key: cord-0048017-9fbltjq0
authors: VandeWeerd, Carla; Lauzardo, Michael; Lowenkron, Jeffrey; Morris, J. Glenn; Tyndall, Joseph A.; Nelson, David R.; Sussman, Elliot J.
title: Patient-Centered Covid-19 Screening in a Community of Older Adults: Combining Educational and Research Components
date: 2020-05-11
journal: NEJM Catal Innov Care Deliv
DOI: 10.1056/cat.20.0117
sha: 7d96405568a1dfd32740901a2d86bf8209a8de2f
doc_id: 48017
cord_uid: 9fbltjq0

The rapid establishment of a Covid-19 screening program in a community of older adults demonstrates effective collaboration between a community health organization and an academic medical center.

Large-scale Covid-19 screening in The Villages could help us understand how the disease spreads in the population, drive public health emergency prevention and preparation, and enhance community education and health care resource planning. The Villages and the University of Florida (UF), which began to partner formally only in November 2019 in an effort to transform The Villages into America's healthiest hometown, resolved to quickly establish and deploy a community screening program for Covid-19 that combined clinical and research objectives, including:

1. Determine the local prevalence rate of Covid-19 in both symptomatic and asymptomatic individuals.

2. Mitigate anxiety and fear in the community by offering a screening program with minimal wait times and 72-hour results return.

3. Use the information to reinforce public health messages to slow the spread of the disease and "flatten the curve."

4. Improve safety for community members by minimizing the use of and exposure to the traditional health system.

Deploying a community screening program within 10 days of initial discussion involved substantial hurdles:

1. Selecting a physical site that would facilitate access and efficient check-in and throughput.

2. Locating personal protective equipment (PPE), testing kits, and universal transport medium during a national shortage.

3. Solving logistics around labor, including hiring and training testers, training traffic control personnel in safely distancing people coming for testing, and training triage and results-delivery staff.

4. Building a tracking system linked to a scheduling system while securing wireless technology at the testing site connecting participants with their results.

5. Dealing with culture differences between a traditional public research university and a dynamic, engaged older adult community.

The study included 4,230 participants divided into two arms. " Site selection: The selection of the testing site was crucial. The site needed to be centrally located, accessible, and known to the community. Access would need to be controlled while distancing cars to provide a sense of safety and relief. We chose The Villages polo grounds, which met these requirements, was not in use due to a cancellation of the season as a result of Covid-19, and contributed a welcome pastoral sense to both those being tested and those doing the testing.

With the support of UF Health, we assembled one set of PPE per day for each person administering tests, swabs, and testing kits from multiple sources including UF, Becton Dickinson, Quest, and LabCorp, facilitating collection of as many as 530 samples per day. County Department of Health officials also provided PPE resources.

Staffing: Because the Association of American Medical Colleges and Liaison Committee on Medical Education had recommended suspending clinical rotations for students in the wake of the pandemic, they were available to us on a volunteer basis.3 , 4 We set up weekend training for 175 UF Health medical, pharmacy, physician assistant, and nursing students. Students completed IRB training, learned the screening process, and mastered the skills and techniques of nasopharyngeal swabbing. During the screening and testing period, between 12 and 30 students drove an hour each way from Gainesville to The Villages to participate.

Traffic control: The flow of patients was controlled to each of the testing tents via a "research line" and a "clinical line" after initial check-in for the first 3 weeks (only testing of clinical/ symptomatic patients was done in week 4). The Villages handled site logistics. Local police, an onsite EMS squad, traffic and registration personnel, and clearly visible traffic flows allowed a single line of streamlined cars and golf carts to enter the testing grounds. Patients did not exit their cars or golf carts.

In setting up our testing program, we wanted to ensure that patients could arrive and be tested with short lines and little waiting, thus limiting potential exposure. An innovative, electronic approach was designed to screen patients to the appropriate testing arm (clinical/ symptomatic or research/asymptomatic) in step 1 and allow them to provide necessary registration information and select and schedule an available appointment time at the polo field in step 2. This flexible appointment system used a combination of ONCEHub and Qualtrics tools hosted on a freestanding webpage. It was tested for 48 hours and then deployed. A summary highlighting program flow is provided in Figure 1 .

These tools allowed the number of daily appointments and the testing times to be adjusted across research and clinical arms in accordance with testing supplies available. Twenty-four hours in advance of each testing day, the website, UFHealthCovid.com, opened at 8:00 a.m. The website showed all available appointment options for the following day's testing. Patients entered answers to screening and registration questions and selected a desired time for testing on a "first come" basis. Sign-ups continued until all available appointment slots were full.The Villages Daily Sun, a newspaper read by 95% of Villagers, published details about the study and the sign-up procedure the day before the trial began (see Appendix) and regularly thereafter.5 , 6

The Team

The team's executive sponsors were the CEO of UF Health and Chairman of The Villages Health. The lead author served as the "field general" on site with significant help from other authors of this paper and two graduate students from the University of South Florida, as well as administrative staff from UF Health, The Villages, and The Villages Health. In addition to students from UF professional/health colleges, other community-based nurses and related personnel -as many as 10 daily -volunteered during the last 2 weeks of testing. A grateful community provided welcome encouragement.

