Implementation of a Self-Triage Web Application for Suspected COVID-19 and Its Impact on Emergency Call Centers: Observational Study

Consequences of the COVID-19 pandemic on the mental health of nurses in the Spanish out-of-hospital Emergency Service

OBJECTIVE

To analyse the impact of the COVID-19 pandemic on the mental health of nurses in Spanish out-of-hospital Emergency Services, identifying predictor factors of greater severity.

METHOD

A multicentre cross-sectional descriptive study was designed, including all nurses working in any Spanish out-of-hospital Emergency Services between 01/02/2021 and 30/04/2021. The main outcomes were the level of depression, anxiety and stress assessed through the DASS-21 scale. Sociodemographic, clinical, and occupational information was also collected. Univariate and multivariate analyses were conducted to determine possible associations between variables.

RESULTS

The sample included 474 nurses. 32.91%, 32.70% and 26.33% of the participants had severe or extremely severe levels of depression, anxiety and stress, respectively. Professionals with fewer competencies to handle stressful situations, those who had used psychotropic drugs and/or psychotherapy on some occasion before the pandemic onset, or those who had changed their working conditions presented more likelihood of developing more severe levels of depression, anxiety and/or stress.

CONCLUSION

Nurses in Spanish out-of-hospital Emergency Services have presented medium levels of depression, anxiety and stress during the pandemic. Clinical and occupational factors have been associated with a higher degree of psychological distress. It is necessary to adopt strategies that promote professionals' self-efficacy and mitigate the triggers of negative emotional states.

Evaluating emergency service response to COVID-19: A scoping review

INTRODUCTION

The issue of how emergency services (police, fire, ambulance, local authorities) respond to pandemics has received greater research focus recently in relation to the COVID-19 outbreak, which saw agencies going beyond usual roles to support communities for prolonged periods. A critical appraisal is needed of this published evidence to take stock of what is known about the effectiveness of emergency service response to Covid-19.

METHOD

A scoping review of scientific and grey literature identified 17 qualitative (N = 9), quantitative (N = 6), or mixed methods (N = 2) studies from across the UK and internationally that focus on the effectiveness of emergency service response to the Covid-19 outbreak. A narrative review was conducted using an interpretive approach. Papers were read, summarised, and then sorted into inductive themes that addressed some aspect of the review question. Eight critical themes emerged from the narrative review.

RESULTS

Across countries, emergency services were required to quickly adapt working practices to reduce spread of infection, support partner agencies facing unprecedented demands, and make effective use of limited resources. Use of technology, access to timely, accurate and relevant information, strong leadership, prior experience, and emergency training were critical to this. However, most research is descriptive rather than evaluative.

CONCLUSIONS

Overall, findings highlight the need for further research that examines what mechanisms facilitate and hinder emergency response to pandemics. This scoping review provides a knowledge framework for informing future research that can support emergency services in preparing for events of national and international significance.

Outcome After Self-Triage App Referral in Urgent Direct-to-Consumer Telemedicine Encounter

Background: The quantification of self-triage effectiveness, guided by mobile applications, in urgent direct-to-consumer telemedicine (TM) encounters requires further investigation. The objective of this study was to evaluate the outcomes of referral guidance provided by a symptom-based self-management mobile application decision algorithm in the context of remote urgent care assessments. Methods: An observational retrospective single-center study was conducted from May 2022 to December 2023. The inclusion criteria encompassed individuals aged >18 years old, and those spontaneously seeking virtual emergency care through the EINSTEIN CONECTA application. Patients experiencing connectivity issues, preventing completion of the encounter, were excluded. The primary outcomes included the rate of patient concurrence with the algorithm's recommendation for seeking in-person emergency care and the referral rate to face-to-face assessment among cases evaluated through TM. The application's algorithm employs scientific evidence based on symptoms to recommend referrals to emergency departments (EDs). Results: Out of 88,834 patients connected to the TM Center, self-triage obviated the need for virtual physician assessment in 53,302 (60%) encounters. A total of 35,532 patients were remotely evaluated by 316 on-duty physicians, resulting in 1,125 ICD-coded diagnoses. Among these, 21,722 (61.1%) were initially advised by self-triage to visit the ED, with subsequent medical assessment leading to in-person referrals in 6,354 (29.3%) of the evaluations. Of the 13,810 patients recommended to continue with virtual care post-self-triage, 157 (1.1%) were referred for in-person assessment. Conclusions: Self-triage effectively reduced the need for physician encounters in approximately three-fifths of TM consultations. Despite being based on scientific evidence, symptom-based referral algorithms demonstrated high sensitivity but poor correlation with physician decision-making.

Outcomes of Emergency Trauma Patients After the Implementation of Web Application Operating Systems

PURPOSE

Trauma has significant impacts on the livelihoods and well-being of patients. Prompt emergency, medical, and nursing care is the key to reducing mortality rates. Digital platforms have become important for patient care. This research aimed to evaluate patient outcomes after implementing a novel web application operating system in trauma care.

METHODS

A descriptive comparative study was conducted on trauma patients. The patients were divided into two groups: those who used the developed application (n = 70) and those who did not (n = 70). The patients' characteristics, the time of the trauma team's arrival at the emergency department (ED) and the length of stay in the ED, and patients' outcomes were collected from electronic medical records and the application database. A statistical analysis was performed to evaluate this data. Sixty registered nurses who used the application completed the survey on the feasibility of the application.

