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

2. 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?

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

4. Analysis

5. Hospital map

6. 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

7. Hospital Statistics - 2005 3,136,772 total visits. (7000-10,000 / day)

8. 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

9. SIGNALS

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

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

12. Signals – 2005

13. 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)

14. 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

15. 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

16. 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)

17. 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

18. DATA VISUALIZATION

19. Intranet

20. Respiratory intranet

21. Signal details 1

22. Signal details 2

23. Signal details 3

24. Signal details 4

25. FUTURE DIRECTIONS

26. ILI age 1

27. ILI age 2 - serfling

28. ILI age 3 - TERS

29. ILI age 4 - daily

30. Resp CC

31. Fev/resp/resp non-feb

32. Diar/vom age 0-4

33. Fev resp/fev cold

34. 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