Latest / The SHEA Podcast / COVID-19: Diagnostic Testing Part 1, 3/19

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COVID-19: Diagnostic Testing Part 1, 3/19 · The SHEA Podcast

• 0:07
  SPEAKER_00: Welcome to the Rapid Response Podcast, brought to you by the Society for Healthcare Epidemiology of America, promoting the prevention of healthcare-associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:22
  SPEAKER_00: I am Dr.
• 0:22
  SPEAKER_00: David Bannock from the University of Connecticut School of Medicine, and I am serving as the moderator for today's podcast.
• 0:28
  SPEAKER_00: Jay is excited to launch the fourth episode of this podcast series, COVID-19 updates, What We Need to Know.
• 0:34
  SPEAKER_00: Today's episode will focus on diagnostic testing.
• 0:37
  SPEAKER_00: Our speakers today are Dr.
• 0:38
  SPEAKER_00: Jennifer Hanrahan from the University of Toledo Medical Center and Dr.
• 0:42
  SPEAKER_00: Claire Rock from Johns Hopkins University.
• 0:44
  SPEAKER_00: So thank you for joining us today.
• 0:46
  SPEAKER_00: I will now turn it over to Dr.
• 0:47
  SPEAKER_00: Hanrahan for a news update and a summary of medical literature and guidelines pertinent to COVID-19.
• 0:54
  SPEAKER_01: Thank you, David.
• 0:55
  SPEAKER_01: I think the thing that has been the most important in the news during this last week is the fact that we have gone clearly from people being able to conjecture about whether or not there's going to be COVID-19 in their community to the fact that there is.
• 1:09
  SPEAKER_01: The numbers have increased, obviously, a great deal throughout the United States over the last week, largely driven by the fact that we are now able to do some testing.
• 1:18
  SPEAKER_01: So one of the things that has happened during the last week is that there have been a number of policies put in place to limit social interaction.
• 1:26
  SPEAKER_01: So social distancing has become a norm now, and the White House has made it clear that people should be practicing social distancing and home isolation as much as possible.
• 1:39
  SPEAKER_01: There has been debate about whether or not these measures would work, and there are people who think that these measures may or may not have an impact.
• 1:47
  SPEAKER_01: There actually are a number of modeling studies that look at whether or not these measures work.
• 1:53
  SPEAKER_01: And overall, the data looks like this should make a difference.
• 1:57
  SPEAKER_01: If you look at measures that were implemented in China, they were able to actually decrease the reproductive rate due to the fact that there was social distancing.
• 2:07
  SPEAKER_01: And there's a number of modeling studies looking at the fatality rate when social distancing is implemented versus when it is not.
• 2:15
  SPEAKER_01: So I think the message needs to be very clear that this can make a difference and we need to take this seriously.
• 2:23
  SPEAKER_01: People need to understand that coronavirus is not like the flu, and that it is actually important that they stay at home and that we try to break the chain of transmission.
• 2:34
  SPEAKER_01: The overall goal of all of this, of course, is to decrease the impact on the healthcare system.
• 2:39
  SPEAKER_01: It's very clear from looking at other countries where these measures were not implemented early on that the healthcare systems become completely overwhelmed.
• 2:49
  SPEAKER_01: And even people who have non-coronavirus related illness have difficulty getting health care because there just are not enough facilities available.
• 2:57
  SPEAKER_01: Italy is currently facing a huge crisis in healthcare, and it's extremely important to realize that we cannot go down that path.
• 3:06
  SPEAKER_01: So people do need to realize that the social distancing and staying at home may be one of the most important things.
• 3:13
  SPEAKER_01: The other thing that has been happening is that there is a great deal more availability of testing.
• 3:20
  SPEAKER_01: During the last week, a number of commercially available tests have become available.
• 3:24
  SPEAKER_01: And in addition, many hospitals are starting to do their own testing.
