York City Emergency Department Research Articles

In Denial: Symptom Negation in New York City Emergency Department Chief Complaints

ObjectiveTo describe the effect of symptom negation in emergencydepartment (ED) chief complaint data received by the New York City(NYC) Department of Health and Mental Hygiene (DOHMH), and todevise a solution to avoid syndrome and symptom misclassificationfor commonly used negations using SAS Perl Regular Expression(PRX) functions.IntroductionIn July 2016, 77% of ED data was transmitted daily via HealthLevel 7 (HL7) messages, compared to only 27% in July 2015(Figure). During this same period, chief complaint (CC) word counthas increased from an average of 3.8 words to 6.0 words, with atwenty-fold increase in the appearance of the word “denies” in thechief complaint (Figure). While HL7 messages provide robust chiefcomplaint data, this may also introduce errors that could lead tosymptom and syndrome misclassification.MethodsUsing SAS 9.4 and Tableau 9.3, we examined data submissionsfrom 14 EDs responsible for 97% of the occurrences of the word‘denies’ in chief complaints in July 2016.To account for variation in chief complaint format among hospitals,we developed three PRX patterns to identify entire phrases in thechief complaint data field that began with conjugations of the word“deny” followed by various combinations of words, punctuation,spaces, and/or characters.Pattern 1: '/DEN(Y|I(ES|ED|NG))(\s|\w|(\/)|(\+)|,|(\\)){1,}((\.)|(\|)|($)|(;)|(\))|(-))/’Pattern 2: '/DEN(Y|I(ES|ED|NG))(\s|\w|(\/)|(\+)|(\\)){1,}((\.)|(\|)|($)|(;)|(\))|(-)|(,))/';Pattern 3: '/DENIES:( |\w|\.|,){1,}/');We separated the ‘denies’ statement from the chief complaint andidentified commonly negated symptoms. We then defined symptomsusing keyword searches of the chief complaint and the ‘denies’statement. We compared symptom classification with and withoutthe consideration of symptom negation.ResultsOf the 14 EDs analyzed, we applied pattern 1 to 8 of the ED’s,pattern 2 to 5 EDs, and patterns 2 and 3 to 1 ED. Approximately98% of denies statements were extracted from chief complaints. Only2% of symptom negation was not captured due to uncommon chiefcomplaint format whose symptom negation didn’t meet one of thepreviously described PRX patterns.The most common words associated with a “denies” statementwere: pain, chest, fever, loc, shortness, breath, vomiting, nausea,travel, headache, recent, trauma, history, abdominal, injury, diarrhea,SOB (shortness of breath), V (vomit), Head, N (nausea), PMH (pastmedical history), suicidal, dizziness, homicidal and D (diarrhea) (seeTable).By not taking negation into consideration in symptom definitions,between 3.5% and 16.5% of symptom visits were misclassified.Symptom misclassification varied greatly by hospital, ranging from0% to 55%.ConclusionsAs hospitals in NYC implement HL7 messaging, symptomnegation is becoming increasingly common in chief complaint data.Current symptom definitions are based on keyword searches that donot take into account symptom negations. This leads to symptommisclassification, and could potentially cause false signals or inflatesyndrome baselines, causing true signals to go undetected. SAS PRXfunctions can be used to flexibly identify symptom negation patternsand exclude them from syndrome definitions. Future studies willquantify the effect symptom negation has had on signal frequency inNYC, and examine symptoms associated with other forms of negationsuch as “Personal Medical History”, “No” and “Negative.”Most Common Symptoms Denied in Emergency Department Chief Complaints

Utility of a near real-time emergency department syndromic surveillance system to track injuries in New York City.

BackgroundThe New York City emergency department (ED) syndromic surveillance (SS) system provides near real-time data on the majority of ED visits. The utility of ED SS for injury surveillance has not been thoroughly evaluated. We created injury syndromes based on ED chief complaint information and evaluated their utility compared to administrative billing data.MethodsSix injury syndromes were developed: traffic-related injuries to pedal cyclists, pedestrians, and motor vehicle occupants; fall-related injuries; firearm-related injuries; and assault-related stabbings. Daily injury counts were compared for ED SS and the administrative billing data for years 2008–2010. We examined characteristics of injury trends and patterns between the two systems, calculating descriptive statistics for temporal patterns and Pearson correlation coefficients (r) for temporal trends. We also calculated proportions of demographic and geospatial patterns for both systems.ResultsAlthough daily volume of the injuries varied between the two systems, the temporal patterns were similar (all r values for daily volume exceeded 0.65). Comparisons of injuries by time of day, day of week, and quarter of year demonstrated high agreement between the two systems—the majority had an absolute percentage point difference of 2.0 or less. Distributions of injury by sex and age group also aligned well. Distribution of injury by neighborhood of residence showed mixed results—some neighborhood comparisons showed a high level of agreement between systems, while others were less successful.ConclusionsAs evidenced by the strong positive correlation coefficients and the small absolute percentage point differences in our comparisons, we conclude that ED SS captures temporal trends and patterns of injury-related ED visits effectively. The system could be used to identify changes in injury patterns, allowing for situational awareness during emergencies, timely response, and public messaging.Electronic supplementary materialThe online version of this article (doi:10.1186/s40621-015-0044-5) contains supplementary material, which is available to authorized users.

