Interview: COVID-19 Rapid and Universal Testing at Maui Memorial Medical Center

By Wendy Osher

In this exclusive interview, we sit down with Dr. Vijak Ayasanonda from the Maui Memorial Medical Center.  Dr. Ayasanonda, who is an emergency room physician at the Maui hospital, answers questions about rapid COVID-19 testing, universal testing at the Maui hospital, and how antibody tests work.

What is Universal Testing?

“Universal testing means what it sounds like–We’re going to be testing every single person coming into the hospital.  This is trying to provide a safety net and catch everyone who is symptomatic as well as asymptomatic.  The purpose of that is to (1) make sure that we catch everyone; (2) try to protect the staff and make everyone aware if we do find someone who is COVID-19 positive; and (3) try to preserve our PPE storage,” said Dr. Ayasanonda.

What is Rapid Testing?

Rapid testing, Dr. Ayasanonda explains, is only a matter of timing.  Rapid testing refers to how fast a test comes back.  “When we first started all of this, rapid testing took up to seven days. We had to either send it out to the DOH our have to send it out to a private lab, which is in Texas. So turnaround time was 3-7 days–not too useful for someone who is coming into the emergency department or into the hospital right away, because we would be treating them as though they were positive, no matter what from day one.”

Maui Memorial Medical Center now has the capability of two rapid testing machines.  “We can say they are much more rapid than what we were used to before.  Turnaround time has now gone to about three hours and they’ve surprised me and have actually gone a little bit faster.  It all is determined by when we get the tests to the labs.”

How Accurate is Rapid Testing?

Dr. Ayasanonda also discussed accuracy of the rapid testing kits:  “Our tests that we are using right now is called the Luminex test.  It’s a PCR, so a polymerase chain reaction test that will detect the RNA virus of the disease.  So if you have COVID and we can catch it in your mucus or in your nose, we can go through this very elaborate, very amazing process, that within hours we can come up with a result that says yes or no (if you’re positive).  We’re trying to use the most sensitive test.  What that means is–if we do not have a positive COVID test, we want to make sure and say that you definitely do not have coronavirus.”

“And so at 97%, which is assuming the best case scenario, we still would miss out on maybe 3% of the people.  Now, this doesn’t mean we would let our guard down, and not wear masks or use any protection.  It just means that we wouldn’t have to use our whole PPE stores, where we would use our full face masks, full shields for example, gowns and gloves–but we would still be on precautions,” said Dr. Ayasanonda.

According to Ayasanonda, there’s other rapid tests out there that have much greater error percentages.  “There is another test that I hear about all the time. I’m sure you guys hear about it all the time.  It’s a 15 minute rapid test.  That one supposedly has about a 15% if not higher imperfect rate. So what good is a test if you say–hey your test is negative and we can kind of relax and say you do not have coronavirus, if we’re going to miss a good chunk of people?”

Universal Testing / Why is it Being Done / Who’s Eligible

“We felt that this was the right time.  We’re in communication all the time with all of the other hospitals in the state of Hawaiʻi, as well as on the mainland.  We have a lot of connections, myself included, who have friends and family and colleagues in California, Chicago, New York–so we’re trying to stay as up to date as possible,” said Dr. Ayasanonda, “Trying to learn from what they did right–and we want to go ahead and make sure to do what we consider the best standard practice for everyone coming into the hospital–that includes universal testing.”

“We had to wait to make sure we had the testing capability, the speed and rapidity of the test, and the good sensitivity and the good test itself.  Technology is always getting better, so we’re always looking for something faster and more accurate,” said Dr. Ayasanonda.

As far as eligibility, Dr. Ayasanonda says everybody, “every single person who is going to be admitted to the hospital, and everyone who is potentially going to be admitted to the hospital will be tested.”

Individuals who come in who have a cough, cold or travel history will be tested.  Even given a 97% testing accuracy rate, Dr. Ayasanonda says a patient exhibiting such symptoms would still likely be treated as positive until proven otherwise.

Someone who comes in for a hip fracture, for example, would undergo testing because they might have to go into the operating room.  Labor and delivery patients would also have all testing, and anyone else who is going to be a direct admission would need to have testing prior to coming in, according to hospital administrators.

