When a healthcare worker tests positive for COVID-19, it kicks off a labor-intensive process inside the hospital to track down which colleagues they've interacted with and therefore could be infected, too.
That's not unique to the novel coronavirus. If an employee is diagnosed with an infectious disease that can be transmitted in the workplace, infection prevention and occupational health teams have to figure out who else might have been exposed.
It's a largely boots-on-the-ground process, where workers are tasked with reviewing work schedules and asking people to recall who they've interacted with.
That sounds like a promising activity to automate with technology, but so far, that hasn't been the case. There are emerging digital tools to aid in the process, but they're just getting off the ground and it's yet to be seen how successful they are.
"It really is a manual (process), looking back on schedules and assessing what the work-flow of the individual is," said Jamie Harkins, senior vice president of quality, safety and risk management at Peoria, Ill.-based OSF HealthCare.
After an employee tests positive for COVID-19 at OSF, a team of workers works on contact tracing—tracking down which other staff members might have been in close proximity to the employee while they were infected. That involves interviewing the employee about who they've had contact with and asking their supervisor about who they typically work near.
The information is shared with OSF's occupational health team, which alerts relevant employees about the COVID-19 exposure and next steps, based on an assessment of whether the exposure was high or low risk. The risk assessment relies on rapidly changing guidelines from the local public health department and the Centers for Disease Control and Prevention.
Most of the health system's recent COVID-19 exposures have been low-risk, on account of policies that require employees to wear masks in clinical areas, Harkins said.
To streamline the process for alerting a growing number of workers about low-risk exposures, OSF developed a system so that email notifications could be pushed to employees from within the health system's quality management software. Employees with low-risk exposures are mainly provided an alert and education materials.
"It really built some efficiencies in," Harkins said of the electronic process.
A high-risk COVID-19 exposure, which is less common, would warrant direct outreach and asking the employee to report symptoms for 14 days.
For most hospitals, practices put in place to alert employees of possible COVID-19 exposures at work have been similar as for other infectious diseases, such as tuberculosis. The difference has been finding a way to manage the "sheer number" of cases to track, said Jo Henman, director of infection prevention at Columbus-based OhioHealth.
"We may have a handful of TB patients in a year," she explained. "The cases of COVID in our communities have been significantly higher than that."
For contact tracing among employees, OhioHealth asks the employee in question to share any instances where they had their mask off at work and were within six feet of another employee. OhioHealth has implemented a universal masking policy, so that's typically only the case if the employee had lunch with a colleague.
OhioHealth reports each positive COVID-19 test to its local public health department—as required by law—which is important to ensure contact tracing can be done at the community level, outside of the hospital.
"We do the follow-up inside of the hospital, but obviously healthcare workers also have a life outside of the hospital," Henman said. "Public health does the contact tracing on that part of it."
At the community level, contact tracing has taken on newfound national attention amid COVID-19.
Contact tracing has existed for decades, as early as the start of the 1900s, said Dr. Georges Benjamin, executive director of the American Public Health Association. It's played a role in slowing the spread of infectious diseases like smallpox.
The purpose of contact tracing is "disease control," Benjamin said, noting that for a disease like COVID-19, where there's no known treatment, it's important for people who may be infected to isolate, watch for symptoms and get tested. Contact tracing "works to break that cycle of infection. That's the fundamental goal of doing this."
While contact tracing has existed for years, in recent months technology companies have released tools they say can help support the time- and labor-intensive process.
Apple and Google in the spring released software tools for public health agencies to build exposure notification apps. The basic idea was for public health agencies to build apps using the companies' application programming interfaces, which can identify devices nearby one another and alert users if they've been in close proximity to someone later diagnosed with COVID-19.
While Apple and Google have billed the project as "privacy-preserving contact tracing," on account of it being opt-in and not collecting identifiable information, it has been met with skepticism as health authorities question whether apps provide useful information and public concern over tech companies getting involved with health efforts continues to grow.
On a smaller scale, employers—including hospitals and health systems—have started rolling out software tools that track time employees spend in close proximity with one another to aid in internal contact tracing efforts.
"I'm not quite sure what value they bring," said APHA's Benjamin, who's skeptical of the tools. Traditional contact tracing practices emphasize testing and monitoring employees who have had exposure to a specific infection, but these new tools screen all employees. That could raise possible privacy concerns, he said.
Regardless of a hospital's process for contact tracing internally, it's important for the organization to report COVID-19 cases to their local public health agency. That's the entity that spearheads the "community piece" of contact tracing, calling up a person's friends, family or others they may have interacted with, Benjamin said.
"You're not in an isolated environment," he said. "Those folks leave and go home."
Flagler Health+ in St. Augustine, Fla., is getting ready to deploy a contact tracing tool. It's part of HealthySite+, an app it developed with digital health company Healthfully to provide employees with COVID-19 education, daily symptom screening, telemedicine visits and other services to manage bringing them back to work.
Healthfully sells the app to other businesses for a monthly subscription based on their number of employees. Flagler Health+, which holds an equity stake in Healthfully, receives a percentage of revenue from sales of the product to area employers who purchase the app, which is white-labeled.
The app's contact tracing feature uses Bluetooth to spot when two mobile devices with the app downloaded—so, presumably two employees—are within roughly 6 feet of one another. The app also records the amount of time that two devices spend near each other.
After an employee tests positive for COVID-19, that proximity information will be shared with Flagler Health+'s infection prevention team. The app can automatically alert employees of a possible exposure, but Flagler Health+ doesn't plan to enable that feature.
The app's contact tracing feature is designed to supplement, but not replace, the health system's historical process for contact tracing, which relies on interviewing staff about where they've spent time in the facility and who they've interacted with, said Kerry Spann-Caride, manager of infection prevention at Flagler Health+. "Unfortunately, there's memory bias involved with that," she said. "They don't always remember everybody."
Flagler Health+ started rolling out some components of the HealthySite+ app, such as the education components, last week. All employees are required to use the app's daily symptom screening; employees without smartphones have the option to access the app online, but that means it won't be able to track their proximity to others.
The contact tracing component hasn't launched at Flagler Health+ yet. It plans to go live on that feature in the next few weeks.
UCSF Health is currently looking into apps that track proximity, but hasn't implemented one, said Dr. Robert Kosnik, director of the occupational health program at the San Francisco-based health system.
A proximity app could help with identifying someone who an employee might have had contact with, but doesn't know the name of. But Kosnik stressed the health system will need to vet tools to ensure they're protecting data privacy, as well as measuring proximity in a useful way—not flagging people who were within 6 feet, but may have been in separate rooms, for example.
While a proximity app could help to flag additional employees in need of COVID-19 testing or monitoring, Kosnik said he wouldn't expect it to change UCSF Health's core work-flow for contact tracing, which involves interviewing the employee and their unit manager.
"I see them as an extra channel for identifying potentially positive individuals," Kosnik said of proximity and contact tracing apps. "I think that they're adding more starting points."