Monitoring Trends of Self-diagnosis in New York City Emergency Departments

Americans are increasingly accessing the internet for health information, and 35% of patients have used the internet to self-diagnose a condition. This analysis examines NYC Emergency Department syndromic surveillance chief complaints to determine if there is an increasing trend in self-diagnosis, and to characterize the types of patients who are most likely to self-diagnose. In addition, this study investigates the health impact of self-diagnosis by comparing hospital admission rates, a proxy for the severity of patient illness upon arrival at the hospital, among patients who self-diagnose versus those who do not.

Tracking HIV Post-Exposure Prophylaxis using Syndromic Surveillance in NYC Emergency Departments

HIV post-exposure prophylaxis (PEP) prescriptions are not uniformly monitored in the United States. We developed a method to identify PEP-related visits in New York City emergency departments (EDs). Using ED data, we observed a threefold increase in PEP-related visits to NYC EDs from 2002-2013. 73% of PEP-related visits were among males, and 45% among adults ages 25-34 years. Incorporation of this method of PEP monitoring in the NYC syndromic surveillance system will be used to observe trends and inform HIV outreach efforts.

Reciprocal Data Sharing: Sending Monthly Summary Reports of Syndromic Data to ED

New York City (NYC) emergency departments (EDs) expressed interest in receiving summary reports of the data they send to the NYC Department of Health and Mental Hygiene (DOHMH) syndromic surveillance system. We conducted key informant interviews with eight ED directors to determine variables of interest, along with preferred format and frequency of reporting. A two-page report was developed, summarizing total number of ED visits, top ten chief complaints, average number of visits by day of week and shift, and zip code distribution of visitors, to be sent monthly. The goal is to strengthen the relationship between the syndromic surveillance unit and the hospitals that provide us data by creating an ongoing bidirectional system of communication.

Comparison between HL7 and Legacy Syndromic Surveillance Data in New York City

As part of the Center for Medicare and Medicaid Services Electronic Health Record Incentive Program, otherwise known as Meaningful Use, many New York City emergency departments participating in the city syndromic surveillance system have switched or are in the process of switching data format from text files to HL7 Messaging Standard Version 2.5.1. We evaluated data completeness, quality, and content from hospitals that are sending in both data formats in parallel. Although the sample size was small (n=4 hospitals), we found data completeness and quality improved as hospitals shifted to HL7 messaging. We will continue monitoring hospitals as they upgrade to this new format.

Personal Branding and Nurse Leader Professional Image

Who is your favorite television nurse? You know we all have one—even if we do not like to admit it. Is it Carol Hathaway from ER? The fact that she got up close and personal with George Clooney is enough for some; however, the fact that she tried to commit suicide at one point may be a detractor. Is it Jackie Peyton from Nurse Jackie, the gritty, adulterer, New York City emergency department registered nurse that has worked impaired, diverted drugs, and is now in a 12-step program after voluntarily giving up custody of her 2 children during a messy divorce? Perhaps you are an old school fan of shows such M*A*S*H and picture yourself a modern Hot Lips Houlihan, who enjoyed romantic trysts frequently throughout the long-running series? No registered nurse that has seen any of the portrayals of nursing in the media has ever gone a whole episode without shaking their head at one point and saying, “That is just not reality.” Maybe they all disgust you, and you quickly turn the channel whenever one of them pops up on your screen. However, we cannot ignore that the image of the nurse as emotionally unstable, addicted, and diverting her patients' medications, and/or sexually promiscuous has been perpetuated for decades, if not centuries. Ever since the 19th century, when most religious orders were no longer caring for the sick, and in their place, women that were convicted prostitutes were assigned to provide the care as part of their sentence, nurses have been euphemized as promiscuous. 1 Morris-Thompson T Shepard J Plata R Marks-Maran D Diversity, fulfillment and privilege: the image of nursing. J Nurs Manag. 2011; 19: 683-692 Crossref PubMed Scopus (25) Google Scholar

Prescription Opioid Guidelines and the Emergency Department

ABSTRACTOn January 10, 2013, Mayor Michael Bloomberg announced a set of recommendations intended to guide opioid analgesic prescribing in New York City emergency departments. The intent and scope of these guidelines are discussed through an interview bu an emergency medicine fellow with an expert in emergency medicine pain management and one of the authors of the guidelines. The guidelines are appended to the commentary.

