FacttoFace: A Clinical Approach to PostDeployment Evaluation Using the DD 2796 at the Deployment Hea

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Fact-to-Face A Clinical Approach to
Post-Deployment Evaluation Using the DD 2796 at
the Deployment Health Clinical CenterThomas
R.Roesel MD, PhD.Charles Engel, M.,
MPHDeployment Health Clinical CenterWalter
Reed Army Medical Center
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DD 2796 Post-Deployment Health Assessment

• Post-deployment health assessment through DD
  2796 provides a mechanism for force health
  protection during redeployment.
• DD 2796 was constructed to help screen
  redeploying service members for medical problems
  at outlying military treatment facilities.

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Unique Use of the DD 2796

• Rather than restricting the DD 2796 encounter
  for use at the demobilization site, it was
  utilized for ambulatory patients seen at Walter
  Reed.

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Overview

• DD 2796 Post Deployment Health Assessment.
• The Face-to-Face Interview as part of the DD
  2796.
• Case Study.
• Retrospective Chart Review of 80 Patients.
• Comparison of 2 groups of ambulatory patients
• 1) those who received additional
  referrals/consults for other health services
  (34) those who didnt (46).
• Individualization of terminal malaria
  prophylaxis.
• Conclusions

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Number of Ambulatory Patient Visits at the DHCC

• Since March 2003 until June 21, 2004
• 1,311 DHCC Ambulatory Visits
• 669 or 51 seen by a DHCC Provider for a
  Face-to-Face Interview.
• Criteria for Interview not previously seen by a
  provider at another MTF location during
  redeployment.

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DD 2796 Post Deployment Health Assessment

• Demographics
• Name, rank, SSN, date of arrival, departure,
  theater(s)
• Deployment Health History
• Health status change, hospitalization,
  vaccinations, preventive medications, e.g,
  anti-malarial
• Past and Current Symptoms During and After
  Deployment
• 21 Items to be checked as whether present or not
  during or after deployment.

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DD 2796 Post Deployment Health AssessmentPast
and Current Symptoms During and After Deployment

• Chronic Cough
• Runny Nose
• Fever
• Weakness
• Headaches
• Swollen, Stiff or Painful Joints
• Back Pain
• Muscle Aches
• Numbness or Tingling in Hands or Feet
• Skin Diseases or Rashes
• Redness of Eyes with Tearing

• Dimming of Vision
• Chest Pain or Pressure
• Dizziness, Fainting, Light Headedness
• Difficulty Breathing
• Still Feeling Tired after Sleeping
• Difficulty Remembering
• Diarrhea
• Frequent Indigestion
• Vomiting
• Ringing of the Ears

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DD 2796 Post Deployment Health Assessment

• Behavioral Health Questions
• Questions 7-10
• 7. Did you see wounded, killed, or dead?
• 8. Engaged in direct combat?
• 9. Ever feel in great danger of being killed?
• 10. Are you currently interested in receiving
  help for a stress, emotional, alcohol or family
  problem?

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DD 2796 Post Deployment Health Assessment

• Behavioral Health Questions
• Questions 11-13
• 11. Depression Screening 3 questions
• Little interest or pleasure in doing things?
• Feeling down, depressed, or hopeless?
• Thoughts that you would be better off dead or
  hurting yourself in some way?
• 12. PTSD Screening 4 questions
• 13. Social Support Screening

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DD 2796 Post Deployment Health Assessment

• Behavioral Health Questions
• Questions 11-13
• 12. PTSD Screening 4 questions on an
  frightening or horrible experience or event
• Re-experiencing Causing nightmares or intrusive
  thoughts?
• Avoidance Tried not to think about the event or
  avoid situations that may remind one of the
  experience?
• Arousal On guard, watchful, or easily startled?
• Avoidance Felt numb or detached from others,
  activities, or your surroundings?
• 13. Social Support Screening 2 questions
• Family conflicts, or hurt or lose control with
  someone?

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DD 2796 Post Deployment Health Assessment

• Exposure Questions 14-18 Question 14

• Deet, Instect Repellant
• Pesticide-treated Uniform
• Enviromental Pesticide
• Flea or Tick Collars
• Pesticide Strips
• Smoke from Oil Fire
• Smoke from Burning Trash or Feces
• Vehicle or Truck Exhaust Fumes
• Tent heater Smoke
• JP8 or other Fuels

• Fog oils (smoke screen)
• Solvents
• Paints
• Ionizing Radiation
• Radar/Microwaves
• Lasers
• Loud Noises
• Excessive Vibration
• Industrial Pollution
• Sand/Dust
• Depleted Uranium
• Other Exposures (list)

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DD 2796 Post Deployment Health Assessment

• Exposure Questions
• Questions 14-18
• 15. Frequency of MOPP Suit wear?
• 16. Frequency of Gas Mask wear?
• 17. Exposure to Destroyed Vehicle?
• 18. Exposure to ABC Agents?

