Abstract

Background

International travel plays a significant role in the emergence and redistribution of major human diseases. The importance of travel medicine clinics for preventing morbidity and mortality has been increasingly appreciated, although few studies have thus far examined the management and staff training strategies that result in successful travel‐clinic operations. Here, we describe an example of travel‐clinic operation and management coordinated through the University of Utah School of Medicine, Division of Infectious Diseases. This program, which involves eight separate clinics distributed statewide, functions both to provide patient consult and care services, as well as medical provider training and continuing medical education (CME).

Methods

Initial training, the use of standardized forms and protocols, routine chart reviews and monthly continuing education meetings are the distinguishing attributes of this program. An Infectious Disease team consisting of one medical doctor (MD) and a physician assistant (PA) act as consultants to travel nurses who comprise the majority of clinic staff.

Results

Eight clinics distributed throughout the state of Utah serve approximately 6,000 travelers a year. Pre‐travel medical services are provided by 11 nurses, including 10 registered nurses (RNs) and 1 licensed practical nurse (LPN). This trained nursing staff receives continuing travel medical education and participate in the training of new providers. All nurses have completed a full training program and 7 of the 11 (64%) of clinic nursing staff serve more than 10 patients a week. Quality assurance measures show that approximately 0.5% of charts reviewed contain a vaccine or prescription error which require patient notification for correction.

Conclusion

Using an initial training program, standardized patient intake forms, vaccine and prescription protocols, preprinted prescriptions, and regular CME, highly trained nurses at travel clinics are able to provide standardized pre‐travel care to international travelers originating from Utah.

It is estimated that 880 million people crossed international borders in 2009 and that this number will rise by 3% to 4% in 2010. 1 Continual increases in international travel have amplified the prevalence of travel‐related morbidity and mortality and have led to the development of the field of travel medicine. 2 In the last two decades, travel medicine has emerged as a field with its own professional society; the International Society of Travel Medicine (ISTM), and a Certificate in Travel Health (CTH) Exam. 3

The Infectious Disease Society of America and the ISTM recommend that pre‐travel health and disease‐prevention advice comes from providers with specialized training in travel medicine. 4 The percent of travelers seeking such pre‐travel health advice is currently estimated at 31% to 86%. 5,6 The increase in people traveling coupled with guidelines advocating that professionals who offer pre‐travel counseling be specially trained in travel medicine has created an increased awareness in the value of a specialized travel clinic. Such a clinic can offer up‐to‐date pre‐travel counseling, vaccinations, prescriptions, and post‐travel evaluation.

The ideal qualifications for travel‐clinic providers include a solid knowledge base, adequate experience, and continuing medical education (CME). 7 This is supported by a study from Canada finding that increased education is the greatest desire of travel medicine practitioners and staff. 8 To date, only one previous study, out of the Netherlands, has tried to quantitate training at travel clinics. It indicated that while 93% of physicians were adequately trained, only 55% of nurses working in travel clinics were sufficiently qualified. 9

The University of Utah has long been a resource for international travelers, and in 2008 an estimated 228,000 airline passengers left Utah for an international destination. 10 In 1996, the University of Utah partnered with a local health department and created a community travel clinic to provide pre‐travel services. There are now eight affiliated travel clinics, representing four county health departments, throughout the state of Utah that provide pre‐travel care. These clinics, staffed principally by nurses, have been providing pre‐travel care and consultations to outbound travelers. Here, we describe a model for a travel‐clinic operation and management that depend upon the training, oversight, and education of core nursing staff to maintain professional services designed to reduce travel‐related sickness and infectious disease distribution.

Methods

The University of Utah has created a consulting affiliation with eight clinics managed by four county health departments throughout the state of Utah. Each clinic is an independently operating, approved yellow fever vaccination center run by nurses. Each clinic maintains an affiliation with the University of Utah and pays a fee to receive uniform patient intake forms, the University of Utah's The Healthy Traveler booklet and Travel Protocol Manual, chart review of each travel visit, on‐call consultation, and monthly continuing education. Information from the Centers for Disease Control and Prevention (CDC) Health Information for International Travel (The Yellow Book), Shoreland's Travax EnCompass, The Healthy Traveler booklet and cultural information are used for travel visits.

