Since March, the overwhelmingly complex challenges associated with testing for COVID-19 have dominated the news and demanded constant attention from policymakers, the scientific community, and the healthcare industry. Even though substantial hurdles have been cleared thanks to unprecedented efforts from developing tests to addressing a wide range of supply chain issues, test effectiveness and accessibility are now — and must remain — a national priority in the foreseeable future.
I have spent the last 9 months sequestered near Philadelphia, a regional epicenter for COVID-19 cases where hospitals and health systems have been under enormous pressure to meet the demand for testing. For some insight into how they are coping, I turned to a colleague at one of the city’s largest hospital systems.
Chris Tomlinson, MBA, is enterprise vice president for the radiology/imaging, clinical laboratory & pathology, and emergency & hospital medicine service lines at Jefferson Health. Throughout the crisis, he and his team have worked not only to meet challenges head-on but also to leverage what they learn into system improvements.
Mounting an effective response to the pandemic has required system agility, flexibility, and ingenuity. Multiple supply chain issues around swabs, testing reagents, and consumable plastic supplies had to be resolved at an organizational level. For example, facing a nationwide shortage of test swabs, the clinical laboratory collaborated with Jefferson’s Health Design Lab to develop a medium for specimen collection, and manufactured 5,000 test swabs using the lab’s 3-D printer.
Even after tests were developed, unpredictable supply chain issues continued to disrupt testing capability for all hospitals in the region. Many commercial testing platforms were unable to meet their commitments in terms of allocations to health systems. Hospitals using only one or two test platforms were often faced with running out of reagent or consumable supplies leading to unacceptably long delays in receiving test results. To resolve this issue, Jefferson built redundancy into its approach; it uses seven different test platforms — including a test developed internally — to ensure adequate testing capacity if one or more platforms experience disruptions in supply.
There is an expanding range of test options available (e.g., molecular, polymerase chain reaction [PCR], and antigen tests). Because the system performed the most tests in the region (over 300,000 to date) and different tests meet different clinical scenarios, a testing strategy was adopted. For all locations in the system:
- A rapid molecular or rapid PCR test (results under 30 minutes) is performed for patients who are symptomatic when admitted to the emergency department (ED). COVID-19 status is documented immediately and isolation protocols are initiated for patients who test positive.
- A midrange test (results in 45 minutes to 1 hour) is administered to patients who do not have overt symptoms when they arrive in the ED, are receiving emergent procedures, etc.
- A longer PCR test (results in 6-15 hours) is required prior to all elective patient admissions or for outpatients who come to the health system’s many testing sites.
With a focus is on keeping staff and patients safe, this dynamic process has been associated with very low transmission rates. On a consistent basis over time, only 1.6%-1.8% of asymptomatic, preprocedural patients have tested positive, and positive results are identified 48-72 hours before surgical admissions.
Going beyond the hospital walls into the community, the system has partnered with the city of Philadelphia on “testing deserts” or areas where there is lack of access to testing or healthcare. They have also partnered with the Commonwealth of Pennsylvania to focus more resources and to help provide a testing safety net for nursing home residents and employees. The system is also working to increase the availability of tests in the neighboring state of New Jersey, where commercial laboratories are sometimes overwhelmed and unable to provide timely test results.
In addition to helping other health systems in the region with testing shortages, the system has forged a partnership with the Philadelphia International Airport to provide testing for passengers.
Tomlinson is encouraged by new tests on the horizon for COVID-19 — for instance, the loop-mediated isothermal amplification (LAMP) method will provide a highly specific, low-cost, fast (15-20 minutes), and portable test. And the next-generation antigen tests will be fast, reliable, and portable and will be produced at mass scale and sometimes paired with a mobile app that functions as a mobile “boarding pass” or is in a pregnancy-test-type format. In addition, many manufacturers have developed a single swab test for both flu A and B and COVID-19 that enables differentiation between the diseases in about 20 minutes to 1 hour, avoiding the need for multiple tests.
Tomlinson predicts that COVID antigen tests will eventually become as easy and commonplace as pregnancy tests – self-administered, reasonably priced, and easily available at pharmacies with results in less than 30 minutes. Healthcare workers could administer these tests and take appropriate action at the point of care (e.g., schools) without having to send the tests to a lab. The more constrained PCR tests will continue to be used for focused applications, whereas the antigen tests will likely become the recommended approach to population screening.
David Nash, MD, MBA, is founding dean emeritus and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at the Jefferson College of Population Health. He serves as special assistant to Bruce Meyer, MD, MBA, president of Jefferson Health. He is also editor-in-chief of the American Journal of Medical Quality and of Population Health Management.