AMGA CMO Council: Testing Procedures for COVID-19
March 20, 2020
This summary is based on a presentation and discussion of AMGA’s Chief Medical Officer Council on March 20, 2020. For more information about the CMO Council, please click here.
Speaker: Jonathan Nasser, M.D., Chief Clinical Transformation Officer, Crystal Run Healthcare, Middletown, NY
Jonathan Nasser: A big shout-out to the AMGA Council listserv, which has been extremely helpful for me. Our friends out at The Everett Clinic have been incredibly useful to us, and I hope we can share something that can be helpful to you.
We are in New York State and, like many of you, are in a community spread area.
- We have an outside testing and evaluation center that started in the urgent care center and now is in the practice center of as of last Monday.
- We locked down buildings, and any patients with URI symptoms are turned towards one of these facilities, like you can see in this picture.
- The bays you see in the picture were a $180 car port from Walmart that we turned over sideways and have team on one side and the patient on the other.
- We have four bays set up. We had me, the CMO, and the CEO all man the stations the first couple of days to get it going. We had three bays on Monday and four on Tuesday doing testing and providing evaluations.
- We developed a workflow, which has evolved over the week.
- Patients coming into our practice that don’t have URI symptoms are seen in the practice. We hand an info sheet to patients when they arrive, which has evolved. We are giving the patients this when they pull into the parking lots. They then wait in their car, and when we are ready, we call them up.
- Our team consists of a provider or an APP, a scribe, and two clinical people who are nurses or MAs. Providers wear all PPE and interact with the patients in the car. Scribes record and document all visits. Then the clinical assistant passes instruments back and forth to providers or APP. All vitals and touching of patients are done by the provider (vitals and testing). Patients come into the bay and they roll down their windows and we all take their history together with the scribe documenting.
- We started on the first day doing flu and COVID testing on all patients. After the visit is completed and we finish taking the sample, the patient is given an info sheet and a home quarantine sheet. We also had a few positive flu tests this week and they are given information on what to do if they have this. We give them brief instructions at time of interaction with what the diagnosis means for them.
- We have a care coordination center to call patients with test results, help with return-to-work notes, and quarantine information. The return-to-work note is not signed and just requires them to fill out their name and the date. The note says they are out of work for five days.
- We see 30 patients a day per provider, and we don’t touch the computer all day. We have seen 1,200 of these visits and we are billing them as provider visits.
- We send the labs to Quest and the turnaround time is 4-5 days. Quest has added some testing capabilities and are promising a testing increase on Monday.
- We have about a 15% positive rate as of yesterday. The majority of testing started on Monday of last week and we are just starting to get those results today.
- Today we have refurbished our care management team internally to become our COVID team that contacts patients with results, coordinates our telehealth program, works with the department of health on findings and testing, as well as helping providers who are working in these sites to contact hospitals or specialists if they need to relay findings. In the first week, only two patients needed to be sent to the hospital. We expect this will change.
- We are doing rapid strep and RSV for patients who have typical symptoms. The bays we have set up are not only for high-risk patients. We see everyone to keep them out of our clinics if they have symptoms. We are a week behind the West Coast and rapidly increasing here in New York State.
Rishi Sud, M.D., CMO, Esse Health, St. Louis, MO: We are behind where you guys are now. I think community spread is soon (not yet). We have a 45-office medical group, mainly primary care focused but some specialty as well. We are going to be starting a centralized outdoor testing site starting Monday. We’re where you were a week ago. My question is are you testing for flu, strep, and COVID all at once to see co-infection? Or if you test for strep and flu and find that it is positive, do you not test for COVID?
Nasser: I am interested to see what others are doing about this too. We made the decision in the beginning that if someone had flu or strep, we were still going to do COVID testing. After the first day, we saw 90 patients and none had flu when we tested for flu and COVID. On second day, we transferred to testing for flu only if the patient had traditional symptoms and, therefore, we are testing for COVID on most. As of right now, I haven’t seen anything published on co-infection.
Sud: Less than 2% is what I have seen published.
Warren Volker, M.D, CCO, HealthCare Partners Nevada, Las Vegas, NV: We are a multispecialty group with 64 clinics and several urgent cares. We are about a week behind you in New York. We are launching drive-up testing today in urgent care. It was very helpful to see how you set it up and your protocol. We are having trouble getting the testing kits. Does anybody have any other sources other than Quest (trying to get Labcorp) that would be helpful for us?
Nasser: We use Labcorp and Quest. Quest was able to supply us with significant testing, but they have a slow turnaround. I don’t know of any other resources; haven’t seen stand-up testing yet locally.
Sud: We have a pretty limited supply as well. We are trying to figure out the kits. Quest just put out that eswabs are allowed now. We are taking inventory in all of offices. The limiting factor for us is that we only have 300.
Nasser: We switched over to eswabs mid-week. We have had ample supply with this.
One other thing I’d like to share is that NP swabs raise the issue of needing to have PPE with every test. One thing I have tried to do is have patients self-test. I did some experimenting with this because the NP swab is not the most comfortable thing. I had some people do their own-did the first one and they did second. About 15% were able to do it successfully. This reduces need to be in PPE. Eswabs also have the reduced PPE potential in obtaining samples.
We are spreading this drive-up model to all urgent cares. We have had six days in this model, and four other locations are going live on Monday. We see a patient in about seven minutes from the start with documentation all the way through to completion of the visit. We are excited to expand this model to the rest of the organization next week.
Question: What is the most beneficial piece of information for someone who is starting to consider drive-in clinics for their organization?
JN: You need to understand the resources and protocol for how to set this up.
- Step 1: Evaluating current PPE supply and how can you do this in a way that minimizes PPE use. We use one N95 mask for the whole day.
- Step 2: What is your testing capability and supply? Testing everyone or only doing high-risk testing?
- Step 3. Understanding what you view your role as. This allowed us to maintain a safe environment for our patients and providers and could help you to build a test case for your organization on rolling this out.
- Step 4: It was really cold here on the first day. For those in warmer climate, it will make things much easier.
Sud: Weather is something we have toyed with as well. We have our own lab and know that development of strep and flu needs to be in a more controlled environment. We are renting a climate-controlled tent to be used for that. For your flu and rapid strep, can you perform that in outside environment without controlled environment?
Nasser: We have our lab inside. We have a lab tech/phlebotomist who runs around to get samples and then brings them inside to be tested.
Sud: We will have to use an outside tent. The building is too far away, about 450 feet away.
Rick Bone, M.D., Senior Medical Director, Population Health, Advocate Medical Group, Palos Park, IL: We have opened up two drive-in clinics that are active, and there are three more in the process. We are in Chicago, and we ran critically short of supplies and had to close them down. We got bad press from closing them down after we had them open. Plan ahead of time to have enough supplies to meet the demand.