“In addition to that, the testing is still three hours.  Our goal is not to have people wait in the emergency department until after we figure out that the person needs to be admitted and wait an additional three hours to have the test come back.  Our goal is to get them into the emergency department, get them a good diagnosis, get them to the treatment that they need to get to as fast as possible.  So if you come in and I have a feeling that you have a good chance–it could be 50%, 70%, (or) 100%–for a stroke or a heart attack or a broken hip, I’m going to be ordering the test the moment you hit the door, so that by the time we have the rest of the labs, x-rays back, that we know what your COVID status is, and we don’t have to delay your care any further,” said Dr. Ayasanonda.

“Because we are also testing not just those who are coming into the hospital, we’re catching a lot of those who could be potentially symptomatic in the community.  So it’s a good surveillance tool as well,” he said.

Where is Testing Done / Where to Wait for Results

“The testing is being done in the emergency department. If you are in the emergency department… we have a set up so that there is extremely low risk.  Someone who is not sick for example who may have been in contact with someone with coronavirus; and then someone who appears sick enough that they would appear to need some type of care–be it labs, IV, imaging studies and probably admission.  So those people who are in the second category would come into the emergency department, be placed in a private room and have all the precautions–masks and everything else in place.  For the first group–those who are in contact, but feel very well–they would be left in our tent area, which is set up outside the emergency department in essentially an open air area that helps decrease the risk of transmission,” said Dr. Ayasanonda.

“For those people who are in the emergency department, who could potentially be admitted, or need rapid testing–those are the people who would get testing done and it could take three hours in general. That’s how long it would take for the test to be collected, sent to the lab, put on a machine, and usually get a result back,” said Dr. Ayasanonda.

“Of course, we’re still limited with the amount of frequency we can do these tests.  We’ve improved it so that every three hours or even faster than that, we’re running a new batch, and the batch can be up to 12 tests, and that’s more than what we need at this time.  And those people, within three hours of course if you get it right after the first batch, might take a little bit longer than those who would catch it right before the batch goes in,” said Dr. Ayasanonda.

Those who are outside, who are low risk, the hospital is saving its rapid supplies for those who absolutely need to know right away.  “Those tests in the tent are now being sent to Oʻahu and I believe the testing now is around three days turnaround time, and sometimes better, depending on what time of day we can get it to the flight and get it to our clinical lab partners,” Dr. Ayasanonda.

Are there enough rapid tests on island?

“There is unfortunately always a concern, and it is a moving target,” said Dr. Ayasanonda. “If we were to run three times as much tests because three times as many patients show up, then I’m sure that our supplies would dwindle quickly,” said Dr. Ayasanonda.

But the hospital monitors supplies in the emergency department every day.  “Unfortunately we have not recovered to our pre-COVID kind of numbers… which is a whole different subject of people avoiding the emergency department out of fear of coronavirus or getting a transmission.  But with the approximately 90-100 patients we see a day–where we are used to seeing up to 140 or 160–we have enough testing capability to keep doing exactly what we we’re doing,” said Dr. Ayasanonda.

“With the return of interisland travel and no quarantine as well as mainland tourism returning, that will change.  Hopefully by then, our testing capabilities will also continue to evolve and ramp up–being faster and more prevalent,” said Dr. Ayasanonda.

What Happens to those who test positive?

“If you have a positive result, we have multiple warm units in the hospital.  By warm units, I mean these are dedicated units in the hospital dedicated to those who are COVID positive,” said Dr. Ayasanonda.

“They have specialty rooms with specialty anti-chambers, plastic-off areas, increased amount of PPE as well as mandates that you wouldn’t go past a certain checkpoint unless you were completely protected head-to-toe.  And at the same time, when you leave that area, all of that material gets put away into a safe bio-hazard container so you don’t spread it throughout the hospital,” said Dr. Ayasanonda.

Hospital administrators say there are specially trained staff including nurses, cleaners, x-ray techs and doctors who are versed in the protocols and procedures so that they won’t accidentally spread the virus or take it home with them.

