EMERGENCY DEPARTMENT SYNDROMIC SURVEILLANCE IN MICHIGAN. Jay Fiedler, Surveillance Section Manager Michigan Department of Health and Human Services
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1 EMERGENCY DEPARTMENT SYNDROMIC SURVEILLANCE IN MICHIGAN Jay Fiedler, Surveillance Section Manager Michigan Department of Health and Human Services
2 SYNDROMIC SURVEILLANCE: Current MSSS System Current Heat Surveillance Integrating Heat Surveillance into MSSS
3 SYNDROMIC SURVEILLANCE: MICHIGAN OBJECTIVE The objective of the Michigan Syndromic Surveillance System (MSSS) is to detect bioterrorism, emerging infections, and naturally occurring outbreaks more rapidly than through normal physician detection and reporting
4 SYNDROMIC SURVEILLANCE: RATIONALE: BIOTERRORISM Overview of Syndromic Surveillance. Henning. MMWR / Sep 24, 2004 / 53(Supple);5-11
5 ED SYNDROMIC SURVEILLANCE: MICHIGAN OVERVIEW Allows for rapid detection of unusual illnesses and potential outbreaks from ED registrations MDHHS has been monitoring trends in syndromic presentation for over a decade LHDs and MDHHS Epidemiologists can view charts, maps and registration data online
6 SYNDROMIC SURVEILLANCE SYSTEM Number of Facilities 109 Number of Referrals/Year Statewide 4.9 Million Number of Referrals per facility per day Varies Greatly
7 ED SYNDROMIC SURVEILLANCE: THE BASICS Based on Real-Time Outbreak Detection System (RODS) developed at the University of Pittsburgh Virtual Private Network (VPN) HL7, a healthcare messaging standard, to exchange data in real-time between participants and MDHHS Each message consists of: Patient age, sex, home ZIP code Visit date and time Data exchange and acknowledgement information Chief complaint
8 ED SYNDROMIC SURVEILLANCE: HOW DOES IT WORK? Patient registers with basic demographic info and the chief complaint a short descriptions of symptoms that led the person to visit the ED Registration triggers a message with the necessary information which is sent securely to MDHHS in Lansing Chief complaint is classified into 1 of 9 syndromic categories that can be aggregated for review and analysis Detection algorithm runs every hour and an alert is generated if aberration in the levels of a syndrome is detected
9 EXAMPLE OF CHIEF COMPLAINTS Stuck bead in nose Fish hook in ear Fell and laid in yard for a couple of hours Fell onto cactus Squirrel bite Rt foot pain, dropped turkey (2 days before thanksgiving) Run over by golf cart Odd behavior after eating fresh peaches Blue plate special Talking to dead people
10 SYNDROMIC SURVEILLANCE CATEGORIES Syndrome % of Visits Example Sample Text (not inclusive) Gastrointestinal 9-13% Stomach Pain Abdominal, stomach, gastric, enteritis, diarrhea, vomiting, nausea, n, v, abdomen, abd, gastroenteritis, nvd Respiratory 8-16% Difficulty Breathing Cough, sore throat, congestion, wheezing, asthma, croup, respiratory, strep, cold, bronchitis, pneumonia, asthma, sob, sinus, uri, dyspnea, dib Constitutional 7-10% General weakness Fever, weakness, dizziness, dizzy, temp, temperature, flu, light headed, chills, lethargy, fatigue, sweating, lethargic, febrile Neurological 6% Confusion Migraine, headache, disoriented, syncope, fainted, paralysis, tingling, seizure, stroke, cva, convulsion, loc, mental, vertigo, meningitis, numb, confusion, dizzy, unconscious Hemorrhagic 3% Nose bleed Epistaxis, bleeding, hemoptysis, hematuria, hematemesis, blood, bleed, hematochesia, hemorrhagic, hemorrhaging Rash % Hives and itching Rash, hives, bumps, petechiae, purpura, ivy, dermatitis, pox, scabies, spots, shingles Botulinic <0.5% Slurred Speech Slurred, diplopia, dysphagia, photophobia, dysarthria, speaking, swallowing, blurred Other 12-19% Right foot injury Laceration, injury, mva, broken, sprain, bite, abrasion, wound, suture, concussion, sunburn, pressure, fall, sugar, gsw, monoxide Default 40-44% Med Refill Everything else (default category) if complaint contains none of the recognized keywords e.g. assault/neck, jumped from moving vehicle
11 SYNDROMIC SURVEILLANCE: MAIN SCREEN
12 SYNDROMIC SURVEILLANCE: STRENGTHS CoCo correctly classified 98% of complaints CoCo originally designed by the RODS team MDHHS version trained using MI ED chief complaints System is trained to recognize terms and categorize based on significance vomiting and fever could be GI, but fever is more significant; categorized as constitutional bleeding lacerations could be hemorrhagic, but lacerations is more significant; categorized as other
13 SYNDROMIC SURVEILLANCE: STRENGTHS Earlier detection of seasonal illnesses Example: Respiratory visits Alerts are triggered as season begins
14 SYNDROMIC SURVEILLANCE: STRENGTHS Ability to compare past seasons Example: Constitutional visits Seasonal influenza season vs. pandemic influenza
