Influenza Pandemic Surveillance: How Emergency Department Tools Help Monitor Emerging Health Threats

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Influenza Pandemic Surveillance How Emergency
Department Tools Help Monitor Emerging Health
Threats

• Presentation To
• Manitoba Nursing Informatics Association
• 15 March 2010
• Trevor Strome MSc, PMP
• Emergency Program, Winnipeg Regional Health
  Authority

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Objectives

• To provide an overview of the WRHA Emergency
  Program informatics and analytics systems
• To discuss some lessons-learned from the
  implementation of ILI (Influenza-like Illness)
  Surveillance
• To offer some next steps

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Emergency Department Informatics Tools Overview
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What is EDIS?

• The Emergency Department Information System
  (EDIS) is a computerized patient tracking and
  electronic medical record system currently being
  deployed throughout the regions seven Emergency
  Departments.
• Adopted in response to the Emergency Care Task
  Force which mandated improved patient safety and
  increased efficiency of patient care.
• EDIS implementation began in 2007 in response to
  a 2004 Task Force report. The final hospital ED
  went live November 2008.
• EDIS is now an integral part of the management
  and care of patients by clinical staff in the
  Emergency Department.

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How can EDIS help?

• The EDIS system helps with the goals of the
  Emergency Care Task Force by
• Collecting, managing and presenting clinical and
  demographic patient information in an efficient,
  organized, and timely manner
• Obtaining data to help identify bottlenecks in
  the ED and throughout the hospital to guide
  process improvement initiatives
• Some of the major changes associated with EDIS
  include
• Implementation of a new computer system for
  patient tracking
• Replacement of e-Triage with a built-in fully
  CTAS compliant triage program

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What does EDIS do?

• EDIS consists of three primary modules
• Triage (clinical documentation, or clindoc)
• Status board
• Display board
• Major components of EDIS are
• Quick registration
• Triage
• Patient tracking (status and display views)
• Results reporting
• Discharge instructions
• Order entry
• Clinical documentation
• Administrative reporting

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Some clinical benefits of EDIS

• Track emergency patients effectively in the ED
• Access pertinent patient information in a timely
  manner
• Recognize and respond to emerging bottlenecks
• View results immediately when flagged as when
  ready for review
• Identify patients ready for reassessment and
  disposition
• Reduce duplication of documentation efforts
• Alerts caregivers of patients in greatest need

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Effective patient tracking

• On a single screen, staff are able access
• Arrivals
• Bed availability
• Patient location and status
• Labs and x-rays ordered
• Results reported
• Consults
• Plans

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Effective patient tracking

• Color-coded screens offer room status alerts,
  wait time indications for the ED, and wait times
  for patients to be triaged
• Tracking boards also help staff members monitor
  the number, acuity, and problems of patients at
  any given time
• Allowing ED staff members to measure their
  effectiveness in moving patients through the
  system.

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EDIS Triage

• WRHA Emergency Departments were using eTriage to
  triage patients since 2004.
• With adoption of EDIS came an opportunity to
  develop an integrated triage note using built-in
  clinical documentation tools.
• EDIS Triage was developed based on the 2004
  Canadian Triage Acuity Scale (CTAS) guidelines,
  and subsequently updated for the 2008 CTAS
  revisions.
• All Emergency Departments (with the exception of
  Childrens) currently use EDIS Triage
• EDIS Triage figures prominently in health
  surveillance efforts

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EDIS Triage

• Built-in to EDIS (not a separate program)
• Fully compliant with the latest CTAS guidelines
• Accessible as part of the electronic patient
  record
• Clinically validated by HSC triage nurses

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Status Board

• The EDIS status board is how clinical staff
  interact with the system to track and manage
  patients, and to access lab results.
• Rules can be implemented to activate flags (i.e.,
  colored highlighting or icons) based on the
  presence of certain values or conditions, for
  example
• Name alert when two or more patients present with
  same last name
• Infection control alert when patients present
  with likely influenza

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What is the Decision Support System (DSS)?

• DSS is the Emergency Programs window of insight
  into the clinical and administrative data
  collected by EDIS
• A collection of tools and reports providing users
  access to the EDIS data repository
• Users of the system will have access to anonymous
  data for all Emergency Department sites
• Ability to access data whenever it is required
• Easy-to-use interface simplifies process of
  obtaining data

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Components

• Real-Time Dashboard
• A snapshot of the current status in regional
  Emergency Departments providing basic information
  about the
• Number and status of patients
• Location of patients
• Lengths of stay
• Consults in progress
• Patients to be admitted
• Dashboard is refreshed every 10 minutes
• Regional view can be drilled-down to site-based
  view

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Components

• EDIS Repository
• A rich data repository containing key dimensions
  and measures extracted from the EDIS production
  database
• Allows for a detailed historical analysis of ED
  visits
• Provides access to anonymous aggregate and
  anonymous tabular format for analysis
• When necessary, WRHA Emergency Program can match
  a data record to actual patient name, visit, and
  MRN
• Repository is updated at midnight every day, but
  can be refreshed on-demand when necessary to
  review a critical incident
• Standard reports, data cubes, and historical
  dashboards (i.e., scorecards) are available

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Components

• Some of the data currently available include
• Triage/registration interval times, and triage
  documentation info
• Overall length of stay
• Patient status interval times
• Consult called and wait times
• Time waiting to be admitted
• Time at location (i.e., waiting room, etc)
• As additional functionality is added to EDIS, the
  data will be incorporated into the DSS
• The EDIS repository consists of two main types of
  analysis tools
• Standard Reports
• Data Cubes

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Analytics A key link in the Emergency
information value chain
Management (Planning, Performance Management)
Enterprise Strategy (goals, objectives, plans,
key performance indicators)
metrics
Quality Standards (Score Cards, National
Benchmarks, Accreditation)
Analytics (Reports, Dashboards, Scorecards)
Process Improvement (Lean, Six Sigma, PDSA)
Patient Safety and Flow
Informatics (EDIS, EPR, EMR, ePCR)
Research (Clinical, Operations)
data
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Systems and Data

• Data is generated by several contributing systems
  such as EDIS, ADT, eTriage, LIS, RIS/PACS
• Data from some ED-related systems not yet
  available to DSS
• Data must be translated, in several stages, from
  the operational system (i.e., EDIS) to a format
  that is easier to report from.

