Question: Maja, thank you for taking the time to speak with us during this hectic time. Stanford Health recently started piloting drive-thru COVID-19 testing at Stanford Express Care Clinics. Can you tell us why you choose the Express Care location as the main testing site?
Maja Artandi: Express Care was the ideal pilot location for a few reasons. We had started doing video visits in November of 2019, so we had the technology in place and all the providers were already familiar with the process of doing video visits. We also have a lot of flexibility with our appointments because we are a same-day clinic. Demand for video visits quickly surpassed capacity and we had to further expand our available appointments. To further increase our capacity, we asked primary care providers across the Stanford system to pick up virtual visit shifts. With the help of these clinicians we were able to increase our video visit volume.
Q: In your recent HMPI publication, you mentioned that to be eligible for drive-thru testing patients required a video visit with an Express Care provider who decides if the patient qualifies for testing. How are you prioritizing which patients to test—and ensuring providers follow the standard?
Artandi: When we initially opened the drive-thru testing site, the testing criteria was clinical (e.g., respiratory symptoms, fever, etc.) and exposure-based. But due to testing shortages, we've modified the criteria to prioritize people who have a greater risk for severe COVID-19 illness and groups of people of community health relevance: frontline responders, the immunocompromised, those who likely need acute-level care, and those living in a large group setting like homeless shelters.
In terms of how we keep providers up-to-date on the latest standard, we have two main ways of communication. First, we send a daily digest email every morning highlighting COVID-19 updates, and any changes that were made to the testing process. This is really the go-to source of information. Second, we integrated a best practice advisory (BPA) alert into our EHR system that asks the provider if the patient meets the criteria for testing when they order a COVID-19 test—and if not, why they ordered the test. It's a soft block and can be overridden, but it ensures our providers are aware of the guidelines.
Q: You also mentioned in the HMPI publication that in the first two days of your drive-thru testing pilot you were able to reduce drive-thru testing times from 15 to 4 minutes. That's an impressive jump! What did you do to trim the time?
Artandi: The first thing we learned was it's easier to run the drive-thru with two providers and one medical assistant (MA). Originally, we'd tried to run it with just two providers.
The benefit of the trio approach is that while both the providers and the MA need to be in full personal protective equipment (PPE), the MA's role is to hold the sterile bag so he or she never comes in contact with the swab or the patient. So, while the provider who did the swab needs all new PPE, the MA only needs to change his or her gloves. That allows the second provider to prepare to handle the next visit with the MA, while the first provider changes into new PPE.
The second thing we realized is that setting up tents and working fully exposed to the environment wasn't ideal. On the third day it was so windy we struggled to do the swabs. We ended up moving into an open-air parking garage—and having a roof made a huge difference! We also have security guards on-site to manage the two lanes of traffic and ensure all the patients in line have been pre-approved for testing. Patients without an appointment are redirected to a virtual visit to see if they meet testing criteria.
Thanks to these adjustment we are now seeing six patients per 15 minute visit slot!
Q: That's an impressive feat. Aside from those conducting the visits, are there any other staff members you've dedicated to the drive-thru testing effort?
Artandi: Yes! We have an advanced practice provider (APP) who is responsible for the logistics of the site and training any of the new staff on the testing. The benefit to having a clinician oversee the logistics is that they can demo the naso-pharyngeal swab for new staff.
Originally, we thought we could label the testing kits on-site, but it turned out to be too complicated, so we dedicated a pool of MAs to manage the scheduling and kit labeling for the testing site. When a patient is scheduled for drive-thru testing, the MAs are responsible for preparing the vials, labeling the testing kit with the patient’s name, delivering them to the testing site, and retrieving them from the testing site when they are ready to be sent to the lab.
Q: What happens on the backend once these patients are tested? How long does it take to get results and how are patients notified?
Artandi: The lab is doing its best to turn around test results within 24. All the negative results are shared with the patient through Stanford's patient portal. We are relying on nurses to handle the positive results. One nurse is dedicated to calling patients to alert them of the diagnosis and discuss next steps and another nurse is responsible for contacting the public health department and filling out the necessary paperwork. These same nurses follow up with patients down the line to make sure they are doing okay.
Q: Given the lag time between a patient getting tested and receiving their test results, what guidance are you giving them immediately after the test? Are you encouraging them to stay home from the time of the virtual visit through—and potentially beyond—the delivery of their results?
Patients are warned to quarantine in place twice—once written in the patient portal and once verbally from the provider who swabs them. Once we've determined a patient needs to be tested for COVID-19, the patient gets a document explaining what they should do while waiting for the results. Additionally, during the testing visit, the provider who swabs the patient explains the need to quarantine in place while they wait for the results.
Q: You've clearly created a great process here. Do you have any advice for an organization looking to stand up their own drive-thru testing site?
Artandi: Communication is key. Everyone involved needs to know what they are doing and what their specific role is.
Today, most of our testing sites are staffed by RNs and most of the virtual visits are conducted by physicians and APPs. Our team meets every day around lunch to raise and resolve any issues. We have consistent communication and are very flexible when it comes to making changes. For organizations starting out, I’d recommend starting with one or two centralized testing sites. It's better to have one site where all the staff are trained on the procedure than lots of smaller sites with limited oversight.
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