The Impact of Systematic Safety Precautions on COVID-19 Risk Exposure and Transmission Rates in Outpatient Healthcare Workers

Original Research The Impact of Systematic Safety Precautions on COVID-19 Risk Exposure and Transmission Rates in Outpatient Healthcare Workers Deepak A. Kapoor, MD,1,2 Kathleen Latino, MD,1,2 Gillian Hodes,2 Ann E. Anderson, MD,1 Jonathan Anderson,2 Marcus Cognetti,3 Chiraag Patel3 1Integrated Medical Professionals, PLLC, Bethpage, NY; 2Solaris Health Holdings, LLC, Fort Lauderdale, FL; 3P4 Diagnostix, Toms River, NJ We evaluated the impact of safety protocols, including rapid testing and contact tracing, on coronavirus disease 2019 (COVID-19) risk exposure and transmission rates amongst healthcare workers in the outpatient care setting. Over an 11-week period, a total of 254 employees representing 38% of our total workforce had potential COVID19 exposure and underwent voluntary COVID-19 testing. Data was stratified based on severity of risk exposure and job description. During this period, the probability of a COVID exposure being high risk decreased in Administrative (293.0%; P , 0.01) and Clinical (277.0%; P , 0.01) staff; simultaneously, viral transmission rates declined in Administrative (273.4%; P 5 0.03) and Clinical (269.9%; P 5 0.04) staff as well. Systematic safety protocols effectively reduce exposure risk and transmission rates in outpatient healthcare workers and should be ubiquitously adopted. [Rev Urol. 2020;22(3):93–101] © 2020 MedReviews®, LLC KEY WORDS COVID-19 diagnostic testing • Contact tracing • Safety T he coronavirus disease 2019 (COVID-19) crisis has posed innumerable challenges to healthcare services nationwide. For many, this pressure has been largely economic, as stay-at-home policies coupled with limitations on elective procedures have dramatically reduced revenue. Although federal grants through the Coronavirus Aid, Relief, and Economic Security (CARES) Act mitigated some Vol. 22 No. 3 • 2020 • Reviews in Urology • 93 4170020_04_RIU0877_V3_ptg01.indd 93 19/10/20 3:14 PM Safety Precautions and COVID-19 continued degree of lost revenue, the degree of financial relief was inconsistent for two reasons. First, the methodology initially used to calculate payments relied on fee-for-service Medicare, which did not necessarily reflect actual provider-payor mix as Medicaid and Medicare Advan­ tage commercial payors were not considered1; and second, after the initial tranche of funds were released, the balance of financial relief has largely been directed towards institutional—rather than independent—providers.2 Practices located in regions with significant COVID-19 infection rates face additional clinical challenges on top of the economic challenges faced nationwide. Nowhere was this more evident than in the New York metropolitan area—the clear initial epicenter for the pandemic within the United States. During the first weeks of the pandemic, independent practices remained open to provide essential services while incidence and hospitalization rates were surging. By expanding care to patients in the outpatient setting, patient encounters could be kept out of the hospital, thereby relieving stress on an overburdened system. During this time, it was imperative that measures were implemented not only for the individual safety of staff and patients, but to also assure that there were sufficient resources available for the physician practice to continue essential care and participate in regional surge efforts. Unfortunately, due to the rapid change in the knowledge base with respect to COVID-19, guidance from local, state, federal, and international agencies have been shifting—and have, at times, been inconsistent or even contradictory.3 Integrated Medical Professionals (IMP) is a urology-centric multi­specialty independent practice providing care at over 50 locations spread across 8 counties in the New York metropolitan area, constituting a significant component of loco-regional care. To ensure a coordinated internal response, IMP created a dedicated task force to address all COVID-19 related issues; all clinical and business authority was delegated to the task force. A principle role of the task force was to create and regularly update safety protocols derived from consensus guidelines and the best available data. We postulated that the most important component of determining the efficacy of any efforts to mitigate transmission to or between staff was the availability of rapid testing of exposed and symptomatic indi­ viduals, with subsequent contact tracing. Unfortunately, during the peak of the crisis, commercial availability of COVID-19 testing was extremely limited, rendering any measurement of the safety initiatives’ efficacy challenging. Consequently, there is little data on the impact of the safety measures implemented to curb COVID19 transmission to healthcare workers, and none specifically addressing this on an outpatient setting. A component of IMP’s services is a comprehensive clinical pathology laboratory that includes in-house