Title: FacttoFace: A Clinical Approach to PostDeployment Evaluation Using the DD 2796 at the Deployment Hea
1Fact-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
2DD 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. -
3Unique 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.
4Overview
- 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
5Number 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.
6DD 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.
7DD 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
8DD 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?
9DD 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
10DD 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?
11DD 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)
12DD 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?
13DD 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
14DD 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)
15DD 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
16Case 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
17Face-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
18Face-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.
19What 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?
20Pilot 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.
21Comparison
22Health Services UtilizationAverage Number of
Services Utilized
23Types 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
24Did 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
25Conclusions
- 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.