# Presentation: 482080

## Improving Efficiency in Mass Dispensing:

- How Exercising Can Strengthen Mass Dispensing Strategies

## Mass Antibiotic Dispensing Planning

- Results of Minnesota Regional
- Planning - 8 regions in state
- Evaluated regional demographics
- Identified sites – sharing sites throughout the regions
- Identified throughput goals at each site

**Notes:**
Minnesota has eight regions with 7-16 counties in each region.  They have been working together to choose sites and plan regionally.  Because of the immense resources required to man the mass dispensing sites, the regions are sharing sites, especially in rural areas.  They estimated the throughput of these clinics using staff modeling.

## Planning Concerns

- Workforce resources –  # nurses & pharmacists
- 1000/ hour throughputs
- Complex antibiotic screening
- Speed required to accomplish throughput
- Safety of screening

**Notes:**
As the planning continued, numerous planning concerns rose to the surface. The concerns focused on the very large clinics with large throughput and the staffing of those sites. Although Doxy and Cipro are common place antibiotics, drug screening is still complicated. Dispensing the drugs safely at a high rate of speed or throughput became the biggest challenge. Was this even possible and what could we do to make it feasible. 

## Mass Antibiotic Dispensing Planning in Minnesota

- Developed the forms and clinic design
- Exercised the forms and design
- Analyzed the accuracy of the forms and design
- Measured the efficiency of the forms and design
- Redesigned the forms and the design

**Notes:**
With all these concerns in mind, Minnesota developed clinic flow design and forms to increase the speed, efficiency and safety of those clinics.  This presentation is about the process of development, testing and revising of those designs and forms.

## Triage – Minnesota continues to develop the processes and forms for symptoms and exposure 

Drug Screening – The focus of this presentation

- Drug Screening – The focus of this presentation

- Developing the Processes

**Notes:**
A point of clarification.  Triage is defined by our planners as the identification of persons exposed or with symptoms.  Both have nothing to do with drug screening.  Triage is a separate process at the mass dispensing site or at an altogether separate queuing or triage site.  This presentation is about the processes involved in the drug screening.  What drugs can they take safely.

## Developing the Forms for Screening for Contraindications

- 	Doxycycline
- 	Ciprofloxacin
- 	Amoxicillin

**Notes:**
There are only three drugs we concern ourselves with.  Doxycycline is our main interest because, except for the USPS BDS cache,  it is what is in our caches.

## Clinical Decision Making in Antibiotic Mass Dispensing 

- Which SNS  antibiotics are safest for client and households?
- What interactions exist between medication the client is presently on and the SNS drugs available?
- What information does the client need to enhance the effectiveness and prevent adverse events?

## Decision Assisting Tools

- Health history/registration forms
- Medical protocols
- Drug dispensing algorithms

**Notes:**
To decrease  the need for staff to make decisions on the fly, Minnesota created the forms and protocol that would encompass the clinical decision making process.  The have been labeled “Decision Assisting Tools” (DATs).  The DATs we are discussing today will focus only on antibiotic drug screening.

## Slide 9

**Notes:**
The basic decision making flow of the drug screening begins with the client doing some type of self screening through the registration form and possibly visual cues and education.  The Forms Reviewer, then, reviews the form and makes a non-educated choice based on the decision assisting qualities of the Registration Form.  The Forms Reviewer sends them on to the appropriate screener/dispenser.  This person, in turn, uses the decision assisting qualities of the Medical Protocol and the accompanying Rationale to decide on prophylaxis and advice.

## Registration Forms/ Health Screening History

- Form asks persons to “self-screen” and provide limited, essential information
- Form asks only information that is necessary to give client doxycycline safely
- Forms “assist” staff persons decide where the client should go next
- Are Drug specific, not agent specific, can be used for anthrax, tularemia, and plague

**Notes:**
The Registration form is actually the health history form.  The questions asked are the only ones that are important to the safe and effective use of Doxycycline, which is the first drug of choice from our Minnesota state, federal and local caches.  The exception is the USPS BDS program which is a Cipro first drug choice. To make the clinic flow process efficient and fast, we must  emphasize to the public via public education that the information on the Registration Form is all we need to know to safely give them Doxycycline.  Since this is a drug specific form, it can be used for multiple agents.

## Registration Form: 5 Initial Drug Screening Questions

- Are  you currently taking any of the following drugs:
- Accutane
- Methotrexate
- Lithium
- Probenecid
- Coumadin
- Digoxin

**Notes:**
There are five main questions that initially need to be asked.  They deal exclusively with the drug of choice, doxycycline.  Ideally, the public would know these five questions before they got to the mass dispensing site, if public communication and education was in place.

## 5 Initial Drug Questions

- Are you taking medication for seizures, tuberculosis, or diabetes?
- Are you pregnant or breastfeeding?
- Are you currently taking, or allergic to any tetracycline antibiotics?
- Do you weigh less than 99 pounds?

## MDS Drug Screening Registration Form

**Notes:**
This was the initial form for an individual coming to a mass dispensing site and picking up only for themselves.  Section A deals with demographics that could be put into a registry. Section B is the five major question needed for the health history.  

## Multiple Regimen Policy

- Persons can pick up medication for up to 10 related or unrelated persons
- Persons must have correct information on  people they are picking up for
- Forms will be distributed in the community and persons will arrive with them filled out
- No proof of ID, citizenship or residency required

**Notes:**
In order to reduce the number of person coming to a clinic and to reduce the inevitable chaos, a multiple regimen policy has been adopted.  One unrelated person can pick up for 10 persons if they have the correct health history information.  A form has been developed to capture the health history of all persons on one form.  Of course, it would be especially helpful if the required information and even the forms were delivered to the public prior to coming to a mass dispensing site.

