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A call to care: A model for creating an employee COVID-19 screening clinic

Author(s): By Linda G. Toomer, DNP, MSN, RN

Takeaways:

  • Setting up an employee COVID testing clinic requires leadership, coordination, and can be a model of patient-centered nursing care.
  • When done well, employee screening can be a valuable tool for healthcare organizations to track, trend, and manage employee exposures.

eNurse-led initiative supports employees

Editor’s note: This is an early release, web exclusive article that will appear in the upcoming February 2021 issue of the American Nurse Journal. 

Since March 2020, U.S. hospitals have grappled with the effects of the COVID-19 pandemic. Specific concerns include the high number of COVID-19-positive hospital admissions, the need for personal protective equipment (PPE), and infection prevention efforts. In addition, comprehensive employee screening has become a priority. Grady Health System in Atlanta, Georgia, a large urban academic health center, took steps to address employee screening. This article outlines the timeline for key decisions and the progression of our employee screening program, including the detailed approach we took to set up the physical testing space and the process we use to ensure safe, quality specimen collection.

Getting started

Our screening program, launched in March, continues 5 days a week. In response to Centers for Disease Control and Prevention (CDC) recommendations, all patients, visitors, and employees are screened (including mandatory digital temperatures) when they enter the facility or outlying clinic. In addition, all employees are required to wear an N-95 facemask and eye protection. Our organization quickly procured its own in-house lab equipment so that we have the internal testing capacity for all patients and employees.

On March 26, 2020, we began symptomatic employee screening using the nasopharyngeal polymerase chain reaction (PCR) swab test. Per CDC recommendations, employees experiencing viral-like symptoms are tested and immediately sent home to self-quarantine for a minimum of 10 days (or 72 hours without symptoms) and to monitor their temperatures and other symptoms. Employee health services (EHS) providers conduct virtual visits with employees to validate the need for quarantine and testing. Before returning to work, quarantined employees receive another COVID-19 PCR test. Voluntary, asymptomatic employee testing began in mid-April.

May 2020 marked the addition of three processes that would help us understand the epidemiology of COVID-19 in our employees.
1. Employees could access a mobile app to monitor themselves electronically for the most common COVID-19 symptoms: fever, cough, muscle aches, and shortness of breath. If the employee had symptoms, an alert would trigger on a dashboard monitored by EHS nurse practitioners. The same system enabled clinical monitoring of positive employees through the course of their illness.
2. Asymptomatic employee testing expanded to include serology (IgG) testing. Staff requesting asymptomatic COVID-19 testing would receive both PCR and serology tests. Combining the tests helped EHS differentiate acute infection from prior infection in asymptomatic employees.
3. We added mandatory asymptomatic testing of all new hires during their onboarding process and weekly testing of all employees at our long-term care facility.

Testing process

Staff selection for a dedicated team to conduct PCR testing was an important anchor for the testing process. We considered using unlicensed staff but ultimately selected RNs who expressed interest and willingness to participate in a 2-day training and skill-validation session. Two physician champions (one specializing in infectious diseases and the other in otolaryngology) supported training, which consisted of computer-based learning and live interactive sessions led by nurses and physicians. Content included a review of anatomical structures, risks, infection control considerations (including PPE), and a simulated skills session. On the second day of training, after skills validation, the newly trained staff (swabbers) performed specimen collections on volunteer “employee-patients” with physicians and nurses available to assist and coach as needed.

Testing site set-up

The physical testing space (Zone 4) was initially a trailer and later a large tent, located just outside the Grady Emergency Center. Zone 4 provided employee testing on weekdays from 8 AM to 4 PM. Times have varied over the months depending on demand, but symptomatic employee testing is always segregated to minimize interaction with asymptomatic employees.

Zone 4 consists of three distinct areas with one entrance into the testing area and one exit. Employees enter the space through Area 1 (a clean area), where orders and patient identification are verified. PCR testing takes place in Area 2 (a dirty area). Area 3 (the exit or passage to serology) is considered clean.

The testing clinic houses supplies, including PPE, hand sanitizer, hospital-grade germicidal wipes, facial tissue, and sterile scissors. Phlebotomists deliver lab specimen collection supplies each day.

Infection prevention and patient safety

Infection prevention and patient safety measures taken during the swabbing process aren’t optional and require strict adherence. This point is emphasized during staff training and each testing day. In addition, we maintain a clear separation between “clean” and “dirty” areas. Flow coordinators at each shift ensure quality and monitor patient flow through the testing clinic. They help maintain spacing, track the number of patients in the area, assist in troubleshooting scheduling errors, and provide patient support. They also remind staff to wash their hands, sanitize stations, or simply breathe.

The teams work in pairs, with a swabber and an assistant. The swabber performs the PCR collection while the assistant handles the collection tube and provides general assistance. (See Infection prevention measures.)

Infection prevention measures

Nurses at Grady Health System established strict infection prevention measures for the COVID-19 testing process.

