Implementation of Pre-Admission Caregiver Testing for COVID-19

Our hospital inpatient units have 34 single rooms and 18 double rooms. When full, this results in a census of 52 patients during single-occupancy and 70 patients if all double rooms are occupied. Before implementation, the testing program was endorsed by the hospital’s family advisory council. In August 2021, we initiated COVID-19 testing by nucleic acid amplified tests of caregivers staying overnight with an admitted child using an ordering pathway (Supplemental Fig 2). Respiratory testing for other viruses was not offered to the caregiver. We continued our hospital cohorting process for patients who were tested for viruses other than COVID-19 (Supplemental Fig 3). Association of positive caregiver test to the corresponding patient was based upon the ordering provider and patient location as specified in Supplemental Fig 2.

For COVID-19 positive children, or those with a known close contact, caregiver testing was not required because COVID-19 isolation precautions were in effect, requiring the child and caregiver to remain in the room unless leaving the floor for a procedure. Caregivers consented to testing, and if a caregiver refused testing, the corresponding pediatric patient was placed under COVID-19 isolation precautions.

Children and caregivers were tested at the same time so that the time to parent result would not delay transfer to the inpatient unit. Patients and caregivers with pending results were booked to a single room with a portable high efficiency portable filter (Supplemental Fig 3). If COVID-19 results returned before bed booking, any positive COVID-19 test resulted in placement in a negative pressure room; negative COVID-19 testing led to bed assignment per normal procedures.

Testing was performed 24 hours a day in the main laboratory. Most testing was performed with the Aptima SARS-CoV-2 assay (Hologic, San Diego, CA), and some testing was performed with Xpert Xpress (Multiple Assays, Cepheid, Sunnyvale, CA) or other methods. The cost per test including labor and reagents is estimated at $35.00. More rapid testing platforms were used during peak times to facilitate patient admission to the floor. An electronic health record dashboard was created in which caregiver test results were flagged. A dedicated group of clinicians (medical director for infection prevention, medical director for inpatient pediatrics, inpatient unit nurse managers) reviewed results and matched them with admitted pediatric patients in real-time to inform bed placement.

Caregiver testing results, testing turn-around time, and testing methods are shown in Table 1. We estimated a cost of $89 530 for testing. Within our local community, Omicron became the predominant circulating SARS-CoV-2 strain during the week of December 19, 2021, and it remained predominant throughout the study period. Caregiver positivity rates increased from 0.6% (Delta variant predominant) to 9.8% (Omicron variant predominant). The median turn-around-time for test results was 4.8 hours from time of sample collection to result reporting, and a total of 2313 tests were performed using the Aptima SARS-CoV-2 assay, whereas 205 and 40 samples were tested by Xpert Xpress or other methods, respectively. The median (interquartile range) number of tests per week was 108 (95–120). The rate, nadir, and peak of caregiver testing positivity closely matched that of patients undergoing preprocedure testing within our health system, which is proxy for the positivity of the asymptomatic general population without a reason for testing (eg, known exposure) (Fig 1).

We linked 76 of 83 positive caregiver tests to corresponding pediatric patients. Nine of these patients were in the NICU and not investigated further given the unique demographics of these patients. Of the remaining 67 positive caregiver tests, 36 (53.7%) were associated with children who tested negative for COVID-19, and 31 (46.3%) were associated with children who tested positive, because caregiver and patient swabs were often obtained at the same time in the PED for workflow purposes. Among the 36 caregiver or child discordant pairs, 29 (80.6%) were identified after December 18, 2021. We did not identify any nosocomial SARS-CoV2 transmission in pediatrics in a double room during the study period via active surveillance by infection prevention, although we did not follow families after discharge for the duration of the SARS-CoV2 incubation period. After the implementation of this policy, our institution reimplemented cohorting of patients and were able to increase the available inpatient beds from 74% (N = 52) to 100% (N = 70).

Although we did not formally record the number of people who refused testing, in an informal poll of PED staff, clinicians recalled that refusals were rare and that there were no refusals for preprocedural admissions. Although the testing program was supported by the family advisory council, we did not formally measure the patient experience.

In response to the initial COVID-19 surge in 2020, we converted double occupancy inpatient rooms to single occupancy. Caregivers staying overnight with pediatric patients were often unmasked, especially when eating and sleeping. In response to increasing patient volumes during the Omicron COVID-19 surge, we reopened double occupancy rooms with a shared bathroom while mitigating nosocomial transmission of COVID-19 by implementing COVID-19 testing of overnight caregivers. With this intervention, we increased our inpatient bed capacity to 100%.

We initially saw low rates of COVID-19 positivity among caregivers reflecting the low to moderate incidence of COVID-19 within our region during this period.^4,7  However, rates dramatically increased as the Omicron variant became predominant. Notably, 53.7% of caregivers who tested positive were associated with pediatric patients who themselves tested negative, with 80.7% of these discordant pairs identified during the Omicron surge. These pediatric patients were placed on COVID-19 isolation because of close contact exposure and would have been missed were this testing plan not in place. These data suggest an increased need for caregiver testing during times of high local prevalence especially when circulating strains are more transmissible and/or less affected by vaccination.

During periods of high community prevalence, caregiver testing can reduce the risk of nosocomial transmission by identifying COVID-19 positive people who are spending long hours in the hospital in which they are likely to be unmasked at various times. Identifying COVID-19 caregivers may inform risk reduction strategies by utilizing negative pressure or high-efficiency portable filtered rooms and airborne precautions while also reducing caregivers’ mobility throughout the hospital.

The additional 2558 tests ordered were a fraction of the 443 070 tests our laboratory processed during this period, and there was minimal disruption to the PED workflow because caregivers self-registered and self-swabbed. The laboratory cost was ∼ $89 530 to identify 18 cases that resulted in a change in isolation and precautions. This may not be a cost-effective measure during periods of low community prevalence.

We assumed that waiting in the ED for an additional 5 hours after the decision to admit awaiting a COVID-19 test would be a major dissatisfier and opted to move patients and caregivers up to the inpatient units with tests pending a result. Patients were moved to the inpatient unit during the daytime when possible to minimize disruption to patients and caregivers. Most families understood the need to move rooms as the possibility was set at the time of admission. At baseline and prepandemic, at our institution, families prefer to be in a single room and not share the room and a bathroom with another ill patient and caregiver; this did not change as single rooms remain preferred. Another more problematic dissatisfier during the pandemic affecting the patient experience was the visitor policy initially limiting a single caregiver at the bedside, later expanding to a second adult but only during visiting hours.

This study has a number of limitations. Because we did not follow patients after discharge, we cannot be certain that there was no nosocomial transmission as symptoms may have developed after leaving the hospital. Our process was unable to capture the potential risks presented by additional caregivers who did not stay overnight, because they were not required to be tested, or caregivers who left the hospital and returned and had outside exposures after the initial testing period. We did not measure the impact of our intervention on the patient experience.

COVID-19 testing of caregivers staying overnight with their child allowed our hospital to increase bed capacity during times of high-patient census, reducing the risk of interfamily COVID-19 transmission in double rooms and generally reducing the risk of COVID-19–positive caregivers moving throughout the hospital exposing other patients and staff. The incidence of caregiver positivity tracked well with rates of positivity in asymptomatic patients undergoing preprocedure testing. As COVID-19 guidance regarding testing and isolation continues to evolve, the point prevalence of caregiver positivity that warrants the institution initiate testing will depend on many factors, including, but not limited to, community transmission rates, COVID-19 vaccination rates of the population, hospital capacity utilization, circulating variants, and disease severity.