Surveillance, intelligence, and intuition: Knowing when to re‐engage in clinical operations

1. PROBLEM

Coronavirus disease 2019 (COVID‐19) is a highly transmissible disease with a basic reproduction number (R₀) of above 3, meaning that, in absence of preventive measures, every patient contaminates at least 3 others. ¹ Through drastic steps that included social distancing and closure of significant parts of the economy, including dental education, the effective reproduction number R_t decreased below 1 in most parts of the United States. ² While general principles to revitalize the economy were outlined in the White House Plan, methodologies for re‐engagement were not delineated. ³ Dental schools have had to navigate uncertainties about how to deliver their clinical, training, and research imperatives through the disruption of traditional, operational paradigms.

2. SOLUTION

The James B. Edwards College of Dental Medicine at the Medical University of South Carolina used World Health Organization (WHO), national, and state guidelines to inform a multi‐phased re‐entry provision of clinical care. The WHO recommends the percentage of positive tests be < 10% prior to re‐engagement. ⁴ Those recommendations, coupled with the R_t level, served as the basis for building a re‐entry framework for the college in ways that align with public health surveillance. The framework includes criteria for progressing from one phase to another, accounting for the potential retraction of some services should COVID‐19 rates increase, or a sentinel event occur.

A surveillance tool was developed at the college using Tableau ver. 9.1 (Tableau Inc., Seattle, WA, USA) to track the daily percent of positive COVID‐19 tests, with a linear regression model over 14‐days of observations (Figure 1, 2, 3). An example of the daily report can be also seen at: https://public.tableau.com/profile/abby.kelly#!/vizhome/622020/Dashboard1?publishnonbreakingspace=yes

FIGURE 1.

Indicator April 8, 2020–April 25, 2020

FIGURE 2.

Indicator April 10, 2020–April 29, 2020

FIGURE 3.

Indicator April 14, 2020–May 9, 2020

Public use data from our state public health agency was used to populate the tool. Other colleges could replicate our approach with data available through the “The COVID tracking project.” ⁵ Testing data were not available at a geographic granularity smaller than state, although county‐level incidence rates as well as zip codes that make up the greater metropolitan area surrounding the college were used to inform the re‐entry framework.

3. RESULTS

Figures 1 and 2 show the linear regression trend pointing to an increase in cases in the past 14 days; however, only the regression line in Figure 1 is statistically significant (P = 0.01), whereas in Figure 2 the line is flattened (P = 0.14). Figure 3 shows the decrease in the the percentage of positive tests attributed to both increased testing and decreased disease spread (P = 0.001).

The tool empowered college leadership to make operational decisions based on public health epidemiological data. It is one tool among many that dental schools can use to make re‐entry decisions and to monitor the ability to progress in the re‐entry. We acknowledge the uncertainty of how low to benchmark percent positive tests under 10%. As such, our tool is operationally augmented with COVID‐19 testing for all patients scheduled for non‐urgent procedures in the foreseeable future.

Kelly A, Martin AB, Teich ST. Surveillance, intelligence, and intuition: knowing when to re‐engage in clinical operations. J Dent Educ. 2021;85(Suppl. 1):1080–1082. 10.1002/jdd.12248