15 SYNDROMIC SURVEILLANCE: STRENGTHS Ability to create Ad Hoc searches Examples: Heat Surveillance Assessment of illness presentations to emergency departments and urgent cares
16 SYNDROMIC SURVEILLANCE: LOCAL HEALTH DEPARTMENT USER Can see all healthcare registrations made by residents of local health jurisdiction Can also see activity for all healthcare providers in their jurisdiction (HPCs that are enrolled in the system) Can access overall statewide Michigan activity
17 EXAMPLES OF USE: LOCAL HEALTH DEPARTMENT USERS Supplement Surveillance Data Norovirus-like illnesses: gastrointestinal Influenza Season: constitutional Respiratory Illnesses: respiratory Rash Illnesses: rash Example: Macomb County
18 SYNDROMIC SURVEILLANCE: HEALTHCARE Can see total healthcare registrations made at a facility or system Can access overall statewide Michigan activity Cannot see specific detailed information about statewide activity
19 EXAMPLES OF USE: HOSPITAL USERS Extract own data Daily or Weekly ILI data from their ED for aggregate reporting to LHD Using a data filter to extract cases who meet the ILI case definition
20 EXISTING HEAT SURVEILLANCE Ad hoc searching and manual reporting
21 FUNCTIONALITY: AD HOC SEARCH HEAT SURVEILLANCE Filter: Sun2 OR: dehyd sun prostration heat hyperthermia NOT: Sunday heater heatrate cheat heatlh wheat flower beat
22 FURTHER ANALYSIS: HEAT SURVEILLANCE Custom charts were created Comparison of previous summers Seasonal (May 15 - August 31) Daily Heat-Related ED Visits,
23 FURTHER ANALYSIS: HEAT SURVEILLANCE Custom charts were created Heat-related illnesses and temperature Statewide Heat-Related ED Visits and National Oceanic and Atmospheric Administration (NOAA) Maximum Daily Temperature Averages for 6 Select Cities (April 1 August 28, 2016)
24 FURTHER ANALYSIS: HEAT SURVEILLANCE Visits were further categorized based on chief complaint Sun-associated: sunburn, sun poisoning, sunscreen reactions Heat-associated: heat exhaustion, heat stroke, heat reaction Dehydration Statewide Heat-Related ED Visits by Syndrome (April 1 August 31, 2013)
25 FURTHER ANALYSIS: HEAT SURVEILLANCE Age In July significant increases in visits were among those years These are age groups that are considered less vulnerable to heatrelated illnesses
26 INTEGRATING MSSS AND EHE Defining Extreme Heat Events and integration into MSSS
27 EHE INTEGRATION PROCESS Contractor and Workplan Altarum Institute, Ann Arbor MI Workplan and Deliverables: 1.0 Requirements Gathering 2.0 Syndrome Development 3.0 Code Development, Implementation, Testing 4.0 Project Reporting and Dissemination
28 EHE INTEGRATION PROCESS Syndrome Development Keywords Probabilities Validation Alerting threshold
29 HEAT SYNDROME KEYWORDS Changes in bold red
30 HEAT SYNDROME WEIGHTING Heat syndrome weighting: Heat, Keyword weighting for Heat (inclusion) and Other (exclusion from Heat)
31 HEAT SYNDROME DEPLOYMENT Existing RODS-based previous 120 days baseline not effective for Heat Altarum developed a custom baseline for the Heat syndrome Used historical data from multiple years to develop a year-round baseline ratio (per 100 visits) of Heat syndrome classifications for State and each Michigan county Also applied a minimum threshold of 5 classifications per county To signal alert, Heat classifications must exceed the minimum and the historical baseline ratio The historical visit baseline was calculated per day, per county, and with a two-week averaging of these values around a given day when calculations are performed When alerts are generated they use the existing MSSS set up to notify the appropriate people
32 EHE INTEGRATION PROCESS Implementation
33 EHE PRELIMINARY RESULTS MDHHS performed a review of results after the final Heat syndrome changes were implemented on 14-Nov-2016 For the time period of 15-Nov-2016 to 27-Nov- 2016, the set of TEST visit (n=184) chief complaints included 161 dehydration, 14 heatassociated, and 11 sun-associated keywords, representing off-season baseline activity No Heat syndrome alerts occurred during this timeline (15-Nov-2016 to 27-Nov-2016) Additional peak season results will be available through MDHHS after the summer of 2017
34 EHE INTEGRATION PROCESS Lessons Learned
35 MERCI, GRACIAS, THANKS For questions about the Heat syndrome and results, please contact: Jay Fiedler Surveillance and Infectious Disease Epidemiology Section Manager Michigan Department of Health and Human Services t (USA) Questions about the implementation and deployment in MSSS can be directed to: John Christensen Project Leader Altarum Institute t (USA)
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