polymerase chain reaction (PCR) and next-generation sequencing (NGS) capabilities. To address the issue of test availability, IMP worked collaboratively with P4 Diagnostix to create a rapidturnover, on-demand COVID-19 testing process that could be offered to IMP staff based on exposure risk and job responsibilities. Our objective was to assess COVID-19 transmission risk longitudinally to determine the impact of systematic safety protocols on COVID-19 incidence amongst healthcare workers in an outpatient setting. Method To facilitate testing of IMP employees, we collaborated with P4 Diagnostix to create a COVID-19 naso-oropharyngeal test to be offered to staff based on recommendations of the company COVID-19 task force. To expedite this procedure, the initial para­ digm utilized a non-commercial research-use only (RUO) pathway; during the course of the study the bridge validation study was accepted for commercial use; this did not change the test process or study protocol. Testing was performed using a modified Applied Biosystems™ TaqPath™ COVID-19 Combo Kit (Thermo Fisher Scientific Inc., Waltham, MA) under emergency use authorization (EUA). Specimen transport was modified by placing nasopharyngeal swabs into DNA/RNA Shield™ (Zymo Research, Irvine, CA) for improved specimen temperature stability and virus inactivation. RNA extraction was done on Centers for Disease Control and Prevention (CDC)–approved QIAsymphony™ (QIAGEN Inc., Germantown, MD) utilizing the Mini Pathogen/Viral RNA extraction kits. Liquid handling was carried out using a Sciclone® G3 NGSx iQ™ Workstation (PerkinElmer, Inc., Shelton, CT) with rRTPCR analysis performed on a QuantStudio 12K™ (Thermo Fisher Scientific). This test was offered to staff without obligation or cost and appropriate informed consent was obtained from each employee prior to testing throughout the study period. Testing became available during the week of March 20, 2020 (calendar week 12). Weeks were numbered in accordance with the ISO 8601 standard. In general, test results were available within 24 hours, and, other than a small number of tests that needed to be 94 • Vol. 22 No. 3 • 2020 • Reviews in Urology 4170020_04_RIU0877_V3_ptg01.indd 94 19/10/20 3:14 PM Safety Precautions and COVID-19 repeated due to technical issues with specimen processes, all results were reported within 48 hours of potential COVID exposure. Data was analyzed based on reporting rather than collection date. Information collected included assessment of exposure risk as well as job type (Clinical, defined as any individual whose job necessitated direct physical contact with the patient or possibly infected secretions; or Administrative, defined as any individual whose job did not require patient contact). Initial risk assessment is listed in Table 1; this classification was revised in accordance with subsequent CDC guidelines.4 Any potential exposure to COVID-19 outside the workplace was assessed, as were the results of any prior COVID-19 testing and any treatment that may have been rendered. For those employees that tested positive, rigorous contact tracing was conducted, and any employee identified as exposed through this process offered testing as well. Any employee that refused testing was subject to quarantine in accordance with New York State Department of Health (NYSDOH) guidelines, and those that opted to undergo testing were quarantined until COVID-19 test results were available. Based on test results, staff were permitted to return to work or referred for appropriate medical treatment; no exceptions to this policy were permitted. Data was collected for the 11 weeks following the initial availability of testing; for comparison purposes, positive test rates for New York State for the same period were obtained from the NYSDOH. Data was tabulated based on result date. Contingency trends were ana­ lyzed using the chi-squared test; contingency tables utilized Yates correction for continuity to prevent overestimation of statistical significance. Linear regression was performed using the leastsquares method, and the slopes of linear regression trend lines were compared using an analysis of covariance. Correlation was determined by calculating Pearson’s product-moment coefficient and proportions compared using Z-score test for two populations. Statistical analysis was performed using GraphPad Prism version 8.4.3 for Windows (GraphPad Software, San Diego, CA). Results A total of 254 tests were performed during the 11-week analysis period, representing approximately 38% of all IMP clinical and administrative staff. No tests were reported in study week 9 as no COVID-19 exposures were reported during that testing interval. A single aberrant data point in a positive result reported in Week 19 was due to timing of result reported from a Week 18 exposure. Overall positive rates for IMP and NYS along with weekly tests reported by IMP are presented in Figure 1. The overall percentage of positive COVID-19 tests decreased significantly over time in both groups (P , 0.01). Overall positive