In-System Clinical Laboratories Kept our Hospitals Open and Solvent During COVID-19

Since the start of the COVID-19 pandemic, clinical laboratories were in the spotlight more than ever before.  The urgency, anxiety, and focus on laboratory testing for COVID-19 led to surprising discussions with colleagues, administration, and even the public about the ins and outs of testing platforms, regulatory pathways, supply chains and even Ct values.  Laboratory staff have scrambled to implement new tests, manage supply chain issues, adjust work schedules, and train new or borrowed staff to deal with the massive demands for COVID-19 testing.

While hospital laboratory data is foundational for all patient care, laboratory testing for COVID-19 is the key for diagnosis and triage, as well as tracking, quarantining, limiting disease spread, and resource management.  The gold standard remains nucleic acid amplification testing of a nasopharyngeal swab (NP), and a multitude of laboratory-developed tests and commercial options are now available using NP and other samples. Faster and cheaper antigen-based options with lower performance capabilities are primarily used for screening programs.

SARS-CoV2 testing is performed at 3 general laboratory sites:  public health, hospital and health systems, and commercial reference labs.  Public health laboratories were first to offer testing and are critical for epidemiologic data, but lack the capacity and infrastructure to provide clinical testing to all segments of patients in a clinically meaningful timeframe.  Large referral laboratories are better equipped to handle large volume testing, but their locations require sample transport, adding hours to days to the time to result; testing at commercial labs is best suited to outpatients who are minimally symptomatic or asymptomatic.  Many hospitals experienced sick patients waiting on a SARS-CoV2 RT-PCR result from a commercial lab, necessitating repeat testing done at our hospitals. It is hospital clinical laboratories that were truly on the front lines of the pandemic.  Sick patients arrived in emergency departments and clinics, with urgent decisions needed for their care, isolation, and more-- there was no time to wait days for a test result. TIME TO RESULT MATTERS!!  Strengthening hospital and health system laboratories will be key to our ability to provide proper patient care during COVID-19 or any future pandemic.

While the importance of SARS-CoV-2 RT-PCR results for appropriate patient care is well recognized, the impact of clinical laboratories and clinical laboratory scientists on the operations and finances of hospitals is less appreciated.  In-system labs with rapidly available results were instrumental in keeping our institutions functioning and solvent during the pandemic.

As a system laboratory that was able to offer in-house testing early in the pandemic, we quantified the financial benefit to our healthcare system (https://journals.sagepub.com/doi/10.1177/23742895211010253).  First, COVID-19 testing provided an important revenue stream at a time that elective medical care was suspended.  We were able to provide all testing needed by our healthcare system at a cost lower than a send-out test.  As our capacity expanded, we were able to provide testing to other area hospitals, state swab collection facilities, nursing homes and more, further increasing revenue—yet maintaining a time to result of about 24 hours.

Patients admitted at risk for COVID-19 were swabbed and placed in contact isolation with N95 mask use until a negative COVID-19 PCR was reported; with isolation practices costing upwards of $150 daily (materials and time), the reduction in use of PPE and effort resulting from a negative COVID-19 result within a day was enormous. Thirty-five thousand isolation days were avoided as a result of our rapid in-house COVID results, savings the hospital upwards of $5 million on isolation costs compared to a slower send-out test. Rapid results became even more important with the state public health requirement of a negative COVID-19 test within 72 hours of entering the hospital.  Rapid COVID-19 results permitted our institutions to resume routine care, and in fact allowed us to perform 89% of the surgeries projected for fiscal year 2020.  This would have been impossible with a referral test; and indeed, we performed testing for other local hospitals for this reason. On-site testing was key, allowing our system to reopen and provide necessary care to our patients.

Our lab’s contribution this past year was not unique, but occurred in countless hospitals across the country, improving both patient care and hospital balance sheets.  For both routine and crisis-level care, recognizing the value of strong clinical laboratories is critical, and empowering these labs is a valuable investment, whether during COVID-19, other public health threats or routine clinical care.

Karen L. Kaul, MD, PhD
Member of the AMP COVID Response Steering Committee
Chair, Department of Pathology and Laboratory Medicine, Northshore University HealthSystem
Clinical Professor of Pathology, University of Chicago Pritzker School of Medicine
Duckworth Family Chair