ASA and ASPF Joint Statement - Perioperative COVID testing

[Mofeen]

Just curious how things are being done at hospitals that are beginning to resume elective cases? Any thoughts on the recent ASA/ASPF statement?

The ASA and APSF Joint Statement on Perioperative Testing for the COVID-19 Virus

www.asahq.org

We cover a few hospitals in a now much improved former hotspot. We are getting some resistance from the hospital and lab about mandatory screening for all elective patients, which falls in line with the linked recommendations. Claims of not enough tests, inability of lab to handle more samples, etc.

---

Members don't see this ad.

 

[deleted162650]

We are testing all patients coming for elective cases. They go to a drive-up testing site 48-72H before their scheduled surgery. If they show up on the DOS and results are still pending, the get a rapid test.

 

[deleted171991]

Just curious how things are being done at hospitals that are beginning to resume elective cases? Any thoughts on the recent ASA/ASPF statement?

The ASA and APSF Joint Statement on Perioperative Testing for the COVID-19 Virus

www.asahq.org

We cover a few hospitals in a now much improved former hotspot. We are getting some resistance from the hospital and lab about mandatory screening for all elective patients, which falls in line with the linked recommendations. Claims of not enough tests, inability of lab to handle more samples, etc.

That declaration is semi-useless, because it does not say how soon one has to do the surgery after a negative result. A 3 day-old negative test only serves as a mental comfort crutch, and possibly puts personnel at risk.

My group tends to draw the line at 48-72 hours in asymptomatic patients.

 

[kmurp]

Testing electives is a requirement in my state. 72hours or less. We have no rapid testing available. When we’re allowed to do electives (still prohibited), it’s a negative test or cancel.

 

[jwk]

All our electives are tested within three days. If longer than that, they get a rapid test DOS. We're having a very very low incidence of positive tests in our pre-op drive-up testing center, so my guess is patients who know they're about to have surgery are staying home. Elective surgery without any testing is usually a no-go. We've had to be adamant about it, but now it's sunk in and clearly understood. If we continue to have the extremely low incidence of positive tests (very surprising to us) we may have to reconsider how hard-core we need to be.

 

[OneFellSwoop]

If patients test negative, are you using airborne precautions for intubation (N95)? Are you waiting for full air exchange after intubation and extubation?


Sent from my iPhone using SDN

 

[Dantrolene FC]

Where I'm at, they require a negative covid test 48 hours prior to an elective surgery, plus they have to self-quarantine from the time of testing until their surgery.

 

[nimbus]

Where I'm at, they require a negative covid test 48 hours prior to an elective surgery, plus they have to self-quarantine from the time of testing until their surgery.

Are Monday cases tested on Saturday?

 

[Dantrolene FC]

Are Monday cases tested on Saturday?

Yes

 

[dingdong28]

Lab guy chiming in: All elective cases have to be tested 24-72 hours prior to surgery, similar to how @SaltyDog 's facility's doing (minus the rapid test part). Any patients that have not had any testing performed will have have their surgeries cancelled and rescheduled for another date. We're only performing testing on-site at our lab on all ED patients, same day cardiac cath lab procedure patients and same day urgent/emergency cases because Abbott is running out of testing supplies for the ID NOW. I'm not sure what we're doing with inpatients that will be having procedure/surgery done. I would hope if they can schedule the procedure 2 days later, we can send out the specimen and have a result back the day before the surgery and not cause any delays.

We are getting some resistance from the hospital and lab about mandatory screening for all elective patients, which falls in line with the linked recommendations. Claims of not enough tests, inability of lab to handle more samples, etc.

I know this may seem like a bag full of excuses (see bold above), but I can guarantee you they're not. We have 1 instrument to perform all of our screens. When the ED sends us 3 swabs at one time and we receive 1 swab from preop a few minutes later, the preop swab will take over an hour because the ED takes priority. The testing takes nearly 20 minutes (if you're quick and efficient) to receive, process, test, result, and call to the respectable floor. There have been times where we had 8-10 specimens waiting from the ED, preop, cardiac cath lab, and PAT because we can only do 1 at a time and each floor is getting pissed because of how long they're taking. If we had kits for our other PCR analyzer, we'd be flying through this testing because we can test 8/hour (each test would take about 50 minutes from receipt to notifying the floor).

 

[vector2]

Lab guy chiming in: All elective cases have to be tested 24-72 hours prior to surgery, similar to how @SaltyDog 's facility's doing (minus the rapid test part). Any patients that have not had any testing performed will have have their surgeries cancelled and rescheduled for another date. We're only performing testing on-site at our lab on all ED patients, same day cardiac cath lab procedure patients and same day urgent/emergency cases because Abbott is running out of testing supplies for the ID NOW. I'm not sure what we're doing with inpatients that will be having procedure/surgery done. I would hope if they can schedule the procedure 2 days later, we can send out the specimen and have a result back the day before the surgery and not cause any delays.