• 3:29
  SPEAKER_01: In infection prevention, the things that are most important in preventing the spread of disease is identifying cases and being able to do source control.
• 3:39
  SPEAKER_01: If you cannot identify the cases, it becomes incredibly difficult to figure out where your problem areas are.
• 3:46
  SPEAKER_01: One of the things that's difficult about coronavirus is that people can have either completely asymptomatic or minimally symptomatic disease.
• 3:54
  SPEAKER_01: And those types of people usually would be walking around and potentially infecting other people.
• 4:00
  SPEAKER_01: Again, another reason why social distancing and home isolation is so important.
• 4:05
  SPEAKER_01: The testing, while it is more available than it was previously, is still not as readily available as we would like.
• 4:14
  SPEAKER_01: There are now shortages of testing supplies, both swabs, viral transport media, and other supplies that are needed, and that makes it more difficult to test.
• 4:24
  SPEAKER_01: So one of the things that I think is important for people to understand is that even though the numbers may not look as scary because the numbers seem to be staying relatively low in some areas, that is largely being driven by the fact that there may not be adequate testing available.
• 4:41
  SPEAKER_01: I would also mention that there is the possibility of some serological testing becoming available.
• 4:48
  SPEAKER_01: We do not yet know what the sensitivity and specificity of those tests are going to be, but that may become an important tool for us to identify cases.
• 5:09
  SPEAKER_00: There's a lot that we're learning about diagnostic testing in a broader context, but some specific challenges to diagnostic testing for this infection.
• 5:17
  SPEAKER_00: So now that we've gotten to this point, can you lend some of your insight as to why you think it's been so difficult to make testing available to patients in the United States?
• 5:27
  SPEAKER_01: Yeah, so I think there's a few components to this.
• 5:29
  SPEAKER_01: I mean, one of them is clearly that this thing happened really quickly.
• 5:33
  SPEAKER_01: So even for people who were thinking that this was going to happen, it just seems like it happened much more quickly.
• 5:39
  SPEAKER_01: And also the the main thing is that when CDC changed the case definition to not just have people who traveled to a specific area, but also including people who just had severe pneumonia, that opened up the criteria quite a bit.
• 5:54
  SPEAKER_01: And that includes a lot of patients who are hospitalized.
• 5:57
  SPEAKER_01: So immediately the need for testing became a great deal more than it was the day before.
• 6:03
  SPEAKER_01: So during that time, the CDC had been trying to roll out the test to state health departments and to regional labs, and that had not yet happened.
• 6:13
  SPEAKER_01: So there was a huge demand for tests to be done.
• 6:16
  SPEAKER_01: I think that is one of the biggest problems.
• 6:18
  SPEAKER_01: And then when hospitals started to realize that it was not going to be possible to rely just on state health laboratories, they started investigating, trying to get their own testing done.
• 6:29
  SPEAKER_01: And also, it should be mentioned that there have been problems with getting viral transport media, which apparently has been on back order.
• 6:36
  SPEAKER_01: There's uh shortages of swabs, there's shortages of test kits.
• 6:40
  SPEAKER_01: So all of these things impact the amount of testing that we can actually get done.
• 6:46
  SPEAKER_00: I agree.
• 6:46
  SPEAKER_00: I think there's so many factors that come into play with uh the challenges that we're facing.
• 6:50
  SPEAKER_00: Everything from understanding and escalating uh need for testing broader populations and how to get broader populations access to testing, as well as some of the technicalities of the test, and then the issues pertaining to materials that are needed for the test.
• 7:04
  SPEAKER_00: So many different factors coming into play.
• 7:06
  SPEAKER_00: So regarding the testing kit shortages, what's your understanding as to why we're seeing that?
• 7:11
  SPEAKER_00: And was it something that was pertaining to reagent issues or testing kits?
• 7:16
  SPEAKER_00: Are you able to speak to that a little bit?
• 7:17
  SPEAKER_01: So my understanding is that it's all of those things.
