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
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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:
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1. Sepsis
2. Respiratory
3. Rash
4. Fever
5. Cold
6. Diarrhea
7. Asthma
8. Vomit
Other
Hospital Statistics - 2005
• 3,136,772 total visits. (7000-10,000 / day)
syndrom e
num ber
percent
other
2351837
74.98%
sepsis
16968
0.54%
258946
8.26%
rash
61352
1.96%
fever
184034
5.87%
cold
54387
1.73%
diarrhea
51027
1.63%
asthma
75566
2.41%
vom it
82655
2.64%
respiratory
Data Analysis
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Ratio of syndrome/other
Citywide and spatial (zip code, hospital)
Age 13+: respiratory and fever
All ages: diarrhea and vomit
Age group
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–
–
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0-4
5-17
18-59
60+
• 7 days/week
SIGNALS
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)
Cluster Doc
• Review data with analyst
• Ask for further details
• Decide on follow up
– guidelines/protocol
– “fingerprint” of signal
Signals – 2005
syndrome
respiratory
fever
diarrhea
vomit
City Hospital
17
3
11
10
28
8
23
10
Zip
1
7
6
10
Investigation of Signals
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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
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First day (Resp/Fev) vs. 2nd day (Vom/Dia)
Perform descriptive statistics, midday log
Examine CUSUM, other systems
Call hospitals with CUSUM alarms
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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
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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
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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
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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
1/25/2003
12/21/2002
11/16/2002
10/12/2002
9/7/2002
8/3/2002
6/29/2002
5/25/2002
4/20/2002
3/16/2002
2/9/2002
1/5/2002
1
Fev/resp/resp non-feb
Sum of RRespnofev
Sum of Rfevflu
0.1
0.01
0.001
Sum of RRfev
1/14/2006
12/10/2005
11/5/2005
10/1/2005
8/27/2005
7/23/2005
6/18/2005
5/14/2005
4/9/2005
3/5/2005
1/29/2005
12/25/2004
11/20/2004
10/16/2004
9/11/2004
8/7/2004
7/3/2004
5/29/2004
4/24/2004
3/20/2004
2/14/2004
1/10/2004
12/6/2003
11/1/2003
9/27/2003
8/23/2003
7/19/2003
6/14/2003
5/10/2003
4/5/2003
3/1/2003
Febrile Respiratory, Fever and Non-febrile Respiratory Syndromes.
Weekly ratio. Log Scale.
Sum of Rvom
Sum of Rdiar
1/14/2006
12/10/2005
11/5/2005
10/1/2005
8/27/2005
7/23/2005
6/18/2005
5/14/2005
4/9/2005
3/5/2005
1/29/2005
12/25/2004
11/20/2004
10/16/2004
9/11/2004
8/7/2004
7/3/2004
5/29/2004
4/24/2004
3/20/2004
2/14/2004
1/10/2004
12/6/2003
11/1/2003
9/27/2003
8/23/2003
7/19/2003
6/14/2003
5/10/2003
0.45
4/5/2003
3/1/2003
1/25/2003
12/21/2002
11/16/2002
10/12/2002
9/7/2002
8/3/2002
6/29/2002
5/25/2002
4/20/2002
3/16/2002
2/9/2002
1/5/2002
Diarrhea and Vomit Syndromes Age 0 - 4.
Weekly Ratio.
Diar/vom age 0-4
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
0.1
1/5/2002
2/9/2002
3/16/2002
4/20/2002
5/25/2002
6/29/2002
8/3/2002
9/7/2002
10/12/2002
11/16/2002
12/21/2002
1/25/2003
3/1/2003
4/5/2003
5/10/2003
6/14/2003
7/19/2003
8/23/2003
9/27/2003
11/1/2003
12/6/2003
1/10/2004
2/14/2004
3/20/2004
4/24/2004
5/29/2004
7/3/2004
8/7/2004
9/11/2004
10/16/2004
11/20/2004
12/25/2004
1/29/2005
3/5/2005
4/9/2005
5/14/2005
6/18/2005
7/23/2005
8/27/2005
10/1/2005
11/5/2005
12/10/2005
1/14/2006
Febrile Respiratory and Cold Syndrome Visits.
Weekly Ratio.
Fev resp/fev cold
0.07
0.06
0.04
0.03
0
Sum of RRfev
Sum of RCLD_fev
0.035
0.09
0.03
0.08
0.025
0.02
0.05
0.015
0.01
0.02
0.01
0.005
0
Questions and Projects
• What are we looking for?
• Are more fields better?
– Discharge diagnosis / ICD-9 code
– Disposition
– Recorded temperature
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Quantify effect of school closings
Day of Week
SaTScan mapping
Age as space