RESULTS

The activated trauma intervals for the non-application-used group and the application-used group were 5.0 ± 1.1 and 3.1 ± 0.4 minutes, respectively (p = .010). The length of stay in the ED for the non-application-used group and the application-used group were 30.1 ± 5.1 and 18.3 ± 6.2 minutes, respectively. A high level of agreement confirms the feasibility of the application.

CONCLUSIONS

This application improves patient outcomes in terms of length of stay. This mobile application can improve the cooperation and communication and efficacy of the trauma care team.

Impact of the COVID-19 Pandemic on the Profile of Patients in SAMU-Asturias EMS (Spain): A Two-Year Retrospective Analysis of Advanced Life Support Unit Data

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic had important consequences on the health system. Emergency Medical Services (EMS) were a key element in the response and were forced to modify their daily procedures. The main objective of this study was to find out if there were differences in response times and in the profile of patients treated by the Advanced Life Support (ALS) units of Servicio de Asistencia Médica Urgente (SAMU)-Asturias, the EMS of the Principality of Asturias, between the pre-pandemic period and the pandemic period.

METHODOLOGY

This was a descriptive, cross-sectional, observational, and retrospective study that included all patients treated by SAMU-Asturias ALS from January 1, 2019 through December 31, 2020.

RESULTS

The pandemic has had an impact on daily activity of SAMU-Asturias, with a 9.2% decrease in daily ALS services during the pandemic, longer prehospital times during the pandemic period (mean = 54'35"; SD = 0'48"; P = 0.00) mainly due to an increase in scene time (mean = 28'01"; SD = 12'57"; P = 0.00), and a slight increase in the average age of patients during the pandemic in relation to the pre-pandemic period. No differences were found between the types of incidents for ALS or between the resolution of the patients.

CONCLUSIONS

The COVID-19 pandemic mainly affects prehospital times in an emergency service, with no differences being observed in types of incidents; in EMS future pandemic planning, this should be taken into consideration.

Readiness of health facilities to manage individuals infected with COVID-19, Uganda, June 2021

BACKGROUND

The COVID-19 pandemic overwhelmed the capacity of health facilities globally, emphasizing the need for readiness to respond to rapid increases in cases. The first wave of COVID-19 in Uganda peaked in late 2020 and demonstrated challenges with facility readiness to manage cases. The second wave began in May 2021. In June 2021, we assessed the readiness of health facilities in Uganda to manage the second wave of COVID-19.

METHODS

Referral hospitals managed severe COVID-19 patients, while lower-level health facilities screened, isolated, and managed mild cases. We assessed 17 of 20 referral hospitals in Uganda and 71 of 3,107 lower-level health facilities, selected using multistage sampling. We interviewed health facility heads in person about case management, coordination and communication and reporting, and preparation for the surge of COVID-19 during first and the start of the second waves of COVID-19, inspected COVID-19 treatment units (CTUs) and other service delivery points. We used an observational checklist to evaluate capacity in infection prevention, medicines, personal protective equipment (PPE), and CTU surge capacity. We used the "ReadyScore" criteria to classify readiness levels as > 80% ('ready'), 40-80% ('work to do'), and < 40% ('not ready') and tailored the assessments to the health facility level. Scores for the lower-level health facilities were weighted to approximate representativeness for their health facility type in Uganda.

RESULTS

The median (interquartile range (IQR)) readiness scores were: 39% (IQR: 30, 51%) for all health facilities, 63% (IQR: 56, 75%) for referral hospitals, and 32% (IQR: 24, 37%) for lower-level facilities. Of 17 referral facilities, two (12%) were 'ready' and 15 (88%) were in the "work to do" category. Fourteen (82%) had an inadequate supply of medicines, 12 (71%) lacked adequate supply of oxygen, and 11 (65%) lacked space to expand their CTU. Fifty-five (77%) lower-level health facilities were "not ready," and 16 (23%) were in the "work to do" category. Seventy (99%) lower-level health facilities lacked medicines, 65 (92%) lacked PPE, and 53 (73%) lacked an emergency plan for COVID-19.

CONCLUSION

Few health facilities were ready to manage the second wave of COVID-19 in Uganda during June 2021. Significant gaps existed for essential medicines, PPE, oxygen, and space to expand CTUs. The Uganda Ministry of Health utilized our findings to set up additional COVID-19 wards in hospitals and deliver medicines and PPE to referral hospitals. Adequate readiness for future waves of COVID-19 requires additional support and action in Uganda.

A Digital First Healthcare Approach to Managing Pandemics: A Scoping Review of Pandemic Self-Triage Tools

BACKGROUND

During the COVID-19 pandemic, many patient-facing digital self-triage tools were designed and deployed to alleviate demand for pandemic virus triage in hospitals and doctors' offices by providing a way for people to self-assess health status and get advice on whether to seek care. These tools, provided via websites, apps, or patient portals allow people to answer questions, e.g., about symptoms and contact history, and receive guidance to appropriate care, which might be self-care.

OBJECTIVE

The purpose of this scoping review was to explore the state of literature on digital self-triage tools that direct or advise care for adults during a pandemic, and to explore what has been learned about intended purpose, use, and quality of guidance, tool usability, impact on providers, and ability to forecast health outcomes or care demand.

METHODS

A literature search was conducted in July 2021 using MEDLINE, Embase, Scopus, PsycINFO, CINAHL and Cochrane databases. Using Covidence, 1227 titles and abstracts were screened by two researchers, with 83 reviewed via full text screening. 22 articles met inclusion criteria: they allowed adults to self-assess for pandemic virus and directed to care. Using Microsoft Excel, we extracted and charted the following data: authors, publication year and country, country the tool was used in, whether the tool was integrated into a healthcare system, research question/purpose, direction of care provided, and key findings.

