Assessment of New York City Urgent Care Centers' Emergency Preparedness and Infection Prevention and Control Practices, 2016-2017.

BACKGROUND: Urgent care centers (UCCs) have become frontline healthcare facilities for individuals with acute infectious diseases. Additionally, UCCs could potentially support the healthcare system response during a public health emergency. Investigators sought to assess NYC UCCs' implementation of nationally-recommended IPC and EP practices. METHODS: Investigators identified 199 eligible UCCs based on criteria defined by the Urgent Care Association of America. Multiple facilities under the same ownership were considered a network. As part of a cross-sectional analysis, an electronic survey was sent to UCC representatives assessing their respective facilities' IPC and EP practices. Representatives of urgent care networks responded on behalf of all UCCs within the network if all sites within the network used the same policies and procedures. RESULTS: Of the respondents, 18 representing 144 UCCs completed the survey. Of these, 8 of them (44.4% of the respondents) represented more than 1 facility that utilized standardized practices (range = 2-60 facilities). Overall, 81.3% have written IPC policies, 75.0% have EP policies, 80.6% require staff to train on IPC, and 75.7% train staff on EP. CONCLUSION: Most UCCs reported implementation of IPC and EP practices; however, the comprehensiveness of these activities varied across UCCs. Public health can better prepare the healthcare system by engaging UCCs in planning and executing of IPC and EP-related initiatives.

Effectiveness of Interventions to Increase Colorectal Cancer Screening Among American Indians and Alaska Natives.

INTRODUCTION: Screening rates for colorectal cancer are low in many American Indian and Alaska Native (AI/AN) communities. Direct mailing of a fecal immunochemical test (FIT) kit can address patient and structural barriers to screening. Our objective was to determine if such an evidence-based intervention could increase colorectal cancer screening among AI/AN populations. METHODS: We recruited study participants from 3 tribally operated health care facilities and randomly assigned them to 1 of 3 study groups: 1) usual care, 2) mailing of FIT kits, and 3) mailing of FIT kits plus follow-up outreach by telephone and/or home visit from an American Indian Community Health Representative (CHR). RESULTS: Among participants who received usual care, 6.4% returned completed FIT kits. Among participants who were mailed FIT kits without outreach, 16.9% returned the kits - a significant increase over usual care (P < .01). Among participants who received mailed FIT kits plus CHR outreach, 18.8% returned kits, which was also a significant increase over usual care (P < .01) but not a significant increase compared with the mailed FIT kit-only group (P = .44). Of 165 participants who returned FIT kits during the study, 39 (23.6%) had a positive result and were referred for colonoscopy of which 23 (59.0%) completed the colonoscopy. Twelve participants who completed a colonoscopy had polyps, and 1 was diagnosed with colorectal cancer. CONCLUSION: Direct mailing of FIT kits to eligible community members may be a useful, population-based strategy to increase colorectal cancer screening among AI/AN people.

Centers for Disease Control and Prevention's Temporary Epidemiology Field Assignee program: Supporting state and local preparedness in the wake of Ebola.

OBJECTIVES: The Centers for Disease Control and Prevention launched the Temporary Epidemiology Field Assignee (TEFA) Program to help state and local jurisdictions respond to the risk of Ebola virus importation during the 2014-2016 Ebola Outbreak in West Africa. We describe steps taken to launch the 2-year program, its outcomes and lessons learned. METHODS: State and local health departments submitted proposals for a TEFA to strengthen local capacity in four key public health preparedness areas: 1) epidemiology and surveillance, 2) health systems preparedness, 3) health communications, and 4) incident management. TEFAs and jurisdictions were selected through a competitive process. Descriptions of TEFA activities in their quarterly reports were reviewed to select illustrative examples for each preparedness area. RESULTS: Eleven TEFAs began in the fall of 2015, assigned to 7 states, 2 cities, 1 county and the District of Columbia. TEFAs strengthened epidemiologic capacity, investigating routine and major outbreaks in addition to implementing event-based and syndromic surveillance systems. They supported improvements in health communications, strengthened healthcare coalitions, and enhanced collaboration between local epidemiology and emergency preparedness units. Several TEFAs deployed to United States territories for the 2016 Zika Outbreak response. CONCLUSION: TEFAs made important contributions to their jurisdictions' preparedness. We believe the TEFA model can be a significant component of a national strategy for surging state and local capacity in future high-consequence events.

Emergency Preparedness Training for Hospital Nursing Staff, New York City, 2012-2016.