• 7:20
  SPEAKER_01: So there's uh shortage of reagents, there's shortage of really all components of the testing kits that are needed.
• 7:28
  SPEAKER_01: And we're experiencing this not just with testing, we're experiencing this with everything that really has to do with this outbreak response.
• 7:38
  SPEAKER_01: So, you know, personal protective equipment, everything that you can think of that we would normally need to be able to control infectious disease and healthcare facilities.
• 7:48
  SPEAKER_01: A lot of different hospitals are trying to order all of these supplies at the same time, and it's creating shortages everywhere and it's making things difficult.
• 7:57
  SPEAKER_00: I agree.
• 7:57
  SPEAKER_00: I think a lot of those factors are all playing into uh the challenges.
• 8:01
  SPEAKER_00: Now, I want to talk a little bit more about the testing itself.
• 8:04
  SPEAKER_00: You know, I think we're hoping to do another podcast that'll get into some of the nitty-gritty details about the test itself, but in a broader scope, in terms of the limitation of the test as it's currently available.
• 8:15
  SPEAKER_00: Can you comment a little bit on your understanding of some of these limitations?
• 8:20
  SPEAKER_01: Sure.
• 8:20
  SPEAKER_01: So I think that one of the main problems is that we don't really fully know the characteristics of the test that we're doing.
• 8:27
  SPEAKER_01: So doctors and healthcare workers tend to think of results as being either yes or no, but that's really not the case with almost any test that we do.
• 8:36
  SPEAKER_01: All tests have a certain sensitivity and specificity.
• 8:40
  SPEAKER_01: And so we need to know what does it really mean when the test comes back positive or negative.
• 8:45
  SPEAKER_01: In this particular case, it makes the really big difference to the patient, obviously, if the test is positive or negative, but we need to know is this going to depend on which day we get the test?
• 8:55
  SPEAKER_01: Is it gonna depend on the specific test that we're doing?
• 8:58
  SPEAKER_01: When SARS was going on, we know retrospectively that serology was actually better than PCR-based testing was.
• 9:05
  SPEAKER_01: Now that was in 2003, so it's possible that things have changed since then, but we don't know that yet.
• 9:11
  SPEAKER_01: So there are definitely limitations to our knowledge about what type of testing should be done.
• 9:16
  SPEAKER_00: I think one of the main limitations that we're finding is we understand some uh fundamental aspects of the test performance in individuals who are symptomatic, but a lot of questions are also coming up about individuals who are contacts who have been exposed and asymptomatic and whether there's any utility in uh testing these uh individuals.
• 9:34
  SPEAKER_00: And I think there may be, but we really just don't understand uh how to approach that based on uh the data and our understanding of the test itself.
• 9:42
  SPEAKER_01: So, you know, David, that's really interesting because my thoughts about who to test have really changed completely based on some public policy ideas recently.
• 9:51
  SPEAKER_01: I mean, one of the important statements that was made yesterday by the White House was that if someone in your family tests positive, then everybody in that household should stay home.
• 10:01
  SPEAKER_01: And that really changes things because that means maybe you don't have to test everybody else when they start having symptoms, because you can assume that they actually do have the same thing going on and maybe save that test for somebody else who needs to have the test on.
• 10:16
  SPEAKER_01: One of the things that I've started to realize is that the patients who have the very typical clinical illness, those are not necessarily the ones that we need to have the test on, because there are certain things that we know that have been published in the medical literature and that are being shared from our colleagues across the country that are fairly characteristic for this disease.
• 10:37
  SPEAKER_01: The biggest problem really is not the ones who are typical.
• 10:41
  SPEAKER_01: The biggest problem is the unknowns.
• 10:43
  SPEAKER_01: So the people who are in the hospital with less severe illness, who have acute respiratory symptoms, those are the ones where you know we don't know what kind of isolation do they really need to be in.
