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Bioterrorism and Other Public Health Emergencies

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Transcript of Web-assisted Audioconference

Linkages with Community Providers

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

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This Web-assisted audio teleconference, broadcast on December 16, 2003, was the fifth in a series on bioterrorism conducted throughout 2003 via the World Wide Web and telephone. The User Liaison Program (ULP) of the Agency for Healthcare Research and Quality (AHRQ) developed and sponsored the program.

Penny Daniels: Good afternoon and welcome to Bioterrorism and Other Public Health Emergencies: Linkages With Community Providers. This is the final event in a series of Web-assisted audio conferences on bioterrorism and health systems preparedness. These events are designed for State and local health policymakers and health systems decision makers. This series is sponsored by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality, which is often referred to by the acronym AHRQ or AHRQ.
My name is Penny Daniels and I will be your moderator for today's session.

The context for these calls is clear and compelling. Bioterrorism represents a significant public health threat to the United States and addressing this threat requires the rapid development of federal, State and local capacity to respond to potential bioterrorism events. This means improving the abilities of public health and healthcare delivery systems to detect and respond to those threats. It also means ensuring that public health, health systems, facilities and providers communicate and coordinate effectively with one another as well as with other related systems such as emergency preparedness and law enforcement.

The intended audience for these calls, State and local health policymakers, program administrators and health systems decision makers, all play an essential role in these efforts. Within their own jurisdictions, regions or deliver systems, they must develop capacity and coordinate efforts across public health, healthcare, law enforcement and related systems. It is therefore extremely important that they have information about emerging health systems, health services research, promising approaches and available tools that assist in the development of readiness plans.

Today's event is the fifth and final event in our 2003 series on Bioterrorism and Health Systems Preparedness. To continue to share new and emerging tools and research on this subject, AHRQ is sponsoring a 2004 audio series that will focus on surge capacity. The first event in the 2004 series is scheduled for Tuesday, March 2, 2004. I will tell you more about the 2004 series later in our broadcast, but right now let's turn to today's call.

We will be examining the key issues, challenges and opportunities for creating linkages with community providers. Let's begin by introducing today's panelists. In the studio with me, I have Dr. Dan Baden, the clinical communication team lead for the Emergency Communications System at the Centers for Disease Control and Prevention. Also Molly Hicks, the associate director of the Department of Federal Affairs at the American Academy of Pediatrics. Dr. Jeralyn Bernier, the research director of the Cincinnati Pediatric Research Group at the Cincinnati Children's Hospital Medical Center. And joining us remotely, Dr. Helen Burstin, the director of the Center for Primary Care, Prevention and Clinical Partnerships at the Agency for Healthcare Research and Quality. Welcome to everyone today.

Before we begin our discussion, I would like to tell the audience a bit about the format of this audio conference. First, we will talk with our four panelists. Then we will open up the lines to take your questions. You will be given instruction on how to send your questions to us later in our program. In the meantime, if you happen to experience any Web-related technical difficulties during this event, please click the "Help" button in your window to troubleshoot your Web connection. If it appears that the slides are not advancing, you may need to restart your browser and log on again. If you are on the phone, dial "*0" to be connected to technical assistance. Also, if you have any difficulty with the Internet audio stream, feel free to access the audio via your phone. The number is 1-888-496-6261. Give the password "bioterrorism" to be connected to the call. However, please note that for this program, we will be timing the changing of the slides with the audio streamed over the Internet. If you are listening to the audio via phone, this means you may notice a delay between when the speaker is talking and when the appropriate slides is presented. This will be done because most of our audience listens via the Internet.

Now I think we are ready to talk about today's topic. Let me begin with Dr. Helen Burstin, director of the Center for Primary Care, Prevention and Clinical Partnerships at the Agency for Healthcare Research and Quality. In addition to heading that center at AHRQ, Helen is also a community provider. Helen, how important do you think it is to develop strong communication and related linkages with community healthcare providers?

Dr. Helen Burstin: I think it is a really critical issue. Many of us know that patients who may present with bioterrorist-kind of syndromes will likely present to their primary care providers with symptoms with cough or flu-kind of symptoms. If the primary care providers and community providers are not effectively linked to folks in public health and emergency preparedness, we could really have a difficult situation on our hands.

