Desperate times call for desperate measures. However, in case of an emergency response plan, a well-thought-out strategy is the need of the hour. A drive-through model for COVID-19 testing is one such example. It requires critical thinking, collaborative approach, government support and robust mechanisms. Having achieved this, a drive-through model can demonstrate a higher throughput rate and good patient outcomes
India, in its fight against the COVID-19 pandemic, has come up with several strategies including that of medical countermeasure response plans through mobile-testing units and drive-through testing models. These strategies have been implemented mainly by private sector initiatives and collaborations with the government. While mobile units have been a tried-and-tested system in the past, a drive-through model is a new concept for India and has triggered a positive momentum among diagnostic players. It was first initiated by Dr Dang Labs in West Punjabi Bagh, Delhi which received a positive response. The initial success of this model encouraged players like SRL Diagnostics, Healthians and Suburban Diagnostics to apply it at certain COVID-19 hotspots of the country and the results seem impressive so far.
An effective emergency response plan
In January 2010, physicians at Stanford Hospital and Clinics reviewed a model drive-through emergency department. The research was prompted by the expectation of a spike in visits to emergency rooms in the event of a serious flu outbreak. The findings of the research confirmed that a drive-through medical clinic is not only a feasible model, but maybe a preferred type of alternative care centre, informed Dr Eric A Weiss, the first author of the study and Associate Professor of emergency medicine at the Stanford University School of Medicine. “It can expedite and facilitate seeing large numbers of patients while mitigating the spread of infectious diseases by providing a social distancing mechanism. And it not only can be used during a pandemic, but also would be an excellent strategy for bioterrorism, or for other emerging infectious disease events,” he wrote.
Now, the concept of drive-through testing units garners inferences from the same model. It focusses on social distancing, patient and provider protection and faster testing. While countries such as South Korea and the US have already implemented it and gained fruitful medical outcomes, Indian diagnostics players also hope for similar results.
As per Dr Sanjay Arora, MD and CEO, Suburban Diagnostics, “The main purpose of a drive-through unit is to give improved access for testing. We have seen that nations that have a higher number of tests/million population has been able to better control the spread of coronavirus. A drive-through allows anyone to get tested from the confines of their car, without the risk of infection spread to self or others. The booking process is fully digital; the person has to show the token at the drive-through and get tested. The reports are also emailed.”
Similarly, Arindam Haldar, CEO, SRL Diagnostics said, “The drive-through facility has been conceptualised to collect the test sample without requiring people to step out of their cars. The facilit,y while ensuring the safety and well-being of the healthcare worker, also ensures minimising human-to-human interaction, and thereby contributing towards minimising transmission, thus contributing to “flattening the curve. ” The idea is simple: keeping potentially sick patients in their cars and allowing plenty of ventilation throughout the testing facility.”
Further, Dr Arjun Dang, Associate Lab Director, Dr Dangs Lab points out, “Since this model requires less time to set up and ensures the seamless, safe and swift collection of the swabs, it’s easily scalable to attain deeper penetration in tier-one cities. As an effective emergency response plan, this will not only reduce the number of infected people entering hospital emergency rooms to be tested and potentially infecting others, but also increase accessibility to people who require the test.”
Excerpts from The Centers for Disease Control and Prevention report mentions some striking advantages of this model:
Speed: These real-life emergency responses have demonstrated a higher throughput rate for drive-throughs than other frequently-used models. Sample collection at drive-through COVID-19 clinics in South Korea took less than one-third the time of sample collection in hospitals.
Staffing: Drive-through models generally require less staff in relation to the population served at a particular unit in comparison to more traditional models.
Social Distancing: Because individuals remain in their vehicles, they do not come in contact with individuals other than healthcare workers wearing proper personal protective equipment (PPE), thereby limiting opportunities for disease transmission.
Convenience: Individuals remain in their vehicles and do not need to find parking or stand in long queues.
Address the challenge of social stigma around tests: The inherent reluctance of people to come forward and do the tests. This concept is more comfortable to people and allows for a sense of privacy.
Providers in India, so far, have received a pleasing response from patients as well as the government. Moreover, the initial roadblocks have been mitigated to a certain extent. “A majority of the patients who have used the facility have complimented Dr Dangs Lab regarding the convenience and ease by which they could give the sample from the comfort of the car. The clarity that is being provided prior to booking regarding the testing process and also several signages has made the process seamless and swift. The entire process takes about five-to-seven minutes per patient. The safety of both the patient and medical staff owing to minimum interaction and exposure has also been appreciated,” shares Dr Dang.
Likewise, Haldar gladly informs, “Both the places – Mumbai and Gurugram have received a lot of attention and generated enormous enthusiasm amongst people. We are promoting the COVID-19 drive-through specimen collection facilities along with our local authorities, so that more number of patients can come and get themselves tested.”
While suburban received a luk warm response from patients at the beginning, they have now managed to reach out to people with the help of the Municipal Corporation of Greater Mumbi (MCGM) authorities. Convincingly, Dr Arora adds, “We expect the testing volumes to pick up once people realise the ease and convenience such facilities provide, along with maintaining higher levels of patient confidentiality as compared to home visits.”