The program needed to balance the different priorities of UF researchers and residents of The Villages. For example, while a relatively small number of tests would have been sufficient for the needs of research, the program needed to have enough capacity to meet community demand, so that any resident who wanted testing would have a reasonable chance to secure a testing slot. Frequent and careful communication, a commitment to trust between the executive sponsors, and modeling of compromise and collegial behaviors amongst the leadership team helped to set the tone for project success. Additionally, group acceptance of and focus on the unique beliefs and needs of older adults (for example, the heightened fear and risk in this vulnerable population) helped to guide decision-making and rally all players.

The need to obtain and efficiently allocate scarce test kits and PPE required rapid decision-making, and project leaders held numerous virtual meetings, often after hours and on weekends or holidays.

The team decided to test on Tuesday and Thursday to use available personnel most efficiently (testing a minimum of 300 community members each time) and to track down needed supplies between test dates.

Responding to inaccurate reporting in the local and national media, especially around predictions of high rates and severe impact for Covid-19 in the community, also required considerable resources to correct the record. The team harnessed strategies such as updating website language and issuing press releases to enhance understanding of services and outcomes within the community.

"

On the first testing day, it took 6 hours to fill the available appointment slots. By the day 5, all 530 available slots were filled within 15 minutes of the 8 a.m. launch of the website scheduler. In the first 5 days, 2,280 tests were completed, and 200 sets of PPE and 2,500 pairs of gloves were consumed. Patients needed 7 1/2 minutes in the clinical arm and 10 minutes in the research arm, where a longer time was necessary to complete informed consent. Each day, tests were taken to UF Health to be run in the hospital lab or the Emerging Pathogens Institute lab.

Patients received results within 72 hours. A nurse or public health specialist from The Villages Health called patients with positive test results and sent e-mails to patients with negative results. Patients with questions had access to a dedicated call center staffed by The Villages Health.

Detailed outcomes for the project are presented in Table 1 . Of the 2,130 clinical tests conducted between March 23, 2020, and April 17, 2020, at the polo field testing site in The Villages, Florida, 2.11% were positive. People who lived in The Villages community (average age 70.1, SD+9.1) had a 1.86% positive rate. Those who traveled into The Villages for testing (average age 51.1, SD+18.5) had a 2.92% positive rate. A major community-wide educational effort to promote social distancing and self-quarantining began 1 week before screening commenced. The low rate of positive results initially suggests that the community commitment to following recommendations for social distancing and other protective actions helped prevent dire consequences.

Of the 2,100 tests for asymptomatic participants, 90.4% were done in Villagers (average age 70.6, SD+8.6). One test was positive for a Villager and two were positive in non-Villagers, yielding a positive rate in research patients of 0.14%. On follow-up, two asymptomatic persons reported fatigue, cough, and/or loss of taste and smell and both indicated recent travel (within 7 days) back from the high-risk region of New York. These findings indicate there are not many asymptomatic individuals in The Villages causing Covid-19 spread.

Over the 4 weeks of testing, positive test rates remained flat in asymptomatic participants and reduced in symptomatic participants (see Figure 2 ). Our results were mirrored by those at the two hospitals serving the majority of Villagers where over the same 4 weeks, cases admitted weekly declined from 10, to 8, to 4, to 1. As a result, we placed our screening on hold on April 20 and are using the data collected as a baseline while pivoting toward safe reopening of our community.

Information from findings was shared with the community via The Villages Daily Sun, as well as social media. Public health messaging highlighted the low level of positive cases within the community and stressed that social distancing, hand-washing, and sheltering in place was working to "flatten the curve" and should be vigorously continued by The Villages community. Community response was positive; Facebook comments, verbal discourse, and media interviews highlighted Villagers' willingness to step up prevention strategies in accordance with state and federal recommendations.

Successfully deploying community-based Covid-19 testing at robust scale requires careful planning, strategic partnerships, and strong, consistent communication. Local community leaders and media should be connected into the program at its outset to facilitate community support and engagement. A "field general" with proven leadership and logistics experience should be designated to lead efforts on the ground. Technology tools such as ONCEHub, Google spreadsheets, iPads, and Qualtrics should be integrated into the system to facilitate ease of use. Necessary data points and data collection strategies should be carefully considered prior to program launch to facilitate reporting needs and outcomes at the individual and community levels. Materials from this project have been made available for the public and may be accessed by reaching out to the corresponding author.

Watching and Waiting for a Coronavirus Surge at The Villages in Florida

Defining the epidemiology of Covid-19 -studies needed

The Future Is Today": Medical Students In The Covid-19 Pandemic

Medical student education in the time of Covid-19

UF Health Brings Testing to The Villages Health. The Villages Daily Sun

Virus Testing Site Opens at The Villages Polo Field. The Villages Daily Sun

The authors wish to thank the many volunteers who helped to make this project possible including students, research, laboratory, and administrative staff from UF Health, members of the Sheriff 's office and EMS personnel from Sumter County, Mitchell Roberts and Erica Sappington, personnel from Aviv Clinics, and staff from The Villages, The Villages Polo Club, Technology Solutions Group (TSG), and Katie Bells. Additionally, the authors wish to thank Becton, Dickinson and Company (BD), LabCorp, and Quest Diagnostics for their donation of testing supplies.