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

1. 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

2. 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

3. Emergency Department Informatics Tools Overview

4. What is EDIS? • The Emergency Department Information System (EDIS) is a computerized patient tracking and electronic medical record system currently being deployed throughout the region’s 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.

5. 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

6. 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 What does EDIS do?

7. 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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. What is the “Decision Support System” (DSS)? • DSS is the Emergency Program’s 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

14. 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

15. 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

16. 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

17. 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

18. 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.

19. EDIS Decision Support Portal

20. Monthly Executive Summary Reports – Site Comparisons

21. Evaluation of EDIS Triage Override Rates

22. Real-Time Patient Waiting Room Wait-times Display Board

23. Influenza Surveillance – Lessons Learned

24. 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 ICU’s • 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

25. 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

26. 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

27. 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

28. Clinical Confirmation of ILI Cases • Children’s ED originally wanted a “flag” on EDIS status board to track ILI patients for infection control purposes • Did the patient (or patient’s 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 Children’s ED, the ILI column flag was implemented on EDIS status boards across the region.

29. 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

30. Total ILI Cases – from 01 April 2009

31. ILI Cases versus all ED Visits – from 01 April 2009

32. ILI Cases as a % of All ED Visits (from 01 April 2009)

33. ILI Cases by Age of Patient

34. 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.

35. 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.

36. 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

37. Questions? Contact Information: Trevor Strome Emergency Program, WRHA 204-632-3395 (v) tstrome@wrha.mb.ca