Here are the key takeaways gleaned from their experiences:
Know the Indian Council of Medical Research (ICMR) guidelines backwards and forward: Following the guidelines for testing is paramount. Even the staff operating these units need to be stringent in following the guidelines. “Testing and collection of samples are of very critical nature and ICMR has only approved players who have the requisite amenities, which is real-time polymerase chain reaction (PCR). Apart from that, they are only approving the labs which are National Accreditation Board for Testing and Calibration Laboratories (NABL)-accredited for conducting tests like this, with experience in identifying RNA virus-based diseases like Swine Flu, HIV or HCV, which are different from typical cellology, or typical blood tests. In my view, this was an important step because it is a critical test and the quality norms and the expertise of being able to handle, even before the test sample is collected is crucial. For drive-through testing, we are partnering with local authorities like MCGM to ensure quality check and also to make the facility available to a larger set of people. For COVID-19 testing, we are following protocols laid down by ICMR on sample collection, storage, transportation and biomedical waste disposal. These guidelines and protocols are followed at the drive-through locations too,” shares Haldar.
Suburban Diagnostics has a dedicated training department that has updated itself on guidelines set by World Health Organization (WHO), Centers for Disease Control and Prevention (CDC) and ICMR. “These guidelines are converted into training sessions taken regularly as well as uploaded on our digital training platform “Upside LMS” which can be used by the operations team as needed,” adds Dr Arora.
Train staff accordingly: Ensure that the phlebotomists and other staff working in these units are agile and quick to respond to any circumstance as opposed to those assigned/repurposed other medical professionals who are just there to fill spots. In addition, there is a need to choose staff who can communicate clearly and calmly with patients in any scenario. “Our specially trained phlebotomists are collecting the samples following all biosafety precautions and using personal protective equipment (PPE). We are undertaking training and re-training of our staff to ensure all safety precautions are undertaken. These relate to the use of protective gear, disposal, sample collection and ensure accurate testing, the safety of patients and employees. This is a sensitive time and we need to ensure that people are staying calm and adhering to the guidelines,” states Haldar.
Clear Communication plan: Provide clear instructions to individuals expected to use the drive-through site.
This includes the address of the site, any special site access instructions, operating hours and required items such as identification or a doctor’s order. Consider options to pre-screen individuals who use the site. Online, telephone or other pre-screening can increase the likelihood that those who arrive at the site are appropriate users of the provided service. A doctor’s order or pre-printed screening form will help organisers plan for an expected number of individuals, particularly if they indicate a time window during which the individual should arrive.
Besides, determine what information will be provided in addition to the service. If individuals are required to take follow-up steps after the service, consider directing them to online information but have hard copies available for those without internet access. Ensure information is available in languages appropriate for the community. Establish a communications plan at the site and with off-site partners – be it municipal department, police, etc. Maintaining social distancing and limiting traffic congestion may require operations over a large area. Consider how staff on-site will communicate with each other (e.g., radios) and a back-up method (e.g., runners).
Seek-out community partners to augment testing efforts: In times of crisis, it is necessary that a collective use of resources and capacity ensure alignment between different community agencies. “We have seen an amazing public-private partnership (PPP) with the Brihanmumbai Municipal Corporation (BMC) in Mumbai. They have truly led from the front in fighting this pandemic. We have also seen a few NGOs and corporate houses, who have volunteered to support the cost of testing for those who cannot afford it. Overall, we have seen an outpouring of support, good wishes and blessings from the public in the appreciation of our efforts. We are indebted to all,” Dr Arora says gratefully.
Build a robust data collection and surveillance system: This is one of the most important factors. Luckily, all private labs are mandated to upload all patient data and reports on the ICMR portal, along with the state authorities. The state govt, along with ICMR, has guidelines for laboratories and regularly interacts with all private labs to understand their difficulties in order to help them achieve the maximum output. “This is extremely important for contact tracing, quarantining, providing medical support, etc. Since the virus is novel and the knowledge pool is ever-evolving, data will help to amplify the understanding that scientists and various health bodies have regarding the behaviour of the virus”, points Dr Dang.
Haldar explains further on the process of data collection, “As per the guidelines, as soon as we do the tests, all the results are uploaded, on the government website (ICMR portal). Each lab has its own dedicated user id and password. All positive samples are then sent to the National Institute of Virology (NIV) in Pune. In addition to that, we also share our COVID test reports of Mumbai with MCGM Epidemiology Cell and all positive reports of Gurugram lab are sent to the Integrated Disease Surveillance Programme (IDSP).”
Dr Arora shares insights on the surveillance and monitoring process they follow at Suburban. “Our measure of process efficiency is the ability to turn around maximum tests with the highest level of accuracy within 24 hours. When we started testing one month ago, we were able to release 200 tests per day. We have now ramped up to 700 tests per day which will soon reach 1,000 tests per day. The senior leadership team is fully hands-on with daily monitoring of all processes to ensure we deliver what is expected and beyond,” he expounds.
Work in line with police and authorities: From his initial experience, Dr Dang clears that it is necessary to get permissions prior to setup from the local police authorities, municipal corporations and also the commercial area. “Although we provide confirmation letters that can be shown to local police authorities, if stopped on the way, owing to strict lockdowns. Initially, there were a few patients who were stopped on the way. For these situations, we have given a helpline number and the matter was resolved within minutes of us speaking to the police,” he revealed.
Access and security: Ensure appropriate security and wayfinding for the unit. Clear, visible signage accompanied by direction from law enforcement or other public safety personnel is important to minimise traffic congestion and enable efficient operations. Signs should remind individuals to remain in their vehicles. Also, it is important to review site considerations. When reviewing potential sites, consider factors such as preventing interference with access to other services and protecting staff from weather conditions. Ensure a reliable power source is available for refrigeration of specimens and laboratory supplies, operation of the printer for specimen labelling and computers/tablets for electronic health record or tracking, and heating/cooling of staff based on weather conditions.