RESULTS

All but two studies reported on tools developed since early 2020 during the COVID-19 pandemic. Studies reported on tools were developed in 17 countries. Direction of care advice included directing to an ER, seek urgent care, contact/see a doctor, be tested, or to stay at home/self-isolate. Only two studies evaluated tool usability. One used 52 use-cases to evaluate quality of advice by tools in four countries, finding advice varied, e.g., tools in the US and UK often advising staying home when clinical assessment was warranted, while tools in Japan and Singapore advised seeking care. No study demonstrated that the tools reduce demand on the health care system, although at least one suggests data can predict demand for care and data allows monitoring public health.

CONCLUSIONS

While self-triage tools developed and used around the world have similarities in directing to care (ER, physician, self-care), they also differ in important ways. Some collect data to predict healthcare demand. Some are for use when concerned about health status; others are intended to be used repeatedly by users to monitor public health. Quality of triage may vary. The high use of such tools during the COVID-19 pandemic suggests research is needed to assess and ensure quality of advice given by self-triage tools, and to assess intended or unintended consequences on public health and health care systems.

CLINICALTRIAL

www.coronabambini.ch: Development and usage of an online decision support tool for paediatric COVID-19-testing in Switzerland: a cross-sectional analysis

OBJECTIVES

To describe the development and usage of www.coronabambini.ch as an example of a paediatric electronic public health application and to explore its potential and limitations in providing information on disease epidemiology and public health policy implementation.

DESIGN

We developed and maintained a non-commercial online decision support tool, www.coronabambini.ch, to translate the Swiss Federal Office of Public Health (FOPH) paediatric (age 0-18 years) COVID-19 guidelines around testing and school/daycare attendance for caregivers, teachers and healthcare personnel. We analysed the online decision tool as well as a voluntary follow-up survey from October 2020 to September 2021 to explore its potential as a surveillance tool for public health policy and epidemiology.

PARTICIPANTS

68 269 users accessed and 52 726 filled out the complete online decision tool. 3% (1399/52 726) filled out a voluntary follow-up. 92% (18 797/20 330) of users were parents.

RESULTS

Certain dynamics of the pandemic and changes in testing strategies were reflected in the data captured by www.coronabambini.ch, for example, in terms of disease epidemiology, gastrointestinal symptoms were reported more frequently in younger age groups (13% (3308/26 180) in children 0-5 years vs 9% (3934/42 089) in children ≥6 years, χ²=184, p≤0.001). As a reflection of public health policy, the proportion of users consulting the tool for a positive contact without symptoms in children 6-12 years increased from 4% (1415/32 215) to 6% (636/9872) after the FOPH loosened testing criteria in this age group, χ²=69, p≤0.001. Adherence to the recommendation was generally high (84% (1131/1352)) but differed by the type of recommendation: 89% (344/385) for 'stay at home and observe', 75% (232/310) for 'school attendance'.

CONCLUSIONS

Usage of www.coronabambini.ch was generally high in areas where it was developed and promoted. Certain patterns in epidemiology and adherence to public health policy could be depicted but selection bias was difficult to measure showing the potential and challenges of digital decision support as public health tools.

Engagement With the Centers for Disease Control and Prevention Coronavirus Self-Checker and Guidance Provided to Users in the United States From March 23, 2020, to April 19, 2021: Thematic and Trend Analysis

BACKGROUND

In 2020, at the onset of the COVID-19 pandemic, the United States experienced surges in healthcare needs, which challenged capacity throughout the healthcare system. Stay-at-home orders in many jurisdictions, cancellation of elective procedures, and closures of outpatient medical offices disrupted patient access to care. To inform symptomatic persons about when to seek care and potentially help alleviate the burden on the healthcare system, Centers for Disease Control and Prevention (CDC) and partners developed the CDC Coronavirus Self-Checker ("Self-Checker"). This interactive tool assists individuals seeking information about COVID-19 to determine the appropriate level of care by asking demographic, clinical, and nonclinical questions during an online "conversation."

OBJECTIVE

This paper describes user characteristics, trends in use, and recommendations delivered by the Self-Checker between March 23, 2020, and April 19, 2021, for pursuing appropriate levels of medical care depending on the severity of user symptoms.

METHODS

User characteristics and trends in completed conversations that resulted in a care message were analyzed. Care messages delivered by the Self-Checker were manually classified into three overarching conversation themes: (1) seek care immediately; (2) take no action, or stay home and self-monitor; and (3) conversation redirected. Trends in 7-day averages of conversations and COVID-19 cases were examined with development and marketing milestones that potentially impacted Self-Checker user engagement.

RESULTS

Among 16,718,667 completed conversations, the Self-Checker delivered recommendations for 69.27% (n=11,580,738) of all conversations to "take no action, or stay home and self-monitor"; 28.8% (n=4,822,138) of conversations to "seek care immediately"; and 1.89% (n=315,791) of conversations were redirected to other resources without providing any care advice. Among 6.8 million conversations initiated for self-reported sick individuals without life-threatening symptoms, 59.21% resulted in a recommendation to "take no action, or stay home and self-monitor." Nearly all individuals (99.8%) who were not sick were also advised to "take no action, or stay home and self-monitor."

CONCLUSIONS

The majority of Self-Checker conversations resulted in advice to take no action, or stay home and self-monitor. This guidance may have reduced patient volume on the medical system; however, future studies evaluating patients' satisfaction, intention to follow the care advice received, course of action, and care modality pursued could clarify the impact of the Self-Checker and similar tools during future public health emergencies.

