Date of Award

Spring 6-2022

Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Elizabeth Perpetua DNP, ACNP-BC, FACC

Faculty Reader

Marie Holt MS, ARNP, FNP-BC

Executive Summary

Executive Summary

Background and Significance: SARS-CoV-2 is a worldwide pandemic (WHO, 2020). The World Health Organization (WHO) and the Centers for Disease Control (CDC) (2020), recommended HCWs wear respirators, gowns, gloves and eye protection while caring for a SARS-CoV-2 positive patient. However, in the early stages of the pandemic, personal protective equipment (PPE) supplies were limited due to panic, hoarding and increasing need (Livingston et al., 2020). Intubating a patient with SARS-CoV-2 is a high-risk procedure due to the proximity of Healthcare Workers (HCWs) to the patient’s secretions which carry a high viral load (Odor et al., 2020). Furukawa et al., (2020) discussed multiple instances of virologic evidence where viral RNA had been detected in individuals prior to the start of symptoms, some of whom never developed symptoms. To better protect staff and to support clinical operations, healthcare organizations developed asymptomatic testing strategies to identify the virus prior to surgical procedures. A thorough and streamlined testing program is highly valuable to organizations. It is for this reason that a thorough program evaluation of processes was needed to identify gaps that contribute to incomplete testing and result in an increased risk of exposure and transmission of the SARS-CoV-2 virus.

Purpose: The purpose of this program evaluation was to identify gaps in processes that may influence exposure to SARS-CoV-2, capacity and resource utilization, and procedural volumes due to incomplete SARS-CoV-2 tests.

Methods: The program evaluation took place at 336-bed acute tertiary care hospital located in Seattle, Washington. The CDC Framework for Program Evaluation and John Kotter’s change model were utilized to guide the evaluation. Testing process gaps were identified by meeting with stakeholders, reviewing Virginia Mason Medical Center’s (VMMC’s) SARS-CoV-2 pre-surgical testing policies/protocols, through gathering pre-surgical testing data from April 2020 – November 2020, through conducting a retrospective chart review and by assessing a staff survey administered through Survey Monkey. Descriptive statistics of categorical variables were used to analyze the data.

Results: After searching VMMC’s online intranet, lack of a formal policy or protocol existed to guide staff through the pre-surgical SARS-CoV-2 testing process. There were 9,132 patients tested for SARS-CoV-2 prior to surgical procedures from April 2020 – November 2020. 81% of the patients tested had completed tests at the time of procedural check-in. Of the 20 surgical specialties included in the data set, general surgery had the highest volume of surgical cases and also had the most incomplete SARS-CoV-2 tests. Retrospective chart review of 19 general surgery patients demonstrated the most common reason for incomplete tests was due to lab delays and rescheduled procedures. Finally, the staff survey was sent to 57 staff members and 6 responded. All 6 staff members who responded to the survey agreed that SARS-CoV-2 testing was important, and that no formal education was given related to the testing process. The main gap identified was the nonexistent formal policy and protocol that would guide staff to ensure all patients were tested prior to their procedural check-in.

Recommendations: After completing the evaluation, recommendations were made to improve the program. These recommendations included creating a formal written protocol following the guidelines set by the ASA and ASPF, providing formal education to staff and implementing tracking metrics to continue improving the efficacy of the program. These metrics included how to measure and trace false negatives in regard to staff/patient transmission within the perioperative area, how to track procedures that were cancelled due to an incomplete SARS-CoV-2 tests and how to track staff education and training related to the testing process.

Sustainability: With the aim of this project being to identify gaps within the SARS-CoV-2 testing program, all gaps identified were given to the program stakeholders in a document with supporting data. The supporting data given showed stakeholders how the project lead arrived at their conclusions, including recommendations on how the gaps could be filled using evidence-based practice. This institution regularly used Kaizen events (component of Toyota Production System (TPS)) to evaluate and inform clinical practice changes (Kenney, 2016). The purpose of the TPS is to identify areas for improvement and to gather team members most knowledgeable in that department to work toward a solution by conducting Kaizen events. The project lead encouraged the organization to use a Kaizen event to fill the gaps identified within the testing program. The program stakeholders were informed on which descriptive statistical tests were performed so they are able to continue running gap analysis checks in order to assess how the program is functioning.

Limitations: A program evaluation involves comparing current practices to a specific standard. However, due to there not being a formal policy for pre-surgical SARS-CoV-2 testing, the program effectiveness was not able to be evaluated against a set standard. The CDC framework for program evaluation recommends programs are evaluated using a mixed-method approach. However, due to the SARS-CoV-2 pandemic, in-person staff observation and interviews were not advised at VMMC. A staff survey was used in place of interviews with a response rate of 9%. Surveys also carry other limitations including possible misinterpretations of questions and a small representation of a larger group.

Implications for Practice: The gaps identified through this program evaluation will improve testing strategies and give the organization a strong foundation on how to create another testing program if needed in the future. This program evaluation has the potential to improve patient and staff safety by ensuring that patients are tested prior to undergoing surgery, in order to minimize the viral transmission through aerosol-generating procedures.


Furukawa, N. W., Brooks, J. T., & Sobel, J. (2020). Evidence Supporting Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 While Presymptomatic or Asymptomatic. Emerging Infectious Diseases, 26(7). doi: 10.3201/eid2607.201595

Health Workers. (n.d.). Retrieved May 8, 2020, from guidance/health-workers

Livingston, E., Desai, A., & Berkwits, M. (2020). Sourcing Personal Protective Equipment During the COVID-19 Pandemic. Jama. doi: 10.1001/jama.2020.531Tran, K., Cimon, K., Severn, M., Pessoa-Silva, C. L., & Conly, J. (2012). Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PloS one, 7(4), e35797.