key: cord-0733826-5edaqjni
authors: Dippel, Kathryn S.; Kelly, Emily K.
title: Implementation of a nurse practitioner led drive through COVID-19 testing site
date: 2020-10-09
journal: J Nurse Pract
DOI: 10.1016/j.nurpra.2020.10.004
sha: cc8688d4bd2d5fffa7613563180994b738ffef73
doc_id: 733826
cord_uid: 5edaqjni

Efficient strategies for testing large numbers of patients must be developed to limit the spread of COVID-19. We demonstrate that our drive-through model is an efficient method of testing large numbers of patients during a pandemic. In the drive-through, cost per patient and PPE use were significantly less than three brick and mortar clinics providing testing. We provide an example of effective nurse practitioner leadership in a drive-through testing site and demonstrate that NPs are ideally suited to provide leadership given their adaptability, ability to function in a variety of settings and extensive experience with care coordination and logistics.

negating the need for exam room cleaning between patients increased throughput significantly. Finally, a 27 pediatric-focused drive through COVID-19 testing site deployed in Philadelphia in March 2020 further 28 supports the argument for efficiency as they were able to perform almost ten percent of all tests 29 performed city-wide at that time. 3 These studies all support the argument that a drive-through testing 30 model can reduce cost, increase throughput and maintain social distancing. 31

In preparation for a predicted surge of patients with COVID-19, the University of California San 33 Francisco (UCSF) health system created Respiratory Screening Clinics (RSC) to redirect patients away 34 from the emergency department (ED). There was a large group of low acuity patients who did not require 35 further evaluation by a provider, yet still needed a quick and safe way to get tested. This included front-36 line employees with mild symptoms or those had a known exposure and required immediate testing. 37

Testing volume quickly overwhelmed the RSC testing capacity and created a backlog, which prevented 38 these employees from returning to work in a timely manner. 39

A drive-through testing site was developed with the aim of efficiently screening a large volume of 41 high risk/low acuity employees for COVID-19. NPs who had seen a decrease in work demands were 42 chosen to provide clinical leadership to maintain patient safety in this unique remote environment. It was 43 expected that the drive-through model would reduce testing wait time and decrease the risk of viral 44

transmission. There is no need for cleaning between patient encounters, which can be time consuming and 45 costly. Capacity for testing is increased and risk of staff exposure is reduced given that the tester does not 46 have to enter the vehicle. There are no parking logistics and check in and testing occurs almost 47 simultaneously, reducing visit time. Additionally, it was expected that supply, namely personal protective 48 equipment (PPE), and labor needs would be less than a typical clinic setting, resulting in significant cost 49 reduction.

Multiple logistical and environmental factors required consideration during the initial 53 construction of the drive-through testing site. An open parking lot attached to a health system office 54 building was chosen as the drive-through site due to limited traffic in the area. An affiliated medical 55 group simultaneously set up a drive-through testing site at this location, which simplified logistics and 56 allowed for splitting of some set up costs. Prior to construction of the testing site, a special event permit 57 was obtained from the city fire marshal as well as permission from the property landlord. The surrounding 58 community was notified of the plan for a drive-through testing site to maintain community relationships 59 and generate buy-in. 60

A plan for the interior and exterior layout of the tent was developed ( Figure 1 ). There was only 61 one entrance and exit to the parking lot to simplify traffic control. The interior of the tent was divided into 62 "dirty" and "clean" sides, with the medical assistants (MA) and spare supplies on the clean side of the 63 tent. The dirty side of the tent included a table with individually marked bins for registered nurses (RN) to 64 store their masks and face shields when on breaks. The RNs performing the testing wore a N95 mask, 65 face shield, coverall/gown and gloves. They would not pass the entrance of the tent when testing patients 66 so as not to contaminate the "clean area". The remainder of the staff worse surgical masks always and 67 gloves when handling specimens in accordance with infection control recommendations. 68

The need for shelter, heat, electricity, internet access, trash removal and storage space were 69 anticipated and required a multidisciplinary effort to coordinate. Shelter, heat and electricity were 70 contracted out to local event companies. Essential equipment was stored in a building approximately one 71 hundred feet from the drive through site. This building also provided an indoor break space and restrooms 72 for drive through site staff. Environmental services came to the site grounds daily to discard waste and 73 clean the restrooms. A supply chain was created to ensure equipment, such as personal protective 74 equipment (PPE), hand sanitizers, antibacterial wipes, swab kits, as well as general office supplies were 75 stocked appropriately (Table 1) . Testing kits were sourced from pre-existing stock and did not add any 76 costs to the drive-through site.

