BACKGROUND: During 2014–2016, Idaho public health officials conducted several sustained, complex, evolving epidemiologic responses, to international emergence of Ebola and Zika viruses and to increasing reports of acute flaccid myelitis in the Pacific Northwest. In October 2014, the U.S. Centers for Disease Control and Prevention (CDC) announced that public health authorities would institute 21-day monitoring of recent travelers returning from countries with widespread Ebola virus transmission. The Idaho Division of Public Health (IDPH), in consultation with Idaho’s local Public Health Districts, developed and implemented monitoring plans. As the outbreak continued in West Africa, CDC updated recommendations, and novel situations not addressed by IDPH protocols arose. Because of personnel resource limitations, IDPH protocols were not updated, resulting in an insufficient number of staff who understood current processes. Inconsistent communication and redundant data storage locations potentially increased the risk for errors. Recognizing the risk, IDPH decided to use continuous quality improvement tools to ensure appropriate epidemiologic response.
METHODS: IDPH developed an initial flowchart from a review of the existing protocol and used it to identify missing tasks, determine critical components of the process, and delineate responsibility for processes. Redundant tasks and data storage areas were evaluated and unnecessary redundancies consolidated. The final, revised process was recorded in a new, responsibility-delineated flowchart. Seven relevant staff received in-person training on the simplified protocol. Process improvements were tested when new travelers arrived in Idaho.
RESULTS: The number of appropriately trained staff was increased from two to seven. Time to completion of notification processes was decreased from an estimated 90–120 minutes to 30 minutes. Errors, such as incomplete data, that had been detected across duplicative data storage areas were eliminated in the consolidated data storage area. Notification of key leadership personnel was corrected from inconsistent to consistently completed. Staff reported improved confidence in completing tasks after receiving training with the flowchart.
CONCLUSIONS: A quality improvement review was successful in standardizing epidemiologic response processes and aiding staff to complete complex response tasks. IDPH recommended using the process for future evolving epidemiologic responses, and implemented it for Idaho’s response to Zika virus and acute flaccid myelitis. Clear, concise, and up-to-date job aids (i.e., flowchart and protocol) and regularly revised protocols ensured continuity of operations, accuracy of data quality, and facilitated coordination among state and local public health agencies, including the state public health laboratory, and healthcare organizations.