Self-care for coronavirus disease through electronic health technologies: A scoping review

Background and Aims

Considering the rapid spread and transmission of COVID-19 and its high mortality rate, self-care practices are of special importance during this pandemic to prevent and control the spread of the virus. In this regard, electronic health systems can play a major role in improving self-care practices related to coronavirus disease. This study aimed to review the electronic health technologies used in each of the constituent elements of the self-care (self-care maintenance, self-care monitoring, and self-care management) during the COVID-19 pandemic.

Methods

This scoping review was conducted based on Arksey and O'Malley's framework. In this study, the specific keywords related to "electronic health," "self-care," and "COVID-19" were searched on PubMed, Web of Science, Scopus, and Google.

Results

Of the 47 articles reviewed, most articles (27 articles) were about self-care monitoring and aimed to monitor the vital signs of patients. The results showed that the use of electronic health tools mainly focuses on training in the control and prevention of coronavirus disease during this pandemic, in the field of self-care maintenance, and medication management, communication, and consultation with healthcare providers, in the field of self-care management. Moreover, the most commonly used electronic health technologies were mobile web applications, smart vital signs monitoring devices, and social networks, respectively.

Conclusion

The study findings suggested that the use of electronic health technologies, such as mobile web applications and social networks, can effectively improve self-care practices for coronavirus disease. In addition, such technologies can be applied by health policymakers and disease control and prevention centers to better manage the COVID-19 pandemic.

Contribution of Live Video to Physicians' Remote Assessment of Suspected COVID-19 Patients in an Emergency Medical Communication Centre: A Retrospective Study and Web-Based Survey

The COVID-19 pandemic had a major impact on emergency medical communication centres (EMCC). A live video facility was made available to second-line physicians in an EMCC with a first-line paramedic to receive emergency calls. The objective of this study was to measure the contribution of live video to remote medical triage. The single-centre retrospective study included all telephone assessments of patients with suspected COVID-19 symptoms from 01.04.2020 to 30.04.2021 in Geneva, Switzerland. The organisation of the EMCC and the characteristics of patients who called the two emergency lines (official emergency number and COVID-19 number) with suspected COVID-19 symptoms were described. A prospective web-based survey of physicians was conducted during the same period to measure the indications, limitations and impact of live video on their decisions. A total of 8957 patients were included, and 2157 (48.0%) of the 4493 patients assessed on the official emergency number had dyspnoea, 4045 (90.6%) of 4464 patients assessed on the COVID-19 number had flu-like symptoms and 1798 (20.1%) patients were reassessed remotely by a physician, including 405 (22.5%) with live video, successfully in 315 (77.8%) attempts. The web-based survey (107 forms) showed that physicians used live video to assess mainly the breathing (81.3%) and general condition (78.5%) of patients. They felt that their decision was modified in 75.7% (n = 81) of cases and caught 7 (7.7%) patients in a life-threatening emergency. Medical triage decisions for suspected COVID-19 patients are strongly influenced by the use of live video.

Evaluating musculoskeletal urgent care center triage and transfer of emergency conditions for emergency surgical assessment and intervention

Musculoskeletal urgent care centers (MUCCs) are an alternative to emergency departments (EDs) for patients to seek care for low acuity orthopedic injuries such as ankle sprains or joint pain, but are not equipped to manage orthopedic emergencies that require a higher level of care provided in the ED. This study aims to evaluate telephone and online triage practices as well as ED transfer procedures for MUCCs for patients presenting with an orthopedic condition requiring urgent surgical intervention. We called 595 MUCCs using a standardized script presenting as a critical patient with symptoms of lower extremity compartment syndrome. We compared direct ED referral frequency and triage frequency for MUCCs for patients insured by either Medicaid or by private insurance. We found that patients presenting with an apparent compartment syndrome were directly referred to the ED by < 1 in 5 MUCCs. Additionally, < 5% of patients were asked additional triage questions that would increase clinician suspicion for compartment syndrome and allow MUCCs to appropriately direct patients to the ED. MUCCs provide limited telephone and online triage for patients, which may result in delays of care for life or limb threatening injuries that require ED resources such as sedation, reductions, and emergency surgery. However, when MUCCs did conduct triage, it significantly increased the likelihood that patients were appropriately referred to the ED. Level of Evidence: Level II, prognostic study.

Utilization patterns and efficiency gains from use of a fully EHR-integrated COVID-19 self-triage and self-scheduling tool: a retrospective analysis

OBJECTIVE

Symptom checkers can help address high demand for SARS-CoV2 (COVID-19) testing and care by providing patients with self-service access to triage recommendations. However, health systems may be hesitant to invest in these tools, as their associated efficiency gains have not been studied. We aimed to quantify the operational efficiency gains associated with use of an online COVID-19 symptom checker as an alternative to a telephone hotline.

METHODS

In our health system, ambulatory patients can either use an online symptom checker or a telephone hotline to be triaged and connected to COVID-19 care. We performed a retrospective analysis of adults who used either method between October 20, 2021 and January 10, 2022, using call logs, electronic health record data, and local wages to calculate labor costs.

RESULTS

Of the 15 549 total COVID-19 triage encounters, 1820 (11.7%) used only the telephone hotline and 13 729 (88.3%) used the symptom checker. Only 271 (2%) of the patients who used the symptom checker also called the hotline. Hotline encounters required more clinician time compared to those involving the symptom checker (17.8 vs 0.4 min/encounter), resulting in higher average labor costs ($24.21 vs $0.55 per encounter). The symptom checker resulted in over 4200 clinician labor hours saved.