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EDIS Decision Support Portal
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Monthly Executive Summary Reports Site
Comparisons
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Evaluation of EDIS Triage Override Rates
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Real-Time Patient Waiting Room Wait-times Display
Board
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Influenza Surveillance Lessons Learned
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The Issue

• Swine Flu outbreak in Mexico March 2009
• Later renamed to H1N1 as virus identified
• Influenza-like-illness (ILI) adopted as the
  generic term
• Alarm and uncertainty rapidly spread regarding
  severity and infectiousness of this emerging
  illness
• Phase I resulted in high numbers of ILI
  patients in Winnipeg ICUs
• Pattern of illness atypical of usual flu victims
• Pandemic planning was in full swing
• EDs and other departments told to prepare for
  outbreak
• Regional planning included implementing flu
  clinics

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The Need

• Emergency Departments were seen as the canary in
  the coalmine
• The sickest patients (i.e., high fever,
  respiratory symptoms) would most likely present
  to EDs
• Regional planners needed data to monitor the
  progress of illness, to be able to activate flu
  clinics before it was too late
• EDIS DSS were recently implemented, and
  therefore could contribute data for patients
  presenting with ILI
• Surveillance data not as easily attainable from
  doctors offices, primary clinics, etc.
• WRHA Emergency program started developing ILI
  reports to monitor ED visits by patients with ILI

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Solution

• Worked with WRHA Population Public Health
  epidemiologists MOHs to refine EDIS ILI case
  definition based on Triage chief complaints that
  was true to WHO case definition
• Weakness
• Shortness of breath
• Cough
• Headache
• Fever
• Cardiac / Respiratory Arrest
• Sore Throat
• URTI Complaints

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Data Quality

• Issue still using two triage tools (EDIS Triage
  eTriage) there are some key differences
  between the two CTAS standards
• Chief complaints are big buckets
• Not all chief complaints are associated strongly
  with ILI
• Shortness of Breath versus Fever
• EDIS does not yet capture Discharge Diagnosis
  (big gap!)
• What was needed was a way to confirm if a case
  was ILI or not
• EDIS ILI surveillance achieved high sensitivity,
  but low specificity

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Clinical Confirmation of ILI Cases

• Childrens ED originally wanted a flag on EDIS
  status board to track ILI patients for infection
  control purposes
• Did the patient (or patients family) appear to
  have ILI symptoms
• ILI confirmation flag had potential to serve as a
  clinical confirmation of ILI for surveillance
  purposes, as well.
• After pilot testing at Childrens ED, the ILI
  column flag was implemented on EDIS status boards
  across the region.

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Clinical Confirmation of ILI Cases

• Chief Complaint turns grey to notify clinicians
  if certain criteria are met
• ILI-related chief complaint or respiratory
  screening flag on triage document
• Clinicians indicate a next to the patient if
  ILI confirmed, or - if not confirmed.
• Clinicians could also confirm ILI for patients
  with non-ILI chief complaints
• i.e., if chief complaint was inaccurate
• Rule If you see gray, make it go away
• Suffered from poor compliance

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Total ILI Cases from 01 April 2009
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ILI Cases versus all ED Visits from 01 April
2009
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ILI Cases as a of All ED Visits (from 01 April
2009)
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ILI Cases by Age of Patient
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Successes

• Informatics provided the capability to
• Electronically capture key patient information
• Access and analyze information rapidly (next day)
• Modify tools in-flight to enhance data capture
  reporting
• Distribute timely reports alerts efficiently
  (i.e., automated)
• Contributed to staff resource planning for EDs
  and regional flu clinics
• Enhanced our understanding of influenza patters
  in the region
• Excellent opportunity to partner and share data
  with other WRHA programs.

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Lessons Learned for Next ILI Wave (Or Other
Emerging Health Threat)

• EDIS needs to capture Discharge Diagnosis
• EDIS Achilles Heel
• Collaborate as early as possible with other
  programs to agree on case definitions for
  commonality in reporting
• Data collection needs to be rich enough to
  prevent
• Overburdening triage other clinical staff with
  too many surveillance-type data elements
• Major changes to EDIS to accommodate surveillance
• Develop a communications plan to guide
  distribution of reports
• Type, frequency, content, etc.

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Next Steps

• Continue ongoing surveillance of ILI and other
  illnesses of interest
• Deepen the collaboration with key partners
  through ongoing working groups and publication of
  research articles
• Improving surveillance reporting capabilities
• Refining algorithms and case definitions to
  improve sensitivity specificity of surveillance
• Adding artificial intelligence capabilities to
  overcome data quality issues and to introduce
  intelligent flagging of possible ILI cases
• Developing simulation models to better predict
  patterns of illness outbreak and determining
  staff and other resource requirements

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• Questions?
• Contact Information
• Trevor Strome
• Emergency Program, WRHA
• 204-632-3395 (v)
• tstrome_at_wrha.mb.ca