So for example, if you think about frontline clinical providers, it is primary care providers; it is folks like me today sitting in a community health center. It is emergency departments as well as hospitals. Although some people think of the healthcare system as being a part of the public health system, much within the public health system including public health departments and State labs and programs in emergency preparedness are not very well linked. In fact, in some work that we have done, we have actually been able to show that a significant number of providers don't feel prepared. We actually had a paper in the Journal of Family Practice just last year showing that approximately two-thirds of family physicians feel unprepared to deal with a bioterrorist event. I don't think they are unique for other community providers. It was just the group that we surveyed. So I think we have got some real issues in terms of their level of comfort as well as what we could do to help them feel more prepared in training issues.

Penny Daniels: I think clearly that is true. It is kind of frightening. Thank you, Helen. I understand that in addition to your responsibilities at AHRQ, you are also a practicing clinician so what insights have your clinical experience provided you on this issue?

Dr. Helen Burstin: Well, it is always helpful to practice. It kind of puts things in perspective in a real kind of way. As we think about what community providers need to actually feel part of the bioterrorism preparedness solution, I think you can kind of break it down into a couple of major problems. The first problem is patients often present to their provider with fairly vague symptoms. Given the current environment, certainly these symptoms could be confused with flu. Obviously a major concern for all our patients waiting in the waiting room today are those kinds of issues. But there really are some potential solutions. I think if we really used the power and the force of information technology, decision support systems, for example, that help clinicians target the key symptoms and signs that they should look for what is a bioterrorism-related diagnosis versus what is a garden-variety flu or virus.

Secondly, I think we really need to do more in terms of training and information at the point of care to help prepare community providers to diagnose and manage their patients appropriately.

Secondly, I think one other major problem is currently many community providers don't really interact with public health departments or the emergency response systems within their local or regional areas. For example, in that survey that I mentioned earlier Penny, we found that in addition to people not feeling prepared for a bioterrorist event, many of them actually said they had no idea how to report anything to the public health department. That on a regular basis, they have no interaction with them. So it is hard to know how they would feel prepared at the time of crisis.

So potential solutions are, first of all, being able to develop those ongoing relationships with the key parts of the public health infrastructure like health departments and EMS, emergency medical services. I am really thrilled that Dan, our colleague from CDC, could be with us today.

Secondly, I think we need to do more to develop community-based data sharing that allows us to do the ongoing surveillance for bioterrorism and other public health emergencies. You can really use the community providers to really help be the sort of the canary in the coal mine, for something just kind of starting to go wrong that might be a sign of something more sinister happening as well.

I think finally, related to that issue, I think we also need to think more about what is the role of community providers and also volunteer providers. I think increasingly we are hearing about people after 9/11, for example, community providers didn't know how they could volunteer or how they could help out in the event of a public health emergency. So there are certainly lots of things we could do to help with that problem, Penny.

Penny Daniels: Tell us about the types of work that AHRQ is sponsoring in this area.

Dr. Helen Burstin: I would be delighted, Penny. Sally Phillips, my colleague who is here today, who coordinates our bioterrorism program can do more under the Q&A for specific programs. But what I want to mainly tell is I think some of the broad areas. First of all, as I mentioned earlier, training is a big issue I think that community clinicians need. We have been trying to develop training programs as well as information tools that really meet the needs of community clinicians. We have just recently funded a grant, for example, at our Vanderbilt, that will look at how we can train volunteer nurses to be prepared in the event of an attack or another public health emergency. We have also got some ongoing work at the University of Alabama at Birmingham and AHRQ have teamed together on a free CME Web-based tool that clinicians can use to do their training, their CME training at no cost. Which is also, I think, making training available in a way that is convenient and works well for the clinician in the community who can't leave off site and go for three days for some sort of training program.

Secondly, we have really tried to support practice-based research networks of community-based providers, who can really help us understand what is really happening at the community level as we try to think about interventions to improve preparedness. We need to not just think about the kind of clinicians who might be affiliated with university teaching hospitals, but also providers who are out there on their own, solo practice, community health centers and how they can actually begin to provide data both for surveillance, but also to help us to understand what their needs are and how the public health system and the healthcare systems can enhance communication to those providers. Today, for example, we will hear from one of our colleagues at the Cincinnati Children's Network that we support that is trying to do exactly that kind of work.