I know this may seem like a bag full of excuses (see bold above), but I can guarantee you they're not. We have 1 instrument to perform all of our screens. When the ED sends us 3 swabs at one time and we receive 1 swab from preop a few minutes later, the preop swab will take over an hour because the ED takes priority. The testing takes nearly 20 minutes (if you're quick and efficient) to receive, process, test, result, and call to the respectable floor. There have been times where we had 8-10 specimens waiting from the ED, preop, cardiac cath lab, and PAT because we can only do 1 at a time and each floor is getting pissed because of how long they're taking. If we had kits for our other PCR analyzer, we'd be flying through this testing because we can test 8/hour (each test would take about 50 minutes from receipt to notifying the floor).

What are your thoughts regarding the sensitivities / specificities of the most common commercially available PCR tests and also antibody tests out there?

 

[dannyboy1]

That declaration is semi-useless, because it does not say how soon one has to do the surgery after a negative result. A 3 day-old negative test only serves as a mental comfort crutch, and possibly puts personnel at risk.

Of course it’s useless. It’s only there to protect from litigation (we followed “protocol”). Our hospitals main source of revenue, and our livelihood is dependent on elective cases. Therefore, elective cases will be done. Get used to it.

 

[kmurp]

If patients test negative, are you using airborne precautions for intubation (N95)? Are you waiting for full air exchange after intubation and extubation?


Sent from my iPhone using SDN

Our hospital is using airborne precautions for PUI and Covid positive with all staff out of the room for six air exchanges at intubation extubation. With unknowns, we have been using N95s for anesthesia personnel but not having staff leave. The medical center by us makes staff briefly leave the room for unknowns. APSF says N95 for all intubation even if covid test is negative. We haven’t developed an agreement on that yet.

 

[kmurp]

Of course it’s useless. It’s only there to protect from litigation (we followed “protocol”). Our hospitals main source of revenue, and our livelihood is dependent on elective cases. Therefore, elective cases will be done. Get used to it.

It’s not useless. With our 2% positive antibody rate locally and 70% sensitivity of the test, it gets us under 1% of patients infected. It’s also a state requirement. That said, the poor availability of testing (despite what the White House says), will, I think, be a stumbling block to full schedule resumption.
When I asked Dr Warner of APSF about the policy , he said he didn’t think testing was really necessary for their local patients due to low prevelence but half their patients come from elsewhere so they are testing all. The PPE recommendation from APSF was a cautious stance to protect providers due to false negatives.

 

[DocVapor]

I'm currently on mandatory quarantine thanks to taking care of a patient with 2 negative tests while inpatient who turned positive after surgery.

You have to consider these tests as worthless.

 

[Dantrolene FC]

It’s not useless. With our 2% positive antibody rate locally and 70% sensitivity of the test, it gets us under 1% of patients infected. It’s also a state requirement. That said, the poor availability of testing (despite what the White House says), will, I think, be a stumbling block to full schedule resumption.
When I asked Dr Warner of APSF about the policy , he said he didn’t think testing was really necessary for their local patients due to low prevelence but half their patients come from elsewhere so they are testing all. The PPE recommendation from APSF was a cautious stance to protect providers due to false negatives.

It all varies by location. My county has a large surplus of tests. So much so, that for a short time period, anyone could be tested for free, even if they didn’t have any symptoms or any suspected Covid contacts.

We’re still sitting pretty with an average of 1 case per week and 0 Covid deaths.

And I’m still not allowed to eat at a restaurant or go to church.

 

[nimbus]

I'm currently on mandatory quarantine thanks to taking care of a patient with 2 negative tests while inpatient who turned positive after surgery.

You have to consider these tests as worthless.

What PPE were you wearing while taking care of that patient? For me, part of the reason to wear an N95 for every single patient is so I won’t have to quarantine in your scenario.

 

[deleted162650]

What PPE were you wearing while taking care of that patient? For me, part of the reason to wear an N95 for every single patient is so I won’t have to quarantine in your scenario.

My group is still on the N95 + surgical mask + eye protection/face shield for all comers plan in addition to our testing protocol.

 

[narcotics999]

What PPE were you wearing while taking care of that patient? For me, part of the reason to wear an N95 for every single patient is so I won’t have to quarantine in your scenario.

Do your guys wait 20mins after intubation and extubation?

 

[nimbus]

Do your guys wait 20mins after intubation and extubation?

I wear it all day long.

 

[deleted162650]

Do your guys wait 20mins after intubation and extubation?

We were doing this, but now that PPE levels aren’t adequate we just have everyone in the room wear an N95 and no more waiting.

I didn’t mind waiting cuz with volumes as low as they were, at least we were getting an extra 3 units/case.

 

[GaseousClay]

My group is still on the N95 + surgical mask + eye protection/face shield for all comers plan in addition to our testing protocol.

regardless of the case? Seems like a lot of PPE to go through or no? not criticizing just curious on the mindset

 

[deleted162650]

regardless of the case? Seems like a lot of PPE to go through or no? not criticizing just curious on the mindset

Yes regardless of case. My group procured it's own apply supply of N95's. We also have a reprocessing program at the hospital. Eye protection/face shields are cleanable/reusable.

