e-Health for COVID-19 Epidemic: The Arizona Poison and Drug Information Center Experience
Introduction
In the United States, public awareness of the impending pandemic caused by the SARS-COV-2 virus, began in the later part of January and early February 2020. The first recognized COVID-19 case in the United States occurred on January 19, 20201 and shortly thereafter many cases were discovered.2 The Arizona Department of Health Services (ADHS) immediately contracted with the Arizona Poison and Drug Information Center (APDIC) to undertake the task of expanding their mission to provide information to the public about COVID-19. The APDIC faculty, along with their partners at the ADHS and Centers for Disease Control and Prevention (CDC), drafted protocols for staff to deal with phone calls concerning COVID-19 and added extra staff in the ensuing year to deal with the enlarging mission.
APDIC, similar to other agencies, adopted practices to protect the health and safety of its staff to include physical distancing, masking, remote work, increased ventilation of office indoor air, and deployment of HEPA filters and sanitizers. Thus, in the Spring of 2020, the APDIC began a major transformation. The APDIC staff were acutely aware of the need for accuracy in the information, mindful of what the World Health Organization terms the “infodemic.”3 We describe in this report some of the procedures and changes that were implemented and the outcome regarding calls and cases that occurred in the past year.
Methods
Data Collection
The APDIC in Tucson, at University of Arizona’s College of Pharmacy, receives calls from 14 out of the 15 counties in Arizona and >2.79 million lives in Arizona, including the metropolitan areas of Tucson and Flagstaff, and many rural and Native American communities. The Banner Poison and Drug Information Center, part of the Arizona Poison Center network, serves Maricopa County (Phoenix) alone. All data are stored in the ToxSentry database. The ToxSentry database was accessed for reports pertaining to COVID-19 information calls and cases from March 3, 2020 through March 3, 2021. Because all data were de-identified, the project was IRB-exempt.
Topics
The following topics were addressed telephonically: COVID-19 testing; exposure to COVID-19; symptoms of COVID-19; information concerning businesses, work, school and attendance at events; isolation and quarantine; who to call regarding contact information; the number and location of cases in Arizona; prevention of COVID-19 and personal protective equipment; contact tracing; travel; antibody testing; and other topics adopted later in the epidemic such as vaccines. An automated calling tree was designed and established as shown in Figure 1.
Fig. 1. Phone tree for incoming calls regarding COVID-19 to the APDIC. The recordings were updated two to three times per week to keep current information current. APDIC, Arizona Poison and Drug Information Center.
Calls and Teleconsults
Call numbers represent unique phone calls to the center that went through the menu of choices of prerecorded information as shown in Figure 1. If callers needed more help they were connected with an information specialist who would open a file in the ToxSentry record system that became part of the permanent record (teleconsult). The information specialist gathered data from the caller and suggested approaches to the question or referred the caller to an APDIC physician. Responses ranged from telephone conversation alone to teleconsult (video linkage with caller or patient by a specialist or physician).
Results
Increase in the Apdic Staff
The APDIC physically resides in the School of Pharmacy, University of Arizona and regularly employs 5 office and training staff, 13 dedicated specialists in poison information, and 8 medical toxicologists. In reaction to the immense numbers of calls and increased teleconsults, 5.25 full-time equivalents (FTE) were added during the ensuing year (2020). These included 2.25 FTE specialists who were trained to deal with cases; 1.0 FTE for a student from the School of Public Health and 2.0 FTE for technicians to deal with the increasing telephone load.
Training
Information specialists underwent extensive training regarding the virus epidemiology and anticipated questions from the public. Use was made of “skits” mimicking live calls from the public and how to access the material needed for various responses. Premade modules were available from the ADHS and CDC. Each specialist received 20–30 h of training per week for several weeks and this was followed up with “spot checks.” The physicians and managers also logged many hours of training. Considerable time was spent learning to work remotely and how to integrate those individuals with the calls as they were received at APDIC.
