Objective: To understand severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing uptake in the labor and delivery unit and rationales for declining testing, and to institute a process to increase equitable testing uptake.
Methods: We conducted a quality-improvement initiative from May 28-June 25, 2020, during the first 4 weeks of universal SARS-CoV-2 testing in the Barnes-Jewish Hospital labor and delivery unit. All consecutive patients presenting for delivery without coronavirus disease 2019 (COVID-19) symptoms were offered testing over four 1-week phases. Phase I documented the rate of testing uptake. Phase II recorded patients' reasons for declining testing. Phase III used phase II findings to create and implement shared decision-making tools. Phase IV offered each patient who declined nasopharyngeal testing an oropharyngeal alternative. The primary outcome was rate of SARS-CoV-2 testing uptake by phase.
Results: Of 270 patients, 223 (83%) accepted testing and 47 (17%) declined. Maternal age and mode of delivery were similar between groups, whereas testing uptake was higher among nulliparous, White, Hispanic, or privately insured patients. There was a significant increase in the primary outcome of SARS-CoV-2 testing across phases I-IV, from 68% to 76% to 94% to 95%, respectively (Somers' D 0.45; 95% CI of association 0.30-0.59). The most commonly cited reason for declining testing was concern regarding testing discomfort. In subgroup analyses by race and insurance type, there was a significant increase in testing uptake across phases I-IV for Black patients (56%, 54%, 91%, 92%; Somers' D 0.36; 95% CI of association 0.28-0.64), White patients (76%, 93%, 96%, 100%; Somers' D 0.59; 95% CI of association 0.38-0.8), those with Medicaid insurance (60%, 64%, 88%, 92%; 95%; Somers' D 0.39; CI of association 0.22 to 0.56), and those with private insurance (77%, 96%, 97%, 100%; Somers' D 0.63; 95% CI of association 0.40-0.86).
Conclusion: Universal SARS-CoV-2 testing uptake significantly increased through a rapid-cycle improvement initiative. Aligning hospital policy with patient-centered approaches led to nearly universally acceptable testing.