Broward County is located in the southeastern portion of the State of Florida with Miami-Dade County to the south and Palm Beach County to the north. Broward County’s 2013 population estimate of 1,838,844, represents 9% of the State’s population, and is the second most populous county of the 67 counties in the State of Florida and eighteenth most populous county in the United States (US Census). Its diverse population includes residents representing more than 200 different countries and speaking more than 130 different languages. 31.4% of the residents are foreign-born. Broward County is a minority/majority county demonstrated by its 2013 population by race (Black 28.5%, Asian 3.6%, Hispanic 26.9%, other races 4.1%, more than one race .2%, for a total of 59.5% and White 40.8%).
The Florida Department of Health in Broward County (DOH-Broward) is the official Public Health Agency in Broward County and has been operational since 1936. It is part of the Integrated Florida Department of Health (DOH) and operates in cooperation with the Broward County Commission under Florida Statute 154. DOH-Broward’s mission is “to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts”. DOH-Broward is the lead agency providing core public health functions and essential services in the county as part of a complex public health system that includes hospitals, clinics, planning agencies, community-based organizations and others. DOH-Broward provides population/community-based services to the county’s 1.8 million residents and over 10 million annual visitors, and is responsible for assessing, maintaining and improving health and safety within the county. The public health issue is that the reported cases of congenital syphilis in Broward County rose from to 0 in 2010, to 10 in 2011, and 15 in 2012. Infectious syphilis in Broward County rose from 13.4 per 100,000 in 2011 to 16.2 per 100,000 in 2012, with the rates among men increasing from 25.1 per 100,000 in 2011 to 30.2 per 100,000 in 2012.Goals and objectives of proposed practice: The overarching goal of the DOH-Broward was to reduce the transmission of syphilis and congenital syphilis. The practice implementation/activities: The DOH-Broward activated an Incident Command (IC) Team to track and document progress for each of the goals/objectives identified in the Incident Action Plan. All of the objectives met.
Utilizing Incident Command to provide structure to a multi-disciplinary team was extremely effective in targeting, tracking and documenting progress in meeting all identified goals and objectives.The Public Health impact of practice was from 2012 to 2013, a 40% reduction in new congenital syphilis cases occurred.
The 2013 Sexually Transmitted Disease (STD) Real World Event documents the Florida Department of Health in Broward County’s (DOH-Broward) response to an increase in incidence of infectious and congenital syphilis cases in Broward County in calendar year 2012. Infectious Syphilis cases in Broward County are high compared to the State of Florida and National data. Congenital syphilis cases in Broward County rose from 0 in 2010 to 10 in 2011. There were 15 reported congenital syphilis cases in 2012 in Broward County. There were 9 reported cases in 2013, representing a 40% decrease from 2012 to 2013. Continued program coordination and integration of STD, TB, Hepatitis and HIV must be encouraged and nurtured. DOH-Broward has developed an integrated team to include STD, TB, Hepatitis, HIV and Epidemiology professionals to meet bi-weekly to continue coordinated and integration program discussions in calendar year 2014.
Retrospective and multi-variant analysis was utilized to define the affected population in Broward County. All eight labor and delivery hospitals, 125 OB/GYN physician practices and 96 pediatric practices were visited at least twice each to provide information and protocols for congenital syphilis. OB/GYN physician practices and delivering hospitals who had experienced congenital births were provided technical assistance and guidance. The multi-faceted social media campaign provided broad marketing to the 1.8 million residents of Broward County.
In the past, STD, HIV, TB and Hepatitis surveillance was conducted as individual stand-alone programs with minimal coordination of activities across programs. Internal agency program coordination and integration of STD, TB, Hepatitis, HIV and Epidemiology provides a team approach to reaching clients who may otherwise be lost to care and follow-up. Clients are now tracked across programs rather than being siloed into a single program. Bi-weekly integrated program meetings are held to discuss cases and coordination of services. The Incident Command System provided an effective structure to manage, track, document, and evaluate a non-emergency response. The integrated team formed for this response (included STD, TB, Hepatitis, HIV and Epidemiology professionals) continues to meet bi-weekly to coordinate and integrate program discussions in calendar year 2014.
DOH-Broward utilized the Incident Command System (ICS), a component of the National Incident Management System, to provide organizational structure, meeting formats (Incident Action Plans (IAP) and Situation Reports) and After Action Planning to manage a non-emergency response across multiple internal and external programs.
The practice was evidenced based as outlined in this paragraph. DOH-Broward utilized the Incident Command System and National Incident Management System to manage the response. The Program Collaboration Service Integration Model (PCSI), CDC guidelines and American Congress of Obstetricians and Gynecologists (ACOG) recommendations regarding the early detection, adequate treatment and timely reporting of communicable diseases, with a focus on the interruption of perinatal transmission guided the DOH-Broward response. The IAP goals and objectives were incorporated into the Broward County Community Health Improvement Plan (CHIP), which utilized Healthy People 2020 (HP 2020) and Mobilizing for Action through Planning and Partnerships (MAPP) in its development.