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DD 2796 Post Deployment Health Assessment

• Health Care Provider Review AssessmentFinal
  Page
• Interview
• Health Status Excellent, Very Good, Good, Fair,
  Poor
• Any Medical or Dental Problems during
  Deployement?
• Any current Profile or Light Duty?
• Had Behavorial Health Counseling been sought
  while deployed?
• Any health concerns about past exposures or
  events? --List
• Any current health concerns or questions? --List
• Classify Exposure Concerns
• Environmental, Occupational, Combat-,
  Mission-Related,
• or None

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DD 2796 Post Deployment Health AssessmentHealth
Care Provider Review AssessmentFinal
PageReferral Indicated For

• None
• Cardiac
• Combat/Operational Stress
• Dental
• Dermatologic
• ENT
• Eye
• Family Problems
• Fatigue, Malaise, Multisystem Complaint

• Audiology
• GI
• GU
• GYN
• Mental Health
• Neurologic
• Orthopedic
• Pregnancy
• Pulmonary
• Other (List)

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DD 2796 Post Deployment Health AssessmentHealth
Care Provider Review AssessmentFinal Page

• Comments SectionFace-to-Face Interview
• Understanding of illness/injury and future care?
• Any other pain or illness/injury Has this been
  addressed?
• Plan on addressing any other pain or
  illness/injury
• Referrals, medications
• Sleep/Fatigue?
• Exposure to Mosquito or Sand Fly Bites
• Antimalarial Use?
• Counseling on Symptoms of Malaria/Leishmaniasis
• Individualization of Terminal Malaria Prophylaxis
• Reactions to Smallpox or Anthrax Vaccination?
• Exposure Concern?
• Counseling on PPD and HIV testing

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Case Study Face-to-Face Interview

• 35 year old male National Guard soldier, E-4,
  past month in Iraq
• Bilateral Subconjunctival Hemorrhage secondary to
  exertional straining while submerged
• Onset 5 days ago

• Ophthalmology Watch, Resolution without
  Treatment
• Disposition Return to Mobilization Station
• No complaints checked offwants to return to unit
  in Iraq

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Face-to-Face Interview Oh, my shoulder hurts
a little.

• Pain with Internal Rotation of Adducted,
  Forwardly Flexed Shoulder (SLAPprehension Test)
• MRI Superior Labrum Anterior-Posterior (SLAP)
  Tear of the Glenoid Labrum (88 Sensitive, 93
  Specific)
• Orthopedics Consult for Arthroscopic Repair

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Face-to-Face Interview Case Study
Individualization of Terminal Anti-Malarial
Prophylaxis

• Tolerating doxycyline prophylaxis, had missed
  some doses with onset of injury, but resumed on
  his own.
• Advised to keep taking doxycyline for at least
  another 30 days after departure from Iraq.
• Since he recalls a significant number of mosquito
  bites, advised to take two weeks of primaquine
  after results of G6PD testing returned.
• G6PD test ordered along with HIV repository
  sample.

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What is the DHCC Experience with DD 2796?

• 550 patients seen
• from March 2003 until April 2004
• 20 of patients received one or more referrals
• What types of consults were being issued?
• What types of cases were needing consults?
• How often was individualization of malaria
  prophylaxis implemented? And why?

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Pilot Study Chart Review

• Retrospective chart review on 80 patients
• 34 patients with a referral at time of DD 2796
  Interview.
• 46 patients without a DD 2796 referral.
• IRB approved review of DD 2796, CHCS, and ICDB.

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Comparison
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Health Services UtilizationAverage Number of
Services Utilized
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Types of Consults/Servicesutilized by the 34
patients who received DD 2796 Referrals

• Primary Admitting Service
• Orthopedics (8)
• Physical Medicine (6)
• ENT (3)
• Neurology (3)
• Cardiology (3)
• Others less than 2 Neurosurgery, Gynecology,
  Internal Medicine, Ophthalmology, GI, Infectious
  Disease, Behavioral Health

• Type of DD 2796 Referral
• Orthopedics (6)
• Sleep Clinic (6)
• Audiology (4)
• Optometry/Ophthalmology (3)
• Behavioral Health (3)
• Dermatology (3)
• GI (3)
• Dental (3)
• Others less than 2 Physical Therapy, Allergy,
  Vaccine Health Clinic, ENT, Infectious Disease,
  Pulmonary, Internal Medicine

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Did the Face-to-Face Interview Make a Difference
in Terms of Terminal Anti-Malarial Prophylaxis?

• 12 of the 80 patients (15) had stopped their
  antimalarial medication, who were then counseled
  and given terminal prophylaxis.
• Reasons for stopping
• Onset of injury or illness
• Adverse Reaction
• Out of medication
• Non-compliance

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Conclusions

• Face-to-Face Interview provided by the DD 2796
  in a tertiary care population helped to identify
  co-morbidity.
• Frequent co-morbidities identified were
  Orthopedic, Sleep, or Hearing related.
• Face-to-Face Interview provided the opportunity
  to individualize terminal anti-malarial
  prophylaxis.