Finally, I think it is also important; again, thinking about the power of information technology is really important in this arena in particular. I think we need to do more to enhance and reinforce linkages and IT connectivity between the healthcare system, meaning the clinics, the hospitals, the individual providers and the public health infrastructure like the public health labs. Like knowing how to report something in a peacetime event so that you can actually be prepared when something bad may unfortunately happen down the road. One example of that is work that we have been funding through our Indiana Research Network that has done a really phenomenal job of using the power of IT to connect community providers, emergency departments, hospitals and public health departments so that everybody has the information they need in real time.

Just as an example on the next slide, Penny, you will is just a Web shot of the first example that I mentioned of our University of Alabama at Birmingham joint AHRQ site that we do on bioterrorism preparedness. Again, free, Web-based tools that providers can use to get CME and CE credits. Something we are proud of working with them in partnership. I think those are the kinds of tools we want to keep developing. Since we know we get such good response to these calls, one particular thing that would be great for use, even if it not so much a question, we would love to hear from you the kinds of things you need or the kind of things your providers need in your communities that we can do as we move forward.

Penny Daniels: Helen, thank you so much and thank you for taking time away from your clinic today to join us on this call. I know you are heading back in there now and won't be available for our Q&A portion, but Dr. Sally Phillips, director of our Bioterrorism Preparedness Research Program, will be available to answer questions about our work in this area.

I would like to turn now to Dr. Dan Baden. Dan is the clinical communication team lead for the Emergency Communication System at the Federal Centers for Disease Control and Interventions or the CDC. He has been working to develop effective strategies to communicate with community providers, not only on the early detection of bioterrorist events, but also on other public health concerns. Dan, tell us, how is CDC alerting clinicians to new information about emerging topics like SARS, for example?

Dr. Dan Baden: Thank you, Penny. There are several ways that CDC is going about communicating with clinicians across the country. The first way I want to highlight is something called COCA. Basically, that is our Clinician Outreach and Communication Activity. This is a network of 84 clinician organizations, professional organizations, across the country. Organizations such as the American Medical Association, American Nursing Association, American Academy of Pediatrics and several other physician organizations, nursing organizations, health plans and even a health care worker union plan representative.

This forum, this network, allows us to have conference calls on a regular schedule and we have two-way communication with these organizations and with the CDC experts. So for example, we would have a call, we are actually having a call coming up tomorrow. On this call we are going to be talking about several different topics but we will have the experts at CDC giving a presentation to all of the representatives of these organizations. Then we will open it up for questions and answers with these organizations so if they themselves or if they have received questions from their members, they can funnel those concerns and educational needs directly to CDC and get them addressed by the experts. So it is a nice two-way communication mechanism that we have tried to establish.

One of the other mechanisms that we currently are employing that started last spring is something we call the CDC Clinician Registry. We currently have a little over 40,000 members. They are all different types of clinicians. It is about 50% nurses, 25% physicians, and 25% other providers, other types of clinicians. Through this mechanism, we send out weekly updates on changes in guidance and things of that sort that CDC has developed. We currently have sent out over 800,000 messages to the members. The next slide actually shows one of the examples of what we send out in the registry.

Penny Daniels: OK. Can you give us a little more on what type of information, a little more specifics on that?

Dr. Dan Baden: Yes. Basically, what we do in these updates is we take the information that has been changed. Normally our outlet is through the Web site, the main CDC Web site, and we make a one or two sentence summary of the specific change. So for example, during SARS, the case definition was getting updated frequently, whether daily, weekly, at rapid intervals. In order for clinicians to stay up to date on what the current case definition was, they would have had to keep going back to the Web site and track down what the changes and look through the entire document to find what the change was. So to meet this need or to ease clinicians getting the information, we now make a summary of what the change is. So for these case definitions, if Taiwan was added to the locations where that met the case definition, we outlined that in the, we outlined that in the update saying this is what is changed. You can look here at the specific link to find where more information is. That is basically what the updates; they summarize all the different information that has changed on these topics in the last week or so.

Penny Daniels: So it is like a news update.

Dr. Dan Baden: Exactly.

Penny Daniels: Great.

Dr. Dan Baden: It makes it much more friendly for the users to be able to find out what has changed on the Web site.

Penny Daniels: What should clinicians do if they have questions about this information or just in general if they want more information?

Dr. Dan Baden: We have several mechanisms to address that also. We have the clinician information line, which is a 24/7 line that can take calls from clinicians from across the country. The number is 877-554-4625. Basically, we are currently taking questions on smallpox, SARS, West Nile virus and we are just going to be adding flu to this line in the next week or so.