  • All testing staff wash their hands before beginning work in the testing area.
  • As recommended by the Centers for Disease Control and Prevention, all testing staff wear full personal protective equipment, including N-95 masks, gloves, gowns, and eye protection. Shoe and hair covers are available but not required.
  • Employees being tested must sanitize their hands during the check-in process.
  • Employees being tested are given supplies (hand sanitizer and tissue boxes); they aren’t allowed to self-serve.
  • Each swabbing station is cleaned between tests followed by a 2-minute wet time as recommended by the disinfecting wipes manufacturer.
  • Environmental services clean and empty trash daily.
  • Only disposable supplies are used.

Testing Results

Initially, negative test results were communicated to employees through their senior leaders, who submitted the initial request for testing. Positive results and medical management instructions were communicated directly to the employee by EHS providers. Now, results are provided via secure electronic health records.

Creating Partnerships

Interdepartmental partnerships have been critical to the success of this program. For example, as the program grew, we relied on phlebotomy support and on laboratory services to provide testing supplies. When we began testing new hires, we used a specially marked specimen bag to identify their tests for expedited processing. Our human resources team became the agents for testing as they were the first contact with new employees. In addition, employee work rules were reviewed. For example, how would a positive COVID test impact the start date of the new hire? Or would staff who were exposed at work be expected to shelter at home and use paid time off? The physical space we use for testing was coordinated through our emergency management and emergency department teams. Environmental services provide regular cleaning and trash removal, and the supply distribution department ensures we have sufficient PPE.

Caring for front-line staff

The decision to implement or continue an employee COVID-19 screening program is one each organization must make for itself. The process requires coordination and support of multiple departments and disciplines. The financial and human resource considerations include the costs associated with adhering to a quarantine-at-home policy for employees who test positive; PCR and serology test lab supplies and processing; and testing area staff, PPE, and supplies. For Grady Health System, the return on investment has been significant. The results of our testing program emphasize the value of employee screening. Early identification of new hires who are positive for COVID-19 has ranged between 3% to 5.51% each month from April to November 2020. This factor alone justifies the existence of the screening program. (See Testing results.)

Testing results

The results of the Grady Health System employee COVID-19 testing program emphasize the importance of testing. The tables show the cumulative results of our screening clinic as of November 30, 2020.

SARS-CoV-2 PCR employee testing (Symptomatic employee testing began 3/26/20; asymptomatic testing began 4/15/20; new hire mandatory screening began 5/16/20.)
Population Tested (#) Positive (#) Positive (%)
Symptomatic employees 652 166 25.4
New hires/asymptomatic employees 5,816 215 3.69
Long-term care* 1,362 22 1.61
Total 7,830 403 3.79
*Long-term care employees are tested weekly.

 

SARS-CoV-2 serology (Post-symptomatic employee testing began 5/6/20; asymptomatic employee screening began 5/6/20.)
Population Tested (#) Positive (#) Positive (%)
Post-symptomatic employees 226 61 26.9
New hires/asymptomatic employees 2,725 170 6.23
Long-term care* 1,130 64 5.66
Total 4,081 295 7.22
*Long-term care employees are tested weekly.

Communication is key to employee safety during the testing process. Testing staff use the AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank you) communication strategy to alleviate employees’ fears and anxiety. As employees leave the testing area, they are encouraged to sanitize their hands and ring a bell (a metal call bell located at the exit that can be fully sanitized at the end of each day) as a symbol of celebration for their successful test completion.

Nurses’ considerable knowledge, compassion, and organizational skills are used to create plans of care that are individualized and move our patients toward health. However, we don’t always think of our own needs. This nurse-led employee screening program is an example of how we can use our nursing skills to care for frontline nurses and other healthcare staff who might otherwise be overlooked as we navigate this pandemic.

Linda G. Toomer is executive director of ambulatory nursing and education at Grady Health System in Atlanta, Georgia.

References

Centers for Disease Control and Prevention. Interim guidelines for collecting, handling, and testing clinical specimens for COVID-19. November 30, 2020. cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html

Chou R, Dana T, Buckley DI, Selph S, Fu R, Totten AM. Epidemiology of and risk factors for coronavirus infection in health care workers: A living rapid review. Ann Intern Med. 2020;173(2):120-36. doi:10.7326/M20-1632

Marty FM, Chen K, Varril KA. How to obtain a nasopharyngeal swab specimen. N Engl J Med. 2020;382(22):e76. doi: 10.1056/NEJMvcm2010260.

Reynolds KA, Sexton JD, Pivo T, Humphrey K, Leslie RA, Gerba CP. Microbial transmission in an outpatient clinic and impact of an intervention with an ethanol-based disinfectant. Am J Infect Control. 2019;47(2):128-32. doi:10.1016/j.ajic.2018.06.017

Self WH, Tenforde MW, Stubblefield WB, et al. Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network—13 academic medical centers, April–June 2020. MMWR. 2020;69(35):1221-6. doi:10.15585/mmwr.mm6935e2

Stubblefield WB, Keipp Talbot H, Feldstein LR, et al. Seroprevalence of SARS-CoV-2 among frontline healthcare personnel during the first month of caring for patients with COVID-19—Nashville, Tennessee. Clin Infect Dis. 2020. academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa936/5868028

 

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