Association of a High-Efficiency Particulate Air Filter COVID-19 Testing Booth With Testing Capacity, Cost Per Test Acquired, and Use of Personal Protective Equipment

In March 2020, COVID-19 testing demand and scarce availability of personal protective equipment (PPE) were concerns for Mass General Brigham (MGB) in Boston. In response, an in-hospital innovation unit engaged frontline clinicians, designers, and engineers to design a solution for outpatient testing to improve throughput and conserve PPE. The result was a high-efficiency particulate air–filtered, positive-pressure personal protection booth with 6 ergonomic glove ports called a Hexapod. Efficiency was gained by using 3 patient bays, 1 of which was wheelchair accessible, for each individual obtaining swab samples. The final model was in use within 28 days (Figure 1).^1,2 Training for new users typically required less than 30 minutes. We assessed the utility of Hexapods for COVID-19 testing.³

A design-thinking approach incorporating observation of nurses, sanitation personnel, and infection control workers at MGB was used for the development of the Hexapods. Learnings were incorporated iteratively until a final model was deployed. Beginning April 16, 2020, 3 final Hexapods were sequentially implemented at MGB. This retrospective quality improvement study, conducted from March 11, 2020, to October 1, 2020, compared COVID-19 testing throughput, PPE use, and cost per test before vs after the introduction of the Hexapods. Staff, PPE use, and daily tests were observed by study staff before and after use of the Hexapods. The cost per day of staff, glove, gown, and consumable supplies used in the Hexapods was calculated and scaled by the number of daily tests. Cost data were obtained from MGB. Analyses were performed using Microsoft Excel, version 16.49. This innovation project met criteria as a quality improvement initiative by the Mass General Brigham Human Research Committee. Informed consent was not required because there were no human experience interviews and data were already routinely collected at the hospital. The study followed the Standards for Quality Improvement Reporting Excellence (SQUIRE) reporting guideline.

Before implementation of the Hexapods, the maximum testing capacity per testing team in a 9-hour period was 54, with 1 patient scheduled every 10 minutes. After implementation of the Hexapods, testing capacity per day scaled, with a mean (SD) daily throughput of 93 (57.6) tests per booth (72% increase) during 311 booth-days and 28 948 tests performed during the evaluation period. The maximum number of tests during a 9-hour day was 245 (354% increase), reflecting a potentially steady amount of testing as demand increased over time.

Testing for each Hexapod required 5 staff members compared with 4 for each testing team before Hexapod implementation. Despite higher total personnel costs, the increase in testing capacity was associated with a decrease in the personnel cost per test from $28.78 before Hexapod implementation to $18.18 at 93 tests per day and $6.90 at 245 tests per day after implementation.

Use of Hexapods was associated with a decrease in disposable gown use of 93.5% at 93 tests per day and 97.6% at 245 tests per day (Figure 2) because the person who obtained the swab sample did not need to change gowns between patients. However, more gloves were used after implementation of the Hexapods because 2 additional personnel, a processor and a cleaner, required glove changes after each patient. Monthly consumable supplies for each Hexapod included 12 pairs of durable gloves and 3 pairs of arm sleeves with O-ring attachments; a new high-efficiency particulate air filter was needed every 3 months. The net PPE costs, including consumable expenses, were lower after implementation of the Hexapods than before implementation ($1.98 before implementation vs $0.62 at 93 tests per day and $0.36 at the 245 tests per day after implementation).

Despite the additional staffing, glove use, consumables, and capital costs required with use of the Hexapods, the increased throughput of the Hexapods was associated with decreased cost per test ($30.77 before implementation vs $19.28 at 93 tests per day and $7.44 at 245 tests per day after implementation). The capital cost of a Hexapod was recouped in 13 days at 93 tests per day and 2 days at 245 tests per day. The annual return on investment was 22.4 at 93 tests per day and 124.3 at 245 tests per day.

In this quality improvement study, Hexapod use was associated with cost savings, decreased use of PPE, and increased testing throughput, suggesting that the use of the Hexapods helped address the aforementioned testing challenges. Engaging frontline staff in human-centered design was associated with a rapid and adoptable solution.^4,5 A limitation of this study is that sites with different demand and cost structures may realize different cost savings. Because the Hexapods were implemented from concept through evaluation in 6 months, this study suggests that design-thinking approaches may be useful for rapid health care innovation during a crisis and for every day challenges.

Accepted for Publication: May 16, 2021.

Published: July 20, 2021. doi:10.1001/jamanetworkopen.2021.17698

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Olson KR et al. JAMA Network Open.

Corresponding Author: Kristian R. Olson, MD, MPH, MGH Springboard Studio, 125 Nashua St, Ste 700, Boston, MA 02114 (krolson@mgh.harvard.edu).

Author Contributions: Dr Olson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Olson, Butler, Blanchfield, Santo, Al-Sultan, Currier.

Acquisition, analysis, or interpretation of data: Olson, Butler, Blanchfield, Bernhardt, Al-Sultan, Currier.

Drafting of the manuscript: Olson, Butler, Blanchfield, Bernhardt, Santo, Currier.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Olson, Butler, Currier.

Obtained funding: Olson.

Administrative, technical, or material support: Olson, Butler, Bernhardt, Santo, Al-Sultan, Currier.

Supervision: Olson, Butler, Al-Sultan, Currier.

Conflict of Interest Disclosures: Dr Olson reported being a noncontrolling founder of Healthcare Innovations Partners, LLC. Dr Blanchfield reported receiving consulting fees from Greybird Ventures LLC outside the submitted work. Dr Currier reported being a noncontrolling founder of Healthcare Innovation Partners, LLC. No other disclosures were reported.

Additional Contributions: Amy Israelian, MSN (Newton-Wellesley Hospital, Newton, Massachusetts), refined the design of the Hexapod; Dixi Saunders, BA (Department of Pathology, Laboratory Support Services, Massachusetts General Hospital), helped refine the testing process; and Giavanna Gaskin, MBA (Division of Practice Improvement, Massachusetts General Hospital), helped with data collection. These individuals did not receive compensation for their roles in this study. We thank the members of the infection control units at Massachusetts General Hospital and Newton-Wellesley Hospital, staff at the Mass General Brigham Center for COVID Innovation, and our colleagues who have been performing testing for COVID-19.