It is staffed by nurses who are able to take questions from clinicians and either answer them directly based on information that CDC as guidance or if they are not able to answer the questions, they take the question and forward it on to CDC experts who will then develop an answer and get that answer back to the clinicians. We also provide that information to anyone else who would ask that question in the future.

Penny Daniels: What a fantastic resource. Dan, thanks so much. I know we will have questions on that later.

Let's turn now to Molly Hicks, who is the associate director of Federal Affairs at the American Academy of Pediatrics, or the AAP. Molly, I understand that the AAP has been working on a number of projects, some of them funded by AHRQ, that are trying to better prepare providers to respond to bioterrorism or any public health emergency for that matter. Can you talk a little bit more about the role of AAP with regard to the healthcare response to terrorism and other catastrophic events?

Molly Hicks: Absolutely. Thank you for having me here, Penny. Let me just give a little background first about the academy. We are a national membership organization. We have 57,000 pediatricians and pediatric specialists as part of our membership. We really are focused on improving the health and safety of all children. That spans from infancy to adolescence, so it is a pretty big window, but the medical experts and the research indicates that that group really does have unique health and mental health needs that require special attention from a pediatric workforce.

Penny Daniels: Why has the Academy been so active in this area, do you think? Is it because children have special needs when it comes to disaster planning?

Molly Hicks: That is exactly right. Children have unique health and mental health needs that really distinguish them from adults and in fact make them more vulnerable than adults on many occasions. They are not only more vulnerable at the front end in terms of the fact that they can be more impacted by some of the agents of terrorism. For example, an aerialized bioterrorism weapon is going to affect children more quickly because children have a faster breathing rate so they are breathing more often per minute; they are going to absorb more of the agent and therefore they are going to be more impacted than adults.

The other angle that children are more vulnerable in is after the event occurs. Children have unique treatment needs that really require specialized care and specialized treatment. As a non-doctor, it wasn't evident to me at first that the medical equipment that is available in my hospital when I go see my doctor would really be of no use if faced with a child. For instance, you can't take blood pressure on an infant with an adult-sized cuff. You can't intubate a child with adult-sized equipment. So there really does need to be from beginning to end of the treatment area, there needs to be some special consideration of children.

Also, as parents will attest to, children have developmental needs that can create new challenges that need to be taken into account with disaster planning. An alert system over a broadcasting network, for instance, is not going to be heard and responded to by children in the same way by adults. Whether physically they can or cannot walk. You have infants who simply could not get out of the way even if they were instructed to. You also have children who aren't going to understand the complexity of an evacuation plan broadcast over a radio or TV or even a public address system. There really are across the board both physical and emotional reasons that children need to specifically addressed and that is why the Academy has been so involved in this, both post-September 11th and even predating September 11th.

Penny Daniels: In general, how well prepared do you think pediatricians and other healthcare providers are to respond to these special needs of children?

Molly Hicks: In general, I think the pediatric workforce is certainly familiar with children's unique needs. They have had the additional training. They have had the additional continuing education that at least makes them familiar with some of the basic differences between children and adults, both physically and emotionally.

I think outside the pediatric community, though, we are concerned. Certainly all of the health field is dealing with new challenges after September 11th. There are new agents and new incidents that we, fortunately, had not been having to consider are now on our plates. I think that the desire that we have to make the information and expertise that we have available to everyone so that local planners, other providers, school nurses, community activists, you name it, anyone who might be involved in disaster planning. We want to make sure we get the information that we have, as the nation's pediatric experts, into their hands, so that they are not reinventing the wheel. They are benefiting from what we know and they are using the resources we are able to generate.

Penny Daniels: Are there other ways the Academy's helping providers to become better prepared?

Molly Hicks: Absolutely. As I mentioned, our work in this field predates September 11th. We have numerous policy Statements, treatment guidelines, and family resources. Everything from family disaster kits to how to stock an emergency room. We have those resources available. We are also sponsoring continuing education and medical training programs through our own professional organization and through outreach.

Penny Daniels: What do you think are some of the ways that providers and communities can work together better to help children survive and cope with terrorism, bioterrorism and other disasters?

