Educational Webinar: Maximizing the Use of Rapid Antigen Testing at Point of Care

Good afternoon. Thank you so much for joining us today. My name is Brandon Martin here at McKesson Medical-Surgical and I'm so excited to welcome you to today's presentation. Let's get to the point maximizing the use of rapid antigen testing at point of care presented by BD. Before we get started, I'd like to direct your attention to our disclaimer while you're reviewing that information. I will remind you that today's presentation is being recorded within a day or two you can expect to receive a link to download a copy of the presentation or you can also download the slides by following the link under the files pod to the left of your screen. If you do not see that link, no worries, you will receive a copy in the coming days if you have a question, feel free to enter into the Q and A panel at the bottom left corner of your webinar window at any time and we will do our best to answer at the end of the presentation. However, if we don't get to your question due to time, uh we will certainly follow up uh our speaker today is Doctor Michelle Prickett, associate professor Pulmonary and critical Care Medicine at Northwestern University and medical director at Respiratory Care Northwestern Memorial Hospital in Chicago. Doctor Michelle Prickett is a pulmonologist in Chicago and is affiliated with multiple hospitals in the area including Northwestern Medicine, Northwestern Memorial Hospital and Ann and Robert H. Lurie Children's Hospital of Chicago. She received her medical degree from University of Illinois College of Medicine at Chicago and has been in practice for more than 20 years. Doctor Prickett, thank you so much for being here today. I will turn the floor over to you. Right. Well, thank you so much for having me here today to talk about a topic um as a pulmonary and critical care specialist has been very important to me, especially over the last few years. And something that I would like to kind of share my thoughts and kind of expand our thinking about this as we understand the respiratory viruses are important and we have new tools to address them. So with that being said again, Doctor Brian, my disclosures are that I work as a consultant for Becton Dickinson. I work as their advisory board specifically on the topic of point of care testing. So that's my one disclosure. but I really want to talk. So, so I work for as a consultant for, for BD. But the really important part to me is we talk about point of care testing. And that during the COVID pandemic, this was a place where I found myself seeing new patients and being quarantined and really hoping, you know, for the idea that I could do point of care testing to know if I was infectious. So I'd like to talk about what point of care testing really is. So point of care testing is doing diagnostic testing that's basically performed near a patient or at the bed side. typically outside of a laboratory based testing, it provides liable and immediate diagnostic data that can influence both our management decisions as a clinician and hopefully with early interventions improve outcomes. So point of care testing, people seem to be talking about it with COVID. But really point of care testing has been around for a long time and it comes in very many different varieties that we may not think of, but we're actually quite used to using in the clinical setting. So for one example, taking vitals and measurements. So for a as a pulmonologist, we do oxygen saturation. So we put a device on page fingers were able to see their percent oxy nation. Alternatively, I might use a peak flow meter where I'm using data that I obtained from a patient either at the bedside or potentially in their home to help with our management decisions. So those are vitals and measurements. We could also look at urine. So many of us are familiar with pregnancy tests that are urine based and we have home tests as well as hospital based test. But it's just using urine and getting immediate information about the pregnancy status. We can also do this with urinalysis. I have not been a general internist in the near future, but I do remember doing my own urinalysis with some test strips on patients in our clinic. So we can really understand, are we dealing with a urinary tract infection based off of some of the, the simple data that I can get at point of care. One of the other ways we can do it is with blood. So, in our ICU, we are all used to glucose testing. People do it at home in the ICU. We'll use it point of care testing at the bedside to help us with titration of our insulin drips. So again, many uses just drop of blood. We can get data within minutes to help us make immediate interventions. You can see it with hemoglobin/INR Coumadin clinics, blood donations, If you've ever donated blood, they're gonna prick your finger, get data and, and help us understand. And then again, as a pulmonologist, respiratory secretions is also something we've been using historically for years. So strep testing in offices. If you've been to a pediatrician in the last few decades, you may have gone in and they've done uh on site strep testing. We've also had influenza testing for many years now in the clinic. So again, the message is point of care testing is not a new phenomenon. We've been using it in many ways that have evolved over the years and hopefully, we can continue with that evolution. So what are some of the benefits and drawbacks of point of care testing? Again, this is these are not new but kind of it's always important to look to see and think about what are the pros and cons. So on the benefit side point of care testing allows clinicians to make database decisions at the point of care, whether either patient in the room or with the patient at the bedside, it really allows us to use data to inform our decision making. Many of them can also empower patients to monitor their own health care conditions and collaborate with their care physicians. So again, peak flows blood glucose