EMERGEncy ID NET: An Emergency Department–Based Emerging Infections Sentinel Network,☆☆,,★★,

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Abstract

Acute infectious disease presentations among many at-risk patient groups (eg, uninsured, homeless, and recent immigrants) are frequently seen in emergency departments. Therefore EDs may be useful sentinel sites for infectious disease surveillance. This article describes the background, development, and implementation of EMERGE ncy ID NET, an interdisciplinary, multicenter, ED-based network for research of emerging infectious diseases. EMERGE ncy ID NET was established in cooperation with the National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC) as part of the CDC’s strategy to expand and complement existing disease detection and control activities. The network is based at 11 university-affiliated, urban hospital EDs with a combined annual patient visit census of more than 900,000. Data are collected during ED evaluation of patients with specific clinical syndromes, and are electronically stored, transferred, and analyzed at a central receiving site. Current projects include investigation of bloody diarrhea and the prevalence of Shiga toxin–producing Escherichia coli , animal exposures and rabies postexposure prophylaxis practices, seizures and prevalence of neurocysticercosis, nosocomial ED Mycobacterium tuberculosis transmission, and hospital isolation bed use for adults admitted for pneumonia or suspected tuberculosis. EMERGE ncy ID NET also was developed to be a mechanism for rapidly responding to new diseases or epidemics. Future plans include study of antimicrobial use, meningitis, and encephalitis, and consideration of other public health concerns such as injury and national and international network expansion. [Talan DA, Moran GJ, Mower WR, Newdow M, Ong S, Slutsker L, Jarvis WR, Conn LA, Pinner RW, for the EMERGE ncy ID Net Study Group: EMERGE ncy ID Net: An emergency department–based emerging infections sentinel network. Ann Emerg Med December 1998;32:703-711]

Section snippets

INTRODUCTION

In the last decade, 3 reports by expert committees convened by the Institute of Medicine emphasized the ongoing threat of emerging infectious diseases to domestic health.1, 2, 3 In 1994 the Centers for Disease Control and Prevention (CDC) issued the report, “Addressing Emerging Infectious Disease Threats: A Preventive Strategy for the US,” that identified the priority of confronting the current limitations of the public health system and proposed a strategic plan to address emerging infections

CONCEPTUAL BASIS

Recognition of the role that EDs could play in the study of infectious diseases prompted Olive View–UCLA investigators to study various syndromes including bacterial meningitis, dog and cat bite infections, pyelonephritis, HIV infection, and tuberculosis infection control. Some of these projects required multicenter study or led to CDC collaboration. These experiences provided the conceptual underpinning for discussions between emergency medicine and CDC representatives that led to development

DEVELOPMENT AND STRUCTURE OF EMERGENCY ID NET

EMERGE ncy ID NET has 3 components: (1) study sites, where patient data are collected, (2) the Olive View–UCLA Medical Center, where the principal investigators administer the network and concatenate data, and (3) the CDC, where collaborative representatives participate in study design, direction, and analyses, and where specialized laboratory testing is done.

In 1995–1996, the network sites were recruited from university-affiliated medical centers that had previously participated in multicenter

DATA COLLECTION

Every study patient initially undergoes a clinical evaluation as per usual practice. The examining physician, typically a resident in training, then determines whether the patient meets the case definition for a syndrome under study. Data capture for qualifying patients occurs at the bedside during the ED visit. To enhance patient enrollment, some study site investigators use incentive programs to enhance physician participation (eg, lotteries for book stipends and tee-shirts).

Data to be

DATA MANAGEMENT AND TRANSFER

IBM-compatible microcomputers are used as workstations at each site. A database application displays data questionnaires and directly stores and manages study data. The program reads screen images from a data table, displays the images, and collects responses into the template via keyboard or mouse. The program is capable of presenting screen images and storing data for multiple concurrent studies. Captured data are initially stored in a relational database on the microcomputer hard disk drive

QUALITY ASSURANCE

Case finding sensitivity is determined through audits at each site. ED patient logs are reviewed during audit periods of 1 month per year. Standardized screening criteria for log entry diagnoses that would possibly include case definitions are established. For example, for bloody diarrhea, all cases with the ED diagnosis of diarrhea, gastroenteritis, and dysentery are reviewed. All charts meeting these screening criteria diagnoses for unenrolled patients are reviewed to identify missed cases

EMERGING INFECTIOUS DISEASES CURRENTLY UNDER STUDY

The process by which emerging infectious diseases and corresponding clinical syndromes are selected for study is as follows. CDC Divisions/Programs/offices are informed about the existence and nature of EMERGE ncy ID NET and are asked to identify emerging infectious diseases that might be studied through this network, particularly those encompassed in acutely presenting syndromes that prompt ED presentation. A prioritized list is developed, based on public health importance, and reviewed with

EMERGENCY MEDICINE EDUCATION

In 1997, in order to foster communication between public health agencies and emergency physicians about emerging infections, EMERGE ncy ID NET established a special section in the Annals of Emergency Medicine entitled “Update on Emerging Infections from the Centers for Disease Control and Prevention.” This bimonthly feature summarizes and provides commentary about important Mortality and Morbidity Weekly Reports (MMWR) articles on emerging infections with relevance to ED practitioners.

FUTURE DIRECTIONS

EMERGE ncy ID NET is designed to be flexible and allow easy incorporation of new sites and new project areas. The network may be expanded according to geographic and demographic considerations. Because of population biases associated with academic emergency centers, consideration will be given to incorporating other types of ED sites, such as community hospital–based EDs. We also have received inquiries from other countries regarding our ability to either expand into an international network,

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    For the EMERGEncy ID NET Study Group

    ☆☆

    From the Olive View–UCLA Medical Center, Sylmar, CA, UCLA School of Medicine,* and the UCLA Emergency Medicine Center, UCLA School of Medicine, Los Angeles, CA, and the National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA.§

    Members of the EMERGEncy ID NET Study Group are listed in the Appendix.

    ★★

    Address for reprints: David A Talan, MD, Department of Emergency Medicine, Olive View–UCLA Medical Center, 14445 Olive View Drive—North Annex, Sylmar, CA 91342, E-mail [email protected]

    47/1/94306

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