CONCLUSION

When given the option, most patients completed COVID-19 triage and visit scheduling online, resulting in substantial efficiency gains. These benefits may encourage health system investment in such tools.

Telehealth and Public Health Practice in the United States-Before, During, and After the COVID-19 Pandemic

Telehealth is the use of electronic information and telecommunication technologies to provide care when the patient and the provider are not in the same room at the same time. Telehealth accounted for less than 1% of all Medicare Fee-for-Service outpatient visits in the United States in 2019 but grew to account for 46% of all visits in April 2020. Changes in reimbursement and licensure policies during the COVID-19 pandemic appeared to greatly facilitate this increased use. Telehealth will continue to account for a substantial portion of care provided in the United States and globally. A better understanding of telehealth approaches and their evidence base by public health practitioners may help improve their ability to collaborate with health care organizations to improve population health. The article summarizes the Centers for Disease Control and Prevention's (CDC's) approach to understanding the evidence base for telehealth in public health practice, possible applications for telehealth in public health practice, and CDC's use of telehealth to improve population health.

Patient Experience and Feedback after Use of an EHR-integrated COVID-19 Symptom Checker

BACKGROUND

Symptom checkers have been widely used during the COVID-19 pandemic to alleviate strain on health systems and offer patients a 24/7 self-service triage option. Although studies suggest that users may positively perceive online symptom checkers, no studies have quantified user feedback after use of an electronic health record (EHR)-integrated COVID-19 symptom checker with self-scheduling functionality.

OBJECTIVE

We aimed to understand user experience, user satisfaction, and user-reported alternatives to use of a COVID-19 symptom checker with self-triage and self-scheduling functionality.

METHODS

We launched a patient-portal based self-triage and self-scheduling tool in March 2020 for patients with COVID-19 symptoms, exposures, or questions. We made an optional, anonymous Qualtrics survey available to patients immediately after they completed the symptom checker.

RESULTS

Between December 16th, 2021 and March 28th, 2022, there were 395 unique responses to the survey. Overall, respondents reported high satisfaction across all demographics, with a median rating of 8 out of 10, and 47.6% of respondents giving a rating of 9 or 10 out of 10. User satisfaction scores were not associated with any demographic factors. The most common user-reported alternatives had the online tool not been available were calling the COVID-19 telephone hotline and sending a patient-portal message to their physician for advice. The ability to schedule a test online was the most important symptom checker feature for respondents. The most common categories of user feedback were regarding other COVID-19 services (e.g. telephone hotline), policies or procedures, or requesting additional features or functionality.

CONCLUSIONS

This analysis suggests that COVID-19 symptom checkers with self-triage and self-scheduling functionality may have high overall user satisfaction, regardless of user demographics. By allowing users to self-triage and self-schedule tests and visits, tools like this may prevent unnecessary calls and messages to clinicians. Individual feedback suggested that the user experience for this type of tool is highly dependent on the organization's operational workflows for COVID-19 testing and care. The study provides insight for the implementation and improvement of COVID-19 symptom checkers to ensure high user satisfaction.  .

Early Detection of Neurodevelopmental Disorders of Toddlers and Postnatal Depression by Mobile Health App: Observational Cross-sectional Study

Background

Delays in the diagnosis of neurodevelopmental disorders (NDDs) in toddlers and postnatal depression (PND) in mothers are major public health issues. In both cases, early intervention is crucial.

Objective

We aimed to assess if a mobile app named Malo can reduce delay in the recognition of NDD and PND.

Methods

We performed an observational, cross-sectional, data-based study in a population of young parents with a minimum of 1 child under 3 years of age at the time of inclusion and using Malo on a regular basis. We included the first 4000 users matching the criteria and agreeing to participate between November 11, 2021, and January 14, 2022. Parents received monthly questionnaires via the app, assessing skills on sociability, hearing, vision, motricity, language of their infants, and possible autism spectrum disorder. Mothers were also requested to answer regular questionnaires regarding PND, from 4-28 weeks after childbirth. When any patient-reported outcomes matched predefined criteria, an in-app notification was sent to the user, recommending the booking of an appointment with their family physician or pediatrician. The main outcomes were the median age of the infant at the time of notification for possible NDD and the median time of PND notifications after childbirth. One secondary outcome was the relevance of the NDD notification for a consultation as assessed by the physicians.

Results

Among 4242 children assessed by 5309 questionnaires, 613 (14.5%) had at least 1 disorder requiring a consultation. The median age of notification for possible autism spectrum, vision, audition, socialization, language, or motor disorders was 11, 9, 17, 12, 22, and 4 months, respectively. The sensitivity of the alert notifications of suspected NDDs as assessed by the physicians was 100%, and the specificity was 73.5%. Among 907 mothers who completed a PND questionnaire, highly probable PND was detected in 151 (16.6%) mothers, and the median time of detection was 8-12 weeks.

Conclusions

The algorithm-based alert suggesting NDD was highly sensitive with good specificity as assessed by real-life practitioners. The app was also efficient in the early detection of PND. Our results suggest that the regular use of this multidomain familial smartphone app would permit the early detection of NDD and PND.

