Point-of-care PCR testing of SARS-CoV-2 in the emergency department: Influence on workflow and efficiency

PLOS ONE RESEARCH ARTICLE Point-of-care PCR testing of SARS-CoV-2 in the emergency department: Influence on workflow and efficiency David Fistera ID1*, Katja Kikull2, Joachim Risse1, Anke Herrmann3, Matthias Brachmann2, Clemens Kill1 1 Center of Emergency Medicine, Essen University Hospital, Essen, Germany, 2 bcmed GmbH, Ulm, Germany, 3 Institute for Virology, Essen University Hospital, Essen, Germany a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 * Abstract Problem OPEN ACCESS Citation: Fistera D, Kikull K, Risse J, Herrmann A, Brachmann M, Kill C (2023) Point-of-care PCR testing of SARS-CoV-2 in the emergency department: Influence on workflow and efficiency. PLoS ONE 18(8): e0288906. https://doi.org/ 10.1371/journal.pone.0288906 Editor: Vittorio Sambri, University of Bologna / Romagna Local Health Authority, ITALY Received: May 12, 2023 Accepted: July 5, 2023 Regarding transmissible viral diseases such as those caused by SARS-CoV-2 virus, one of the key challenges is isolation management until final diagnosis. This study investigates the influence of SARS-CoV-2 point-of-care (POC) PCR on workflow and efficiency in an emergency department (ED) of a tertiary university hospital. Method An analysis of 17,875 ED patients receiving either SARS-CoV-2 POC PCR (rapid PCR, 11,686 patients) or conventional laboratory SARS-CoV-2 PCR (conventional PCR, 6,189 patients) was performed. The pathways for both groups were mapped and compared, and process times from admission to diagnosis were measured. Effects on resource management within the ED were quantified. Direct costs due to isolation, loss of capacities, and revenues were calculated for inpatients. Published: August 3, 2023 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0288906 Copyright: © 2023 Fistera et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Results The mean time from admission to result was 1.62 h with rapid PCR and 16.08 h with conventional PCR (p < 0.01), reducing the isolation time by 14.46 h. In the first 2 h after testing, test results were available for > 75% of the rapid PCR group and none of the conventional PCR group. Ninety percent of the results were available within 3 h for the rapid PCR and within 21 h for the conventional PCR group. For the conventional PCR group, an increase in direct costs of €35.74 and lost revenues of €421.06 for each inpatient case was detected. Conclusion Rapid PCR significantly reduces the time-to-results and time for isolation relative to conventional PCR. Although testing costs for rapid PCR are higher, it benefits workflow, reduces total costs, and frees up ward capacity. PLOS ONE | https://doi.org/10.1371/journal.pone.0288906 August 3, 2023 1 / 12 PLOS ONE Funding: The analysis was supported by a grant to Essen University Hospital, Essen, Germany, from Cepheid, Buckinghamshire, UK (www.cepheid. com). None of the authors received a personal grant. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. SARS-CoV-2 point of care PCR in the ED Introduction The coronavirus disease 2019 (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus (order: Nidovirales, family: Coronaviridae, subfamily: Coronavirinae) [1]. The unpredictability of COVID outbreaks (point of time and incidence rates), the novelty of the virus, and the risk of staff members being infected have put healthcare systems worldwide under unprecedented pressure [2–6]. Uncertainty about a patient’s health or infection status upon arrival is a problem for healthcare providers, especially hospitals and their emergency departments (EDs). Clinical COVID diagnoses are difficult because symptoms can resemble other respiratory diseases (e.g., influenza or respiratory syncytial virus [RSV]), or an infected person may be asymptomatic [7,8]. These hurdles make it necessary to isolate all patients; to protect patients and staff members [9]. Isolation management during pandemics can be defined as the key challenge for the ED and inpatient wards. The standard diagnostic approach for alleged COVID-19 patients is the polymerase chain reaction (PCR) test method [10–12], with test results available within a wide range of up to 24 hours due to varying availability of PCR testing, which can be limited during nights and weekends, and the number of tests. Consequently, alleged COVID-19 patients are fully hospitalized and isolated in a normal ward or in a holding area (blocking a twin bedroom) until the test results are available. Cohort isolation is only possible with a valid test result. Health authorities of many countries have relied on rapid antigen testing to prevent or reduce the spread of the SARS-CoV-2 virus [13]. Studies on the comparability of the two test methods (antigen and PCR) show that the rapid antigen test is less sensitive, especially among patients with a lower viral load, such as vaccinated patients or those tested very early or late in the course of infection [14–17]. Therefore, PCR testing remains the gold standard for diagnosing SARS-CoV-2 infections. Point-of-care PCR diagnostic testing of suspected COVID-19 patients can ensure rapid, qualitative, reliable results [18,19]. A point-of-care device has 24/7 availability and can be directly installed in the ED. When point-of-care devices are available, all patients with COVID-19 symptoms can be rapidly diagnosed, discharged, or admitted without isolation or with necessary cohort isolation. Therefore, this study investigates the influence of point-of-care PCR testing on the workflow and efficiency of a large ED. Materials and methods A process analysis was conducted with the aim of evaluating the operational and economic effects of point of care rapid PCR analysis (rapid PCR) compared to conventional laboratory PCR (conventional PCR) for detecting the SARS-CoV-2 virus in emergency patients from April 1, 2020, to March 31, 2022. The study was approved by the institutional ethics committee “Ethik-Kommission der Medizinischen Fakultät der Universität Duisburg-Essen” (approval no. 22-10786-BO, date: June 17th 2022) and registered in the German trial registry (study no. DRKS00029370). The study inclusion criteria were: adult patients presenting to the ED during the study period (admission by emergency medical servic (...truncated)