Public Health Liaison Pilot Project

State: MO Type: Model Practice Year: 2007

The Public Health Liaison Pilot Project targets 14 Metropolitan Hospitals regarding the issue of public health preparedness. The program had four main goals at the program’s inception: Reduce the burden of work imposed upon regional hospitals by public health.  Establish a highly visible and accessible public health presence in regional hospitals. Enhance syndromic and active surveillance. Reduce reporting times for reportable conditions.   Decreasing the workload associated with disease reporting is a major objective for liaisons. It is the main incentive offered to the hospitals for accepting a public health liaison into their facility. Liaison duties include fielding phone calls and requests for information from public health agencies performing case investigations; completing required case reports, and pulling charts to determine treatment information. The liaisons become a resource for the hospitals and concurrently work on the other three goals. The liaisons establish themselves and become a very visible public health presence by visiting ED’s, hospital laboratories and infection control departments on a daily basis. Most of them have a workspace designated for their use, and spend about half of every business day at the hospital. This allows them to keep up with the reportable conditions coming through the facility and act as a resource for all public health concerns. The daily visits also allow the liaisons to conduct syndromic surveillance on ED’s chief complaints and active surveillance when there is a condition of interest. The liaisons’ integration and access to electronic medical records (for patients with reportable conditions) allows rapid case identification, investigation and reduces overall reporting times. The St. Louis County Public Health Liaison Pilot has improved the effectiveness of communicable disease reporting in the region by building strong working relationships with key hospital departments including infection control, emergency department, emergency preparedness and laboratory. The communication between the participating regional hospitals and their respective health departments has improved dramatically. Public Health Liaisons have improved the timeliness and quality of reporting, enhanced emergency preparedness and lessened the paperwork burden of all facilities. They have also become a valuable resource to surrounding health jurisdictions who often have difficulty extracting case information from our metropolitan hospitals.
The issue that the PHLP addresses is public health preparedness, including preparedness for emergency events and also typical reportable conditions. Public health emergencies have been shown to stress traditional methods of communication between hospitals and public health (SARS, anthrax attacks 2001). Traditional means of information collection (telephone and fax) are probably the worst form of communication in a public health crisis. Liaisons integrated into a hospital become the human interface between their hospital and public health. They are a visible and trusted presence that promotes real time problem solving. They are public health’s eyes at the scene, and they communicate knowledgably with public health. The threat to public health from bioterorism and emerging diseases such as pandemic influenza emphasize the need for heightened preparedness. Communication problems are often cited as issues in post-emergency event discussions (9/11, Katrina). Liaisons are familiar with redundant communication, and are very familiar with their hospitals’ incident command. They take part in monthly emergency preparedness meetings, assist with communication during actual events, and assist a regional response group with capacity assessments. The liaisons utility was apparent during a recent emergency event. Bio-Watch air monitoring in October of 2006 identified tularemia at an air monitoring station. The liaisons were provided a case definition of Tularemia, dispatched to their respective hospitals to discuss the event with Emergency Department (ED) staff, and began active surveillance. Within hours, all the liaisons’ emergency departments were briefed on tularemia, its signs, symptoms and pathogenicity. Active surveillance included liaison review of over 400 ED patient charts that week. Patients meeting the case definition were monitored for positive blood cultures. Liaisons visited microbiology labs daily while blood cultures incubated. The ability to perform chart review so quickly and thoroughly is beyond what St. Louis County could have done without the liaisons. The St. Louis County Public Health Liaison concept is unique because it is the only practice that is based on voluntary in-house, face-to-face daily collaboration between public health and regional hospitals. The liaisons actually go through hospital employee orientation, wear hospital badges, have electronic access to medical records and participate in infection control and emergency preparedness meetings. The daily interaction and collaboration leads to very close professional relationships between liaisons and their associated hospital staff. These relationships are what make the liaison the “face of public health” and the benefits that follow are all due to those strong relationships.
