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ISDS Annual Conference Proceedings 2012. This is an Open Access article distributed under the terms of the Creative Commons Attribution-
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ISDS 2012 Conference Abstracts

Use of a Real-Time Syndromic Surveillance System to
Improve Influenza Like Illness Screening and
Documentation in Emergency Departments during the
H1N1 Pandemic
David Meurer*1, 3 and James Talbot2, 1

1University of Alberta, Edmonton, AB, Canada; 2Government of Alberta, Edmonton, AB, Canada; 3Alberta Health Services,
Edmonton, AB, Canada

Objective
Screening for Influenza Like Illness (ILI) is an important infec-

tion control activity within emergency departments (ED). When ILI
screening is routinely completed in the ED it becomes clinically use-
ful in isolating potentially infectious persons and protecting others
from exposure to disease. When routinely collected, ILI screening in
an electronic clinical application, with real time reporting, can be use-
ful in Public Health surveillance activities and can support resource
allocation decisions e.g. increasing decontamination cleaning. How-
ever, the reliability of documentation is unproven. Efforts to support
the adoption of ILI screening documentation in a computer applica-
tion, without mandatory field support, can lead to long term success
and increased adherence.

Methods
We evaluated the impact of efforts to improve ILI screening doc-

umentation adherence in an electronic ED information system (EDIS)
during wave 2 of the September-November 2009 H1N1 pandemic.
ILI screening documentation rates were calculated across the 8 sites
in Edmonton Zone of Alberta Health Services and subsequently cor-
related to interventions. Five interventions were evaluated: real-time
verbal reminders (one-to-one nurse reminders), delayed email re-
minders (with the ILI screening documentation rates), meetings
(strategize to improve documentation rate), media (visual media
broadcasts) and clinic awareness (opening and operation of the in-
fluenza assessment clinic).  A logistic regression model was used to
derive odds ratios (OR) and 95% confidence intervals (CI) for corre-
lation between the interventions and the screening rate change.

Results
The ILI screening not-documented (N/D) rate on September 27,

2009, was 75% (N/D = 781; ED visits = 1039). By November 25, the
N/D rate had fallen to 11% and remained below 20% into July 2010.
October 18, 2009 marked the first day that the daily positive (POS)
ILI screen rate was at or above 10% of patient visits with a rate of
12% (POS = 139; ED visits = 1164). The POS rate sustained values
>10% until November 25(peaking at 40% on October 28, 2009) re-

flecting influenza activity and informing public health and other de-
cision makers. When all site screening rates were aggregated and
compared to the intervention variables – e-mail reminders (OR =
2.176; 95% CI: 2.078-2.279), meetings (OR = 2.286; 95% CI: 2.089-
2.501), media (OR = 4.894; 95% CI: 4.219-5.677), clinic awareness
(OR = 1.145; 95% CI: 0.998-1.313) were positively associated with
increased adherence. Where one-to-one reminders to document ILI
screening were provided at one site, the ILI documentation increased
(OR = 2.663; 95% CI: 2.260-3.138). E-mail reminders (OR = 0.852;
95% CI: 0.732-0.992) and meetings (OR = 0.696; 95% CI: 0.505-
0.960) had less influence on ILI documentation when the single site
was analyzed.

Conclusions
A variety of interventions successfully improved ILI screening

documentation. The greatest impact was associated with e-mail re-
minders for recording ILI screening results, meetings on how to im-
prove adherence and media broadcasts associated with the circulating
pandemic influenza. The strongest reported effect size was seen in
one site following one-to-one nurse reminders to record the ILI
screening results. These results suggest that ILI documentation ad-
herence can be successfully increased using a variety of interven-
tions. Implementing and monitoring the effect of the interventions
was made possible by the syndromic surveillance system, which at
the same time, contributed to improved data used for infection pre-
vention and control and public health purposes.

Keywords
decision support; Influenza Like Illness; screening; documentation;
adherence

Acknowledgments

Alberta Health and Wellness, Government of Alberta. Alberta Health
Services.

*David Meurer
E-mail: david.meurer@ualberta.ca

Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 5(1):e34, 2013