 

[nimbus]

False negative rate vs time since infection.


“Results:
Over the 4 days of infection before the typical time of symptom onset (day 5), the probability of a false-negative result in an infected person decreases from 100% (95% CI, 100% to 100%) on day 1 to 67% (CI, 27% to 94%) on day 4. On the day of symptom onset, the median false-negative rate was 38% (CI, 18% to 65%). This decreased to 20% (CI, 12% to 30%) on day 8 (3 days after symptom onset) then began to increase again, from 21% (CI, 13% to 31%) on day 9 to 66% (CI, 54% to 77%) on day 21.


Limitation:
Imprecise estimates due to heterogeneity in the design of studies on which results were based.


Conclusion:
Care must be taken in interpreting RT-PCR tests for SARS-CoV-2 infection—particularly early in the course of infection—when using these results as a basis for removing precautions intended to prevent onward transmission. If clinical suspicion is high, infection should not be ruled out on the basis of RT-PCR alone, and the clinical and epidemiologic situation should be carefully considered.”

ACP Journals

 

[dingdong28]

What are your thoughts regarding the sensitivities / specificities of the most common commercially available PCR tests and also antibody tests out there?

I'm not qualified to speak on the technical aspects, especially on the antibody testing or the other test platforms out there (Cepheid, DiaSarin, etc.). Our system went live with the antibody testing about 2 weeks ago after validating our own antibody test. Every other day I was sending out tons of plasma and serum on all positive patients for their testing. Only the ID physicians can order this test when a recently positive patient has 2 negative tests in 48 hours and their systems reduced. I'm extremely cautious about the antibody testing performance from Abbott, especially when you continue reading below.

As far as the Abbott ID NOW, I think it's an absolute turd. I'll say a few positive things first: It's fast, our clinicians have a result within 2 hours versus 2 days, and I had a patient who tested positive at Rite Aid also test positive on our instrument. Now the bad: It came from Abbott without them performing their own validation study/testing - huge red flag. Abbott stated it's poor collection technique, the swab used for collection, the media it's transported in, contamination, etc., why they've had poor reliability. In my honest opinion, Abbott released a substandard testing platform to impress the shareholders and future investors that has a crap accuracy rate. It's great that you have a result in 20 minutes, but at what cost to our patients and staff with it's terrible detection of the virus? It's sole purpose is to detect the virus and having a hard time doing just that.

I just Googled "Abbott ID NOW COVID 19 accuracy" and funny enough there's 2 articles recently published by CNN and WaPo (and others) about how it's missing too many positive cases. Too add more fuel to the fire, here's a great little read that made my stomach twist a bit:

Performance of the rapid Nucleic Acid Amplification by Abbott ID NOW COVID-19 in nasopharyngeal swabs transported in viral media and dry nasal swabs, in a New York City academic institution

The recent emergence of the SARS-CoV-2 pandemic has posed formidable challenges for clinical laboratories seeking reliable laboratory diagnostic confirmation. The swift advance of the crisis in the United States has led to Emergency Use Authorization (EUA) facilitating the availability of...

www.biorxiv.org

From the article: In search for a platform with shorter turnaround time, we sought to evaluate the recently released Abbott ID NOW COVID-19 assay which is capable of producing positive results in as little as 5 minutes. We present here the result comparisons between Abbot ID NOW COVID-19 and Cepheid Xpert Xpress SARS-CoV-2 using nasopharyngeal swabs transported in VTM as well as dry nasal swabs for the Abbott assay. Regardless of method of collection and sample type, Abbot ID NOW COVID-19 missed a third of the samples detected positive by Cepheid Xpert Xpress when using NP swabs in VTM and over 48% when using dry nasal swabs.

 

[kmurp]

False negative rate vs time since infection.


“Results:
Over the 4 days of infection before the typical time of symptom onset (day 5), the probability of a false-negative result in an infected person decreases from 100% (95% CI, 100% to 100%) on day 1 to 67% (CI, 27% to 94%) on day 4. On the day of symptom onset, the median false-negative rate was 38% (CI, 18% to 65%). This decreased to 20% (CI, 12% to 30%) on day 8 (3 days after symptom onset) then began to increase again, from 21% (CI, 13% to 31%) on day 9 to 66% (CI, 54% to 77%) on day 21.


Limitation:
Imprecise estimates due to heterogeneity in the design of studies on which results were based.


Conclusion:
Care must be taken in interpreting RT-PCR tests for SARS-CoV-2 infection—particularly early in the course of infection—when using these results as a basis for removing precautions intended to prevent onward transmission. If clinical suspicion is high, infection should not be ruled out on the basis of RT-PCR alone, and the clinical and epidemiologic situation should be carefully considered.”

ACP Journals

Thanks for linking this. There is a hopeful speculation in the discussion:
"The relationship between a false-negative result and infectiousness is unclear, and patients who test negative on samples from nasopharyngeal swabs may be less likely to transmit the virus regardless of true case status."

That makes some intuitive sense and provides some comfort, I guess.