Molly Hicks: Absolutely. There are certainly some things that can be done. It is daunting to hear that you have a new population that you need to be paying attention to, but we do have the information at hand. Some of the things that we have done is we have established a national task force on terrorism. This group was really pulled together after September 11th to coordinate the work of the Academy in this area and that group has really served as a central resource for providers and communities. That group and its efforts have developed some specific tools and we have had some very generous support from some outside organizations that have helped us pull together some resources.

I think one of the first things that I would draw people's attention to is a Web site that was launched last year. It is called Children, Terrorism and Disasters. It is available online through the academy's Web site. It is We really designed this as a one-stop shop. We know you can be inundated with information. We wanted to make sure that we had all of the information that we have generated and other organizations have generated available at one stop. We also wanted to make sure that all of the federal agencies that were working in this field were represented, so we have an extensive array of links to federal resources to try and pull everything together when it has to do with children.

One of the other resources that we developed is a children, terrorism and disasters tool kit. This is really a hard copy folder that compliments the Web site. I think one thing that didn't strike me when we started working in the area but I learned quickly, if an event occurs, people might not be able to get online. They may not be able to get Web-based information so it is important to be tackling this from a couple of fronts. Have a Web site available that people can go to ahead of time, download relevant materials, but also have some hardcopy paper at hand in case of an emergency and in case you can't reach the Internet.

The third resource that we have available is something that is currently under development. This is something that we have been working on with the generous support of AHRQ and it is called the Pediatric Terrorism Preparedness Resource. It is a very long name, but it basically boils down to a CD-ROM compendium that we are going to pull together all the best information that we have on children and terrorism and put it in one place so that providers, communities and others working in the field can access this. Some of the information that at this point that we are considering including in the resource are equipment lists. What exactly should you have on hand as a community to make sure that you can have the bare necessities to care for children? Educational material. We will have material that not only the audience can learn from but they can then go and almost train the trainers and provide some additional information about children. And also illustrations. It is often true in the medical field that a written description of something is not necessarily the best way to get information across and the inclusion of illustrations and other material will really give a good example to bring to life some of the challenges that we are facing with. The range of topics that will be included in this resource go from everything from systems management, how do you get all the people working in this field working together to mental health. How can families and children cope with terrorism and disasters?

We are in the planning stages now. We have got some outlines that we have been pulling together and we are hopeful, with some additional support, we will be able to distribute this in the next year to 16 months I think is probably a realistic target for us.

The final thing I want to touch on that I have alluded to throughout is the mental health needs. Children really are a different population in this situation. They not only are going to respond to the community around them, they are going to very much respond to their parents and their caregivers. So, you are really looking at a multi-layered mental health environment. As a result, we are trying to pull together some resources that will help providers respond to children and their families and their mental health needs. I think it was mentioned earlier, a child who presents at a pediatrician who is under stress and under emotional duress may not be able to articulate as much. He or she is going to go in and complain about a stomachache or headache or maybe have a rash. We need to be able to be sure that the providers are able to recognize some of the mental health issues that are presented and that they also have a place and know the resources to make referrals. It is something that is going to be available to folks in 2004. It is being supported by the Hasbro Foundation and we hope it will be out in the next six months.

I know with all of that said, that was a huge amount of information to try and digest quickly. The last slide that you will see as I am speaking here is how to get some more information and really how to be active in the community. I think first and foremost, I would encourage people to visit our Web site. All of the resources that we have produced and assembled are available and all of them are downloadable. Please feel free to take them, make copies, and distribute as you see fit.

The second thing I would encourage folks to do is tap into our national experts. We have this national task force on terrorism. We have national committees on issues as specific as drugs, infectious diseases and environmental health. All of our pediatricians, at the national level, are available with guidance. They are available for speaking. They are available to review material. Those are all experts that will help you address children's needs without having you search in the dark for the answers.

I think the last and I think perhaps the most practical for this audience is tapping into our local experts. The American Academy of Pediatrics has chapters in every State. In the big States we have more than one chapter. In each of those chapters, we have pediatricians who are willing to work on disaster planning and terrorism issues and more importantly, who are trained. They know issues like emergency medicine. They know toxicology. They know mental health. They can work with you in your local community to make sure that children's needs are addressed in all of the planning and all of the response efforts. I think the underlying message here is kids are different, but we do have the information to help you meet their needs and the Academy certainly stands ready with the support of other organizations like AHRQ and Hasbro and Robert Wood Johnson to get the material into your hands, in your community.

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