Disclaimer: We aim to present letters from our readership that may generate further discussion on managing patients with COVID-19. Given the novelty of COVID-19, best-available clinical evidence is limited and supported from anecdotal reports from China, South Korea, Italy and other sites, and from studies of previous epidemics like SARS and MERS. The opinions expressed are those of the authors and not the APSF. These materials are presented for informational and educational purposes only and do not establish a standard of care or constitute medical or legal advice. The APSF does not support or endorse any specific idea, product, equipment, or trademarked technique. We strongly promote consistency with your governing bodies and organizations such as the CDC, WHO, ASA, AANA, and AAAA. Readers are reminded to consult with their institutions and medical/legal advisors regarding any of the views and opinions expressed by the authors.
The current COVID-19 pandemic is unprecedented and being such, it is ushering in change and requiring us as a nation to think on our feet and make things up as we go. Hospitals as a whole have heightened scrutiny for those who enter compared to nearly none only a few months ago; screening questions at the door, universal masking, temperature checks and limited visitation for their patients, all in an attempt to limit viral spread. These precautions vary greatly between institutions, specifically with actual COVID-19 PCR testing. The government has expanded testing to make it widely available.1 In hospitals, though, who is being tested, when, and how often?
Many hospitals are now testing every inpatient and outpatient before procedures. Unfortunate variations to this precaution are seen, though, such as testing only those that are symptomatic. While it is currently impossible to account for the time between outpatient testing and hospital admission, false negatives or 100% compliance of masking etc., there is a large silent risk that is being either overlooked by most institutions: the testing of hospital personnel. Roughly half of COVID-19 transmission occurs within the 6 days from viral exposure to symptom onset potentially making asymptomatic spread a threat to our patients, and many screening policies insufficient.2
Screening hospital employees and healthcare providers with questionnaires, thermometers, and an attempt at prevention of spread with universal masking are all important steps to take. The arguably equally important step of limiting infection within our own walls through testing hospital personnel does not seem to be something that is universally performed.3 Shouldn’t we test staff and healthcare providers as well?4 However, the question arises as to how often and under what circumstances should we be tested.5 We should think of the risk our patients face when presenting to our institutions, and lower that risk as best we can.6
In general, lowering infection risk from hospital personnel is being addressed by entrance screening with universal masking, contact tracing for those who have been found to be in close proximity with positive cases and mandatory quarantine for symptomatic individuals. However, asymptomatic contacts may be allowed to return to work. One example of a step in the right direction is exhibited by Mount Sinai in New York City which offers PCR testing every 28 days upon request to staff who are concerned that they may have the COVID-19 virus without having manifested symptoms.7 More hospital personnel should be tested. Direct patient care for a COVID positive patient without personal protective equipment (PPE) and interaction with symptomatic workers should trigger mandatory testing for any close contacts among co-workers. The rapid and accurate diagnosis of COVID patients and carriers may be key for preventing and controlling spread.8 PPE is also of utmost importance. Regular scheduled testing of these healthcare professionals may reduce the spread to other workers when PPE is not being worn or when it is donned improperly. To minimize spending and maximize efficiency in the implementation of our solution, ‘multi-step group testing’ may be used on entire departments, hospital wards or contact tracings.9 Group testing involves the use of one PCR cycle for the successful testing of numerous individuals in order to rule out infection in a large group.10 Group testing should be considered especially when test availability is limited.
We may not have the best solution but hope to stimulate further discussion in order to generate improvement. Let us use this unprecedented time to analyze our resolve and emphasize our personal as well as institutional determination to care for our patients by making our healthcare environment safer through continued use of appropriate PPE, hygiene practices, and consideration of a more broad healthcare professional testing approach.
“This article was supported (in whole or part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this presentation represent those of the author and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.”
Wayne Simmons is a CA2 Anesthesiology resident of the HCA Healthcare / USF Morsani College of Medicine GME/Oak Hill Hospital Anesthesiology Residency Program in Brooksville, FL.
Jeffrey Huang is program director of the HCA Healthcare/USF Morsani College of Medicine GME Anesthesiology Residency/Transitional Year Residency at Oak Hill Hospital in Brooksville, FL, Professor at the USF Morsani College of Medicine and Professor at the University of Central Florida College of Medicine. He serves on the APSF Committee on Education and Training.
The authors have no conflicts of interest.
- HHS, “HHS Awards More than Half Billion Dollars Across the Nation to Expand COVID-19 Testing | HHS.gov.” [Online]. Available: https://www.hhs.gov/about/news/2020/05/07/hhs-awards-more-than-half-billion-across-the-nation-to-expand-covid19-testing.html. [Accessed: 26-Jun-2020].
- ASPR and CDC, “COVID-19 Pandemic Planning Scenarios | CDC.” [Online]. Available: https://www.cdc.gov/coronavirus/2019-ncov/hcp/planning-scenarios.html. [Accessed: 26-Jun-2020].
- D. Sutton, K. Fuchs, M. D’Alton, and D. Goffman, “Universal screening for SARS-CoV-2 in women admitted for delivery,” New England Journal of Medicine, vol. 382, no. 22. Massachussetts Medical Society, pp. 2163–2164, 28-May-2020.
- J. R. M. Black, C. Bailey, J. Przewrocka, K. K. Dijkstra, and C. Swanton, “COVID-19: the case for health-care worker screening to prevent hospital transmission,” The Lancet, vol. 395, no. 10234. Lancet Publishing Group, pp. 1418–1420, 02-May-2020.
- J. Riou and C. L. Althaus, “Pattern of early human-to-human transmission of Wuhan 2019 novel coronavirus (2019-nCoV), December 2019 to January 2020,” Eurosurveillance, vol. 25, no. 4, p. 2000058, Jan. 2020.
- A. F. Monegro and H. Regunath, “Hospital Acquired Infections,” StatPearls Publ. [Internet]. Treasure Isl., Jan. 2020.
- MSHS, “MSHS_COVID_19_Employee Monitoring_Testing Clearance,” Last Revised May 9, 2020. [Online]. Available: https://www.mountsinai.org/files/MSHealth/Assets/HS/About/Coronavirus/MSHS-COVID-19-Employee-Monitoring-Testing-Clearance.pdf. [Accessed: 26-Jun-2020].
- M. Wang et al., “Clinical diagnosis of 8274 samples with 2019-novel coronavirus in Wuhan,” Cold Spring Harbor Laboratory Press, Feb. 2020.
- J. N. Eberhardt, N. P. Breuckmann, and C. S. Eberhardt, “Multi-Stage Group Testing Improves Efficiency of Large-Scale COVID-19 Screening,” J. Clin. Virol., vol. 128, p. 104382, Jul. 2020.
- R. Ben-Ami et al., “Large-scale implementation of pooled RNA extraction and RT-PCR for SARS-CoV-2 detection,” Clin. Microbiol. Infect., vol. 0, no. 0, Jun. 2020.