Calls and Teleconsults in 2019 Before the Pandemic
There were 24,721 calls and teleconsults in 2019: 988 animal exposures, 17, 378 human exposures and 6,355 information requests. This is the baseline we used to compare the activities for 2020–2021.4
COVID-19 Calls and Teleconsults Marh 2020 to March 2021
More than 640,0000 phone calls were received by Arizona Poison and Drug Information network, which includes APDIC. More than 320,0000 phone calls were received by APDIC alone in the 1-year period. Of those calls, 27,688 (or ∼76/day) calls, concerned COVID-19 and required specialist intervention and thus became teleconsults. In addition, APDIC logged 20,728 (or 58/day) teleconsults about chemical exposures, envenomation, overdoses, and poisonings that required specialist intervention. The total number of teleconsults handled by specialists at APDIC came to 48,346, double the annual case load in the absence of the pandemic.
The major difference between COVID-19 and poisoning cases was the need for follow-up calls and involvement of specialists and toxicologists in the diagnosis, monitoring, management, and care of “poisoned patients.” Generally, COVID-19 cases required a single response at the point of contact.
Early in the epidemic most calls concerned COVID-19 testing to include information on testing locations; whether or not callers should be tested; and the meaning of the results. There were 9,434 calls (34% of all calls) for this topic (Table 1). This was followed by vaccines and therapeutics with 6,413 calls (23%). The least number of calls were for the topic of antibody testing (99, <1%); (Table 1). Figure 2 plots the confirmed cases of COVID-19 in Arizona5 versus calls to APDIC. Before the epidemic started in Arizona calls mainly concerned personal protective gear and in the second peak of the epidemic, calls were mostly about vaccination. The APDIC registered >2,132 individuals to receive COVID-19 vaccination. Cases associated with vaccine registration took 10 min on average, whereas general COVID-19 calls averaged 5 min.
Fig. 2. COVID-19 confirmed cases in Arizona by date5 (bold black line) plotted against calls to the APDIC regarding PPE in the first peak (thin grey line) and vaccines in the second peak (thin grey line). PPE, personal protective equipment.
| CATEGORY | n (%) |
|---|---|
| COVID-19 testing (info/locations/if they should/results) | 9,434 (34) |
| Antibody testing (added to topics April 5, 2020) | 99 (<1) |
| Pinal county contact tracing program | 302 (1) |
| Prevention | 657 (2) |
| Travel | 213 (1) |
| Businesses/work/school/events | 2,649 (10) |
| Isolation/quarantine | 1,296 (5) |
| Who to call/contact information | 924 (3) |
| Exposure/symptoms/what to do | 3,941 (14) |
| Number and location of cases of COVID-19 in AZ | 562 (2) |
| Supplies (PPE, masks, etc.) | 237 (1) |
| Vaccines/therapeutics (added to topics November 10, 2020) | 6,413 (23) |
| Other | 961 (3) |
| Total teleconsults | 27,688 |
On February 7, 2021, 7,000 calls were received. The phone tree was assessed and updated two to three times per week during the year as information and data became available. Thus, the prerecorded information was kept “real-time.”
Discussion
This report shows that an organization with a long established and focused mission such as the APDIC can expand its capacity to take on a new mission and responsibility. The APDIC has dealt successfully with the public for >65 years and enjoys an excellent reputation for careful and informative communication with the public through phone calls as well as patient management through consultation. In the latter role the APDIC utilizes telephones, telemedicine visual linkups and in-person consultation as needed to achieve their mission.
For the past two decades as part of preparedness training and response the APDIC has practiced remote work assignments. On several past occasions the APDIC assisted ADHS and local health departments with disease information and epidemiological data gathering regarding exposure to Zika and H1N1 influenza. The University of Arizona annually sponsors a university-wide response to a mock influenza pandemic with which the APDIC played a leading role.
It is noteworthy that the APDIC continued to deal efficiently with poison and drug-related calls/cases during major transformations beginning in March 2020 and succeeded in its new role as an information provider to the public regarding the COVID-19 epidemic in the state of Arizona. By practicing potential client calls and teleconsults the information specialists uniformly provided only factual comments or concepts that had been mooted in group sessions. This avoided adding to mis-infodemiology,6 which is clearly accelerating with >110 retracted scientific articles on COVID-19.7
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received.
References
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