The Healthy Traveler booklet, written by the University of Utah travel medicine group, summarizes important information for the international traveler. The University of Utah's Travel Protocol Manual consists of 30 algorithms for travel‐related illnesses and vaccinations. Fifteen algorithms pertain to treatment or prevention of travel‐related illnesses ranging from altitude sickness to leptospirosis. Five are dedicated to malaria prophylaxis and self‐treatment, and incorporate patient age and weight, and chloroquine or mefloquine resistance areas. Allergies, deep venous thrombosis prevention, jetlag, motion sickness, vaginal candidiasis, and travelers' diarrhea also are covered. Fifteen additional protocols for vaccine administration are included in the manual. These protocols were developed by an infectious disease physician, certified in travel health, and are updated quarterly or as new travel medicine information becomes available.

Each nurse receives initial training and continuing education from the University of Utah. Initial training sessions are conducted by a physician assistant (PA); a medical professional trained, nationally certified, and licensed in the United States, to provide diagnostic, therapeutic, and preventive healthcare services, under the supervision of a physician. Nurse training involves one‐on‐one meetings in which The Yellow Book, the University of Utah's Travel Protocol Manual and The Healthy Traveler booklet are reviewed. Topics reviewed include vaccination and prescription protocols as well as common health concerns of the traveler, with an emphasis on malaria, yellow fever, and travelers' diarrhea. The University of Utah's training protocol requires that the trainee participate in pre‐travel consults with a trained travel‐medicine provider. The trainee must first observe pre‐travel consults, and then complete actual patient consults while being observed. The trainee works independently once they are felt to have acquired the basic principles of providing a travel visit.

Support is provided via phone or e‐mail consultation with either the physician or PA during working hours, and every chart is reviewed and signed. Review of charts is performed to ensure that the correct vaccinations have been recommended, that patient education has been accomplished, and that necessary patient background information has been obtained and documented. Feedback is shared with the nurse who provided the care.

Continuing education is provided on a one‐on‐one basis through the chart reviews, and through monthly meetings and international conferences. Since the clinics are dispersed over more than 300 miles, the monthly meetings are done both in person and through teleconferencing. The local nurses and the University of Utah staff meet on the University of Utah School of Medicine campus and connect electronically with the nurses located in more remote locations. Each clinic has equipment which allows two‐way audio‐visual communication among the clinics. Meeting agenda items can include current alerts and updates from the CDC's Morbidity and Mortality Weekly Report, the International Society for Infectious Diseases' ProMED Digest, vaccine updates, medication shortages, and availability, feedback on the Travel Protocol Manual and The Healthy Traveler booklet, review of The CDC's Yellow Book, the ISTM's Journal of Travel Medicine, and guest lectures from regional travel experts.

Within the framework of the ISTM's recommendations for a travel‐clinic provider, the University of Utah considers nurses fully trained when they have completed initial training, worked in a travel clinic for a minimum of 6 months, serve an average of 10 travelers per week and attend required monthly meetings. 7 All travel‐clinic providers are encouraged to pass the CTH Exam offered by the ISTM.

Results

There are a total of eight clinics included in this study. Clinic 1 is the University of Utah International Travel Clinic. Clinics 2 to 8 are county health clinics throughout the state of Utah. All the clinics offer pre‐travel counseling, while clinic 1 also provides post‐travel consults for returned travelers by the physician or PA. These clinics are run by a total of 11 nurses, 10 registered nurses (RNs), and 1 licensed practical nurse (LPN), and collectively served 5,452 travelers in 2008 (Table 1).