Agency Community RolesThe St. Louis County Department of Health developed the liaison pilot program from the ground up. The Communicable Disease Control Division has taken full responsibility from drafting the request for funding to integrating liaisons within regional hospitals. The partnership with regional hospitals has led to additional collaboration with other divisions, other health departments and has even led to the formation of a neighboring county’s own hospital liaison program. The liaisons are in an excellent position to receive first hand knowledge of reportable conditions. Their access to laboratory and emergency department staff allows them to investigate reportable conditions and relay the information to the appropriate parties immediately. For example, a laboratory report of West Nile Virus prompts the liaison to interview an in-patient or call an outpatient. They collect all the required reporting information and obtain permission to have the vector-control division set traps and spray the patient’s property. Another example is the under-reported condition of animal bites. The liaisons pull these each morning while performing syndromic surveillance of previous day’s chief complaints. These are reported to Animal Control which will make the judgment on quarantine or collecting the animal in question. The liaisons also work very closely with the communicable disease investigators. The investigators no longer call the hospitals’ medical records department or laboratories to gather information about pending cases. Liaisons are now perfoming these tasks, saving time for both hospital and public health personnel. They have also become a useful resource for public health agencies outside of St. Louis County. On an annual basis, the liaisons will perform approximately 1300 chart pulls on behalf of out of jurisdiction health departments.  Costs and ExpendituresThe program was funded through a HRSA Grant through Missouri Department of Health and Senior Services and costs totaled $350,000. ImplementationEstablishing the positions and recruiting staff took several months, but the biggest challenge was convincing hospitals to accept a public health employee at their facilities on a daily basis. An effective liaison needs a workspace, telephone, and access to the hospital’s intranet and electronic medical records. This is a huge request of any hospital where space is at a premium and confidentiality is always a concern. Most of the hospitals in the Saint Louis region are operated by one of two corporate systems. St. Louis County Health Department approached these systems at a corporate level and met with infectious disease physicians and infection control managers. With the support of the Infection Control, program staff were able to demonstrate the utility of the pilot to corporate administrators. This made implementation at each hospital in their systems much easier. Each hospital’s infection control department then coordinated a meeting including hospital administration and staff from emergency department, information technology, emergency preparedness, laboratory and medical records. At these meetings, program staff explained the benefits of the program and discussed the benefits to public health in general. The independent hospitals took longer to bring onboard because program staff had to approach each one individually, meet with the infection control coordinators from these facilities, and propose the pilot. They typically had heard about the project from their colleagues or from the program's presentations at Infection Control Conferences, and they were receptive to the program. They arranged for a meeting with their hospital’s administrators, and if they were receptive, a multi-department meeting was arranged and logistics were resolved. Only one of fourteen hospitals we approached declined to participate. The first hospital to accept the pilot was staffed by a county communicable disease nurse investigator who was a former infection control nurse for that hospital. This facilitated training for the new liaisons. Training of the new liaisons was conducted at the same time the program was arranging for their placement in the hospitals. Training covered three issues; communicable disease investigation, departmental procedural training, and liaison shadowing at the first hospital. The entire communicable disease manual and each communicable disease it covers was reviewed and discussed. Liaisons researched past cases and included case histories in the discussion. The departmental training included mentoring by seasoned communicable disease nurses and emergency preparedness training. The mentoring consisted of sitting in on case investigations, performing case investigations with the nurses present and then eventually working their own cases. Emergency preparedness training included web-based FEMA courses and training by St Louis County’s emergency preparedness planners and epidemiology specialists.
Objective 1: Establish a highly visible and accessible public health presence in regional hospitals.  Performance Measures: St. Louis County expected most hospitals to collaborate with us on this pilot. The number of hospitals participating vs the number approached is the performance measure. Feedback: St. Louis County received the data and disseminated it back to the hospitals, Infection Control Departments and ERs as ongoing feedback and communication. It also shared information with the St. Louis City and St. Charles County Departments of Health. All of the feedback was positive and no modifications were made. Outcome: 93% (13 of 14) hospitals approached to participate, admitted the liaison program into their facilities. St. Louis County Liaisons became out- of-jurisdiction resources for other Departments of Health. Objective 2: Enhance syndromic and active surveillance. Performance Measures: Syndromic surveillance is measured by collection of syndromic data on a daily basis from ED complaint review. Each ED visit is grouped into particular syndromes. Active surveillance is performed for cases of interest such as influenza or in response to emergencies (tularemia 2006, hypothermia 2006, etc).  Feedback: St. Louis County received the data and disseminated it back to the hospitals, ICNs and ERs as ongoing feedback and communication. It also released press alerts to the news media and provided similar information to the State of Missouri’s Department of Health and Senior Services. One lesson learned was that the liaisons effectiveness at active surveillance was better than expected. As a result, St . Louis County will deploy liaisons to conduct active surveillance in future events. Outcome: Syndromic surveillance was greatly improved by virtue of the liaisons having direct access to regional hospital’s daily ED chief complaint list. Liaison enhanced active surveillance proved to be better than classic active surveillance during a recent ice storm and power outage(see figure 1). Objective 3: Reduce reporting times for reportable conditions. Performance Measure: The liaisons assistance with case identification and investigation gave us the expectation that reporting times would be reduced for many reportable conditions. Feedback: St. Louis County received the data and disseminated it to the hospitals, ICNs and ERs as ongoing feedback and communication. It also released reports to the State of Missouri’s Department of Health and Senior Services. All of the feedback was positive and no modifications were made. Outcome: STD reporting times decreased by 8 days. Enteric reporting times decreased from 1.6 days to 1.3 days. Hepatitis B decreased from 5.4 days to 4.3 days (see figures 2 &3).
SustainabilityThe hospitals are the key stakeholders and have been very supportive of the PHLP. It provides them with their own specific public health advocate and conduit to the Saint Louis County Department of Health. This can be demonstrated by the positive feedback the program received during liaison project steering committee meetings, letters of support for continuation of funding, and positive articles about the program in their hospital periodicals. Keeping the program's promise to reduce their disease reporting burden while improving public health readiness has ensured the commitment by the hospitals to the program. Infection control departments are typically under-staffed. Assisting them as a means of becoming integrated into hospital operations, is a win/win situation. The program has received its second round of funding for the period of December 2006 through November 2007. Plans to sustain the practice over time include keeping current commitments and increasing involvement in hospital emergency preparedness. The funding of the pilot comes from emergency preparedness sources, so now that integration is complete and routines are established, the liaisons will spend more time working with hospital emergency planners. They will attend local and state emergency preparedness training in order to become more knowledgeable resources. They will also participate in their hospitals’ emergency preparedness drills and exercises. Lessons LearnedOne lesson learned was that the liaisons effectiveness at active surveillance was better than expected. As a result, St . Louis County will deploy liaisons to conduct active surveillance in future events.