## Slide 15

**Notes:**
Initially, this sheet was the back side of the individual form that was seen in a previous slide.  Section D is the names of the ten persons and Section E is the health histories.  

## Drug Dispensing Algorithm

- Part of the Medical Protocol
- It is a decision assisting tool for the drug screeners
- Blueprint for moving persons through a mass dispensing site
- Based on an “express dispensing” concept
- Included in Medical Protocol with rationale stated

**Notes:**
The Drug Dispensing Algorithm is a pictoral of the Medical Protocol or standing orders. It is meant to be laminated and kept as a blueprint for the screeners/dispensers.  Along with it is a detailed rationale that explains the algorithm. 

## Slide 17

**Notes:**
The green symbols are the basic five questions on the Registration Form related to the drug Doxycycline.  Those questions will lead to the Cipro Dispenser or the Drug Advisor.  The Cipro dispenser will ask the questions that are applicable to Ciprofloxacin.   Depending on the answer to those questions, the person will either be dispensed Cipro or move to the Drug Advisor.  Theoretically, the decisions are built into this algorithm, so the dispenser does not need indepth knowledge of this subject, decreasing the need for pharmacists for RNS dispensing.  This is always dependent on the State laws. 

## Objectives of Exercise

- Test clinic design
- Analyze the function and accuracy of the forms and algorithms
- Analyze staff roles
- Do time and motion studies

**Notes:**
Minnesota created these designs and these forms and felt they were solid tools, but had no idea if they would work.  Testing of the design, forms  and roles were the goals of the exercise. 

## Exercise Format

- Exercised a clinic 1⁄4 the size of a 1000/hr throughput
- Drilled the Head of Household (HOH) form and the Individual form
- Training was done prior to the drill and *Just in Time Training* at drill
- Participants were county mass dispensing planners (half of state counties were represented)

## Exercise Scenarios

- Client participants were given assigned scenarios
- 70% of client participants got meds dispensed in express line
- 30% of client participants got meds dispensed in Level I or Level II line

**Notes:**
A major question that arose was the % people in the community that would naturally fall in the express line, the Cipro line and how many would require drug advising.  For the purposes of this exercise, we chose 70 % express, and 30% Level I & II.

## Forms & Design Analysis

- Screening Accuracy
- Dispensing Accuracy
- Overall Speed (Throughput)

## Forms & Design Analysis

**Screening Accuracy** – Did the form
- get to correct staff person (Express
- Dispenser, Level I Screener or
- Level II Screener)?
- 99.5 – 100% accuracy in HOH form

## Forms & Design Analysis

**Dispensing Accuracy** – How many
- persons/households were dispensed to
- correctly?
- 98 – 100 % accuracy for Express and Level I (Cipro)
- 72% accuracy for Level II

## Forms Analysis

**Overall Speed** – Dispensing outcomes
- Throughputs
- Individual projected to large clinic 850 hour/hour
- HOH projected to large clinic 1550/hour

## Slide 25

**Notes:**
This bar chart depicts what one dispenser did in the exercise.  The results were projected to an hourly rate.

## Slide 26

**Notes:**
This bar chart projected the rates comparing the two different types of forms.  Even with a clinic flow and staffing ratios that we found not adequate, the Head of Household forms hold promise to have a large throughput.

## From Exercise to Revision

- Clinic design
- Form design
- Staffing roles and staffing ratios

**Notes:**
Many things were learned at the exercise.

## Clinic Design 

- Separate line for Cipro – allergic, pregnant, breastfeeding
- Separate line for Head of Household

**Notes:**
There are only a few types of persons that should go to the Cipro Line, the allergic to Tetracyclines, pregnant and breastfeeding.  These people can easily self screen and go straight to a line specific to Cipro.  Possibly a family line for those with multiple persons could go to a separate line.

## Slide 29

## Form Design

- Head of Household form became a
-    one page form
- Design was made more “readable”, more intuitive
- Fewer persons put on each form (person may have to fill out two at mass dispensing site)

**Notes:**
The Head of Household form was redesigned.   People felt that reading the health history on top was too difficult.  The position of the names and the health history was reversed.  For space reasons and guessing that most households would be six or less, the number on each form was decreased to six.

## Slide 31

## Staffing Roles and Ratios

- More Level I Screeners
- Many more Level II Screeners
- Pairing up Express & Level II Screeners
- Pharmacists available should serve as consultants for Level I and especially Level II Screeners
- Support staff to do the administrative work for Level I &  Level II Screeners

**Notes:**
The roles and speed of the three types of dispensers needed the most revision, particularly in terms of ratios of staffing.  The express dispensing was very fast and without bottlenecks.  The Level I screener was slower but still efficient.  Level II Screening was a huge bottleneck.  Many more Level II Screeners would be necessary.  Since it would probably not be possible to find enough pharmacists, the role of available pharmacist should be as Leads or consultants to all the dispensers.  Pairing up Level II Screeners and Express Screeners. If a person picked up for six people and 5 could get Doxy but one needed advice, the express person could take care of all the dispensing while the other advises.

## Slide 33

**Notes:**
So, we continue to work towards our goal in all this intensive work, to get huge numbers of people quickly and safely through the mass dispensing sites.

## Minnesota Department of Health

- Infectious Disease Epidemiology
- Prevention and Control
- Immunization, Tuberculosis, & International Health
- LuAnne McNichols RN MN
- _[Luanne.mcnichols@health.state.mn.us](mailto:Luanne.mcnichols@health.state.mn.us)_
- Judy Farlow RN PHN
- Judy.farlow@health.state.mn.us