test rates for IMP showed significant positive correlation with test rates for New York State (Pearson’s correlation coefficient TABLE 1 Initial COVID-19 Exposure Risk Definitions Low risk • Being in the same room as person diagnosed with COVID-19 for a prolonged period but not close contact ($6 ft) • Face-to-face contact with a person diagnosed with COVID-19, ,6 ft for a non-prolonged period (,15 min) Medium risk • Direct physical contact with a person diagnosed with COVID-19 (eg, shaking hands, hugging) • Prolonged close contact with a person diagnosed with COVID-19 (usually this means being ,6 ft for .15 min) High risk • Living in the same house with a person diagnosed with COVID-19 • Unprotected contact with infectious secretions of a person diagnosed with COVID-19 COVID-19, coronavirus disease 2019. Vol. 22 No. 3 • 2020 • Reviews in Urology • 95 4170020_04_RIU0877_V3_ptg01.indd 95 19/10/20 3:14 PM Safety Precautions and COVID-19 continued 1 120 0.9 % Positive 0.7 80 0.6 60 0.5 0.4 40 0.3 0.2 IMP Number Tested 100 0.8 20 0.1 0 12 13 14 15 16 IMP Number Tested 17 Week 18 19 IMP % Positive 20 21 0 22 NY % Positive Figure 1. Coronavirus disease 2019 (COVID-19) positive tests, as a percentage of total over time, Integrated Medical Professionals (IMP) versus New York State (NY). 100.0% 100.0% 90.0% 90.0% 80.0% 80.0% 70.0% 70.0% 60.0% 60.0% 50.0% 50.0% 40.0% 40.0% 30.0% 30.0% 20.0% 20.0% 10.0% 10.0% 0.0% 12 13 14 15 16 17 18 19 20 21 22 0.0% Week Administrative Clinical High Risk Low Risk Total Figure 2. Positive test results by job type and risk. (r) 5 0.65; P 5 0.04). The rate decline in COVID-19 positivity rates between IMP and NYS declined similarly over the 11-week study period (slope of regression lines for IMP and New York State 20.03 and 20.04, respectively; P 5 0.62); however, the initial rate of decline at IMP was significantly greater than NYS as a whole (slope of regression lines for IMP and New York State 20.09 and 20.01, respectively; P 5 0.03). Positive test rates stratified by exposure risk and job category are presented in Figure 2. When stratifying test results by job type and risk, similar significant differences were observed in Clinical (P , 0.01), Administrative (P 5 0.04), and high-exposure risk groups (P , 0.01); positive test rates did not change significantly in the low-exposure risk group over the study period (P 5 0.85). Comparison of contingency tables and split regression analysis suggested that the absolute percentage of positive COVID19 test results—and the rate of decline of these results—differed substantially over the study period. Analysis suggested that an appropriate break point was Week 5 of the study. Based on this, test results were grouped into two groups: Early (first 5 weeks of reporting) and Late (last 6 weeks TABLE 2 Positive COVID-19 Tests, as Percentage of Total, by Job and Exposure Type Percentage Total Clinical Administrative Early 26.1% 28.9% 23.5% 38.2% 2.9% Late 7.3% 8.7% 6.3% 14.3% 2.9% 72.2% 69.9% 73.4% 62.6% 0.0% 0.04 0.03 0.03 1.00 Difference P value ,0.01 High Risk Low Risk COVID-19, coronavirus disease 2019. 96 • Vol. 22 No. 3 • 2020 • Reviews in Urology 4170020_04_RIU0877_V3_ptg01.indd 96 19/10/20 3:14 PM Safety Precautions and COVID-19 100% 70 60 80% 50 70% 60% 40 50% 30 40% 30% 20 20% 10 10% 0% Total High-risk Exposure % Total COVID-19 Exposures 90% 12 13 14 15 16 17 18 19 20 21 22 0 Week High Risk % Low Risk N Figure 3. High-risk exposures by week, overall and as a percentage of total. COVID-19, coronavirus disease 2019. of reporting). Comparison of COVID-19 positive rates for the Early and Late groups of the study are presented in Table 2. Overall, positive test rates between groups declined from 26.1% to 7.3% (272.2%: P , 0.01); similar results were noted for Clinical (−69.9%; P 5 0.04), Administrative (273.4%; P 5 0.03), and High Risk (262.2%; P 5 0.03) categories. There was no difference in COVID-19 positive test rates in the Low Risk category in the Early versus Late period of the study (0.00%; P 5 1.00). The ratio of high-risk exposures to total exposures and absolute number of high-risk exposures over time is illustrated in Figure 3. The probability of an exposure being high risk versus low risk for COVID-19 in the Early versus Late groups was 65.8% to 34.1%, respectively (248.1%; P , 0.01). As depicted in Table 3, the decrease in both high- and low-risk exposure in the Clinical and Administrative staff groups was significant in all categories. The comparative probability of positive COVID-19 results based on exposure risk between Clinical and Administrative staff job categories in the Early and Late groups is depicted in Table 4. For low-risk exposures, neither the difference in COVID-19 positive test rates between Clinical and Administrative staff during in the Early (5.0% and 0.0%, respectively) nor Late (0.0% and 6.7%, respec­ tively) groups was significant (P 5 0.23 and 0.25, respectively). In the Early group, the rate of positivity for high-risk exposures between Administrative and Clinical staff was similar (45.6% vs 