Mother-to-Child Transmission of HIV and Syphilis
DOH-Broward activated an incident command team to: conduct targeted epidemiological investigation and study, including retrospective analysis; implement continuous quality improvements to STD program activities; manage internal and external strike teams; recruit and train a competent STD program staff; develop and implement a social marketing campaign; conduct provider and community outreach and education; and, monitor the effectiveness of mitigation strategies and campaign activities.
Steps taken to implement the program: ICS meetings were held from May 30, 2013, through January 2, 2014. The initial Incident Action Plan (IAP) was prepared on May 30, 2013. A total of 22 IAPs were developed over the course of the event. A total of 46 Situation Reports were developed. The ICS structure assisted in tracking and documenting progress for each of the goals/objectives identified in the IAP. An electronic survey was distributed to gather feedback from the eleven incident command team members with a final After Action meeting held on March 13, 2014, which was utilized to develop the After Action report. This activation also allowed DOH-Broward to test its All-Hazards Response Plan and Communications and Epidemiology Annexes in a real world event scenario.
A descriptive analysis of the characteristics of mothers of live infants with congenital syphilis in Broward County, Florida from 2007 – 2012 was developed utilizing a data set of all sexually transmitted diseases reported from 2007 through 2012 in Broward County. For missing variables, the data set was supplemented with information extracted from the narrative section of reported cases in the Florida STD database and PRISM. Other databases such as Florida Shots, Vital Statistics, Man Driver and Vehicle Express (MDAVE), and Health Management System (HMS) were also searched. Attempts were also made to contact clients. The trimester of prenatal test frequency was calculated using the gestational calculator and the estimate date of delivery.
An analysis of syphilis trend data was also developed for the period 2007 – 2012. Maps were developed depicting location of congenital syphilis, infectious syphilis and HIV cases occurring in calendar year 2012 in Broward County. A GIS map overlay of calendar year 2012 chlamydia, gonorrhea and syphilis cases was also developed. The analysis and mapping assisted the Incident Command Team to understand the incidence and the geographic concentration of cases to develop targeted strategies for prevention and education activities.
DOH-Broward successfully developed and implemented two new social marketing campaigns “Protect Your Baby” and “Protect Yourself”. In addition to initial, stand-alone, activities, these campaigns were later combined with the “Broward is Greater than AIDS” campaign to promote awareness of STDs including HIV/AIDS. Campaign materials were culturally and linguistically appropriate. During fiscal year 2013/14, educational signage was placed on storefronts, bus bench ads were installed, the sides of Broward County transit buses were wrapped with the campaign and deployed, 200,000 palm cards were distributed throughout Broward County, 3 rotating billboards were installed on heavily travelled roads, displays on the sides of area trollies were installed, advertisements were placed in culturally and linguistically appropriate print and broadcast media and physician ambassadors recorded television advertisements. Staff, Physician and Legislative Ambassadors, and a local elected official also participated in live events including Caribbean radio talk shows and local festivals and outreach events.
Provider Outreach was successfully targeted to affected communities. The perinatal prevention staff position duties was enhanced, redefined and resourced which then positively impacted the campaign efforts including the outreach and education to every Obstetric and Pediatric provider and delivering hospitals in Broward County in an extremely short timeframe. A Syphilis 101 guide was developed and the development, training and implementation of standing orders for labor and delivery for client’s diagnosed with HIV and syphilis begun during the campaign will continue to assist in consistent application of standards in the community. The use of the existing physician contact database to email and fax information to physicians was beneficial to initiating communication to the target audience quickly and consistently. Increased presentation to providers and physicians including grand rounds, physician groups, meetings, conferences provides ongoing opportunities to present the public health mission and vision. The timeframe for the practice? May 30, 2013 – January 2, 2014DOH-Broward has strong collaborative relationships with public and private health care providers, faith-based organizations, local governmental agencies, civic associations, the Miccosukee and Seminole tribal nations, and serve on many committees, Boards and provider networks that work to address minority health and health disparities in Broward County including: the Urban League, Urban Coalition for HIV/AIDS Prevention Services, Coordinating Council of Broward, Broward Healthy Start Coalition, Health Care Access, Primary Care Group, and Medical Services Planning. The goals and objectives from the IAP were incorporated into the Broward County Health Improvement Plan (CHIP). Quarterly progress on CHIP implementation is presented to the Broward County Health Care Access Committee, one of the community planning groups that assisted in the development of the Community Health Assessment and subsequent CHIP. Multiple stakeholders assisted in implementing activities from the Action Plan. Local government officials championed messages to their constituents. Physician ambassadors worked within their communities to assist in creating awareness and reducing stigma. In addition, Broward County delivering hospitals, as well as OB/GYN and Pediatric physician practices were receptive to in-person discussions and educational sessions regarding testing and treatment protocols. Reductions in infectious and congenital syphilis could not have been achieved without these collaborative relationships.
