Rapid On-demand CovIdTesting (ROCIT)

COVID-19 is a novel illness that presents with non-specific signs and symptoms including cough, fever, and shortness of breath.  As many as 45% of all deaths related to COVID-19 have been in the nursing home setting.  Most Veterans residing in VA nursing homes or CLCs, who have a new or worsening respiratory symptom related to suspected COVID-19, are transported to the emergency department (ED) for further evaluation and triage.  Many of these transports to the ED for purposes of triage are potentially unnecessary, expose additional patients and providers to COVID, utilize unneeded resources, and make it more difficult to provide the right level of care.

Clinical triage is an important strategy to optimize survival and resources, by translating the best available evidence into reliable and reproducible approaches.  New approaches are needed to allow for forward triage (NEJMp2003539).  These forward-triage approaches utilizing telemedicine allow Veteran assessment in the CLC, to optimize survival and resources, while reducing the risk of community spread.

The goal is to have a Telemedicine LPN dispatched to the CLC within 2 hours of receiving a call for a non-emergent new or worsening respiratory symptom related to suspected COVID-19.  The Telemedicine LPN would be equipped with a ruggedized case containing an iPad Pro that can connect to the VA Wi-Fi network, appropriate PPE, COVID-19 testing supplies, and Bluetooth stethoscope, blood pressure cuff, thermometer, and pulse oximeter.

Once at the CLC, the Telemedicine LPN will use the COVID-19 structured clinical protocol to gather and document additional clinical information.  After their initial assessment, the Telemedicine LPN will connect to a provider who will complete a synchronous telemedicine consultation using VA Video Connect.  The provider will make the final triage decision.  If the Veteran is triaged to emergency care, the Telemedicine LPN will assist with coordination and wait for EMS to arrive.  If the Veteran can treat in place, the Telemedicine LPN will collect a COVID-19 nasopharyngeal specimen, deliver it to the local lab, and carry out other orders under the direction of the provider.

We believe that this approach is superior to existing telephonic consults, as the face to face interaction with providers and ability to collect nasopharyngeal specimens will yield additional information to the provider and improve triage and treatment decisions.  Providers will also be able to give reassurance and guidance to the Veteran and/or family members.  Future iterations of this approach can be used to target other post-acute and long-term care settings such as those that reside at home as part of home-based primary care and PACT programs by including cellular modems that can access the FirstNet dedicated first-responder cellular network.