On March 12, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic. A pandemic occurs when a new disease, for which people have no immunity, spreads across the globe, being readily transmitted from person to person. In the last century we’ve had four pandemics, all caused by novel strains of flu, the worst being the pandemic of 1918 in which a third of the world’s population became ill and about 675,000 people in the US died. The most recent flu pandemic occurred in 2009. In contrast to previous pandemics, it was considered mild. Yet the CDC recorded over 60 million cases in the US, including 274,000 hospitalizations and over 12,000 deaths.
On March 26, 2020, the Institute of Health Metrics and Evaluation, a group committed to helping policymakers and donors determine how best to help people live longer and healthier lives, presented their first set of estimates predicting use of health services due to COVID-19. They estimated more demand for hospital services than there is capacity to deliver. Health systems have been preparing for weeks in anticipation of a tsunami of patients. Through public health policies aimed at keeping us physically separated (or socially distanced), the acceleration of the outbreak and total number of people sick at any given point in time can be reduced. Hospitals will make more space for patients by decreasing non-COVID related hospital utilization through cancelation of elective surgeries, and by setting up tents in their parking lots.
It will also be important to reserve hospital resources for those who need it most. If millions rush to the emergency department to get answers about their COVID-19 symptoms, it would not only make access to care for patients with time-critical conditions harder, but it could fuel the pandemic by causing people sick with COVID-19 and patients at risk for catching it to spend hours together in crowded waiting rooms.
In 2008, Emory University convened a group of experts to devise a strategy to assess huge numbers of patients during a hypothetical flu pandemic. Their goal was to develop a tool that could identify persons in greatest need of hospital services. The product of their deliberations was SORT or “Strategy for Off-Site Rapid Triage.” SORT employs a 3-stage process: the first stage asks the person’s sign and symptoms of illness, the second helps determine if the person is having a medical emergency, and the third inquires whether the individual has underlying medical conditions that could put them at risk for more serious disease.
Based on this assessment, persons are either identified as “high risk” and referred immediately for emergency care, “intermediate risk” advising timely evaluation by a healthcare provider, or “low risk” advising recuperation at home. Using this tool, people are educated about their health condition, thereby decreasing demand for hospital services without discouraging appropriate use. The tool was rapidly adapted for the 2009 H1N1 flu pandemic for use by nurse advice call lines and through an interactive website. After rapid validation, and review and endorsement by government agencies and professional associations, the SORT self-evaluation application was hosted on the HHS flu.gov website, as well as on the Microsoft Corporation’s H1N1 Response Center. The sites had over 2 million hits and over 670,000 completed self-evaluations in a little over two months.
Recently, with a surge of patients expected due to COVID-19, Emory, together with technology partner Vital, convened experts in infectious disease, emergency medicine, health literacy and public health to adapt the SORT tool for the new pandemic and created C19check.com, a web-based, public facing, consumer-grade COVID-19 specific self-assessment platform.
The tool is not a diagnostic, and not a replacement for a healthcare provider evaluation, but rather it helps the general public to better understand their signs, symptoms and risk factors for more serious disease, and helps by directing them to the CDC guidance that best serves their needs. The tool also helps the public use this guidance as they consider how best to seek evaluation and care. It is free to the public, collects no personally identifiable health information and can be used daily to register any changes you might have in symptoms. It can even alert you to reassess yourself if you desire.
In the first three days after its launch, C19check.com had over 600,000 hits and had been accessed in 20 different countries. It has been translated into Spanish, Portuguese, Italian, German and many other languages. A “white label” option allows an organization to assign custom output language, creating opportunities to direct persons using the tool to additional personalized health assessment options, such as connection with a telehealth provider, a nurse advice call line or a local health department hotline. Its underpinning, the original SORT algorithm, has since been widely emulated, as demonstrated by CDC, Apple, and many health organizations deploying similar symptom checkers.
These tools serve to educate the public about their illness, advise those with medical emergencies to get help immediately, and when appropriate, steer individuals away from crowded hospital and office waiting rooms, helping to maintain social distancing and reduce inadvertent disease transmission in crowded spaces. Creating an opportunity for data aggregation, they can also help identify hotspots of COVID-19 activity, and can provide some estimate of the number of affected persons with underlying medical conditions and those being directed to seek emergency care.
Much will need to be done in the coming weeks and months for our communities to be best prepared to meet the challenges of this alarming pandemic. Tools that help to educate the public, direct them to credible information sources, address demands for health system resources, and further facilitate social distancing, will play an important role in our fight to beat the pandemic.