Staffing of the drive-through testing site required a multidisciplinary approach playing to the 78 strengths of each professionals' role. The NP supervised RN staff to ensure proper testing technique and 79 monitored for adherence to PPE guidelines disseminated by the health system. They were also responsible 80 for assessing patients who presented to the drive-through more ill than expected. Though onsite 81 monitoring equipment was limited, if patient vital signs were abnormal, or they appeared unwell on 82 assessment, the NP was to call emergency services and have them transported to the closest emergency 83 department. This escalation of care was not necessary during the time of data collection. Additionally, 84 many patients had complex health histories and it was necessary for the NP to review each patients' 85 medical history and indication for testing. This was done in preparation for potential emergencies as well 86 as to evaluate for barriers to testing, such as history of head and neck surgery. Orders for the COVID-19 87 test were ideally placed in the EMR prior to patient arrival, however the NP was also on site to place 88 orders real time if necessary. 89

A clinical lead RN assisted with supply chain management, staffing, and communication with 90 executive leadership. Two MAs were required each shift to facilitate the appointment check-in/check-out 91 process and proper labeling and storage of the specimens. Two RNs were responsible for sample 92 collection, patient education and notifying the NP about any patients who appeared more ill than expected 93 (i.e.: short of breath, diaphoretic, lethargic). In addition to clinical staff, successful tent operation required 94 the daily coordination of environmental services, lab couriers, on-site security and executive leadership. 95

Interventions 96 COVID-19 testing at the drive-through site was available by appointment only. Patients were 97 required to first call the health system COVID-19 hotline, which was staffed by occupational health 98 department nurses who screened patients for acuity and need for testing based on an algorithm developed 99 by the health system. If determined to be low acuity, patients were scheduled at the drive-through testing 100 site. Higher acuity patients were scheduled for either telehealth or in-person visits with a provider.

medical group drive-through lane. The patient would then be greeted by a RN who would obtain the 104 patient's name and date of birth. The MA would check-in the patient via the electronic medical record and 105 prepare the swab kit, while the RN gave a surgical mask and discharge instructions to the patient. 106

Discharge instructions were provided in six languages commonly spoken in the area (Spanish, Tagalog, 107

Cantonese, Hindi, Russian, and Mandarin). Additionally, an "Interpreter on Wheels" was onsite that 108 provided face-to-face real-time translation with a live interpreter via an interpreter service contracted with 109 

We demonstrate that drive-through testing site is an efficient method of rapidly testing low acuity 118 patients for COVID-19. Efficiency has been defined by the Institute of Medicine (IOM) as the use of 119 resources, "to get the best value for the money spent" and is considered "the opposite of waste" . 5 120

However, quality must not be sacrificed to achieve efficiency and thus to understand if an intervention is 121 truly efficient, both cost of care and clinical outcomes needed to be examined. 5, 6,9 Furthermore, we 122 demonstrate that NPs are able to quickly adapt and define their role in a new and remote setting, allowing 123

for not only successful daily operation, but the maintenance of patient and staff safety. 124

Clinical outcomes were measured by the number of tests performed each day. Cost of care was 126 calculated by totaling the startup, monthly and daily operating costs for the drive-through testing site. 127

These costs were compared to the number of patients seen each day to determine cost per patient, which 128 was used as an indicator of efficiency. A portion of the startup costs were split with the affiliate medical 129 J o u r n a l P r e -p r o o f PUT THE LID ON COVID 6 group operating a drive-through site adjacent to the UCSF site. Environmental services, some supplies 130 such as tables and chairs and COVID-19 test kits were not included in the drive-through budget because 131 they were already accounted for by other budgets in the health system. 132

Daily costs were composed of labor which were averaged from reported hourly wage data by 133 discipline obtained from the human resources database. Providers (MDs, APPs), RNs, and "support staff" 134 (generally MAs) were each assigned an average hourly rate which was multiplied by the open hours of 135 operation to yield a daily total labor cost. 136

Data collection occurred during first month of operation between March 25th and April 25th, 138 2020, which totaled to 27 operational days. Total startup, monthly and daily operating costs of the drive-139 through were calculated and compared to daily patient census to yield a daily cost per patient. To provide 140 a basis for comparison, labor costs of each RSC and the drive through testing site were estimated based 141 on each sites' daily staffing needs. This method of cost comparison obviously did not account for total 142 operating costs of each location. It was beyond the scope of the study to understand the total operating 143 cost of each RSC because they each attached to larger medical centers and the operating costs of each 144 clinic are absorbed into the overall medical center operating costs. Total daily labor costs were used to 145 calculate an average cost per patient in order to demonstrate one area in which the drive through testing 146 site generated considerable cost savings. Additionally, to further represent cost differences between the 147 RSC's and drive through testing site, total PPE usage was compared between each location. 148