32.4%; P 5 0.12) as well. We did observe significantly greater positive test rate amongst Administrative staff in the Late group (50.0% vs 5.9%; P 5 0.02). Discussion The COVID-19 crisis has presented unprecedented challenges for healthcare services. As inpatient TABLE 3 COVID-19 Exposures, by Job Type and Risk and Study Period High Risk Low Risk Clinical Administrative Clinical Administrative Early 74 57 28 40 Late 17 4 15 19 277.0% 293.0% 246.4% 252.5% ,0.01 ,0.01 ,0.01 ,0.01 % change P value COVID-19, coronavirus disease 2019. Vol. 22 No. 3 • 2020 • Reviews in Urology • 97 4170020_04_RIU0877_V3_ptg01.indd 97 19/10/20 3:14 PM Safety Precautions and COVID-19 continued TABLE 4 COVID-19 Tests, as Percentage of Total, by Job Type, Risk Exposure, and Study Period High Risk Low Risk Early Late Early Late Administrative, % positive 45.6% 50.0% 5.0% 0.0% Clinical, % positive 32.4% 5.9% 0.0% 6.7% 0.12 0.02 0.23 0.25 P value COVID-19, coronavirus disease 2019. As inpatient services have filled beyond capacity, outpatient offices have played a critical role by expanding care to patients, thereby keeping less severe cases out of the overburdened hospital system. services have filled beyond capacity, outpatient offices have played a critical role by expanding care to patients, thereby keeping less severe cases out of the overburdened hospital system. To provide these services, protocols must be adopted that not only ensure the safety of staff and patients, but also preserve practice resources. The lack of clear and consistent guidelines, coupled with limited availability of testing to assess the efficacy of these measures, undermines the efforts of independent practices to serve their communities. Recently, data are emerging regarding exposure risks to healthcare workers, but these studies are largely focused on institutional employees.5-7 Although a number of quality manuscripts have been published specifically related to urology, these have been focused on general patterns of urology care,8,9 the benefits of virtual visits,10 and the impact of COVID-19 on urological training.11,12 This study is the first of its kind to assess COVID-19 risk longitudinally to determine the impact of safety measures on disease transmission among staff in outpatient practices utilizing real-time COVID-19 testing and contact tracing. Overall, our study demonstrates that coordinated, standardized protocols can be effective in reducing the incidence of COVID-19 transmission in staff, particularly those with a high risk of exposures. This is especially important as current World Health Organization (WHO) and CDC recommendations are that healthcare workers be quarantined for 14 days following a high-risk exposure. This can create significant pressure on practices in terms of maintaining adequate staffing to sustain operations, which could result in reduced access to vital services. In addition to patient care issues, practice resources can be financially strained as declines in patient throughput reduce revenue and quarantined employees must be compensated at their regular wages for up to 2 weeks of quarantine after COVID exposure.13 Our data show that with rapid testing and contact tracing, nearly 4 out of 5 employees exposed to COVID-19 did not require quarantine. Importantly, proper safety and risk stratification further mitigated the probability of disease transmission to staff. In addition to benefitting the welfare of healthcare workers, the ability to keep the majority of staff in the office is essential to maintaining operations—during the pandemic surge, it was critical that patients that could be managed in an office setting be kept from the already overburdened hospitals.14-16 We found that the overall risk of transmission was nearly 13 times greater with High versus Low risk exposure groups early in the study period; however, this was greatly impacted by the implementation of safety factors in the office. We observed that the significant difference in both exposure risk and COVID-19 positive test result rates over time coincided with the implementation of safety factors such as (1) screening patients and staff on arrival to determine exposure risk, including assessment for fever or new upper respiratory symptoms, with staff undergoing a second screening midway through their work shift; (2) requiring all staff and visitors to wear a mask covering both nose and mouth; (3) when feasible, having patients wait for appointments in their vehicle; (4) limiting office access only to individuals necessary for patient mobility or communication; and (5) requiring strict social 98 • Vol. 22 No. 3 • 2020 • Reviews in Urology 4170020_04_RIU0877_V3_ptg01.indd 98 19/10/20 3:14 PM Safety Precautions and COVID-19 distancing for patients once within the office. Our data confirm that the impact over time of these protocols on both the probability of high-risk exposure and transmission rate if exposed was dramatic. Although transmission rates started declining upon adoption of the above-described safety measures, special mention