Why Every Hospital Needs a COVID-19 Clinical Case Review Team

ULJRI | https://doi.org/10.18297/jri/vol4/iss1/51 1 Abstract A hospital’s response to a global pandemic requires a coordinated effort to provide consistent guidance, as information rapidly changes. In the early months of the COVID-19 pandemic, diagnosis and subsequent containment was challenging due to unfamiliarity with disease presentation, unknown reverse transcription-polymerase chain reaction sensitivity and inconsistent access to testing supplies. A centralized COVID-19 clinical case review team can provide guidance on test interpretation, isolation, resource coordination and more.


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Why Every Hospital Needs a COVID-19 Clinical Case Review Team er surveillance information on changing epidemiologic or clinical presentation based on provider's clinical suspicion.
Subsequently, the clinical case review team reviews all adult inpatients with pending COVID-19 tests each day. The case review consists of a radiographic and clinical review. Chest CTs were recommended at Norton Healthcare on all adult inpatients with suspected COVID-19 disease due to the higher specificity than clinical presentation of COVID-19 disease. [6] The radiologist discusses cases with the infectious diseases pharmacists to identify timeline of the CT in relation to symptom presentation, and other comorbidities that could explain abnormal findings on CT. The radiologist then designates the patient's radiographic review as high, indeterminate, or low risk of being COVID-19 disease.
The infectious diseases pharmacist or physician perform an independent clinical review of the patient. Their chart review consists of three areas: epidemiological risk, signs/symptoms consistent with COVID-19 disease, and alternative explanation for clinical presentation. Based on the presence or absence of these three areas, the clinical reviewer would use the grid outlined in Figure 2 to designate the clinical review as high, indeterminate, or low risk of COVID-19 disease.
The radiographic and clinical reviews are then combined using Figure 3 to estimate the patient's overall risk of having COVID-19 disease as high, indeterminate, or low. This comprehensive case review is completed prior to the COVID-19 test result being available. If the patient's test results as positive, the patient is managed as such. If the patient's test result is negative, the clinical case review team's assessment is communicated to the healthcare team through a progress    This patient is at HIGH RISK for having COVID-19 disease at this time.
 Isolation status will remain in COVID-19 appropriate isolation.
The COVID-19 case review team consists of infectious diseases physician, infectious diseases pharmacist, and radiologist input. The purpose of the team is to identify a possible false negative COVID-19 test result in the changing COVID-19 pandemic.  If the assessment is a high probability of a false negative test result, the patient is managed as if the test result is positive. An example documentation of a patient at high risk of having COVID-19 is seen in Figure 4. Figure 5 illustrates the impact of the clinical case review process on the distribution of patients with a laboratory diagnosis of COVID-19 versus a clinical diagnosis of COVID-19. On average, 62% of our COVID-19 patients were diagnosed via RT-PCR and 38% of our COVID-19 patients had a clinical diagnosis of COVID-19 as defined by having a negative RT-PCR but deemed high risk of false negative or indeterminate risk of false negative. Of the 38% COVID-19 patients with a clinical diagnosis, on average approximately one-third were classified as high risk of false negative and two-thirds were classified as indeterminate risk of false negative.
The COVID-19 clinical case review team follows suspected COVID-19 patients throughout their hospitalization. Follow up activities include making recommendations on pharmacologic treatment and safety monitoring, screening candidates for participation in clinical trials, and ordering repeat COVID-19 testing either to clear the patient from isolation or to make a definitive diagnosis.

Discussion
Many benefits have been actualized from the Norton Healthcare COVID-19 clinical case review team. The first is reduction in patients being removed from isolation inappropriately. During the early days of the pandemic, many providers were eager to rule out COVID-19 cases with a single negative nasopharyngeal sample. Given that so little is known about varied presentation of COVID-19 disease, a multidisciplinary approach is necessary. At our hospitals, only infection preventionists can remove patients from isolation. Through partnership with the COVID-19 clinical case review team, we are able to provide a standardized approach to assessing risk of false negative SARS-CoV-2 RT-PCR test results. Additionally, we are able to quickly identify patients who are being tested for COVID-19 that are not in the necessary isolation.
Another benefit of the COVID-19 clinical case review team is the ability to adapt to the changing epidemiology of the pandemic. Exposure risk factors can change almost daily as certain populations may experience small-scale outbreaks of COVID-19 such as nursing homes, dialysis centers, or even groups within the community. By having a central team reviewing a large number of cases each day, we are able to rapidly identify changes and work with public health officials to identify trends. Our central team is also able to adjust our risk stratification based on learning through test results. Since inception, our assessment grids have been modified to better identify potential cases seen within our hospitals.
The last benefit seen with our process is a central coordination center for data and resource monitoring. Our centralized approach is able to track and follow trends of inpatient resource utilization, which can be matched to PPE supply and medication supplies. If a dire shortage of PPE was trending, we would be able to quickly adapt to recommend more patients be removed from isolation with a negative test.
There are several limitations to our approach. The first is that it is time consuming and resource intense to review every patient being worked up for COVID-19. We are fortunate to have a group of dedicated individuals that were willing to participate in a rotation to review patients seven days a week. The ability to test every suspected patient may not be feasible at all hospitals due to limited testing capacity. Our approach with providers to use the "see something, say something" method allowed us to stay ahead of epidemiologic trends. Institutions that are not able to test at will should at least consider isolating any suspected COVID-19 patients. The non-specific clinical presentation and widespread transmissibility of SARS-CoV-2 makes strict testing criteria challenging to implement.
Secondly, our approach to assessing negative test results was not in concordance with the CDC recommendations. Our conservative approach may have led to some unnecessary use of PPE resources and may not be feasible in other centers depending on PPE availability. However, our priority was to protect our healthcare workers that in turn protects our community.
Lastly, our approach of having a clinical and radiographic review is difficult to extrapolate to pediatric populations where chest CTs are not routinely used. Fortunately, COVID-19 has not been as prevalent in hospitalized pediatric patients.
In conclusion, the Norton Healthcare COVID-19 clinical case review team approach to monitoring inpatient COVID-19 testing provides a standardized, adaptable, multidisciplinary, and patient centric approach to managing the coronavi-ULJRI Why Every Hospital Needs a COVID-19 Clinical Case Review Team rus pandemic. Institutions may consider a centralized approach with resources adapted to their institution's needs.

Appendix: Center of Excellence for Research in Infectious Diseases (CERID) COVID-19 Study Group
The aforementioned appendix is available upon request.