Flu Triage

SORTing it Out: Increasing Efficiency in the Face of a Flu Pandemic

The idea for SORT —Strategy for Off-Site Rapid Triage—emerged from a fear: that during a pandemic, people with flu-like symptoms would flood emergency rooms and clinics. Crowded waiting rooms would, ironically, become prime sites for flu transmission and the constant influx of patients could topple an already overloaded healthcare system.

So in December 2008, even before H1N1 was on the world’s radar, Emory researchers and clinicians developed a screening tool that could work outside the hospital setting to reduce patient surges during a flu pandemic.

With funding from the Robert W. Woodruff Foundation and the Georgia Division of Public Health, the Emory team and a small group of consultants created a strategy to assess huge numbers of patients using the best and most current information from the fields of infectious disease, public health, emergency medicine, and nursing.

Arthur Kellermann, MD, PhD
Arthur Kellermann, MD, PhD

"The goal of effective screening is do identify the most severely ill, while safely redirecting large numbers of symptomatic individuals away from crowded hospital and office waiting rooms without compromising their care," says Alex Isakov, MD, PhD, executive director of Emory's Office of Critical Event Preparedness and Response.

SORT employs a three-stage process, says emergency physician Arthur Kellermann, MD, PhD, former associate dean for health policy at Emory and a member of the committee who developed the screening tool. "First, individuals are asked standard questions to determine whether they meet the CDC criteria for influenza-like illness," Kellermann says. "Then they are asked about signs or symptoms of critical illness. And finally, they are asked whether they have a condition that increases their risk of progressing to severe disease."

Based on the answers, SORT categorizes individuals as high risk (in need of immediate attention and likely hospitalization), intermediate risk (should go to their doctor for further evaluation) or low risk (encouraged to recover at home.)

SORT was envisioned to be administered in a variety of settings, including ambulatory care clinics, call centers, and self-assessment via the Web.

When H1N1 emerged in 2009 and was declared a pandemic, the Emory team pulled SORT off the shelf and quickly revised it to include new information specific to that strain, as well as collaborating with experts around the country to verify that the algorithm was safe and effective at distinguishing low risk patients from those who need immediate treatment.

In October 2009, the CDC adopted a slightly modified version of SORT for adults and posted it on the agency’s web site. The CDC later posted a child version, built on Emory’s approach and developed in collaboration with the American Academy of Pediatrics.

Emory team members went even further. Recognizing that millions of flu suffers might be reluctant to reach out to their doctor, or unable to contact one even if they tried, they developed a prototype website to help patients self-assess their condition using the science in the SORT process. To ensure that this material was easy to understand, they engaged another group of Emory experts – the Grady Health Literacy Team.

Ruth Parker, MD
Ruth Parker, MD

"Studies show that half of patients have difficulty understanding medical information," says Ruth Parker, MD, a professor at the School of Medicine and the literacy team’s leader. "We were happy to assist by translating the SORT’s clinical terminology into simple, understandable language."

To verify that the site would perform as intended, Parker and team members Kara Jacobson, MPH, of the Rollins School of Public Health, and Lorenzo DiFrancesco, MD, of the School of Medicine, tested various questions and messages with more than120 people of diverse ages, races, education levels and backgrounds in multiple cities. Some had recently recovered from the flu or were still feeling its effects.

Emory's Office of Technology Transfer (OTT) provided intellectual property protection strategy and licensing advice. "We worked with Drs. Kellermann and Isakov on the best strategy to protect this intellectual property, which was a real challenge since SORT was very different from the projects we typically manage," says Justin Burns, licensing associate in OTT. "It had a very short development timeline, and we had to select the best protection route—copyright or patenting—as well as our strategy for making this available to physicians and other groups who could use this tool. Our number one priority was how to best use the tool to benefit sick patients."

Screen Shot
Screen Shot

Emory's pilot website quickly generated attention. In early September, the Institute of Medicine hosted a national workshop on communicating with the public about H1N1. Shortly after that meeting, Microsoft signed a no-cost licensing agreement with Emory and launched a free self-assessment website. The same day Microsoft rolled out its site, U.S. Department of Health and Human Services Secretary Katherine Sibelius announced on Good Morning America that her department was offering a self-assessment website to the public. It was developed in close consultation with Emory's team.

The professional community has taken notice. Both the American College of Emergency Physicians and the American College of Physicians endorse SORT.

The President's Council of Advisors on Science and Technology predicts that H1N1 could ultimately infect up to half of the U.S. population, producing symptoms in 20 to 40 percent. If just half of these individuals seek medical attention, it would push 30 million to 60 million additional patients into the healthcare system, hindering everyone’s access to care, says Kellermann. "SORT is designed to moderate that surge and allow ER and hospital care to be targeted to those who need it most," he says.

As SORT's effectiveness is evaluated it may prove to be a model for providing a rapid response and engaging the public, not only in the event of a pandemic, but for emerging public health threats of all types.

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