Why Would Someone Want to get an Antibody Test?

An individual would seek an antibody test to determine if they’ve had coronavirus.  “A lot of us have experienced really bad colds and coughs–all the way from December and January–and we wonder if we had coronavirus and is there a chance that I could be immune to that going ahead,” said Dr. Ayasanonda.

“Unfortunately the answers are still unclear.  The best research that I’ve been able to look up, as well as my group and the hospital, is that it is still unclear.  All we can say is that if you were to have a positive antibody test, it only means that you could have a disease at some point,” said Dr. Ayasanonda. “It could be right now.  I could have been months ago–if you are positive.  So that usually mandates that you would still need to have a secondary test–which is the rapid test.  Obviously any health care providers who have chosen to get antibody testing–we’ve had one who is positive–wound up coming back in to get tested,” said Dr. Ayasanonda.

“An interesting fact is that you could still be shedding RNA virus from the virus itself for many months afterwards; and we can’t tell exactly when this RNA virus is no longer infectious.  The best expert evidence we have are that after two or three weeks, you probably aren’t infected anymore; but you could still be having dead virus particles still in your body (and) in your system somewhere that can be detected,” said Dr. Ayasanonda.

“We just need a little more time as a medical profession and medical field, to really figure out which one is the best test, what are we measuring and what are we going to do with those results,” said Dr. Ayasanonda.

Will Universal Testing Help to Prevent a Second Cluster at the Hospital?

“Absolutely.  So I totally agree with that.  Universal testing will capture every single person who would be coming into the hospital so that even if you’re asymptomatic–which is our biggest fear. Not many people who come in coughing and waving their arms saying I have COVID are going to miss.  But someone who comes in for something otherwise–chest pain, a stroke for example, a broken bone who needs to have an operation–we weren’t able to test those people beforehand because we didn’t have the test capabilities or the rapid turnaround.  Now we would,” said Dr. Ayasanonda.

Is the Hospital Better prepared for a Second Wave given the experience with the previous cluster?

“Yes.  I believe, especially with looking at all the numbers on the mainland, we’re not going to be able to avoid it.  There will be disease that will be coming back to the islands and we are definitely much more prepared.  We implemented something like an emergency command center made up of physicians–we have clinical staff as well as hospital administrator staff– and we are coordinating much better than we were prior to this epidemic,” said Dr. Ayasanonda.

“So we’re better prepared for that.  Our PPE storage is much higher than what it was… (when we were) waiting for that first wave to come.  Our processes are much more in line–the tent, the processes we have in place in the emergency department, the universal masking procedure which is one of the most important things within the hospital for both staff as well as patients–will prevent any further outbreaks or clusters in the hospital,” said Dr. Ayasanonda.

“And for that matter with universal testing, that is going to exceed more than just those being admitted to the hospital, I have a feeling that we’ll be able to pick up some cases in the emergency department even before we see more testing available in the community,” said Dr. Ayasanonda.

What would you tell people who are delaying care because they are afraid they’ll get infected?

“Unfortunately I’ve had several experiences where it’s just heartbreaking.  Those who have had heart attacks, who have waited at home for three days or five days –something where we could have taken care of them much better and provided a them with better service if they had come in right away–which would have happened prior to coronavirus.  They chose not to because they were afraid of getting COVID,” said Dr. Ayasanonda.

“I just had a person recently, unfortunately break their hip weeks before coming into the emergency department with multiple fractures–one being ‘I thought it might just get better on it’s own,’ ‘I fell walking my dog,’ and ‘I did not want to take the risk of coronavirus.’ And that’s unfortunate.  I mean someone who doesn’t need to suffer, they really should come in,” said Dr. Ayasanonda.

“We have taken every precaution.  I can tell you, I am more than 100% that if my family members, my mom, grandmother–anyone I know–my friends, my family, my neighbors, if anyone gets sick, I would say please come to the emergency department.  It’s one of the safest places you could imagine between all of the mask protocols, the cleaning, we are prepared and we are guaranteed to prevent any further spread to the community from anyone to anyone else who’s coming to the emergency department.