should be made of the dramatic decrease (288.3%) in the number of reported high-risk exposures that contemporaneously corresponded to the relatively simultaneous issuance of guidelines requiring masks for the general population when in public by the CDC and the NYSDOH.4,21 Our initial safety protocols included recommendations regarding face masks for staff, but we did not mandate this for patients and visitors in advance of state and national guidelines. Although correlation does not infer causation, masks have been shown to be tracing explains certain observed confounding results. The very high exposure positivity rate in the late study period amongst administrative staff was determined to have been the consequence of interactions that occurred outside the workplace where proper safety precautions were not observed. For example, for the single positive test reported in Week 19, a staff member was found to be febrile during a mid-shift screening; history revealed that the individual had a high-risk exposure at a large gathering that occurred outside the workspace. Immediate contact tracing identified staffers who encountered the affected individual, and all personnel received testing. The affected employee was found to be positive for COVID-19 and underwent appropriate medical evaluation and treatment, whereas the 5 exposed staff members all tested negative and returned to work without Although correlation does not infer causation, masks have been shown to be instrumental in reducing the spread of COVID-19 in both inpatient hospital settings and in the general population; indeed, data suggest that person-to-person transmission risk is dramatically reduced if both individuals are wearing masks. instrumental in reducing the spread of COVID-19 in both inpatient hospital settings and in the general population; indeed, data suggest that person-to-person transmission risk is dramatically reduced if both individuals are wearing masks.22 Thus, although this variable was not specifically evaluated in this study, it stands to reason that mask use by the public, reinforced by practice safety guidelines, played an important role in reducing the incidence of COVID-19 amongst healthcare workers in the outpatient setting as well. The complementary nature of rapid testing and contact extended quarantine (although the test results were reported within 12 hours of each other, week naming conventions placed the negative and positive results in week 18 and 19, respectively). Coincidentally, the timing of the exposure was such that the office location only needed closure for a portion of a single day. Given the number of staff involved, it is likely that the site would have been closed for the full 14-day quarantine period had contact tracing and immediate testing not been available. Another factor that cannot be overlooked is the importance of telemedicine services. Although they have been contemplated for some time, these services have had limited adoption due to logistical and economic considerations.17 Regulatory changes and practical considerations removed many of these issues, and, as a consequence, interest in the use of virtual office visits internationally has Virtual greatly increased.18,19 visits have been demonstrated to be effective in urology.20 Use of telemedicine enables providers to keep in contact with patients while decreasing exposure risk. Our providers performed well over 2000 telemedicine visits per week, at times accounting for nearly twothirds of all outpatient encounters. The reduction in physical traffic in the office served the additional benefit of facilitating compliance with screening and social distancing guidelines. An important consideration when designing safety protocols is the importance of extending and enforcing these policies to administrative staff. Our findings indicate that the probability of high-risk exposure in clinical and administrative staff was not materially different, and although not significant (P 5 0.12), overall COVID-19 transmission after high-risk exposure was 22.4% more likely in administrative staff. These data suggest that administrative staff in an outpatient setting are equally—if not more—vulnerable to COVID-19 transmission when compared with clinical staff who are more directly exposed to patients. We postulate that measures such as the utilization of PPE and proper, diligent hand hygiene are historically more familiar to clinical staff. It is possible individuals unaccustomed to these measures may have required time to acclimate to these protocols. Furthermore, although not specific to COVID-19, workspace design has been shown to impact illness Vol. 22 No. 3 • 2020 • Reviews in Urology • 99 4170020_04_RIU0877_V3_ptg01.indd 99 19/10/20 3:14 PM Safety Precautions and COVID-19 continued rates in office staff.23 As such, administrative staff, particularly those at check-in and check-out workstations, tend to work in closer proximity to each other, and may have shared surfaces, equipment, and workspaces; these factors may impact transmission