Autonomic function test during the COVID-19 pandemic: the Stanford experience

Abstract

Recently, the American Autonomic Society (AAS) released a position statement, providing guidance for safely resuming autonomic function tests (AFTs) during the coronavirus disease 2019 (COVID-19) pandemic [1]. When mandatory shelter-at-home orders were issued by local governments in March 2020, our autonomic center began developing its own AFT safety protocol pursuant to institutional policy and the recommendations from the Centers for Disease Control and Prevention (CDC) [2]. When both personal protective equipment (PPE) supply and COVID-19 polymerase chain reaction (PCR) test availability improved, the center, armed with our safety protocol, felt confident enough to gradually resume AFTs. We would like to share our experience from implementing such protocol. Our current safety protocol is as follows: All AFTs are scheduled in advance. Two weeks before the AFT, a nurse contacts the patient to convey information regarding institutional safety protocol and the requirement that the patient must receive a negative COVID-19 PCR report no earlier than 7 days prior to the AFT. A technician contacts the patient to reaffirm the requirement. Only one entrance of our facility is open, where clinic staff screen each patient and health care worker (HCW) for COVID-19 symptoms. They receive new surgical masks. They must cover the mouth and the nostrils. A family member can accompany a patient only when the patient requires assistance. A technician accompanies a patient from the waiting area. HCWs must wear surgical masks, protective eye (or facial) shields and disposable gloves during AFT. Wearing a disposable gown is not mandatory. Patients must keep the surgical masks on, except during thermoregulatory sweat test (TST) and Valsalva maneuver (VM). During TST, the patient wears an N95 mask while indicator powder is applied, and a surgical mask may be used afterwards. For VM, a single-use mouthpiece with a bacterial/viral filter is used. If the first attempt of deep breathing or VM shows unequivocally normal findings, the technician may move forward to the next test at his/her discretion. Other single-use items include tubes used during VM and capsules used for quantitative sudomotor tests. A technician is permitted to leave the suite when a physician enters for a tilt-table test. When possible, physical distance is encouraged as recommended by the CDC [2]. All surfaces that the patient may contact are cleansed thoroughly between patients. There are no specific parameters regarding the adequate amount of time necessary for air change in the suites between tests. For quality improvement and assurance, performance data between March 16 and August 21 were analyzed. No patients were denied entrance due to COVID-19 symptoms. A total of 267 patients had AFTs during the period, and 201 (75.3%) visited the center on or after the week of May 11, when our protocol began to require the COVID-19 PCR test. Initially, PCR screening no earlier than 3 days before AFT was recommended only for VM. If a patient was unable to obtain PCR screening, the protocol permitted the performance of VM with additional PPE. There were two major incidents that caused our center to refine the protocol. The first incident involved an urgent PCR test on the same day as AFT. Its negative result, however, become available the following day. The second incident involved a patient who received a PCR test at a different facility 4 days prior. The test result was positive, but neither the patient nor the * Dong In Sinn [email protected]