Clinical Decision Support Tool Accelerates COVID-19 Evaluations

A clinical decision support tool can guide clinicians through diagnostic evaluations of patients with COVID-19 symptoms, significantly reducing the time it takes to assess these patients, according to a study published in Clinical Infectious Diseases.

When patients go to the hospital or emergency department with COVID-19 symptoms, it’s essential to isolate them so that the infection doesn’t spread. However, keeping patients isolated longer than necessary can delay patient care, take up beds needed for other patients, and unnecessarily utilize personal protective equipment.  

In spring 2020, the Infectious Diseases Society of America recommended repeating a COVID-19 test in patients with moderate to high probability of COVID-19. But there was little guidance about what factors contributed to a patient being low or high probability. Experts at Massachusetts General Hospital (MGH) aimed to develop a solution.

“A team of infectious disease specialists at MGH worked around the clock to review admitted patients one by one to provide guidance about who needed additional testing and whose probability of COVID-19 was low enough that isolation could be discontinued," said Caitlin Dugdale, MD, an infectious disease physician at MGH and one of the study's co-first authors.

The effort led to the development of a clinical decision support tool called the COvid Risk cALculator (CORAL). The tool is embedded within the EHR, and was developed based on a review of the medical literature and the experience of a team of infectious disease experts.

When using CORAL to evaluate a patient with symptoms of COVID-19, a clinician will answer several questions about the patient’s risk factors, symptoms, and imaging findings, and is guided through a standardized COVID-19 diagnostic workup of the patient based on up-to-date guidelines.

"We designed the CORAL tool to be easy for frontline clinicians to use and also to help ensure patient and health care personnel safety," said Erica Shenoy, MD, PhD, an infectious diseases physician and infection control expert and co-senior author of the study, who has served as the infection control clinical lead for Mass General Brigham's electronic health record for several years.

"By standardizing the approach to the assessment of patients with symptoms of COVID-19, we minimize the chance that a patient with a false-negative test escapes detection, which could put other patients and health care personnel at risk of exposure."

The study showed that CORAL significantly reduced the time required by clinicians to assess patients, and it also decreased the average time that patients were kept in isolation during evaluation for COVID-19.

Among 2,000 patients assessed with CORAL, none had a positive COVID-19 test within seven days after discontinuation of precautions via CORAL.

Researchers noted that since CORAL’s launch in May 2020, the tool has been used more than 30,000 times and is now in place at eight acute care hospitals in the Boston area, as well as four rehabilitation hospitals. In October 2020, the team launched an outpatient version of CORAL that is now in use in hundreds of Mass General Brigham affiliated practices.

CORAL can also be adapted as new guidelines or research associated with COVID-19 diagnostics emerge.

The study was limited in that it was conducted a single institution with specific testing protocols and guidelines for discontinuing precautions to prevent the spread of the virus. However, the team pointed out that other organizations have similar protocols and guidelines, and CORAL has since been implemented in other affiliated facilities.

The group believes that CORAL can provide clinicians with valuable insights – while seamlessly integrating with existing workflows.

“While other scoring systems have demonstrated reasonable sensitivity for COVID-19 infection compared with a single SARS-CoV-2 nucleic acid amplification test, CORAL remains unique as the only algorithm, to our knowledge, that has been incorporated into routine, prospective clinician workflow via an EHR clinical decision support system,” researchers concluded.

“CORAL guides clinicians through additional diagnostic recommendations after a negative test, which other published tools do not incorporate.”