Taking the Whoop out of a Pertussis Outbreak: Improving a Community's Pertussis Mitigation Efforts

Once the team of experts was gathered, a series of meetings was set up over the next few months. The team met on average once per month. During the first meeting, the team used a sticky wall to create the process flow mapping. Each person provided input about what happened within each of their work sites when an outbreak was occurring. During this creation time, gaps between the current process and best practices appeared. This process also provided the team with a better understanding of the process from multiple viewpoints. Several disciplines were on the team and represented in the process. These disciplines included local and state public health, medical systems, schools, and local child care. Having this multidisciplinary team create the flow engaged the QI team, showed the importance of the process, and allowed for a clearer understanding. This step allowed the group to begin identifying problems. At the second meeting, several problems that were identified from the first meeting were discussed, and the fishbone diagram was developed. At the head of the diagram was “spread of pertussis in the community; lack of control.” Several causes for the specific problem were discussed. Nonstandard categories emerged as the discussion ensued. For each cause identified, the team asked why it happened. This approach helped the team determine the true drivers of the problem. Once the fishbone diagram was complete, some causes appeared in more than one category. Problems that became apparent from the two QI tools included no standard operating procedure with medical providers, lack of understanding of isolation measures, parents' and stakeholders' lack of knowledge about pertussis and the get-well centers for sick children, lack of resources (running out of pertussis tests), nonmedical associates not knowing when a pertussis outbreak was happening, and other issues. The third meeting allowed the team to begin working on solutions to the identified problems. The team used the QI documentation form for tracking potential improvements. Solutions and improvements included the following: • changing the health alert recipients and the content of the message; • revising the general letters that were sent to children who attended school with a confirmed pertussis case; • revising the close contact letters sent to parents of children who interacted closely with a confirmed pertussis patient; • creating algorithms for child care providers, school staff, and medical staff to use when pertussis is identified in the community; • creating specialized toolkits that contain the letters, health alerts, fact sheets, and algorithms described previously for each of the stakeholders involved (child care centers, schools, and medical facilities); • introducing public health officials to child care centers and developing a process for public health officials to meet and greet the parents during orientation; and • developing a protocol to access the schools' One Call automated system for use during disease outbreak. Because the team would be unable to test the potential solutions identified for this process, it used a process decision program chart (PDPC) in the third meeting to systematically identify what might go wrong in a plan under development. The implementation tasks, potential items that could go wrong, and the probability for each to go wrong were discussed. The team developed countermeasures to address each of the issues, so those could be avoided during the next pertussis outbreak. Karen Crimmings was the project coordinator for this QI initiative. She was also the team lead for the last pertussis outbreak. The process for pertussis control was chosen because of her insight into the breakdown in the system, the unnecessary disease spread, and the financial burden it placed on the community. Initially, Ms. Crimmings identified other key players in the community and at the state level to bring in on the QI initiative. Each player was carefully chosen because of his or her expertise level and role in their work environment. Ms. Crimmings made contact with each of the team members and persuaded them to buy in to the project because of their existing relationships. Building this multidisciplinary team effectively was at the core of determining the project’s future success. One of the more difficult tasks to complete during the process would be finding appropriate meeting times for all team members to participate. The team members were told up front about the amount of time the initiative would take and worked that time into their busy schedules. The QI initiative was implemented in a virtual world around a small conference room table at the Cerro Gordo County Department of Public Health. The outbreak diminished during the time of this initiative; therefore, the team could not actually test it in real time. The six QI team members were exposed to the initiative first because it was a simulated exercise. Many others were brought in to test the developed tools' viability. Those individuals included all school nurses, all medical providers, and all licensed child care staff within Cerro Gordo County.

Outbreak investigation data are captured via an internal tracking system available to all of the registered nurses in the disease prevention and investigation service section within Cerro Gordo County Department of Public Health. Data include the following parameters: name, sex, age, and address of case; date of disease report; date of cough onset; case and close contacts; prescribed antibiotics; number of patients who refused medication; whether the case was epidemiologically linked or laboratory-confirmed; number of coughing fits; number of patients who vomited; and the workplace, child care center, or school attended. In theory, had the outbreak continued through the duration of this project, the mean number of days between the date of disease report and date of cough onset would have been compared with the original calculation of 16.4 days. The goal was to reduce that difference to 7 days, a reduction of 57%. The outbreak waned before testing the improvements in the process, but revised existing documents and new tools were shared. Per protocol, the Cerro Gordo County Department of Public Health sent a health alert to specific medical providers during an outbreak of pertussis; this health alert was revised and tested. The health alert originally was sent via e-mail to certain identified individuals within the medical system. During this process, it was determined that others needed to be included on the health alert, such as additional medical personnel and school and child care personnel. The health alert was revised to include a call to action and to stress the importance of stopping the spread of pertussis. Feedback from that revised alert was gathered, and the final health alert is now in place. Also revised were letters to patients or cases, schools, and child care centers. The team reviewed these letters, gathered feedback from them, revised them, and will use them in the future. The team developed algorithms for medical personnel and for school and child care staff to aid in the identification and subsequent treatment of children identified as possible pertussis cases. Each of these items was sent to stakeholders with a survey to determine whether it would be effective. The results of the QI initiative are in the Results section.