Table 1

Demographics

Clinic Population* Affiliation Initial consults 2008 Nurses Mid‐levels Physicians 
Clinic 1 Urban University Hospital 830 
Clinic 2 Urban County Health 2,750 
Clinic 3 Urban County Health 572 
Clinic 4 Urban County Health 607 
Clinic 5 Urban County Health 363 
Clinic 6 Large urban cluster County Health 170 
Clinic 7 Small urban cluster County Health 0 
Clinic 8 Small urban cluster County Health 160 
Total   5,452 11 
Clinic Population* Affiliation Initial consults 2008 Nurses Mid‐levels Physicians 
Clinic 1 Urban University Hospital 830 
Clinic 2 Urban County Health 2,750 
Clinic 3 Urban County Health 572 
Clinic 4 Urban County Health 607 
Clinic 5 Urban County Health 363 
Clinic 6 Large urban cluster County Health 170 
Clinic 7 Small urban cluster County Health 0 
Clinic 8 Small urban cluster County Health 160 
Total   5,452 11 

*Urban = Population ≥ 50,000; large urban cluster = population 10,000–49,999; small urban cluster = 2,500–9,999.

This clinic affiliation began in May 2009. It currently serves about one patient a month.

The nurses provide the pre‐travel consults which include intake and travel needs assessment based on geography and duration of travel as well as the age and health of the traveler. Pre‐travel counseling is given at all clinics with a core emphasis on immunizations, malaria, and travelers' diarrhea education. Routine vaccinations are updated, recommended travel vaccines are administered, and travel‐related prescriptions are given according to the University of Utah's Travel Protocol Manual. All the travelers are provided a copy of the Healthy Traveler booklet.

Initial training has been provided to all 11 nurses (100%). This occurred either when a nurse started at one of the travel clinics or when the travel clinic initiated its affiliation with the University of Utah. In the clinics where there is only one nurse employed, the nurse in training will observe, then work under the supervision of a trained nurse at a facility remote from her own. Ten of the 11 nurses (90.9%) have provided pre‐travel consultation for more than 6 months, and 7 of 11 nurses (63.6%) provide care for at least 10 travelers per week. Nine of the 11 nurses (81.8%) attend CME regularly. In accordance with the framework for travel‐medicine provider qualification, 7 of the 11 nurses are considered optimally trained (Table 2). Four of the 11 nurses (36%) and both consulting travel medicine specialists have taken the CTH Exam and all have passed (100%).

Table 2

Nurses trained

Category Competency Number Percent 
Fund of Knowledge* Initial training 11/11 100 
 More than 6 months work experience 10/11 90.9 
Experience More than 10 patients served per week 7/11 63.6 
Continuing education Continuing education 9/11 81.8 
Total Optimally trained 7/11 63.6 
Category Competency Number Percent 
Fund of Knowledge* Initial training 11/11 100 
 More than 6 months work experience 10/11 90.9 
Experience More than 10 patients served per week 7/11 63.6 
Continuing education Continuing education 9/11 81.8 
Total Optimally trained 7/11 63.6 

*9 of 11 nurses came with prior immunization experience. All had prior nursing experience.

Random patient chart review, performed over an 18‐month period, looked at nurse compliance. Documentation omissions were counted as missing patient information such as travel destination, duration of trip, drug allergies, medications, or medical history. Omissions also included the lack of information regarding a patient's malaria or yellow fever risk, the quantity of medication dispensed, country specific education discussed, provider signature, or date of service. Vaccine deviation was noted if a routine or travel vaccine was offered when it was not indicated, or was not offered when it was indicated in accordance with the vaccine protocols. Prescription protocol deviation was noted if a medication was dispensed which was an incorrect quantity, not first line therapy for the destination, or if it was contraindicated due to a patient's drug allergy or medical history. Results show that of 2,605 charts reviewed, 7.3% charts included a documentation omission, 6.4% involved a variation from the vaccine protocols of which more than 50% were omission of patient's history of vaccine or patient's refusal of a vaccine, and 0.6% included a deviation from the prescription protocols. Approximately 0.5% of charts involved a vaccine or prescription error which required patient notification for correction.