• 10:55
  SPEAKER_01: And it becomes a big problem because when you have plenty of isolation materials, then you can put everybody in droplet isolation.
• 11:03
  SPEAKER_01: But hospitals in the United States right now are experiencing PPE shortages, and so you can't just put everybody in isolation.
• 11:11
  SPEAKER_01: You really have to figure out ahead of time, or you know, when they show up, you have to figure out what the probability is that they're actually sick.
• 11:18
  SPEAKER_01: And that's where testing would be the most useful.
• 11:21
  SPEAKER_00: I agree.
• 11:21
  SPEAKER_00: I think you know you raise a lot of points about uh how we target our testing.
• 11:25
  SPEAKER_00: And I I want to actually get Dr.
• 11:26
  SPEAKER_00: Rock's thoughts on this as well.
• 11:28
  SPEAKER_00: Dr.
• 11:28
  SPEAKER_00: Rock, based on your experience in your uh institution, can you share your insights as far as how we should target our testing in terms of patient populations that would benefit most?
• 11:39
  SPEAKER_02: Yeah, so the groups that we've really focused on, and it's in keeping with what you've been discussing about conservation of PPE and really conservation of our healthcare worker workforce.
• 11:52
  SPEAKER_02: So we have really prioritized testing on ED patients who are getting admitted to our floors, and we have also prioritized our healthcare workers who are having symptoms or part of an exposure with very mild symptoms.
• 12:09
  SPEAKER_02: And that's really in the global effort to sustain our critical care units, our medical surgical floors, our pediatric units that will be able to care for patients safely in the surge that we're anticipating can happen in Maryland over the coming weeks.
• 12:28
  SPEAKER_02: And so locally, for our epidemiology, we're at that cup where we're really going from the containment strategy into more of a mitigation strategy across the state.
• 12:40
  SPEAKER_02: And that is really helping us understand the very important role of testing in use of personal protective equipment and how we can use testing, negative tests to ensure that we can remove PPE for the most part, and then the positive test to ensure that we keep the PPE for those that truly need it.
• 13:05
  SPEAKER_02: And I think thinking about the testing for those sort of strategies is very important, particularly when we're also looking at a nationwide shortage of the reagents, like Jennifer was mentioning, and also looking at nationwide shortages of the nasal, the MP swaps with the viral media.
• 13:25
  SPEAKER_02: And so it really brings to the forum what exactly the information that the test is going to give us and how that can direct us to focus our inpatient care safely with the maximum workforce that we possibly can have.
• 13:42
  SPEAKER_02: And so that's the area that we've really been prioritizing.
• 13:46
  SPEAKER_02: We've also been doing um ambulatory testing across our health system.
• 13:52
  SPEAKER_02: And the way that we've managed to do that is by use of tents at our emergency department and also at our main campus, in addition to some of our community settings.
• 14:04
  SPEAKER_02: And those tents are really for the well patients who don't require the emergency room or clinical assessment, but are presenting with symptoms where physicians have determined that they need testing, and so scheduling them to come into a tent to get tested.
• 14:23
  SPEAKER_02: We're also having drive-through testing, and so in an effort to get testing done quickly for those that need it, we're doing that in a safe way with the concept of a drive-thru test.
• 14:37
  SPEAKER_02: So we have our testers in the PPE outside of our hospital, and then basically doing quick tests for people as they drive by.
• 14:47
  SPEAKER_02: We're also having a lot of education with our emergency physicians and providers, and that's really in the thoughts of judicious testing when we're in a state that does not have very widespread community transmission in the effort to not use a necessary PPE, also, because there is a turnaround time for any of the tests, even though we do have an in-house test here.
• 15:11
  SPEAKER_02: And so they're sort of an array of the strategies that we've been using and really trying to focus and prioritize our testing.
• 15:18
  SPEAKER_00: No, I agree.
• 15:18
  SPEAKER_00: I think a lot of institutions are focusing on those different aspects of testing and those different target populations.