A Survey of Data Recording Procedures at New York City Emergency Departments

The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) routinely collects daily emergency department (ED) data from 49 of NYC‰Ûªs 52 EDs. Very little information regarding ED-specific coding practices, procedures or health information systems was available to the DOHMH. With the goal of gaining more inforamtion about ED-specific coding practices, members of the DOHMH interviewed ED personnel at all 49 EDs. The information from these surveys is to be used to improve the DOHMH‰Ûªs ability to categorize ED visits into syndrome groupings.

HIV pre-exposure prophylaxis (PrEP)- knowledge and attitudes among a New York City emergency department patient population

Background HIV Pre-exposure Prophylaxis (PrEP), in which HIV-negative individuals receive antiretroviral medications to prevent HIV acquisition, has shown potential as a means to reduce HIV incidence among high-risk persons. The acceptability of PrEP among at-risk persons will strongly impact the effectiveness of PrEP. This study aimed to assess knowledge and attitudes towards PrEP within a demographically-mixed community with high HIV prevalence. Materials and methods A cross-sectional study was conducted with a convenience sample of Emergency Department (ED) patients at two New York City municipal hospitals. Eligible participants completed an anonymous written survey about knowledge and acceptability of PrEP. Means and standard deviations were calculated for continuous variables and proportions for categorical variables. Standard bivariate methods were used to compare acceptability and knowledge by race, ethnicity and gender. Results 474 ED patients agreed to participate. The study population was 40.9% male, 40.7% Latino and 38.2% non-Hispanic Black. 7 participants (1.5%) self-identified as MSM. Mean age was 35.3, SD +/- 13.1 years. 66.4% reported inconsistent condom use and 78.4% had previously had an HIV test. 13.3% reported knowledge of either the term “PrEP” or the use of antiretroviral medications to prevent HIV acquisition. More people indicated they were unlikely or extremely unlikely to use PrEP (40.1%) than indicated they would likely take PrEP if available (32.2%). Many (27.7%) were unsure if they would or would not take PrEP. 44.4% thought that individuals would stop using condoms if on PrEP, while 27.0% thought that individuals would continue using them. Some participants (28.4%) incorrectly thought that PrEP needed to be taken only prior to sex. There were no differences in knowledge or acceptability of PrEP by gender. Latinos were more likely (17.6%) than blacks (8.8%) and others (12.4%) to report knowledge of PrEP. Conclusions Potential providers of PrEP must consider limitations in acceptability to this HIV prevention strategy. Future administration of PrEP must incorporate patient education to ensure user understanding of the technology and its potential limitations.

Evaluating the New York City Emergency Department Syndromic Surveillance for Monitoring Influenza Activity during the 2009-10 Influenza Season

Objective: To use laboratory data to assess the specificity of syndromes used by the New York City emergency department (ED) syndromic surveillance system to monitor influenza activity. Design: For the period from October 1, 2009 through March 31, 2010, we examined the correlation between citywide ED syndrome assignment and laboratory-confirmed influenza and respiratory syncytial virus (RSV). In addition, ED syndromic data from five select NYC hospitals were matched at the patient and visit level to corresponding laboratory reports of influenza and RSV. The matched dataset was used to evaluate syndrome assignment by disease and to calculate the sensitivity and specificity of the influenza-like illness (ILI) syndrome. Results: Citywide ED visits for ILI correlated well with influenza laboratory diagnoses (R=0.92). From October 1, 2009, through March 31, 2010, there were 264,532 ED visits at the five select hospitals, from which the NYC Department of Health and Mental Hygiene (DOHMH) received confirmatory laboratory reports of 655 unique cases of influenza and 1348 cases of RSV. The ED visit of most (56%) influenza cases had been categorized in the fever/flu syndrome; only 15% were labeled ILI. Compared to other influenza-related syndromes, ILI had the lowest sensitivity (15%) but the highest specificity (90%) for laboratory-confirmed influenza. Sensitivity and specificity varied by age group and influenza activity level. Conclusions: The ILI syndrome in the NYC ED syndromic surveillance system served as a specific but not sensitive indicator for influenza during the 2009-2010 influenza season. Despite its limited sensitivity, the ILI syndrome can be more informative for tracking influenza trends than the fever/flu or respiratory syndromes because it is less likely to capture cases of other respiratory viruses. However, ED ILI among specific age groups should be interpreted alongside laboratory surveillance data. ILI remains a valuable tool for monitoring influenza activity and trends as it facilitates comparisons nationally and across jurisdictions and is easily communicated to the public.

Results From a New York City Emergency Department Rapid HIV Testing Program

Results From a New York City Emergency Department Rapid HIV Testing Program