Trial Registration

ClinicalTrials.gov NCT04958174; https://clinicaltrials.gov/ct2/show/NCT04958174

Assessing a new pre-screening score for the simplified evaluation of the clinical quality and relevance of e-health applications. (Preprint)

Background

In 2020, more than 250 eHealth solutions were added to app stores each day, or 90,000 in the year; however, the vast majority of these solutions have not undergone clinical validation, their quality is unknown, and the user does not know if they are effective and safe. We sought to develop a simple prescreening scoring method that would assess the quality and clinical relevance of each app. We designed this tool with 3 health care stakeholder groups in mind: eHealth solution designers seeking to evaluate a potential competitor or their own tool, investors considering a fundraising candidate, and a hospital clinician or IT department wishing to evaluate a current or potential eHealth solution.

Objective

We built and tested a novel prescreening scoring tool (the Medical Digital Solution scoring tool). The tool, which consists of 26 questions that enable the quick assessment and comparison of the clinical relevance and quality of eHealth apps, was tested on 68 eHealth solutions.

Methods

The Medical Digital Solution scoring tool is based on the 2021 evaluation criteria of the French National Health Authority, the 2022 European Society of Medical Oncology recommendations, and other provided scores. We built the scoring tool with patient association and eHealth experts and submitted it to eHealth app creators, who evaluated their apps via the web-based form in January 2022. After completing the evaluation criteria, their apps obtained an overall score and 4 categories of subscores. These criteria evaluated the type of solution and domain, the solution’s targeted population size, the level of clinical assessment, and information about the provider.

Results

In total, 68 eHealth solutions were evaluated with the scoring tool. Oncology apps (22%, 20/90) and general health solutions (23%, 21/90) were the most represented. Of the 68 apps, 32 (47%) were involved in remote monitoring by health professionals. Regarding clinical outcomes, 5% (9/169) of the apps assessed overall survival. Randomized studies had been conducted for 21% (23/110) of the apps to assess their benefit. Of the 68 providers, 38 (56%) declared the objective of obtaining reimbursement, and 7 (18%) out of the 38 solutions seeking reimbursement were assessed as having a high probability of reimbursement. The median global score was 11.2 (range 4.7-17.4) out of 20 and the distribution of the scores followed a normal distribution pattern (Shapiro-Wilk test: P=.33).

Conclusions

This multidomain prescreening scoring tool is simple, fast, and can be deployed on a large scale to initiate an assessment of the clinical relevance and quality of a clinical eHealth app. This simple tool can help a decision-maker determine which aspects of the app require further analysis and improvement.

The Rapid Development of Virtual Care Tools in Response to COVID-19: Case Studies in Three Australian Health Services

BACKGROUND

News of the impact of COVID-19 around the world delivered a brief opportunity for Australian health services to plan new ways of delivering care to large numbers of people while maintaining staff safety through greater physical separation. The rapid pivot to telemedicine and virtual care provided immediate and longer term benefits; however, such rapid-cycle development also created risks.

OBJECTIVE

The aim of this study was to understand the sociotechnical aspects of the rapid-cycle development of seven different COVID-19 virtual care tools, and to identify enablers, barriers, and risks at three health services in Victoria, Australia.

METHODS

A qualitative, embedded, multiple case study design was adopted. Researchers from three health services collaborated with university researchers who were independent from those health services to gather and analyze structured interview data from key people involved in either clinical or technical aspects of designing and deploying seven different virtual care tools.

RESULTS

The overall objectives of each health service reflected the international requirements for managing large numbers of patients safely but remotely and for protecting staff. However, the governance, digital maturity, and specific use cases at each institution shaped the methodology and specific outcomes required. Dependence on key individuals and their domain knowledge within an existing governance framework generally enabled rapid deployment, but sometimes posed barriers. Existing relationships with technical service developers enabled strong solutions, which in some cases were highly scalable. Conventional project methodologies such as steering committees, scope, budget control, tight functional specification, consumer engagement and codesign, universal accessibility, and postimplementation evaluation were ignored almost universally in this environment.

CONCLUSIONS

These three health services took a variety of approaches to the rapid-cycle development of virtual care tools to meet their urgent needs for triaging and remote monitoring during the first year of the COVID-19 pandemic. Their experiences provided insights into many social and technical barriers and enablers to the development of virtual care tools. If these are addressed proactively, they will improve clinical governance and technical management of future virtual care. Some changes can be made within individual health services, while others entail health system policy reforms. Enhancing the environment for virtual care tool design and implementation now will yield returns not only during future health emergencies but also in many more routine care settings.

Impact of a CE-Marked Medical Software Sensor on COVID-19 Pandemic Progression Prediction: a Register Study Using Machine Learning Methods

Background

To address the current COVID-19 and any future pandemic, we need robust, real-time, and population-scale collection and analysis of data. Rapid and comprehensive knowledge on the trends in reported symptoms in populations provides an earlier window into the progression of viral spread, and helps to predict the needs and timing of professional health care.

Objective

The objective of this study was to use a Conformité Européenne (CE)-marked medical online symptom checker service, Omaolo, and validate the data against the national demand for COVID-19–related care to predict the pandemic progression in Finland.

Methods

Our data comprised real-time Omaolo COVID-19 symptom checker responses (414,477 in total) and daily admission counts in nationwide inpatient and outpatient registers provided by the Finnish Institute for Health and Welfare from March 16 to June 15, 2020 (the first wave of the pandemic in Finland). The symptom checker responses provide self-triage information input to a medically qualified algorithm that produces a personalized probability of having COVID-19, and provides graded recommendations for further actions. We trained linear regression and extreme gradient boosting (XGBoost) models together with F-score and mutual information feature preselectors to predict the admissions once a week, 1 week in advance.