• 15:24
  SPEAKER_00: I can speak for my institution that, you know, initially we were very attentive to focusing on our hospitalized patients precisely for the reason you mentioned, to really dictate the need for PPE and essentially be stewardship of our PPE.
• 15:38
  SPEAKER_00: And then we've been also really attentive to our healthcare staff, being able to test them and get relatively quick turnaround time because of the implications that it has on our hospital workforce.
• 15:49
  SPEAKER_00: The drive-thru testing is really something that is catching on nationally.
• 15:53
  SPEAKER_00: And when you think about setting up these drive-thru testing specimen collection stations, you know, I was wondering, can either of you speak to some of the potentially the challenges or any recommendations you would have for a hospital that's looking to set up drive-thru specimen collection location?
• 16:09
  SPEAKER_01: Yes, I can say that it's actually not through my institution, but actually our health department set something up with two hospitals in the area.
• 16:18
  SPEAKER_01: And it's actually a very interesting idea.
• 16:21
  SPEAKER_01: What they did was set up two hotlines that people could call, and they have to call that hotline with their symptoms, and they are asked some questions.
• 16:30
  SPEAKER_01: If they meet criteria for testing, then they're assigned a number and then they have to go and get the testing.
• 16:35
  SPEAKER_01: So it's not like drive-through testing, like you drive up to McDonald's and get, you know, your hamburger.
• 16:41
  SPEAKER_01: It's not like it's just readily available.
• 16:43
  SPEAKER_01: You actually have to go through a process first.
• 16:45
  SPEAKER_01: And the reason that's being done is, of course, because again, there is a shortage of tests, so we want to make sure that we're testing the right people.
• 16:53
  SPEAKER_01: I think that as tests become more available, we're going to be able to much more broadly test people.
• 16:59
  SPEAKER_01: But one of the problems with this approach is that people are complaining that you know they call and it's really difficult to get through because there's a lot of people that want to get tested.
• 17:09
  SPEAKER_01: I think that the reality is, you know, most people would want to get tested if that test was readily available.
• 17:15
  SPEAKER_01: So how you implement this is not that straightforward.
• 17:19
  SPEAKER_00: I agree 100%.
• 17:20
  SPEAKER_00: There's different models.
• 17:20
  SPEAKER_00: You mentioned that yours is through the health department, which is available to the general public.
• 17:25
  SPEAKER_00: Um, Claire, you had mentioned that yours is specifically for patients within your health system.
• 17:31
  SPEAKER_00: So is that something that's guided by and testing that's ordered by individual providers for patients, or do you have a more centralized kind of process?
• 17:39
  SPEAKER_00: Can you speak to that a little bit?
• 17:40
  SPEAKER_02: Yes, and I definitely echo completely what Jennifer is saying about really having a system set up so it can be safely done.
• 17:48
  SPEAKER_02: We have 800 ambulatory clinics through our health system, so a real need to direct patients for testing and offer guidance for our ambulatory providers.
• 17:59
  SPEAKER_02: The process is that basically a patient would call up their provider with their symptoms, and then we have initial screening that the person who is initially taking that call would go through and it's it's scripted and it's basically done by our triage documents.
• 18:16
  SPEAKER_02: That is then registered to the individual provider or physician of that patient, and then they call back that patient to further discuss their symptoms.
• 18:27
  SPEAKER_02: Obviously, if they need emergency room or clinical evaluation, essentially that is done in the emergency room, and so they would be told to go to the emergency room, and the provider would call ahead to let our emergency room know that there was a you know patient who may need a testament for COVID-19 on the way.
• 18:48
  SPEAKER_02: Otherwise, if they're clinically stable and it seems that they meet criteria for testing, and we have that triage to really focus on some of the higher risk populations in the ambulatory setting.
