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ED Surveillance System Covers Public Health, Bioterrorism, and Disasters

Scheck, Anne

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It was a bunch of sick college kids in North Carolina who helped demonstrate the potential of the state's new emergency surveillance system for detecting bioterrorism.

When flu-like symptoms from a rather rampant norovirus began cropping up in teens and young adults in one corner of the Tarheel State, the presentations seemed pretty far flung: Some students had low fevers, others had high ones, some had no fevers at all. As for gastrointestinal signs, they were all over the map, too.

But the concurrence nonetheless raised a red flag, making a state alert possible almost as soon as a common infective agent was suspected. Still, sounding the alert was the last thing public health officials wanted to do without veritable proof.

“It could be like the little boy who cried wolf,” explained Anna Waller, ScD, an associate professor of emergency medicine at the University of North Carolina. Instead, state health experts sought to quickly answer the question, “Is this really a cluster, or is it a random variation?” They found that the broad GI syndrome, as it was dubbed, stemmed from a single cause: a Norwalk-like virus.

The incident showed how well the state-of-the-art, real-time reporting system works, but it also revealed that “you still need good human brain [power] when something looks fishy,” Dr. Waller said.

“It is giving us insight into the burden of disease.” - Dr. Megan Davies

At a time when potential bioterrorism is seen as a threat to national security, North Carolina has set up what is believed to be the first statewide bioterror-detection network in the nation: a hospital-based monitoring system that analyzes clinical data as it is collected by emergency departments in more than 100 North Carolina hospitals.

“In the case of Katrina, we were able to look at ‘live data’ to determine need.” - Dr. Lana Deyneka

“This is no longer an idea; it is a reality,” observed Steve Cline, DDS, MPH, who is the chief of epidemiology for the North Carolina Division of Public Health.

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Spotting Trends

Though still new and not without a few snags, the system is seen as a blueprint for other states and regions. This past year, the Healthcare Information and Management Systems Society honored the North Carolina emerging infection and prevention system with the Nicholas E. Davies Award of Excellence for public health contribution. It was one of only two such winners.

Initially developed by the department of emergency medicine at the University of North Carolina at Chapel Hill in conjunction with the state's division of public health, the system combines information through a database, which is designed to spot illness trends and track outbreaks.

Although it was built with federal funding for bioterrorism surveillance, the system already has a very beneficial public health application, said Megan Davies, MD, an epidemiology field officer for the Centers for Disease Control and Prevention, who is based in Raleigh, NC. “It is giving us insight into the burden of disease,” she said, and is likely to shed new light on effective approaches.

Dr. Davies cited asthma as one example. The system may provide answers to questions such as, “How many asthma attacks occur in kids?” and “What treatments help?” and “Where do we need to institute such programs?”

Dr. Cline agreed. “Already we have detected other events of public health significance such as foodborne disease outbreaks, surveillance of Hurricane Katrina evacuees seeking care in North Carolina … and more,” he noted.

“You still need good human brain [power] when something looks fishy.” - Dr. Anna Waller

“This is no longer an idea; it is a reality.” - Dr. Steve Cline

“In the case of Katrina, we were able to look at ‘live data’ to determine need,” concurred Lana Deyneka, MD, a syndromic surveillance coordinator for North Carolina and an epidemiologist in the state's department of public health.

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Stumbling Blocks

The partnership among hospitals has meant “we are able to better communicate and better understand each other's roles,” Dr. Cline said. The concept, if not the very same system, could easily be imported to other areas of the country, added Dr. Waller. And some of the stumbling blocks might be more quickly overcome in other parts of the nation.

In North Carolina, colloquial phrases are abundant, making recording the chief complaint problematic in some places. For example, an acronym for dizziness might reflect the saying, “Done fell out,” which is a local way of describing vertigo. On the other hand, some of the obstacles to data gathering seen in North Carolina may be even more pronounced in other states.

In places with a high immigrant population, such recording can be a challenge. In some Hispanic populations, for instance, specificity diminishes in some interpretations. A Spanish term for general queasiness can be used to indicate pain anywhere from the pelvis to the chest, Dr. Waller said.

She said using the system underscores the need for a common language in the ED. “I think we have a long way to go before we can use chief complaint effectively,” she said, observing that she and her colleagues found a pull-down menu of key words infeasible. Instead, a text box allowing users to describe signs and symptoms works much better. As a result, the system is still a far cry from being fully automated.

“We were naive thinking computers could be a complete answer,” she said. And they learned an important lesson in implementation: Solution-seeking is a lot better than head-banging. “We had to stop talking about how bad it was, how hard it was, and get going and just do something.”

The result of all that work is “a major step toward a national system of electronic health records whereby critical time sensitive health information can be shared while maintaining patient privacy and security,” said Dr. Cline, who was a principal investigator of the bioterrorism grant from the CDC.

“Think of the advantages this type of system could have offered to the Katrina victims who lost all their medical record information,” he said. Maybe that kind of advantage will be available the next time disaster strikes, said Dr. Waller.

© 2006 Lippincott Williams & Wilkins, Inc.

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