Research Letter
November 28, 2022
Analysis of Failure Rates for COVID-19 Entrance Screening at a US Academic Medical Center
Scott C. Roberts, Ridwan N. Faruq, Anne K. Wilkinson, et al
JAMA Intern Med. Published online November 28, 2022. doi:10.1001/jamainternmed.2022.5426
Many health care facilities use entrance screening to prevent individuals with acute COVID-19 from entering. In ambulatory settings, 1 study found failures (defined as an exposure, sign, or symptom concerning for COVID-19) for an average 0.1% of persons that peaked at 1.5% during the first pandemic wave.1 Less is known about screening in inpatient facilities. The aim of this study was to evaluate hospital entrance screening failure rates for patients, visitors, and health care personnel at a large academic medical center.
In this quality improvement study, screening occurred at 10 entrances at Yale New Haven Hospital, a 1541-bed academic medical center with 2 campuses in New Haven, Connecticut, from March 17, 2020, to May 8, 2021. Criteria for a failed screening were temperature of 38 °C (100.4 °F) or greater, any exposure to or symptom suggestive of COVID-19 or positive SARS-CoV-2 test result in the preceding 2 weeks, or recent travel to high-risk areas. Entrance screeners also evaluated masking and provided masks to those who were unmasked or had unacceptable coverings, such as cloth masks or bandanas. Data on the incidence of COVID-19 in Connecticut were obtained.2 High incidence was defined as greater than and low incidence as fewer than 10 cases per 100 000 individuals averaged over a month. Additional methods are included in eMethods in the Supplement. The Yale University Institutional Review Board deemed the study exempt from review and waived the informed consent requirement because it met all the criteria for a quality improvement study. We followed the STROBE reporting guideline.
A total of 951 033 screenings were performed with 631 (0.07%) failures, which totaled 0.66 per 1000 individuals screened. The rate of individuals who failed entrance screening varied substantially, peaking in March 2020 with 2.64% failed screenings (26.40 failures per 1000 individuals screened) before decreasing in subsequent months (Table 1). During the first wave of the pandemic, 0.69% individuals had a failed screening (6.94 failures per 1000 individuals screened; Table 2). After the first wave, screening failure rates were consistent across times of high (0.36 failures per 1000 individuals screened) and low (0.34 failures per 1000 individuals screened) community SARS-CoV-2 incidence. A total of 62 009 patients and visitors (6.84% of entrance encounters) and 7742 health care personnel were provided a mask due to inadequate or absent masking.
A total of 29.5 full-time equivalent staff were required to maintain 24-hour screening, which equates to $1 288 560 in total annual compensation (using an hourly minimum wage of $15 for Connecticut as an example) plus benefits (estimated at 40%); this estimate excludes managerial staff and supplies, such as gloves, masks, and thermometers. This total estimates the minimum cost to identify 1 screening failure as $223.58 during the first wave and $2350.96 across the entire study.
We found limited benefit in maintaining hospital entrance screening for COVID-19 symptoms, exposures, or travel. Of the nearly 1 million persons screened, less than 0.1% had a failed screening. The failure rate was substantially higher in the beginning of the pandemic, possibly because of greater adherence to screening protocols and enhanced symptom and exposure vigilance. It is also possible that patient education and increased communication may have meant patients and visitors stayed home with exposures or symptoms or that people were not truthful on subsequent visits. We do not know whether having an entrance screener served as a deterrent, keeping sick persons from attempting to enter the hospital.
A high proportion of patients and visitors arrived with inadequate face masks. Given the effectiveness of masks and need for source control of asymptomatic contagious persons, this service represents an additional value of screeners in mitigating COVID-19 spread. A limitation of this study was that the true incidence of COVID-19 in those screened was unknown; thus, we were unable to ascertain the effectiveness of our screening strategy.
