Horizon, Vitalité drop routine COVID-19 testing of most hospital patients

New Brunswick's two regional health authorities have stopped routinely testing all patients for COVID-19 before hospital admission, before surgery, and before transfer between facilities.

Only patients with symptoms of the virus are being tested, with some exceptions.

In an internal document obtained by CBC, Horizon Health Network cites being in a "transitional phase" of the pandemic and the need to provide a "more sustainable and stable approach" to managing suspected and confirmed COVID cases.

"Testing all patients at admission or prior to surgery was recommended during the acute state of the pandemic, when there was a high rate of community transmission and a low level of immune protection. This testing strategy no longer applies," the Jan. 18 bulletin from Horizon's infectious disease and infection prevention and control COVID-19 committee states.

"The morbidity and mortality rates with Omicron are much less than with earlier variants," reads the memo.

There is also a high level of hybrid immunity against COVID now that about 70 to 75 per cent of New Brunswickers have been infected and roughly 50 per cent have received at least three doses of a COVID-19 vaccine.

In addition, universal testing has been associated with "multiple unintentional adverse consequences," including delays and backlog, strain on health-care workers, and increased costs "with minimum benefits."

The revised COVID-19 testing strategy "aligns with our partners at Vitalité and reflects updated practices in health care organizations in other provinces," Merita MacMillan, the regional infection prevention and control lead for Horizon, said in an emailed statement.

"All provinces in Canada have pivoted COVID-19 testing in acute care to focus on persons with symptoms," she said.

These updated measures will improve patient flow and access to outpatient procedures and surgeries.- Merita MacMillan, regional infection prevention and control lead for Horizon

"These updated measures will improve patient flow and access to outpatient procedures and surgeries," according to MacMillan. "Reduction in the surgical backlog is an ongoing priority for Horizon."

MacMillan noted all patients attending appointments, visitors and designated support persons are still actively screened at the entrance of hospitals by being asked whether they've tested positive for COVID within the past 10 days, have any symptoms, or had close contact with a confirmed case.

"Rigorous" infection prevention and control measures also remain in place, she said, such as isolation of suspected or confirmed positive patients, continuous masking and hand hygiene.

'Downward trend'

In an emailed statement, Vitalité Health Network confirmed its testing policy has also changed, as of the end of January.

"Key indicators related to the pandemic, such as the seven-day positivity rate, the number of outbreaks and the incidence of COVID-19 within the two regional health authorities show a downward trend," said Dr. Natalie Banville, senior vice-president of client programs and medical affairs.

Vitalité's team of infection prevention and control professionals is working with Horizon and the Department of Health to "put in place appropriate protective measures based on the current situation to ensure the safety of patients and health-care workers while limiting the spread of the virus," she said.

New Brunswick confirmed eight more deaths from COVID-19 in its weekly report Tuesday, 12 people newly admitted to hospital for COVID, including one in intensive care, and 265 new lab-confirmed cases of the virus.

Horizon and Vitalité, which report people admitted to hospital because of COVID-19, as well as those initially admitted for another reason who later test positive for the virus, said there are 63 people hospitalized, nine of whom require intensive care.

Took extra labour, resources

Horizon developed its new COVID-19 testing "algorithm" taking into consideration that asymptomatic testing requires "high utilization of resources associated with extra labour, [personal protective equipment] and laboratory work," according to the three-page memo.

There are now a limited number of situations where asymptomatic patients will be tested. These include:

• Hospital unit outbreaks.
• Pre-operative patients who have had a recent high-risk exposure to someone with COVID-19
• Patients being admitted to a cancer care unit, intensive care unit, psychiatric unit or addiction services.

Following a review, other changes to the infection prevention control guidance for operating rooms to "improve surgical flow" include:

• The need to use COVID-19 operating room pods with suspect/proven COVID-19 patients has been eliminated. These negative pressure rooms were installed at the entrances of OR theatres as an infection prevention control measure early in the pandemic. "There is no evidence that these are necessary," the bulletin states.
• Implementing routine cleaning after all cases and leaving terminal cleaning — the disinfection of a discharged patient's room and equipment before another patient can occupy the space —  to the end of the day.

Patients being transferred will only be tested for COVID if they have symptoms, according to the memo.

"Patients with a recent high-risk exposure who are being admitted or transferred require droplet/contact isolation, not testing," it states.

"Testing or the requirement for isolation should not delay delivery of appropriate care of patient transfer," it adds.

Change in definition of symptomatic

Horizon has also changed its definition of symptomatic. It has expanded the list of symptoms, any one of which can indicate a person might have COVID, to:

• Fever, chills or sweats.
• Loss of taste or smell.
• Cough.
• Sore throat.
• Difficulty breathing.
• Vomiting or diarrhea.
• Runny nose or sneezing.

Previously, a person was considered symptomatic if they had one or more of the following symptoms:

• Fever/signs of fever (e.g., chills, feeling cold, shivers, etc.).
• Loss of taste.
• Loss of smell.

Under the changes, a person who has two or more of the following symptoms will also be considered symptomatic:

• Muscle aches.
• Loss of appetite.
• Headache.
• Unexplained skin rash.
• Fatigue.

Benefit of asymptomatic testing unclear, false reassurance

The benefit of testing asymptomatic patients is unclear when added to the other "multiple infection prevention and control measures in place," the memo states. No examples are given.

Among the other reasons cited for the new testing strategy: Symptomatic patients with COVID-19 are more likely to transmit infection than asymptomatic patients.

A negative COVID-19 test in an asymptomatic patient with a recent high-risk exposure has significant potential to create false reassurance. "Isolation is more important than testing," it states.

A positive COVID-19 test in an asymptomatic patient is often associated with an old infection in a patient who is no longer contagious. A polymerase chain reaction test, commonly known as a PCR, can remain positive for 12 or more weeks after an acute infection, according to the memo.

Aerosol-generating medical procedures performed in the operating room "tend to be associated with low bioaerosol concentrations," it says, and transmissions of COVID-19 in the OR setting have been "exceptionally low." Examples of aerosol-generating medical procedures include intubation, tracheotomy and cardiopulmonary resuscitation.

The memo goes on to say that universal testing for all admitted or surgical patients has been associated with delays in patient placement, delays in patient transfer and transition of care, postponement of necessary procedures and worsening surgical backlog, strain on health-care workers, and increased costs associated with minimum benefits.

CBC requested Horizon's statistics on delays, backlog and costs. Instead, MacMillan responded by saying, "statistics regarding the unintentional adverse consequences are well documented in a recent article by a group of infection control experts in the United States," and provided a link.

Vitalité's new testing policy

At Vitalité, the only asymptomatic patients now being tested for COVID-19 before admission or before surgery are those admitted to a cancer or intensive care unit, "which are care settings where patients are more vulnerable, and where routine screening is still in effect," said Banville.

Asymptomatic patients who are transferred from another facility will only be tested if their original unit was in a COVID-19 outbreak situation, she said.

Asked whether Vitalité's definition of symptomatic has also changed, Banville did not answer directly.

"The measures put in place by the Network always take into account the recognized symptoms of COVID-19 to determine whether a patient is symptomatic or not."