PURPOSE: Many nurses are trained inadequately in emergency preparedness (EP), preventing them from effectively executing response roles during disasters, such as chemical, biological, radiological, nuclear, and explosive (CBRNE) events. Nurses also indicate lacking confidence in their abilities to perform EP activities. The purpose of this article is to describe the phased development of, and delivery strategies for, a CBRNE curriculum to enhance EP among nursing professionals. The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) and the National Center for Disaster Preparedness at Columbia University's Earth Institute led the initiative. METHODS: Curriculum development included four phases. In Phases I and II, nursing staff at 20 participating NYC hospitals conducted 7,177 surveys and participated in 20 focus groups to identify training gaps in EP. In Phase III, investigators developed and later refined the CBRNE curriculum based on gaps identified. In Phase IV, 22 nurse educators (representing 7 of the original 20 participating hospitals) completed train-the-trainer sessions. Of these nurse educators, three were evaluated on their ability to train other nurses using the curriculum, which investigators finalized. FINDINGS: The CBRNE curriculum included six modules, a just-in-time training, and an online annual refresher course that addressed EP gaps identified in surveys and focus groups. Among the 11 nurses who were trained by three nurse educators during a pilot training, participant knowledge of CBRNE events and response roles increased from an average of 54% (range 45%-75%) on the pre-test to 89% (range 80%-90%) on the posttest. CONCLUSIONS: By participating in nursing CBRNE training, nurses increased their knowledge of and preparedness to respond to disasters. The train-the-trainer curriculum is easily adaptable to meet the needs of other healthcare settings. CLINICAL RELEVANCE: The CBRNE curriculum can be used to train nurses to better prepare for and more effectively respond to disasters.

Active Monitoring of Travelers for Ebola Virus Disease-New York City, October 25, 2014-December 29, 2015.

The CDC recommended active monitoring of travelers potentially exposed to Ebola virus during the 2014 West African Ebola virus disease outbreak, which involved daily contact between travelers and health authorities to ascertain the presence of fever or symptoms for 21 days after the travelers' last potential Ebola virus exposure. From October 25, 2014, to December 29, 2015, the New York City Department of Health and Mental Hygiene (DOHMH) monitored 5,359 persons for Ebola virus disease, corresponding to 5,793 active monitoring events. Most active monitoring events were in travelers classified as low (but not zero) risk (n = 5,778; 99%). There were no gaps in contact with DOHMH of ≥2 days during 95% of active monitoring events. Instances of not making any contact with travelers decreased after CDC began distributing mobile telephones at the airport. Ebola virus disease-like symptoms or a temperature ≥100.0°F were reported in 122 (2%) active monitoring events. In the final month of active monitoring, an optional health insurance enrollment referral was offered for interested travelers, through which 8 travelers are known to have received coverage. Because it is possible that active monitoring will be used again for an infectious threat, the experience we describe might help to inform future such efforts.

Rapid Patient Discharge Contribution to Bed Surge Capacity During a Mass Casualty Incident: Findings From an Exercise With New York City Hospitals.

BACKGROUND: Mass casualty incidents may increase patient volume suddenly and dramatically, requiring hospitals to expeditiously manage bed inventories to release acute care beds for disaster victims. Electronic patient tracking systems combined with unit walk-throughs can identify patients for rapid discharge. The New York City (NYC) Department of Health and Mental Hygiene's 2013 Rapid Patient Discharge Assessment (RPDA) aimed to determine the maximum number of beds NYC hospitals could make available through rapid patient discharge and to characterize discharge barriers. METHODS: Unit representatives identified discharge candidates within normal operations in round 1 and additional discharge candidates during a disaster scenario in round 2. Descriptive statistics were performed. RESULTS: Fifty-five NYC hospitals participated in the RPDA exercise; 45 provided discharge candidate counts in both rounds. Representatives identified 4225 patients through the RPDA: among these, 1138 (26.9%) were already confirmed for discharge; 1854 (43.9%) were round 1 discharge candidates; and 1233 (29.2%) were round 2 discharge candidates. These 4225 patients represented 21.4% of total bed capacity. Frequently reported barriers included missing prescriptions for aftercare or discharge orders. CONCLUSION: The NYC hospitals could implement rapid patient discharge to clear one-fifth of occupied inpatient beds for disaster victims, given they address barriers affecting patients' safe and efficient discharge.

Human Papillomavirus Vaccine Uptake: Increase for American Indian Adolescents, 2013-2015.

