From Data to Signals to Screenshots: Recent Developments in NYCDOHMH ED Syndromic Surveillance. Marc Paladini New York City Department of Health and Mental Hygiene

Questions What are we looking for? How are we looking for it? What do we need to find it? What do we do after we find it? How does this help us do our job more effectively?

Outline Introduction to NYC emergency department syndromic surveillance. –Analysis –Signal Investigation Data Visualization Future Directions

Analysis

Hospital map

ED Syndromic Surveillance in NYC Chief complaint – hierarchical syndrome coding Syndromes: –1. Sepsis –2. Respiratory –3. Rash –4. Fever –5. Cold –6. Diarrhea –7. Asthma –8. Vomit –Other

Hospital Statistics ,136,772 total visits. ( ,000 / day)

Data Analysis Ratio of syndrome/other Citywide and spatial (zip code, hospital) Age 13+: respiratory and fever All ages: diarrhea and vomit Age group –0-4 –5-17 –18-59 –60+ 7 days/week

SIGNALS

Syndromic Analyst Run surveillance – 2 hours Review output for signals Review signal details –Linelist –Baseline vs. signal frequency tables Consult with DOH Physician on call (Cluster Doc)

Cluster Doc Review data with analyst Ask for further details Decide on follow up –guidelines/protocol –“fingerprint” of signal

Signals – 2005

Investigation of Signals Review line list Check complimentary systems Acquire interim data (12 hour log) Call to EDs Chart reviews Patient follow up (phone calls) Augment lab testing/collect specimens On site epi teams Special studies (case-control)

Routine Steps First day (Resp/Fev) vs. 2 nd day (Vom/Dia) Perform descriptive statistics, midday log Examine CUSUM, other systems Call hospitals with CUSUM alarms –What did they see yesterday? –What are the seeing today? –Clinical clusters, unexpected severe illness? –Augment lab testing Alert ED staff

Concerning Features of a Syndromic Signal Sustained Multiple hospitals Large number of excess cases Uniformity of chief complaints Young adults or age/sex clustering Overlapping syndrome signals Coincident clinician call Coincident with high profile public event Concordance with other surveillance systems

Results of Investigations Some clear seasonal patterns evident Sharp spikes associated with known events Rich ecological associations Difficult to investigate Used to reinforce public health messages (influenza, viral GI, heat wave, blackout, asthma)

Proposed Prospective Investigation Protocol All significant resp and fever signals Chart reviews Patient interviews Classify if cases in signal are related –by lab diagnosis, i.e. strep pharyngitis –by clinical diagnosis, i.e. pharyngitis –by risk factor, i.e. subway travel

DATA VISUALIZATION

Intranet

Respiratory intranet

Signal details 1

Signal details 2

Signal details 3

Signal details 4

FUTURE DIRECTIONS

ILI age 1

ILI age 2 - serfling

ILI age 3 - TERS

ILI age 4 - daily

Resp CC

Fev/resp/resp non-feb

Diar/vom age 0-4

Fev resp/fev cold

Questions and Projects What are we looking for? Are more fields better? –Discharge diagnosis / ICD-9 code –Disposition –Recorded temperature Quantify effect of school closings Day of Week SaTScan mapping Age as space