What-if questions can torment a doctor making coronavirus retest decisions: What if a patient’s initial negative test was a false negative, and he or she needs a second test? What if they don’t need it, and a retest would use up a scarce test kit and treatments that other patients need?

Such challenges led Piedmont Healthcare in Atlanta to establish a paper-based decision tree for ordering COVID-19 retests, and researchers at the Georgia Institute of Technology turned it into an automated digital tool. Piedmont further developed the tool and has now built it into the hospital’s electronic medical record, where it influences the ordering of retests.

A user can answer their “ifs” by clicking through questions, and the “if-this-then-do-that” algorithm makes recommendations for best courses of action, ranging from immediately treating a patient for COVID-19 to retesting to consulting a specialist. The final decision remains with the physician.

The questions are deceptively simple, but the recommendations are not always obvious. That reflects the algorithm’s usefulness to fill gaps in thinking about the new sickness, which can confront clinicians with surprises.

“If a patient has not had close contact with positive patients and the first test came back negative, a physician may think the patient does not need to be retested. But actually, the patient may need a second test because they are in intensive care and also have suspicious chest X-rays,” said Georgia Tech graduate research assistant April Yu, who converted the decision tree into a digital tool.

“One of our big worries in using a brand-new test like the coronavirus test is that it will miss real cases, and this tool helps prevent that,” said Dr. Bronwen Garner, who helped develop the original decision tree and is an infectious disease specialist at Piedmont Healthcare. “It also helps reassure physicians when they get a negative result that it is probably a true negative.”

Suspenseful decision-making

A physician’s reaction to an initial negative test can mean life or death because the physician not only decides on follow-up testing but also on treatment pathways and quarantine.

“If you make a misstep in the thought process, it can lead to cascading impacts not only for the patient but also for healthcare professionals and family members, who may be exposed to the patient,” said Pinar Keskinocak, William W. George Chair and Professor in Georgia Tech’s Stewart School of Industrial and Systems Engineering. “This tool is meant to help doctors easily stay on the decision tree path.”

Michael O’Toole, executive director of Piedmont Healthcare’s quality improvement department, originally pictured doctors getting an automated version of the decision tree to use on their phones. O’Toole called Keskinocak, and she tapped Yu, a member of her research group.

“Literally within four hours they had it ready for us. It was incredible,” said O’Toole, a Georgia Tech alumnus who studied industrial and systems engineering.

“It was a very pleasant surprise,” said Dr. Garner, who is also a Georgia Tech graduate. “Automated tools are better than a paper format because they’re in the same format as orders in our electronic system. We get notifications in real time instead of having to remember to check a piece of paper.”

The tool is in place in the system where doctors order retests and is specific to Piedmont’s workflow. It may not be directly transferable to other health care systems.

Piedmont Healthcare simplified the logic even more, and the hospital built its own custom alerts to guide physicians on retesting. For cases that are more ambiguous, Piedmont Healthcare’s final version of the tool also gives physicians inside the hospital guidance to consult with their in-house infectious disease specialists.

If-this-then-retest

In her original version, Yu had turned the decision tree criteria into a short panel of questions with yes and no answers. It took her six iterations to arrive at her final version.

Yu’s version asked whether the patient:

• has a relevant ailment
• previously tested positive for coronavirus
• is now in an intensive care unit
• has worsening lung conditions
• shows telltale lung damage in imaging
• has been diagnosed with a different ailment
• the patient has had contact with someone else who tested positive for coronavirus.

On the back end, the algorithm guided the user through risks of coronavirus presence based on the answers.

“The steps were easy to follow, and the answers were color-coded for urgency with white, yellow, and red,” said Keskinocak, who also directs Georgia Tech’s Center for Health and Humanitarian Systems.

One bright yellow answer read: “This patient needs re-testing 24 hours after the initial test!” And there were further recommendations on how to handle the case.

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Also read: Advice on DIY masks

Writer & Media Representative: Ben Brumfield (404-272-2780), email: ben.brumfield@comm.gatech.edu

Georgia Institute of Technology

Georgia Tech Arts is still seeking projects for the 2021 ACCelerate: ACC Smithsonian
Creativity and Innovation Festival in Washington, DC. All Georgia Tech students, faculty, and staff are invited to apply by May 1, 2020.

Even if you do not have a finished project exploring the intersection of science,
engineering, art, design, and technology, we encourage you to speak with Es
Famojure at esther.famojure@arts.gatech.edu about your concepts.

Learn about Georgia Tech's 2019 participants for some inspiration.

The festival brings together all institutions included in the Atlantic Coast Conference to
celebrate creativity and innovation with a specific focus on science, engineering, arts, and
design. It will be held April 9 -11, 2021 at the Smithsonian National Museum of American
History.