rates. Importantly, the Occupational Safety and Health Administration mandates that medical offices have in place a written Pandemic Preparedness Policy, and staff training is specified as an impor­ tant component to that policy.23 It is essential that education of administrative staff and man­ agement of their workspace not be overlooked when crafting safety protocols. This study has several lim­ itations. Although strongly encouraged amongst staff with viral exposure, COVID-19 testing remained strictly voluntary. That said, the authors are not aware of any employee with COVID-19 exposure who declined testing. An additional limitation was in risk stratification; although staff was questioned regarding the nature of exposure and attempts were made to verify the nature of exposure, ultimately, this was a self-reported measure and could not be fully objectively quantified. In addition, we could not independently assess contact risk when staff were not in the office, nor did our testing authorization permit testing of non-employees. Although the sample size was sufficiently powered to assess risk exposure (High vs Low), job type (Clinical vs Administrative), and study period (Early vs Late), statistical analysis of subgroups within these categories was limited due to number of samples. Most importantly, this study was performed in outpatient healthcare facilities. These findings cannot be directly extrapolated to the facility setting nor to the population at large. However, the results should be applicable to freestanding outpatient sites of service regardless of specialty. This study demonstrated the efficacy of initial safety protocols established in response to the COVID-19 pandemic and identified other factors that may impact disease transmission in healthcare workers in the outpatient setting. Even during the short duration of this study, safety protocols were being continuously evaluated and updated to reflect changes in consensus standards—ongoing review of safety protocols should be considered mandatory. Future studies should continue to look at the impact of safety guidelines on risk and assess additional factors that may influence rates of positivity; these results may also be influenced by antibody testing. We were fortunate that we were able to address the issue concerning the overall availability and shortage of testing by developing on-site capabilities. It is hoped, as technology becomes more available, this solution will be within the reach of more physician group practices; however, groups with fully integrated pathology laboratories and sufficient patient This study demonstrated the efficacy of initial safety protocols established in response to the COVID-19 pandemic and identified other factors that may impact disease transmission in healthcare workers in the outpatient setting. Main Points • Coordinated, standardized protocols can be effective in reducing the incidence of COVID-19 transmission in staff, particularly those with a high risk of exposure. • Data show that with rapid testing and contact tracing, nearly 4 out of 5 employees exposed to COVID-19 did not require quarantine. Proper safety and risk stratification further mitigated the probability of disease transmission to staff. • In addition to benefitting the welfare of healthcare workers, the ability to keep the majority of staff in the office is essential to maintaining operations—during the pandemic surge, it was critical that patients that could be managed in an office setting be kept from the already overburdened hospitals. • Data suggest that administrative staff in an outpatient setting are equally—if not more—vulnerable to COVID-19 transmission when compared with clinical staff who are more directly exposed to patients. It is essential that education of administrative staff and management of their workspace is not overlooked when crafting safety protocols. 100 • Vol. 22 No. 3 • 2020 • Reviews in Urology 4170020_04_RIU0877_V3_ptg01.indd 100 19/10/20 3:14 PM Safety Precautions and COVID-19 throughput should consider more immediate implementation of this capability. Conclusions Systemic safety initiatives reduce both exposure risk and COVID-19 transmission rates amongst healthcare workers in the outpatient care setting. Safety measures in the outpatient healthcare setting must include both clinical and administrative staff and should be monitored using real-time testing and contact tracing. Implementation and monitoring of standardized safety protocols based on current best practice guidelines not only allows outpatient practices to safely continue operations and participate in COVID-19 surge management, but can also reduce operating costs by reducing the need for potentially unnecessary quarantining of healthcare workers. Protocols should be developed in advance so that safety guidelines, testing, and contact tracing can be immediately implemented should there be subsequent waves of the present outbreak or should another novel virus surface in the future. 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