This surveillance system goes beyond bioterrorism

Patterns, outbreaks show up in EDs

A project that started out as a response to post-9/11 bioterrorism fears is turning out to have much more practical everyday applications, say two ED managers who have pioneered the use of a system that monitors for unusual patterns or patient surges. While still valuable for detecting terrorist attacks, the system can reveal more mundane but useful information in any ED, they say.

Several hospitals in Florida have been trying a unique bioterrorism surveillance system, developed by the University of South Florida’s Center for Biological Defense in Tampa, that uses real-time monitoring of ED patients for evidence of exposure to biological agents and health epidemics. The hospitals were chosen because of their proximity to MacDill Air Force Base in Tampa and the large theme parks in central Florida — all prime targets for a bioterrorism attack.

There haven’t been any attacks yet, but the ED managers at two of the hospitals tell ED Management the system has revealed other patterns and naturally occurring outbreaks that otherwise might have gone unnoticed.

The project began about three years ago, originally as a research project, says Michael Leon, RN, research coordinator for the project at Celebration (FL) Health, which provides health care to the town of Celebration, originally designed by the Walt Disney Company. After 1½ years of research, hospital leaders decided to implement the system fully at the hospital and also at two sister facilities, Florida Hospital Kissimmee and Florida Hospital East Orlando.

"We spotted a Legionnaire’s [disease] case recently that we might not have caught," Leon says. "The system is constantly looking for symptoms that match a list that could mean trouble."

The program involves screening patients for signs of eight major syndromes indicative of biological exposures from naturally occurring outbreaks and intentional bioterrorism attacks. These syndromes include upper- and lower-respiratory tract infections, influenzalike illnesses, botulismlike syndromes, and many others. The information then is used to provide timely alerts of epidemics that occur naturally or intentionally.

Any ED can implement the surveillance system, Leon says, and the surveillance could prove useful in any well-populated area. (For contact information for the Center of Biological Defense and to find out more about the system, see sources at the end of this article.) The alert from the system can be received as an e-mail, a page, a phone call, or all three. At Celebration Health, the ED spent between $8,000 and $12,000 for the surveillance system and employs two data collection clerks who work two hours a day, seven days a week, at a cost about $15,000 per year combined.

The Florida EDs have detected numerous illnesses that might have gone undetected without the system, Leon says. One of the best benefits so far was when the surveillance helped Celebration Health detect the onset of the flu season in October, long before the local health department clued in.

"The state didn’t say anything until February, but by then we’d made sure we had enough antibiotics in stock and the staff were prepared for the increased load," Leon says. "We were able to spot those patients earlier and make sure they weren’t spreading the flu through our waiting area."

To avoid spreading the flu, patients with flu symptoms were directed to separate waiting areas and generally kept away from other patients as much as possible, Leon says.

The system also helped identify cases of meningitis and gastroenteritis at Florida Celebration Health, says Barb Gabel, BSN, CEN, director of the ED.

"With that notification, we can be more aware of what’s going on in the ED and what we might expect to come in the door next," she says. "It helps us be more proactive."

One more piece of paper in the chart doesn’t add any significant work burden, and participation in the system is well worth the effort, she says. In particular, the ED staff are assured they have a way to spot naturally occurring infections or bioterrorist attacks at the local theme parks as early as possible. The possibility of a major outbreak among tourists is a constant concern, she explains. "It’s always better to know earlier rather than later," Gabel says.

The program is designed to run manually or automated. If the ED has an automated documentation system, the surveillance system will add a pop-up screen that asks if the patient has certain symptoms that correspond with the illnesses under surveillance. That information is sent immediately to an Internet site that compares the data to what is typical for that ED.

At Celebration, there is no automated documentation system, so the surveillance relies on a manual system instead. The triage nurse fills out a special blue form that asks if the patient meets certain criteria for the illnesses under surveillance. If not, the nurse simply checks the "no syndrome" box indicating so. Ninety-seven percent of the ED patients fall into that category.

For the other 3% with symptoms, the form includes further questions such as whether the person has attended one of the local theme parks or been on a cruise ship. That blue sheet stays with the patient’s chart, and at the end of the day, information from all of the forms is entered into the computer and sent to the surveillance system’s web site for analysis.

Patient data are de-identified, but there is a tracking number the ED can use to trace back to the patient if needed. The system immediately can return any alerts based on that information, which Leon says is faster than an infection control practitioner or ED manager reviewing all the charts daily or weekly to look for trends.

"On our own, we may not realize trends until way down the line," he says. "Staff work their shift and go home, and then it may take several shifts before anyone starts talking and realizes that we’ve had an awful lot of patients with a strange rash lately."


For more about the surveillance system, contact:

  • Center for Biological Defense, Tampa, FL. Phone: (813) 974-6663. Web:
  • Barb Gabel, BSN, CEN, Director, Emergency Department, Celebration Health, 400 Celebration Place, Celebration, FL 34747. Phone: (407) 764-4000.
  • Michael Leon, RN, Research Coordinator, Celebration Health, 400 Celebration Place, Celebration, FL 34747. Phone: (407) 764-4000.