Coronavirus Disease 2019 (COVID-19) Diagnostic Clinical Decision Support: A Pre-Post Implementation Study of CORAL (COvid Risk cALculator)

Abstract

Background Isolation of hospitalized persons under investigation (PUIs) for COVID-19 reduces nosocomial transmission risk. Efficient PUI evaluation is needed to preserve scarce healthcare resources. We describe the development, implementation, and outcomes of an inpatient diagnostic algorithm and clinical decision support system (CDSS) to evaluate PUIs. Methods We conducted a pre-post study of CORAL (COvid Risk cALculator), a CDSS that guides frontline clinicians through a risk-stratified COVID-19 diagnostic workup, removes transmission-based precautions when workup is complete and negative, and triages complex cases to Infectious Diseases (ID) physician review. Pre-CORAL, ID physicians reviewed all PUI records to guide workup and precautions. Post-CORAL, frontline clinicians evaluated PUIs directly using CORAL. We compared pre- and post-CORAL frequency of repeat SARS-CoV-2 nucleic acid amplification tests (NAATs), time from NAAT result to PUI status discontinuation, total duration of PUI status, and ID physician work-hours, using linear and logistic regression, adjusted for COVID-19 incidence. Results Fewer PUIs underwent repeat testing after an initial negative NAAT post-CORAL than pre-CORAL (54% vs. 67%; aOR 0.53, 95% CI: 0.44-0.63, p<0.01). CORAL significantly reduced average time to PUI status discontinuation (adjusted difference: -7.4 [SE 0.8] hours/patient; p<0.01), total duration of PUI status (adjusted difference: -19.5 [SE 1.9] hours/patient; p<0.01), and average ID physician work-hours (adjusted difference: -57.4 [SE 2.0] hours/day; p<0.01). No patients had a positive NAAT within 7 days after discontinuation of precautions via CORAL. Conclusions CORAL is an efficient and effective CDSS to guide frontline clinicians through the diagnostic evaluation of PUIs and safe discontinuation of precautions.

Yield of Severe Acute Respiratory Syndrome Coronavirus 2 Lower Respiratory Tract Testing After a Negative Nasopharyngeal Test Among Hospitalized Persons Under Investigation for Coronavirus Disease 2019

“…Repeated NAATs for diagnosis were recommended either by infectious diseases physicians (through 20 May 2020) or by the CORAL (COvid Risk cALculator) diagnostic algorithm (21 May 2020 onward) [ 9 ]. Sputum induction was not recommended.…”

“…Sputum induction was not recommended. URT NAATs were almost exclusively performed on nasopharyngeal specimens using US Food and Drug Administration (FDA) emergency use authorization (EUA) assays [ 9 , 10 ]. LRT NAATs were performed at the Massachusetts state laboratory, or with an internally validated protocol using the Cepheid Xpert Xpress SARS-CoV-2 assay.…”

COVID-19 and the future of clinical epidemiology

“…Implementation of CORAL resulted in a reduction in the time that patients were in diagnostic limbo and in the more efficient use of the limited COVID-19 test capacity. 19 …”

A Simplified Point-of-Care Lung Ultrasound Protocol to Detect Coronavirus Disease 2019 in Inpatients: A Prospective Observational Study

“…6,10 In our hospital system, either a CXR or a CT is required for all admitted patients with a clinical suspicion for COVID-19 (based on history and demographics) and a negative swab. 11 If CXR findings are concerning for COVID-19, a CT scan and second NAT are often recommended.…”