As healthcare professionals, we all concur that our nation has demonstrated considerable indolence in responding to the current global COVID-19 pandemic. First, it all started with our leaders adamantly denying any threat at all and an untimely response to institute stringent quarantine measures and provide adequate healthcare worker safety and ICU support. This was only followed by a lack of a tests for over a month after the first US patient was diagnosed.
Testing kits have finally become more available in the last few weeks, with the FDA expediting the approval of PCR-based COVID-19 testing kits by several private manufacturers. Albeit, results from a typical test take anywhere between 5-7 days, despite the promising turnaround time of 24-48 hours. The distance of the lab from the hospital and long transit times of samples account for a considerable lapse in time. On top of this, tedious preparation of large volume samples, lack of supplies required for taking swabs and mismatch between the demand and overall capacity also exacerbate delays. Some large academic medical centers and health systems have their own molecular testing labs with turnaround times of less than 24 hours. However, with rapidly escalating numbers of PUIs, they are also running at an overwhelming pace exceeding their capacity. In most community-based hospitals, swabs are outsourced to commercial labs which unfortunately results in long turnaround times.
For hospitalized PUIs, the consequences of long test turnaround times are multifaceted and wasteful. Once a patient is deemed a PUI for COVID-19 in the ER, every individual who interacts personally with the patient must don appropriate PPE at every encounter. This includes the nurse, nursing assistants, physician, intensivists and any consultants whose evaluation is outside the scope of teleconsultation, including respiratory therapists, phlebotomist, imaging technicians and housekeeping staff. A timely negative test result can save 4-6 days’ worth of the already frustratingly scarce PPE.
Our hospital is implementing real-time strategies to conserve PPE for the coming surge as projected by experts. We have designated COVID-19 units so that appointed physicians can round with reduced interval doffing between patient encounters. Telemedicine encounters for consultants have already been instituted at several centers, including ours. Hospitalists are even more emphatic about timely discharges. Improvement in primary medical conditions should prompt discharge planning irrespective of PUI status. Where possible, PUIs can be discharged and continue home isolation as mandated by guidelines. Secondly, each high-risk PUI requires a separate room, and patients who are respiratory-compromised will require an airborne infection isolation room with negative pressure, which is also tied down while we await negative results.
Time is a priceless asset, especially in our profession. Donning and doffing of PPE is quintessential, but it does take time, which increases with each suspected case, further stretching daily hospital rounds. Lastly, both patients and family members endure anxiety and stress amidst the fear of unknown results. Besides taking a toll on their emotional health, there is ample evidence that anxiety can negatively accentuate underlying medical conditions, particularly cardiopulmonary diseases. In fulfilling our role as their main advocates during hospitalization, we are primarily responsible for allaying these fears.
A caveat to the above argument is the suboptimal sensitivity that reminds us to not completely depend on a test result. For clinicians, strong clinical judgement supersedes any test result. It is indeed an arduous conversation to have not only with the patient and family regarding the high suspicion and continuing isolation measures despite negative testing but also with nursing staff – especially in the context of limited PPE.
What I have described are experiences from a community hospital, and we eagerly await a quicker test. As of last week, two additional private manufacturers received FDA approval for rapid point-of-care tests with results purported to be available in less than an hour. Hopefully, this should roll out to hospitals soon enough where we can overcome these unnecessary barriers to patient care.