The cost of the social marketing campaign totaled $189,000.00 which included educational signage that was placed on storefronts, bus bench ads, Broward County transit buses were wrapped with the campaign information and deployed, 200,000 palm cards were distributed, 3 rotating billboards, displays on the sides of area trollies, and broadcast media including physician ambassadors recorded television advertisements from May 30, 2013 – January 2, 2014.
The after action report developed includes discussion of how each of the objectives in the Incident Action Plan were met during the activation of the multi-disciplinary team. The major strengths identified during this activation are as follows:• Restructure of the STD program increased capacity and capability of the program;• DOH-Broward’s Epidemiology program has experienced, skilled, and competent staff that are able to quickly provide data that is detailed and easily understood;• The collaborations across programs (Epidemiology, HIV, STD, TB) required by action planning advanced the implementation of the DOH-Broward collaborative leadership structure;• Outreach and education provided during the campaign has strengthened the visibility of DOH-Broward in the community and continues to increase awareness of the public health mission and vision in the community;• Continous use of the Syphilis 101 guide and the development, training and implementation of standing orders for labor and delivery hospitals for HIV and syphilis begun during the campaign will continue to assist in consistent application of standards in the community; and,• Ability to rapidly develop and implement a multi-faceted, multi-media campaign that included linguistically and culturally appropriate messaging.
There were 15 reported congenital syphilis cases in 2012 in Broward County. There were 9 reported cases in 2013, representing a 40% decrease from 2012 to 2013. An electronic survey was distributed to the eleven incident command team members to gather feedback with a final After Action meeting held on March 13, 2014. This activation also allowed DOH-Broward to test its All-Hazards Response Plan and Communications and Epidemiology Annexes in a real world event scenario. An Improvement Plan was developed with recommendations for improvement incorporated into associated All-Hazards Response Plan Annexes. Position Descriptions have been revised to include outcome based goals and objectives.
DOH-Broward has a mature and robust quality management program. The Florida Department of Health Quality Plan and DOH-Broward alignment tool incorporate local, state and federal guidelines and ensure adherence to standards of care. DOH-Broward has an internal quality council to ensure the standards of care are met through quarterly programmatic auditing that include components of staff involvement through peer audits which contain teaching, mentoring, coaching, teamwork, and communication. DOH-Broward plans and activities also align with the National Association of County & City Health Officials (NACCHO) best practices and quality improvement tools as well as Health Resources and Services Administration (HRSA) standards and program guidance. DOH-Broward Leadership meets monthly to review programmatic and organizational performance.
DOH-Broward has developed a coordinated approach to addressing quality assessment and process improvement for DOH-Broward programs and services that integrate programmatic Quality Management with Agency Quality Management. The program has established as its mission excellence in patient care, provision of high-quality professional services, and client satisfaction.
ActiveStrategy software is the DOH-Broward internal performance management system that provides ongoing programmatic reporting of measures related to patient care, customer satisfaction, productivity, and manages the resources of the organization in an ongoing & systematic way for the best possible resource management.
Program data is collected through the statewide Florida Department of Health (DOH) Health Management Systems (HMS). The Community Health Director reviews the data entered into HMS to ensure it meets the established programmatic guidelines.
Program outcomes are collected and reported monthly and quarterly to the state office of DOH and the Health Care Access Committee.
Existing databases that DOH-Broward utilizes to collect data contain incomplete data making it difficult to conduct a complete analysis until additional data resources are secured to supplement missing data. Consistent follow-up is needed to ensure these long-term goals are met.
DOH-Broward learned that it is difficult to stress the importance of reporting active STD surveillance cases to DOH-Broward from external partners when an emergency has not been officially declared. Ongoing education of community providers will continue to stress the importance of conducting STD surveillance and reporting active cases to DOH-Broward. Existing relationships between Infection Control Practitioners and Epidemiology were extremely valuable in the successes of this campaign.
A cost/benefit analysis was not conducted.
Sustainability plans include : • As STD was integrated with the Prevention Planning Council, the Perinatal Prevention Task Force and other HIV and community planning groups which includes planning efforts led by DOH-Broward and others; there is confidence of sustainability of the project. • The DOH-Broward perinatal prevention staff position was enhanced, redefined and resourced which positively impacted the campaign efforts including the outreach and education of every Obstetric and Pediatric provider and delivering hospitals in Broward County in an extremely short timeframe. Increased presentations to providers and physicians including grand rounds, physician groups, meetings, conferences provides ongoing opportunities to present the public health mission and vision. This position will continue to be resourced. • Collaborations across programs (Epidemiology, HIV, STD, TB) required by the action plan advanced the Implementation of the DOH-Broward collaborative leadership structure and continues. This includes the integration of perinatal prevention with HIV/Hepatitis. • The Syphilis 101 guide and the development, training and implementation of standing orders for labor and delivery for HIV and syphilis begun during the campaign will continue to assist in consistent application of standards in the community.• The development and use of a physician contact database to email and fax information to physicians was beneficial to initiating communication to the target audience quickly and consistently and will continuously be updated.
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