Results

Our models reached a mean absolute percentage error between 24.2% and 36.4% in predicting the national daily patient admissions. The best result was achieved by combining both Omaolo and historical patient admission counts. Our best predictor was linear regression with mutual information as the feature preselector.

Conclusions

Accurate short-term predictions of COVID-19 patient admissions can be made, and both symptom check questionnaires and daily admissions data contribute to the accuracy of the predictions. Thus, symptom checkers can be used to estimate the progression of the pandemic, which can be considered when predicting the health care burden in a future pandemic.

Pandemic Preparedness

Pandemic preparedness is a key function of any health care facility. Activities pertaining to pandemic preparedness should be developed and maintained within a broader emergency management plan. The use of a Hospital Incident Command System can centralize coordination of the response and facilitate internal and external communication. This review addresses several components of pandemic preparedness, including incident management, health care personnel safety, strategies to support ongoing clinical activities, and organizational communication during a pandemic. Preparations addressing potential ethical challenges and the psychological impact associated with pandemic response are also reviewed.

COVID-19 in Brazil-Preliminary Analysis of Response Supported by Artificial Intelligence in Municipalities

The novel coronavirus disease (COVID-19) forced rapid adaptations in the way healthcare is delivered and coordinated by health systems. Brazil has a universal public health system (Sistema Unico de Saúde-SUS), being the main source of care for 75% of the population. Therefore, a saturation of the system was foreseen with the continuous increase of cases. The use of Artificial Intelligence (AI) to empower telehealth could help to tackle this by increasing a coordinated patient access to the health system. In the present study we describe a descriptive case report analyzing the use of Laura Digital Emergency Room-an AI-powered telehealth platform-in three different cities. It was computed around 130,000 interactions made by the chatbot and 24,162 patients completed the digital triage. Almost half (44.8%) of the patients were classified as having mild symptoms, 33.6% were classified as moderate and only 14.2% were classified as severe. The implementation of an AI-powered telehealth to increase accessibility while maintaining safety and leveraging value amid the unprecedent impact of the COVID-19 pandemic was feasible in Brazil and may reduce healthcare overload. New efforts to yield sustainability of affordable and scalable solutions are needed to truly leverage value in health care systems, particularly in the context of middle-low-income countries.

Digital Surveillance Through an Online Decision Support Tool for COVID-19 Over One Year of the Pandemic in Italy: Observational Study

BACKGROUND

Italy has experienced severe consequences (ie, hospitalizations and deaths) during the COVID-19 pandemic. Online decision support systems (DSS) and self-triage applications have been used in several settings to supplement health authority recommendations to prevent and manage COVID-19. A digital Italian health tech startup, Paginemediche, developed a noncommercial, online DSS with a chat user interface to assist individuals in Italy manage their potential exposure to COVID-19 and interpret their symptoms since early in the pandemic.

OBJECTIVE

This study aimed to compare the trend in online DSS sessions with that of COVID-19 cases reported by the national health surveillance system in Italy, from February 2020 to March 2021.

METHODS

We compared the number of sessions by users with a COVID-19-positive contact and users with COVID-19-compatible symptoms with the number of cases reported by the national surveillance system. To calculate the distance between the time series, we used the dynamic time warping algorithm. We applied Symbolic Aggregate approXimation (SAX) encoding to the time series in 1-week periods. We calculated the Hamming distance between the SAX strings. We shifted time series of online DSS sessions 1 week ahead. We measured the improvement in Hamming distance to verify the hypothesis that online DSS sessions anticipate the trends in cases reported to the official surveillance system.

RESULTS

We analyzed 75,557 sessions in the online DSS; 65,207 were sessions by symptomatic users, while 19,062 were by contacts of individuals with COVID-19. The highest number of online DSS sessions was recorded early in the pandemic. Second and third peaks were observed in October 2020 and March 2021, respectively, preceding the surge in notified COVID-19 cases by approximately 1 week. The distance between sessions by users with COVID-19 contacts and reported cases calculated by dynamic time warping was 61.23; the distance between sessions by symptomatic users was 93.72. The time series of users with a COVID-19 contact was more consistent with the trend in confirmed cases. With the 1-week shift, the Hamming distance between the time series of sessions by users with a COVID-19 contact and reported cases improved from 0.49 to 0.46. We repeated the analysis, restricting the time window to between July 2020 and December 2020. The corresponding Hamming distance was 0.16 before and improved to 0.08 after the time shift.

CONCLUSIONS

Temporal trends in the number of online COVID-19 DSS sessions may precede the trend in reported COVID-19 cases through traditional surveillance. The trends in sessions by users with a contact with COVID-19 may better predict reported cases of COVID-19 than sessions by symptomatic users. Data from online DSS may represent a useful supplement to traditional surveillance and support the identification of early warning signals in the COVID-19 pandemic.

Olfactory Training and Visual Stimulation Assisted by a Web Application for Patients With Persistent Olfactory Dysfunction After SARS-CoV-2 Infection: Observational Study

Background

Persistent olfactory dysfunction is a significant complication of SARS-CoV-2 infection. Olfactory training involving aromatic oils has been recommended to improve olfactory recovery, but quantitative data are missing.

Objective

We aimed to quantify the benefit of olfactory training and visual stimulation assisted by a dedicated web application for patients who experienced olfactory dysfunction for ≥1 month.

Methods

We performed an observational, real-life, data-based study on a cohort of patients who experienced at least 1 month of persistent olfactory dysfunction between January 30 and March 26, 2021. An analysis was performed after a mean olfactory training time of 4 weeks, and at least 500 patients were assessable for primary outcome assessment. Participants exposed themselves twice daily to odors from 4 high-concentration oils and visual stimulation assisted by a dedicated web application. Improvement was defined as a 2-point increase on a 10-point, self-assessed olfactory visual analogue scale.