• 19:01
  SPEAKER_02: So focusing on those that are over 65 and that have um comorbidity, for example, cardiac, pulmonary renal disease, those that are immunocompromised, or those that are pregnant or within a couple of weeks of delivery, and really thinking that the reason for them is really to know the diagnosis in case that they were to deteriorate at home and required to come back in for medical evaluation.
• 19:27
  SPEAKER_02: Those are people that are higher risk of having more severe disease.
• 19:31
  SPEAKER_02: We are at the same time as taking the COVID-19 test, and we also take a nasopharyngial test for influenza A, influenza B, and RFC.
• 19:43
  SPEAKER_02: And we basically employ a reflex type of testing.
• 19:48
  SPEAKER_02: So within Maryland, we're still in influenza season, and so actually the vast majority of what we're seeing is actually still influenza.
• 19:56
  SPEAKER_02: So if flu A or flu B is positive, then basically the COVID test is not run.
• 20:02
  SPEAKER_02: If the influenza A or influenza B is negative, then the COVID-19 test is run.
• 20:09
  SPEAKER_02: And that's really based on our local epidemiology in quite close communication with our local department of health.
• 20:16
  SPEAKER_02: When the flu starts to decline further over the coming week or two, and likely COVID-19 positivity starts to increase, we obviously have to readdress that strategy.
• 20:29
  SPEAKER_02: But for now, that's the reflex testing that we have in place.
• 20:32
  SPEAKER_02: Then there is a lot of the logistics as to who is then going to follow up on those tests and how is the patient going to be communicated with the results.
• 20:42
  SPEAKER_02: And so we've had to really involve our Epic team and our incident command center to really help support the routing of the test results to all these ambulatory providers and embedding the support within Epic with the various links to our internet and the CDC website, as well as our my chart, which is what we use for patient communication, as the results simultaneously become available for patients to know.
• 21:08
  SPEAKER_02: And so being clear to embed the most current recommendations that we have regarding self-isolation, etc., at home.
• 21:16
  SPEAKER_02: And so I would say it's a very transdisciplinary approach.
• 21:21
  SPEAKER_02: We're really running it through our incident command here that involves all of our health systems as well as our university and all the affiliated ambulatory clinics in a very centralized way.
• 21:32
  SPEAKER_02: And it's really to make sure that we're able to safely do the testing, safely get the results back to people, and safely give them the advice that they they need to receive.
• 21:42
  SPEAKER_00: Thank you for sharing that perspective.
• 21:44
  SPEAKER_00: It sounds like we you've heard about two different types of approaches to ambulatory testing.
• 21:49
  SPEAKER_00: And you know, I think that's important in a few ways.
• 21:51
  SPEAKER_00: First, to think about what really suits your own specific institutional needs, but also looking a little bit broadly into what's happening at your state and your regional level.
• 22:01
  SPEAKER_00: You know, just thinking about this in general, it sounds like with different strategies it's going to be really difficult to understand the broader epidemiology of COVID-19 testing, acknowledging that different regions, different institutions are approaching testing differently.
• 22:15
  SPEAKER_00: Stay tuned.
• 22:15
  SPEAKER_00: I think we're learning a lot and we will um continue to understand testing strategies better and be able to gather a lot of new information as we move forward.
• 22:24
  SPEAKER_00: Dr.
• 22:24
  SPEAKER_00: Rock and Dr.
• 22:25
  SPEAKER_00: Hanrahan, I do want to thank you for sharing your perspectives on the COVID-19 outbreak, specifically with regard to approaches to testing.
• 22:32
  SPEAKER_00: I think in future episodes we're going to explore the testing in more detail.
• 22:36
  SPEAKER_00: This podcast can be accessed on Shay's online education center, learning CE, under the Rapid Response Program.
• 22:43
  SPEAKER_00: You will also find additional resources such as the recorded webinar Healthcare Facility Outbreak Preparedness.
• 22:49
  SPEAKER_00: That concludes this episode of the Rapid Response Podcast.
• 22:52
  SPEAKER_00: Thank you for tuning in.