Managing Death Reporting at a Peak of the COVID-19 Pandemic in New York City in Spring 2020

The COVID-19 pandemic increased interest in death data and accelerated demand for accurate, timely death certificates and permits to facilitate appropriate disposition of the deceased.¹ Researchers may have little awareness of the death registration process, including how data are collected and verified and how these processes can be improved locally to ensure timely, high-quality data. One of 57 independent vital records jurisdictions in the United States responsible for the registration of births and deaths, New York City (NYC) registers approximately 55 000 deaths in a typical year. As NYC braced for the impact of the COVID-19 pandemic in March 2020, it made changes to its operations to accommodate excess deaths it anticipated but could not predict in magnitude. Ultimately, all-cause deaths rose from an average baseline of 150 per day to 1200, hovering at approximately 1000 deaths per day for two weeks.² This editorial summarizes changes made to staffing, systems, policy, and reporting to manage the surge. Knowledge of these changes may improve understanding of death data; provide insight into how to interpret heterogeneity in national data, which reflects the policy and practices of each of the 57 jurisdictions; and enhance other jurisdictions’ ability to respond to mass fatalities.

STAFFING

Death registration and analysis are essential services. The vital statistics team supports medical and funeral home staff who report deaths electronically through NYC’s electronic death registration system, eVital; manually enters paper certificates; codes literal text on death certificates to International Classification of Diseases, 10th Revision (ICD-10; Geneva, Switzerland: World Health Organization; 1992), standards; registers deaths in the official NYC record; and issues death certificates. Staffing and scheduling accommodate the usual volume of interactions required to manage 150 deaths per day, with the ability to flex to accommodate a modest increase in work, roughly equivalent to 50 additional calls or deaths per day. The volume of deaths during the first wave of the pandemic far exceeded this flexibility. Staffing was doubled, and schedules were either expanded or reduced, based on task, to better support electronic reporting, maximize capacity for producing death certificates for mailing and pickup by funeral directors, and make data available for analyses.

Corrections and amendments to death certificates, also essential, increased during the peak, likely because of the sudden and unexpected nature of the deaths that occurred. Corrections reflect loved ones needing time to make and then possibly change burial or cremation plans. Staff were tasked with prioritizing this work to manage the volume and scheduled to be on call after hours for urgent requests.

Although many employees in the agency transitioned to 100% remote work, most of the team reported to work in person at least one day per week, and the death registration team reported to work five days per week. Because this work was traumatic and difficult, we provided mental health resources for staff working on our death registration team.

SYSTEMS

Our electronic vital event management system, eVital, supports electronic reporting of vital events. In early 2020, 95% of deaths were reported electronically and 5% were reported on paper. Significant additional functionality was implemented in response to COVID-19. First, although human review of each death report had been part of our business process, we implemented automatic death registration. This action was feasible because extensive validation rules are already built into the data entry system to filter out poor-quality data and because we imposed a “hold” period during which a death reporter could make modifications to their entry before registration. To monitor the quality of the data, we initiated more frequent data quality assessments. We also created a new interface with our local medical examiner’s office, which facilitated more timely insight into and management of human remains at hospitals and nursing homes that had met their morgue capacity and needed city morgue storage. Pop-up boxes and modifications to the death and disposition data entry pages were made to ensure that deaths were properly characterized on death certificates. Finally, the system’s user list was leveraged to communicate guidance on how to complete the cause-of-death section on death certificates as per the World Health Organization and National Center for Health Statistics. All these changes were necessary to facilitate timely reporting of death data.

POLICY

Although staffing helped us process the electronically reported deaths, there were still deaths being reported on paper. Paper not only required in-person interactions but also forced a laborious and time-consuming process of manual death registration and slowed data reporting. A highly proficient staff member could manually register a paper death certificate in about 15 minutes, but we were receiving up to 50 such certificates each day, requiring 12.5 person-hours of work to complete, which was not sustainable. Thus, Emergency Executive Order No. 106 was issued on April 9, 2020, by the NYC mayor to suspend section 17-196 of the NYC Administrative Code, and on April 10, 2020, the NYC Commissioner of Health issued an emergency order to modify subdivision (4) of section 205.03 of the NYC Health Code. As a result, regulatory changes allowing NYC to require electronic death reporting, eliminating the need for funeral directors to bring paper certificates to the health department for registration, were implemented. Instead, funeral directors could print a work copy of a registered death certificate along with the burial permit and proceed with their efforts to support a family’s funeral preparation process. This change also allowed deaths to be registered and analyzed more rapidly.

ANALYTIC REPORTING

Timely provision of mortality data to decision-makers was critical to COVID-19 response planning. After deaths were electronically reported, they were coded by NYC nosologists, who assigned ICD-10 codes to each death more quickly than would have been possible if they had waited for national coding. To speed the transfer of data from eVital to our analysts, an extract from eVital to our mortality surveillance system was updated to capture certified but unregistered deaths for analysis. Seven days per week, analysts matched incoming lists of laboratory results with the list of deaths reported in NYC. Matched cases were reported as confirmed COVID-19 deaths, whereas those with a mention of COVID-19 on the death certificate but no positive laboratory test result were deemed probable COVID-19 deaths. The rich demographic data on the death certificate were also used for reporting. Data were posted to the NYC health department’s website each day. In addition, our mortality surveillance system was updated to include reports of deaths caused by COVID-19, which were analyzed in the context of other cause-of-death trends. Numerous additional ad hoc reports were also created. These were provided to city leadership to support planning for the response, modeling efforts by academic partners, and countless data requests by the media.

Data accuracy and timeliness are driven by local staffing, systems, policy, and reporting decisions. High-quality death data at the national level require investment and commitment to scientific integrity in each of the 57 independent vital records jurisdictions in the United States. In NYC, at a peak of the COVID-19 pandemic, we leveraged our existing staffing, administrative and health codes, electronic system, and analytic strengths to ensure timely and complete registration of each death and near real-time data reporting. This enabled NYC to fulfill its mandate to provide the documents, services, and data needed to support its response to the pandemic and New Yorkers’ response to the loss of their loved ones.