 2009. Concern amongst the citizens of New Brunswick resulted in a significant increase of call volume to the New Brunswick Tele-Care service beginning in early May 2009. Average daily call volumes in May were 10% greater than at the same time in the previous year. The volume returned to normal from June until August when media reports predicting a second wave of the pandemic became prevalent.
Concern about Wave II
Many in the Public Health Service were concerned with the potential for a second wave of the pandemic and preparations were made to plan for the possibility that the second wave would be more wide spread and the virus more virulent. Concern for the impact on healthcare workers was significant based on estimates that absenteeism from the flu could range as high as 40% of the workforce.
In May of 2009 Assistance Services Group began to work closely with the New Brunswick Department of Health, The Office of the Chief Medical Officer of Health and the Emergency Operations Centre to prepare for the second wave. It was determined by the Province that most communication to the citizens would be provided through two main channels. The first was a recently created Pandemic Influenza web site and the second the Tele-Care program. These two channels would be the most flexible means to provide timely and accurate information to the citizens of New Brunswick. Local radio, television and newspapers were also widely used to disseminate information to the population. Attempts to use mailing campaigns proved fruitless given the rapidly changing nature of the situation.
Assistance Services Group had in excess of 300 RNs working in six locations in New Brunswick and Ontario and had the additional flexibility afforded by having over fifty of these nurses working at home. However, based on experience and in light of the potential for significant absence due to the flu a significant spike in volume would make it impossible to provide reliable service with registered nurses alone. Also the low probability of the pandemic being restricted to one geographic area made it unlikely that resources from other jurisdictions would be available in a crisis. New Brunswick needed a solution that could provide real time information on immunization clinics as well as provide basic health information on the pandemic flu while making the Tele-Care nurses available to support callers who had more complex questions or a symptom.
|Existing daily call volumes average:||250|
|Daily volume in a significant flu season:||350|
|Expected daily call volumes during a Pandemic Flu:||500|
H1N1 Service Requirements as of June 30th
- Communicate information on immunization clinics that were set up for healthcare providers and then the general public
- Location, times and dates
- Rapid turn around based on changing priorities and availability of vaccine
- Assumption that there would be ample vaccine to cover healthcare providers immediately followed by the general public
- Basic Health Information to be Provided to the Public
- Diagnosis of H1N1
- Prevention / Public Health Measures (hand washing, social distancing etc.)
- Treatment (symptom management and use of anti viral medications)
- Other Service Referral Locations
- Public Health Offices
- VON Immunization Clinics
- Physicians Offices, Hospitals and Community Health Centres
- Pandemic Assessment Centres
- Symptom Assessment
- Nursing assessment based on PHAC H1N1 Case Definition
- Tracking for syndromic surveillance ( ILI chief complaint, location, patient characteristics, time of day and day of week)
- Special approaches for at risk groups (Pregnancy, Chronic Diseases)
- Customized reporting
- Daily and or weekly depending on volume
- By postal code, community and health zone
- Service referrals
- Health information topics grouped into four sub categories
- Influenza Like Illness (ILI) tracking for surveillance (postal code, community and health zone)
A dedicated H1N1 information line with separate toll free number was set up and New Brunswick based Health Services Representatives (HSRs) were trained to provide basic H1N1 specific health information and referral to community resources. Any callers with complex questions or who had a symptom were transferred to the Tele-Care program where they would speak to a registered nurse. We identified ten health information topics covering the four required information areas. These topics were written in plain language and edited for use by the HSRs. The most frequently requested of these topics were recorded for use on the auto attendant so that callers could listen to them in case that this information was all that they required. We worked with NB based stakeholders to develop a community resource data base containing locations, contact information and availability for a myriad of key delivery areas. Vaccination clinic information was updated at least weekly on the H1N1 web site and was used by the HSR as the primary resource for this information. All service referrals were tracked and reported using an electronic decision support application. The service went live on October 1st, 2009.
On Saturday October 17th an advertisement was placed indicating that the immunization campaign would start soon. On Monday October 19th call volume in New Brunswick began to increase culminating in an incoming call volume of 1749 on Friday October 23rd. This represented an increase of 450% between Monday and Friday of the same week. On October 28th call volume peaked at 9,377 calls. The addition of the HSRs enabled the program to handle the initial surge however, the incredible demand for information on vaccination clinics made it impossible to manage all of the volume. We added an additional 8 HSRs from our Assistance Services Division on October 26th and 5 on November 16th to support the service referral program. By the end of October the New Brunswick service was handling an average of 1000 calls per day. The addition of the HSR resource helped Tele-Care to increase capacity by 250%.
It became clear that the vast majority of non symptomatic callers were seeking information regarding the timing and availability of the H1N1 vaccine. To provide the most cost effective solution the program implemented an automated voice response solution in early November. The application allowed callers the choice to speak to a nurse, a HSR or to listen to information regarding immunization clinics in their geographic area. By the second week of November an average of 800 people were obtaining the information that they required each day without transferring to a live voice. On November 30th the combined Tele-Care, H1N1 HSR line and IVR provided service to 2987 callers.
Summary and Conclusion
By implementing an innovative option to provide service referral and basic health information to callers of the Tele-Care service Assistance Services Group was able to more than double the capacity of the provincial program. Also by relieving pressure on the Tele-Care nurses the HSRs facilitated a significant increase in the capacity of the nurses to manage symptomatic callers. Finally by implementing an IVR and adding significant staff to the H1N1 line Assistance Services Group was able to meet the requirements for information in the time of a pandemic. The combination of the web, IVR, HSR and nurse channels helped the New Brunswick government reach its goals for immunization and dissemination of health information and advice during the H1N1 Pandemic in the fall of 2009. In fact after review the Province was able to demonstrate that over 60% of the population was able to receive the vaccine. This high rate of vaccination significantly impacted the burden of the illness in the Province and the number of people impacted by the flu seasons in 2010 and 2011.