CLINICAL LABORATORY DIRECTORS IN MICHIGAN are developing plans to test patients who will return when hospitals reopen for routine care. Included in those plans are strategies to do testing for the novel coronavirus on patients who will return for everyday care and elective procedures, said Barton P. Buxton, EdD, President and CEO of McLaren Health Management Group.
MHMG provides laboratory and other services in 30 Michigan counties. After Buxton and clinical lab scientists at McLaren developed coronavirus testing for patients in hospitals and in congregate settings, Buxton recognized that the health system needed to develop two other testing strategies.
A Need for Two Strategies
“Once our hospitals reopen for elective procedures, we need a twofold-testing strategy,” Buxton explained. “That’s because of the differences in the testing done at our hospitals and health systems for the coronavirus, and the virus testing done within our health system for contact tracing and for the purposes of epidemiology.
“We also need to develop a COVID-19 testing strategy for public health,” he added. “Each kind of testing is different, and I don’t think we’ve found a good way to do both yet. “When our lab team talks about building up its COVID-19 molecular test strategy, we must keep in mind that those patients who test positive with a molecular test will have a viral load and will have virus shedding,” he explained.
“However, if a lab doesn’t have enough tests or supplies to test everyone, then testing people who have no symptoms creates a unique set of problems. Plus, tests done on people who are asymptomatic are valid only for the time when the specimen was collected.
Contact Tracing Required
“If someone is tested for COVID-19 on a Monday, and that person comes in contact with an infected person shortly thereafter, the first person may no longer be negative on Wednesday or later,” added Buxton. “That person may have symptoms or have symptoms coming. That’s one of the most difficult challenges hospitals must address as they reopen, in cases where patients are tested for COVID-19 two to three days in advance of their admission. Our first priority has to be to take care of patients, of course.
“We don’t know that any COVID-19 test is a panacea,” he added, “or if any COVID-19 testing strategy will give us every answer we need. “Take the example of patients who’ve tested negative but who have full-blown symptoms of COVID-19,” stated Buxton. “Our lab cannot say if that result is from a false negative; if those patients were tested too early; or, if they have a DNA structure that confounds the molecular test in some way. Our lab has had all of those patients and lots of them.
“Even if our lab could run 3,000 COVID-19 tests per day, I wouldn’t recommend testing asymptomatic patients unless like they’ve been exposed and there’s a reason to think they should be tested,” Buxton concluded.
At Michigan Medicine Laboratories (MLabs), Julia Dahl, MD, the Associate Director at MLabs, is wrestling with some of the same issues related to hospitals doing routine surgical care. MLabs is part of the University of Michigan Health System, in Ann Arbor.
Keeping Patients Isolated
“When hospitals open up, we’ll want to test patients coming in for care that’s not COVID-related—meaning surgical and other patients,” she noted.
“Since it’s difficult to ensure that patients remain isolated after a COVID-19 test unless they are already admitted, it makes little sense to test these patients for the virus well before the day of surgery,” she explained. “Testing several days or more than a week prior to surgery requires that patients—and all of their at-home contacts—must stay at home and not go out before their admission for surgery or treatment.
“We know this to be true because we’ve had instances of patients who arrived sick at our hospital, had a nasal swab specimen drawn, and a negative result for COVID-19, or they had a different coronavirus,” Dahl reported. “But when we tested these patients three days later, they had a new exposure to COVID-19 and the SARS-CoV-2 was positive at that time.
Questions about Quarantines
“Re-opening medical facilities for non-COVID care while providing a safe environment for patients, providers, and staff will require expansion of testing to asymptomatic people with results available as quickly as possible,” she added. “When planning for pre-procedure or pre-admission testing, consider the requirement that the result of this COVID-19 test is valid only as long as those patients are quarantined and everyone else in their quarantine environment also is quarantined.
“If patients and their contacts cannot be assured of complete quarantine between the test collection and arriving for the procedure, then our lab’s testing plan can shift to providing testing immediately prior to the procedure,” she advised.
“Many facilities are requesting COVID-19 testing days in advance of procedures. That tells us it is absolutely essential to work with our facilities to provide accurate information about COVID-19 test results,” she explained. “And we have to explain that if hospital staff are relying on the RT-PCR assay to be a true positive about the exposure and infection risk of COVID 19, then that test must be done on the day those patients arrive at the facility.”
50,000 Students This Fall
At the end of April, MLabs was finishing the validation steps for serologic tests for the new coronavirus. “Being in Ann Arbor, we’ve got possibly 50,000 students coming back in the fall to the University of Michigan. We have to plan for and prepare to test those returning students,” Dahl noted. “Right now, the university has not made that decision, but it could do so at any time.
“Plus, we’re not far from Detroit and employers there will be interested in testing their employees returning to work. Those employers want their workers to return into a safe environment,” she said.
“For those reasons, we’re looking at how to do serologic tests for the SARS-CoV-2 virus on a large scale and the utility of giving every patient an RNA test,” observed Dahl. “To do all that testing, we have a very limited timeframe before students return in the fall. That means if we are not prepared to do so by July, there will be some very tough decisions to make in the coming months.”
Contact Julia Dahl, MD, at firstname.lastname@example.org, or Barton Buxton, EdD, at email@example.com.