INTRODUCTION: Although Indian Health Service, tribally-operated, and urban Indian (I/T/U) healthcare facilities have higher human papillomavirus (HPV) vaccine series initiation and completion rates among adolescent patients aged 13-17 years than the general U.S. population, challenges remain. I/T/U facilities have lower coverage for HPV vaccine first dose compared with coverage for other adolescent vaccines, and HPV vaccine series completion rates are lower than initiation rates. Researchers aimed to assist I/T/U facilities in identifying interventions to increase HPV vaccination series initiation and completion rates. STUDY DESIGN: Best practice and intervention I/T/U healthcare facilities were identified based on baseline adolescent HPV vaccine coverage data. Healthcare professionals were interviewed about barriers and facilitators to HPV vaccination. Researchers used responses and evidence-based practices to identify and assist facilities in implementing interventions to increase adolescent HPV vaccine series initiation and completion. Coverage and interview data were collected from June 2013 to June 2015; data were analyzed in 2015. SETTING/PARTICIPANTS: I/T/U healthcare facilities located within five Indian Health Service regions. INTERVENTION: Interventions included analyzing and providing feedback on facility vaccine coverage data, educating providers about HPV vaccine, expanding access to HPV vaccine, and establishing or expanding reminder recall and education efforts. MAIN OUTCOME MEASURES: Impact of evidence-based strategies and best practices to support HPV vaccination. RESULTS: Mean baseline first dose coverage with HPV vaccine at best practice facilities was 78% compared with 46% at intervention facilities. Mean third dose coverage was 48% at best practice facilities versus 19% at intervention facilities. Intervention facilities implemented multiple low-cost, evidence-based strategies and best practices to increase vaccine coverage. At baseline, most facilities used electronic provider reminders, had standing orders in place for administering HPV vaccine, and administered tetanus, diphtheria, and acellular pertussis and HPV vaccines during the same visit. At intervention sites, mean coverage for HPV initiation and completion increased by 24% and 22%, respectively. CONCLUSIONS: A tailored multifaceted approach addressing vaccine delivery processes and patient and provider education may increase HPV vaccine coverage.

Causes and Disparities in Death Rates Among Urban American Indian and Alaska Native Populations, 1999-2009.

OBJECTIVES: To characterize the leading causes of death for the urban American Indian/Alaska Native (AI/AN) population and compare with urban White and rural AI/AN populations. METHODS: We linked Indian Health Service patient registration records with the National Death Index to reduce racial misclassification in death certificate data. We calculated age-adjusted urban AI/AN death rates for the period 1999-2009 and compared those with corresponding urban White and rural AI/AN death rates. RESULTS: The top-5 leading causes of death among urban AI/AN persons were heart disease, cancer, unintentional injury, diabetes, and chronic liver disease and cirrhosis. Compared with urban White persons, urban AI/AN persons experienced significantly higher death rates for all top-5 leading causes. The largest disparities were for diabetes and chronic liver disease and cirrhosis. In general, urban and rural AI/AN persons had the same leading causes of death, although urban AI/AN persons had lower death rates for most conditions. CONCLUSIONS: Urban AI/AN persons experience significant disparities in death rates compared with their White counterparts. Public health and clinical interventions should target urban AI/AN persons to address behaviors and conditions contributing to health disparities.

Using a call center to coordinate Zika virus testing-New York City, 2016.

BACKGROUND: After local testing criteria for Zika virus expanded to include asymptomatic pregnant women who traveled to areas with active Zika virus transmission while pregnant, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) experienced a surge in test requests and subsequent testing delays due to factors such as incorrectly completed laboratory requisition forms. The authors describe how DOHMH addressed these issues by establishing the Zika Testing Call Center (ZTCC). METHODS: Using a case study approach, the authors illustrate how DOHMH leveraged protocols, equipment, and other resources used previously during DOHMH&s Ebola emergency response to meet NYC's urgent Zika virus testing needs. To request Zika virus testing, providers call the ZTCC; if patients meet testing criteria, the ZTCC collects data necessary to complete requisition forms and sends the forms back to providers. The ZTCC also provides guidance on specimens needed for Zika virus testing. Providers submit completed requisition forms and appropriate specimens to DOHMH for testing. RESULTS: During March 21 through July 21, 2016, testing for 3,866 patients was coordinated through the ZTCC. CONCLUSION: The ZTCC exemplifies how a health department, using previous emergency response experiences, can quickly address local testing needs for an emerging infectious disease.