Extreme rationing of test kits has been necessary in order to ensure that those at highest risk are 150 able to get tested during the coronavirus pandemic. In this study, testing ability was limited to current 151 employees and health system patients. This, unfortunately, excluded large portions of the population, specifically low-income groups, those without access to healthcare, and the homeless population. Those The average cost per patient based on labor costs alone for the drive-through site was $81. This 168 was significantly lower than the cost per patient of any of the RSCs, which averaged $315 to $540. It is 169 important to note that this comparison is limited only to cost of labor and the authors recognize the 170 limitation of this cost comparison. The cost per patient at all RSCs began to trend upwards towards the 171 later part of data collection period as increased numbers of patients were directed exclusively to the drive-172 through. From the initial deployment of the drive-through testing site, the average cost per patient based 173 on labor costs was significantly less than the RSCs, even when the sites were seeing similar numbers of 174 patients (Figure 3) . 175

Another aspect of cost reduction and resource utilization that indicated efficiency was the 176 difference in PPE utilization between the drive-through site and the RSCs. During the data collection 177 period, the drive-through site ordered $547.54 of PPE, compared to $756.40 and $1,241.84 two of the gown or coverall, N95 mask, face shield, and gloves. While this cost savings further supports the 182 argument for efficiency, it is critical to note that no health care workers have experienced symptoms or 183 tested positive for COVID-19 while working in the drive-through site. 184

The implementation of the drive-through testing site was an evolving process responding to the 186 needs of the community. Within days of opening, testing appointments were quickly shortened from 187 every fifteen minutes to every five minutes in response to demand. By week two, asymptomatic bone 188 marrow transplant patients became eligible for testing for pre-procedural rule out. By week three services 189

were expanded to all patients who met COVID-19 testing criteria, as well as essential non-local 190 caregivers of hospitalized children. At week four testing was expanded to all health system patients for 191

pre-procedural COVID-19 rule out. NPs' advanced assessment skills, ability to diagnose and experience designing and managing treatment 208 plans was necessary to provide support to the testing RNs. 1 RNs have the skills to perform excellent 209 patient assessments, however while they are able enact treatment plans, they cannot design them. In 210 practice, the RN would see a patient drive up who concerned him or her and would request the NP 211 evaluate the patient and provide a diagnosis and treatment plan if necessary. Finally, as leaders in 212 healthcare with a responsibility to remain up to date on evidence-based care 1 , including COVID-19, the 213 site NPs were a valuable source of knowledge for staff and patients. 214

Our NP led drive-through COVID-19 testing model is an efficient method of testing large 215 numbers of low acuity patients. Operational costs remained stable as daily patient volume increased, 216

indicating quality was not sacrificed to achieve cost reduction. Additionally, the drive-through model 217 requires less utilization of PPE without increasing risk for exposure, further reducing costs while 218 maintaining quality. Increased testing capacity allowed the health system to more efficiently provide care 219 for patients suspected of having COVID-19, as well as facilitated the reintroduction of elective 220 procedures through rapid pre-procedure COVID-19 screening. 221 Important differences exist between our drive-through model and other models described in the 222 literature. Implementation of the other drive-through sites described included onsite patient registration, 223 assessment and triage 7,10 . In our model, these processes were done prior to patient arrival via a hotline, There were several limitations which impacted our ability to fully evaluate the efficiency of the 234 drive-through testing site. Given that the drive through site remains operational, cost information is 235 approximate and likely incomplete. Additionally, comparison of cost per patient between the drive-236 through and RSCs was based only on labor costs and did not account for the full operating costs of the 237

RSCs. Another limitation was the limited quantity of testing kits available, which restricted testing 238 eligibility and prevented us from truly understanding the maximum capacity of the drive-through site. 239

Third, certain specimen vials leaked and/or cracked for unknown reasons, causing multiple patients to 240 require re-testing. A fourth limitation was the delay in printing the patient identification label due to 241 connectivity issues that were unresolvable given the remote nature of the site. 242

A final limitation of the drive-through testing model is that it excludes those do not have access to 243 a vehicle. This likely disproportionately effects vulnerable groups, such as the economically 244 disadvantaged, racial and ethnic minorities, those with chronic conditions, the elderly and the homeless, 245 among others. Although walk-ups were accepted, these numbers were limited because at the time of 246 implementation, large portions of public transportation were not operational. Strategies for addressing this 247 issue will need to be developed in future versions of drive-through testing sites, with emphasis placed on 248 constructing these sites in areas accessible to these vulnerable groups. 249

A drive-through testing site is an efficient method of safely and rapidly testing large numbers of 251 patients for COVID-19. NP's are ideally suited to provide leadership in these sites. Our model can be 252 used as a blueprint for other drive-through testing efforts and could be scaled up to test larger numbers of 253 patients, even in remote and resource poor areas. While the startup costs were significant, the daily 254 operating costs remain relatively predictable and are less than a standard clinic. 255

Large-scale community testing will help slow the spread quickly, especially for those in the 

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