Results

In total, 548 patients were assessable for primary outcome assessment. The mean baseline, self-assessed olfactory score was 1.9 (SD 1.7), and this increased to 4.6 (SD 2.8) after a mean olfactory training time of 27.7 days (SD 17.2). Olfactory training was associated with at least a 2-point increase in 64.2% (352/548) of patients. The rate of patients’ olfactory improvement was higher for patients who trained for more than 28 days than that rate for patients who trained for less than 28 days (73.3% vs 59%; P=.002). The time to olfactory improvement was 8 days faster for patients with hyposmia compared to the time to improvement for patients with anosmia (P<.001). This benefit was observed regardless of the duration of the olfactory dysfunction.

Conclusions

Olfactory training and visual stimulation assisted by a dedicated web application was associated with significant improvement in olfaction, especially after 28 days of olfactory training.

Analysis of COVID-19 Transmission Sources in France by Self-Assessment Before and After the Partial Lockdown: Observational Study

Background

We developed a questionnaire on a web application for analyzing COVID-19 contamination circumstances in France during the second wave of the pandemic.

Objective

This study aims to analyze the impact on contamination characteristics before and after the second partial lockdown in France to adapt public health restrictions to further prevent pandemic surges.

Methods

Between December 15 and 24, 2020, after a national media campaign, users of the sourcecovid.fr web application were asked questions about their own or a close relative’s COVID-19 contamination after August 15, 2020, in France. The data of the contamination’s circumstances were assessed and compared before and after the second partial lockdown, which occurred on October 25, 2020, during the second wave of the pandemic and was ongoing on December 24, 2020.

Results

As of December 24, 2020, 441,000 connections on the web application were observed. A total of 2218 questionnaires were assessable for analysis. About 61.8% (n=1309) of the participants were sure of their contamination origin, and 38.2% (n=809) thought they knew it. The median age of users was 43.0 (IQR 32-56) years, and 50.7% (n=1073) were male. The median incubation time of the assessed cohort was 4.0 (IQR 3-5) days. Private areas (family’s or friend’s house) were the main source of contamination (1048/2090, 50.2%), followed by work colleagues (579/2090, 27.7%). The main time of day for the contamination was the evening (339/961, 35.3%) before the lockdown and was reduced to 18.2% (86/473) after the lockdown (P<.001). The person who transmitted the virus to the user before and after the lockdown was significantly different (P<.001): a friend (382/1317, 29% vs 109/773, 14.1%), a close relative (304/1317, 23.1% vs 253/773, 32.7%), or a work colleague (315/1317, 23.9% vs 264/773, 34.2%). The main location where the virus was transmitted to the users before and after the lockdown was significantly different too (P<.001): home (278/1305, 21.3% vs 194/760, 25.5%), work (293/1305, 22.5% vs 225/760, 29.6%), collective places (430/1305, 33% vs 114/760, 15%), and care centers (58/1305, 4.4% vs 74/760, 9.7%).

Conclusions

Modalities of transmissions significantly changed before and after the second lockdown in France. The main sources of contamination remained the private areas and with work colleagues. Work became the main location of contamination after the lockdown, whereas contaminations in collective places were strongly reduced.

Trial Registration

ClinicalTrials.gov NCT04670003; https://clinicaltrials.gov/ct2/show/NCT04670003

A Self-Assessment Web-Based App to Assess Trends of the COVID-19 Pandemic in France: Observational Study

Background

We developed a self-assessment and participatory web-based triage app to assess the trends of the COVID-19 pandemic in France in March 2020.

Objective

We compared daily large-scale RT–PCR test results to monitor recent reports of anosmia through a web-based app to assess the dynamics of emergency department visits, hospitalizations, and intensive care unit (ICU) admissions among individuals with COVID-19 in France.

Methods

Between March 21 and November 18, 2020, users of the maladiecoronavirus.fr self-triage app were asked questions about COVID-19 symptoms. Data on daily hospitalizations, large-scale positive results on RT–PCR tests, emergency department visits, and ICU admission of individuals with COVID-19 were compared to data on daily reports of anosmia on the app.

Results

As of November 18, 2020, recent anosmia was reported 575,214 times from among approximately 13,000,000 responses. Daily anosmia reports during peak engagement with the app on September 16, 2020, were spatially correlated with the peak in daily COVID-19–related hospitalizations in November 2020 (Spearman rank correlation coefficient [ρ]=0.77; P<.001). This peak in daily anosmia reports was observed primarily among young adults (age range 18-40 years), being observed 49 days before the peak of hospitalizations that corresponded to the first wave of infections among the young population, followed by a peak in hospitalizations among older individuals (aged ≥50 years) in November 2020. The reduction in the daily reports of anosmia associated with the peaks in the number of cases preceded the reduction in daily hospitalizations by 10 and 9 days during the first and the second waves of infection, respectively, although the reduction in the positivity rates on RT–PCR tests preceded the reduction in daily hospitalizations by only 2 days during the second wave of infections.

Conclusions

Data on daily reports of anosmia collected through a nationwide, web-based self-assessment app can be a relevant tool to anticipate surges in outbreaks, hospitalizations, and ICU admission during the COVID-19 pandemic.

Trial Registration

ClinicalTrials.gov NCT04331171; https://clinicaltrials.gov/ct2/show/NCT04331171