Discussion

High‐quality employee training is critical for the successful operation of an international travel clinic. Indeed, work by Newman and colleagues has shown that of the 123 US travelers who died of malaria between 1963 and 2001, 35% were given the wrong medicine for their destination of travel. 11 While there will always be the problem of proper compliance, proper training can decrease the provider error. This article presents a model for professional training of nurses to create safe and effective nurse‐run travel medicine clinics.

Nurse prescribing capabilities vary from state to state and from country to country. In Utah, nurses employed within the public health system are legally authorized to dispense pre‐signed prescriptions according to the written protocols, 12 making a nurse‐run travel clinic possible. Financially, nurse‐run travel clinics provide an economic advantage to the patient, as consultation can be offered at a lower cost than a consult given by a physician or PA. While addressing nursing practices around the world is beyond the scope of this article, our model is not without precedent. Even in areas where it is not possible for nurses to prescribe, they can still play a central role in travel‐clinic operation by taking histories, providing education, administering vaccinations, and performing other tasks that maximize their training.

Monthly meetings provide excellent reinforcement of prior training and also include new educational topics. Teleconferencing allows for communication with nurses over a 300 mile radius, and makes an ideal venue for discussing new standards of care. This is a key element in maintaining the level of expertise desired among those providing the pre‐travel care.

Teleconferencing helps address the concern that not all nurses in our program are able to take care of an optimal number of travelers. While the optimal number of travelers needed to be seen per week to maintain adequate experience is still being defined, 7 the cutoff used for this study to determine adequate experience was set at 10 travelers per week. Using this criterion, 4 of the 11 (36%) nurses within the affiliation do not provide care for the desired volume of travelers, due largely to the fact that their clinics are located in sparsely populated communities.

Teleconferencing overcomes this issue by allowing nurses in smaller, more remote clinics to present, listen and learn from the cases discussed in this forum. Combined with the availability of on‐call access to one of the providers during office hours and personal chart review sessions, a high experiential level is maintained amongst nurses in small clinics, allowing for the provision of travel‐medicine services in rural Utah.

One of the distinguishing strengths of the program described here is that the nurses always have access to a consulting physician or PA during clinic hours. First, a physician or PA is available either by phone, page, or e‐mail during all times when a clinic is in operation. This allows for point‐of‐care decision making for the estimated 2% to 4% of travelers who fall outside of the established protocols, giving individualized care to those who have special needs. Secondly, quality assurance is provided through chart reviews on all paper charts from all clinics, and feedback is given regularly to address concerns and allow for learning opportunities.

Finally, this study shows that a training program can be created that raises the standard for what nurses can be expected to achieve in both training and knowledge acquisition to more fully realize their potential in providing pre‐travel services. Owing to this study, the University of Utah now requires that new nurses observe a minimum of five pre‐travel consults, participate in five mock travel consults, and are observed for five complete pre‐travel consults.

The model presented here is reliable, reproducible, and can be tailored according to the local needs and legal requirements regarding the scope of nursing practice. It could be used in large urban areas where physicians and subspecialists are in high demand with many factors competing for their time. It also has application for training and maintaining qualified personnel in rural and other remote areas where it is difficult to regularly serve the critical number of travelers to receive adequate experience.

Conclusion

There is a growing need for standardized travel clinics throughout the world. The University of Utah has created a model where multiple pre‐travel clinics throughout the state can be staffed by nurses, who are effectively trained, consistently supervised and who maintain a high level of expertise. Further work is needed to gather data to objectively demonstrate the effectiveness of these clinics in safely providing for the travel needs of the population and in preventing disease in the international traveler.

The authors would like to thank Charles Langelier, MD, PhD candidate, for his help with editing and proof reading the manuscript.

Declaration of Interests

The authors state that they have no conflicts of interest to declare.

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This paper was presented in part at the 10th Conference of the International Society of Travel Medicine, held May 20 to 24, 2007, in Vancouver, Canada.