Submit your project for consideration by May 1, 2020 to be considered.

LEARN MORE & APPLY

What-if questions can torment a doctor making coronavirus retest decisions: What if a patient’s initial negative test was a false negative, and he or she needs a second test? What if they don’t need it, and a retest would use up a scarce test kit and treatments that other patients need?

Such challenges led Piedmont Healthcare in Atlanta to establish a paper-based decision tree for ordering COVID-19 retests, and researchers at the Georgia Institute of Technology turned it into an automated digital tool. Piedmont further developed the tool and has now built it into the hospital’s electronic medical record, where it influences the ordering of retests.

A user can answer their “ifs” by clicking through questions, and the “if-this-then-do-that” algorithm makes recommendations for best courses of action, ranging from immediately treating a patient for COVID-19 to retesting to consulting a specialist. The final decision remains with the physician.

The questions are deceptively simple, but the recommendations are not always obvious. That reflects the algorithm’s usefulness to fill gaps in thinking about the new sickness, which can confront clinicians with surprises.

“If a patient has not had close contact with positive patients and the first test came back negative, a physician may think the patient does not need to be retested. But actually, the patient may need a second test because they are in intensive care and also have suspicious chest X-rays,” said Georgia Tech graduate research assistant April Yu, who converted the decision tree into a digital tool.

“One of our big worries in using a brand-new test like the coronavirus test is that it will miss real cases, and this tool helps prevent that,” said Dr. Bronwen Garner, who helped develop the original decision tree and is an infectious disease specialist at Piedmont Healthcare. “It also helps reassure physicians when they get a negative result that it is probably a true negative.”

Suspenseful decision-making

A physician’s reaction to an initial negative test can mean life or death because the physician not only decides on follow-up testing but also on treatment pathways and quarantine.

“If you make a misstep in the thought process, it can lead to cascading impacts not only for the patient but also for healthcare professionals and family members, who may be exposed to the patient,” said Pinar Keskinocak, William W. George Chair and Professor in Georgia Tech’s Stewart School of Industrial and Systems Engineering. “This tool is meant to help doctors easily stay on the decision tree path.”

Michael O’Toole, executive director of Piedmont Healthcare’s quality improvement department, originally pictured doctors getting an automated version of the decision tree to use on their phones. O’Toole called Keskinocak, and she tapped Yu, a member of her research group.

“Literally within four hours they had it ready for us. It was incredible,” said O’Toole, a Georgia Tech alumnus who studied industrial and systems engineering.

“It was a very pleasant surprise,” said Dr. Garner, who is also a Georgia Tech graduate. “Automated tools are better than a paper format because they’re in the same format as orders in our electronic system. We get notifications in real time instead of having to remember to check a piece of paper.”

The tool is in place in the system where doctors order retests and is specific to Piedmont’s workflow. It may not be directly transferable to other health care systems.

Piedmont Healthcare simplified the logic even more, and the hospital built its own custom alerts to guide physicians on retesting. For cases that are more ambiguous, Piedmont Healthcare’s final version of the tool also gives physicians inside the hospital guidance to consult with their in-house infectious disease specialists.

If-this-then-retest

In her original version, Yu had turned the decision tree criteria into a short panel of questions with yes and no answers. It took her six iterations to arrive at her final version.

Yu’s version asked whether the patient:

• has a relevant ailment
• previously tested positive for coronavirus
• is now in an intensive care unit
• has worsening lung conditions
• shows telltale lung damage in imaging
• has been diagnosed with a different ailment
• the patient has had contact with someone else who tested positive for coronavirus.

On the back end, the algorithm guided the user through risks of coronavirus presence based on the answers.

“The steps were easy to follow, and the answers were color-coded for urgency with white, yellow, and red,” said Keskinocak, who also directs Georgia Tech’s Center for Health and Humanitarian Systems.

One bright yellow answer read: “This patient needs re-testing 24 hours after the initial test!” And there were further recommendations on how to handle the case.

Here's how to subscribe to our free science and technology newsletter

Also read: Advice on DIY masks

Writer & Media Representative: Ben Brumfield (404-272-2780), email: ben.brumfield@comm.gatech.edu

Georgia Institute of Technology

COVID-19 has caught Pinar Keskinocak well prepared. For years, she has studied how societies manage pandemics, and how outbreaks overtax the health care system and wrack supply chains to worsen pandemics. Here she shares her insights.

Empty classrooms and supermarket shelves marked the beginning of the COVID-19 pandemic. But Keskinocak expects more signs of the times to come – such as pop-up pandemic clinics and the shortage and rationing of medical supplies beyond masks and ventilators.

Keskinocak is the director of the Center for Health and Humanitarian Systems at the Georgia Institute of Technology, which studies how government and private sectors can cooperate to handle health and humanitarian crises. And she is William W. George Chair and Professor in Georgia Tech’s H. Milton Stewart School of Industrial and Systems Engineering.

