John Newton—VP of Operations at The Everett Clinic, a physician-led group in Washington's Snohomish and King counties—recently spoke with Advisory Board's Taylor Hurst and Virginia Reid about how the group launched self-testing across their drive-thru testing sites—and how patients and staff are responding.
Q: John, thank you for taking the time to speak with us. Testing access and capacity have been two key hurdles the country has faced in its response to the new coronavirus, and your group's use of nasal self-testing caught our attention. Can you tell us a little more about why you sought out an alternative testing method?
John Newton: We were running short on nasopharyngeal (NP) swabs, which is the gold standard for respiratory virus testing, so one of our providers ran a study that compared the sensitivity of a NP swab collected by a health care worker to three alternative testing methods that were self-collected by the patient. It turns out they were all pretty accurate when compared with the NP swabs, so we decided to make the switch to a midturbinate swab and eliminate the bottleneck.
We were also facing a bottleneck in getting our results back from the reference labs. We were fortunate that the local university expanded capacity and we are in the process of purchasing our own molecular analyzer, which will continue to improve turnaround times for results.
With those bottlenecks addressed, we have been able to expand from testing only moderate patients to patients with mild symptoms.
Q: That's pretty impressive considering the limits we've seen on testing elsewhere in the country. Can you walk us through what happens when a patient with mild symptoms comes to one of your drive-thru sites to receive a test?
Newton: Our workflow is built around a three-person testing team—two RNs and one MA—and it is integrated into our EHR. We've also added another person to the team to backfill during lunch breaks and conduct traffic control. The staff running the drive-thrus are mostly redeployed teammates from other sites of care such as ASC nurses.
When a patient drives up to a check-in tent, they interact with a patient services representative or MA. The staff identify the patient on the schedule and print three labels. They attach one label to the vial and place the other two in the biohazard bag and then hand a testing kit to the patient. The patients are also provided a handout with instructions on self-care and a visual guide on how to self-collect at the next station.
From there, the patient moves on to the testing tent where an RN or other provider places an order with a protocol on the backend. The RN instructs the patient on how to administer the swab test: pick up the swab, gently insert the entire soft tip of the swab into one nostril until they feel a bit of resistance, circle around the nostril 4-5 times, repeat on the other side, put the swab into the vial, put the cap on, and place the vial in the dirty biohazard bag.
We want to minimize handoffs and cross contamination, so the RN holds a clean bag and asks the patient to place their dirty biohazard bag inside. Then they seal the bag and keep it in a cooler for up to 2.5 hours before transporting it to the lab.
It's been an efficient workflow and we’ve put a lot of thought into how to avoid cross contamination and keep our teammates safe. In fact, staff are loving this approach and want to step into these drive-thru positions, which is fun to see.
Given the response, we’re also now using self-testing in our Covid-19 clinic sites for those with moderate symptoms that require an in-person visit.
Q: And what type of PPE are staff wearing during these interactions?
Newton: One of the exciting things about this process is that since the patient is self-testing we don't need the N95 mask. Staff are able to just wear gloves, a surgical mask, linen gown and a face shield.
Q: So once a patient finishes the self-swab, how are the results processed and communicated?
Newton: Right now, we're getting results back in 24-48 hours, but it can vary. Since we're not reliant on physicians placing orders, all of the results go into a central in basket where a provider reviews the results and makes a care plan suggestion. We typically inform patients of negative results via MyChart and have a team of nurses who call patients for positive results and ask them to self-isolate.
We're also planning to get our own molecular analyzer in two weeks and that will enable us to process our own tests and further speed up this process. We estimate the new system will allow us to run up to 540 tests every 24 hours.
Q: So I'd like to take a step back. We talked about some early bottlenecks that drove you toward this process, but what initial barriers did you encounter in switching to a self-testing system?
Newton: The biggest concern at the start was whether the patient would be able to open the swab peel pack without spilling the media in their car. Fortunately, that hasn't been a problem and parents have even been able to test young children successfully.
But that's not to say we didn't face some hurdles. Our tents have struggled to stand up to the elements. We ordered commercial grade tents and they quickly tore, so we are moving to renting bigger tents that one might use for a wedding.
We also had issues with scheduling in our EHR, but now we've got the system set up so that it only takes three clicks to go through the entire process. We have a practice manager come in and they'll do a quick training on the process, but it doesn’t really require much additional training.
The actual testing process that we designed works incredibly well so far. The cycle time from check-in to departure takes only 3-6 minutes. We initially had patients scheduled at 15-minute increments and now we’re down to about 10 minutes for each appointment. Each testing team tests about 85 patients per day.
Q: Being in Washington, your group is clearly further along the curve than providers in other parts of the country. Do you think this new method of testing could be applied elsewhere? What could it mean for Covid-19 testing overall?
Newton: For us, this has really been a win-win. We were fortunate to have a fairly robust lab and a clinic that has good access to process results quickly. But other organizations looking to launch a similar process may have to go through a reference lab, and if it takes 7 to 8 days to get results, then you probably don't want to flood the system with tests for patients with mild symptoms. If you look back to a week ago, the CDC wasn’t recommending testing mild patients at all.
We’ve been fortunate and have been able to eliminate a lot of the barriers that kept us from testing mildly symptomatic patients. We’re not testing asymptomatic people, but for those with mild symptoms our thought is that the more people we can test, the more we can help people do the right thing. It’s the difference between them self-isolating and just following standard social distancing recommendations.