In previous research, Keskinocak’s team created a model that accurately ran the course of the 1918 Spanish flu pandemic, and when COVID-19 struck, her team was already in the middle of modeling how special clinics could significantly slow a pandemic. In the meantime, temporary clinics in Wuhan, China, appear to have validated her model.

Healthcare expansion now

The surge of COVID-19 patients pushed Italy’s health care system into a very ugly crisis, and the U.S. needs to take measures now to handle similar patient surges. Pandemics often strike in two waves or more, and the second is usually the worst, so measures need to be lasting, Keskinocak said.

Even without COVID-19, the U.S. healthcare system has been under strain. Emergency rooms are often overcrowded; it takes a long time to schedule an appointment, and there is a chronic shortage of nursing staff.

[Read Keskinocak's guest op-ed in the New York Daily News: COVID clinics now]

“We need to expand capacity and unleash creative flexibility in our healthcare systems. We should use more telemedicine and create self-service stations for testing. I would particularly like to see specialized COVID-19 clinics established now,” Keskinocak said.

“Special clinics could be separate spaces in existing facilities or standalone facilities. As COVID-19 spreads, we expect a lot more people with cold- and flu-like symptoms to seek testing and care. The healthcare capacities are just not there for a business as usual approach, and taking it could harm patients by delaying care and increasing risk of infection.”

Gathering COVID-19 patients in tight spaces like waiting rooms with other patients would increase the coronavirus’ spread, and patients with preexisting conditions could face mortal threat. Contagion could also spread into hospitals.

“Dedicated pandemic clinics could implement targeted hygiene, air filtration, and specialized protective equipment beyond masks and gloves for healthcare workers. They can tailor workflows to test and care for patients quickly and effectively and keep them away from other patients and staff,” Keskinocak said.

Payment needs to be easy, too, including financing the uninsured. In the middle of a public health emergency, it is vital to not get bogged down by restrictions meant for normal times.

Potentially dangerous shortages

Toilet paper will make a comeback in supermarkets, but in its place, life-saving medications could become perilously scarce. Countries need to act now to prevent this from compounding the COVID-19 crisis.

“Dwindling availability of hospital beds, ventilators, and personal protective equipment like masks and gloves during a patient surge – those are the obvious things. But we could also see shortages of items like asthma medication or antidepressants. Worst case, even food supplies could run low,” Keskinocak said.

[Read Keskinocak's guest op-ed in The Hill: medical supply chain dangers]

Here’s how shortages work and can lead to price gouging and also rationing. The latter can have good effects.

“Shortages are the result of supply-demand imbalance caused by either an unexpected increase in demand or unexpected decrease in supply or both. Shortages are common in crises such as natural disasters or health emergencies. But given the worldwide slowdown of economic activity in pandemics, disruptions could get much worse this time,” Keskinocak said.

“Supply chains are actually intricate webs of multiple parts that span the globe. Pandemics damage many of those parts, and it can take time to recover. This creates a more serious and worrisome imbalance between supply and demand.”

Toilet paper will return because people fear-hoard it in a panic but consume it at normal rates. When the panic runs its course, demand slows back down to the actual rate of consumption and its normal supply chain, which is relatively simple, catches up.

“With medicine and healthcare services and supplies, the increase in demand is typically already in line with consumption, so a shortage in supply or increase in demand can create a supply-demand gap that continues for a long time,” Keskinocak said. “Medical supply chains are also very complex and fragile.”

Future vaccine distribution

In normal times, most supply chains work at a plodding pace, and when crisis strikes, it is tough to ramp them up due to expensive equipment, complex logistics, and strict regulations, particularly in health care. Even temporary shortages of medicines and medical devices can have consequences for patients who need them.

“If shortages become serious, rationing – with a priority allocation to those most in need – can help balance demand and supply for critical items like medications.”

Once created and approved, the production of vaccines or antivirals for COVID-19 will ramp up slowly and could be in short supply at first. Decision-makers need plan investments now in the supply chains necessary for their effective distribution.

This will include painful, necessary decisions like prioritizing first doses for healthcare workers, people with pre-existing conditions, and the elderly. The current system of restocking vaccines in the U.S. after initial distribution also has serious gaps that need fixing to save many more lives.

In the meantime, social distancing is one of the best ways to protect everyone and reduce the patient surge into clinics. Do it if you or anyone in your household has any cold-like symptoms.

[Read Keskinocak's commentary on social distancing on AJC.com]

Also read: Vaccine Supply Gaps Can Make Pandemics Deadlier

Media contacts: Ben Brumfield (ben.brumfield@comm.gatech.edu) and John Toon (john.toon@comm.gatech.edu)