are all ways that patients can empower their decision making, which we know is related to better health outcomes. It's also a cheaper and easier access when we're talking about repeated diagnostic testing. So thinking if you had to go to the lab to get your blood glucose every time you wanted to take your insulin, that would be very, very laborious and probably very difficult for most people. But if I can test it at home, I have much better access. So those are the pros, what are some of the cons? So typically, when we talk about point of care, they're not as accurate as something we might have in a lab based testing. So we know that we're gonna have a little bit of precision for the flexibility of having something available and multiple takes it also requires us to educate patients on its use or educate people that might be outside of a lab on how it's used and how to analyze the information we get it back. And the last drawback I'll just put out there is for many tests out of pocket costs for some patients. So something for us to think about if we're discussing repeat testing or having it done at home, these are not always covered for patients. So as healthcare professionals, it's something that we should think about as in that realm. So again, this is really important to me because we hit the COVID pandemic. And this is me in March of 2020 seeing some of the first patients with COVID in our hospital in Chicago. And so with that, we actually couldn't get any COVID testing and I needed to quarantine in my basement. So the slide on the right is actually me in my basement. not the best cultural aesthetic, but I was, I was expecting to live down there for a very long time at, at the, at the point. But I found myself going to work in the ICU and coming home and having to separate and I kept thinking about how wonderful it would be to have a point of care test where I can just say, hey, I'm not infectious. I can go and see my sons and my husband upstairs. And so really, to me, my full disclosure is that this is an important thing that helps to empower not only patients but healthcare providers to know um what our symptoms are and aren't keep our coworkers and our families safe. So, with that, I want to talk a little bit about COVID test in particular. So, I just wanna make sure that we're all thinking about them and having the language and in this correct. So I'm gonna break them down into two groups. So one group is gonna be, we're talking about laboratory. The other term we might use is molecular. Other names that we might use in the realms of laboratory are PCR or nucleic acid amplification tested or NAAT. Our other category is going to be our point of care testing. The other term that may be used when you talk about point of care is going to be antigen testing. It could also be referred to commonly as rapid testing or home testing. So again, these are the two categories when people refer to types of COVID testing in particular, but they're large categories and I want to break down how they are similar but how they are different. So when we talk about the laboratory, molecular testing, we're really looking for genetic material of the virus. If we're talking about COVID and particular, the RNA of COVID is what our laboratory based testing. This is different from our point of care testing or antigen testing for COVID that looks at proteins that are secreted by a replicating virus. So in that measure, we can tell if the, the virus is replicating and because of the proteins we're seeing. So we're seeing two different things on the laboratory side. it takes a while. So the processing time when we get samples, it's been several years since I worked in the lab doing PCR. but processing time just to run these samples can take anywhere from 2 to 4 hours. And then the results and communication time is also can be quite long depending on where you're at. If you're in the hospital or if this is a send out that needed to be collected and run. So once we have them run, communicating those results can also be anywhere from 4 to 48 hours. In terms of laboratory testing, this is highly sensitive. It's felt to be the gold standard because it's able to detect things very, very early and it can detect things for up to 90 days in terms of COVID post symptom onset. So we're just looking for virus, whether it's replicating or not, it's being cleared by the immune system. So we can see it early, it's highly sensitive, but also will show us whether they've been infected at any point in the last 90 days. Conversely looking at our point of care antigen testing. Again, we're looking at proteins, the nice part of the antigen testing is we're getting results in minutes. So anywhere from 15 to 30 minutes, are we're able to communicate with patients immediately. So we'll run it usually outside the room, we'll go in and talk to the patient. This is the results that we just received sensitivity for antigen testing is actually very good but is not as sensitive of as our lab based testing. So if it is negative, we it's recommended that antigen testing is repeated in 24 and or 48 hours it's negative. and the window of detection is most sensitive while they're infectious. So our antigen testing is really helpful to know if patients are infectious and when they stop being infectious. So there is again, this is a a benefit of using antigen testing. So as I alluded to timing is everything. So and in terms of infections, the faster you can detect infect infection the sooner you can inform patients. So that means as a clinician and someone who works in a clinic reduces my amount of phone calls, I can do my education of patients in person when I'm seeing them at the point of care. I can also decrease the spread and limit the spread to others. So when I know immediately, I can tell patients, hey, we need to take appropriate precautions, masking isolation ventilation. They're also able to alert more recent contacts earlier to say, hey, you may have been exposed, keep an eye out. And then the third point is just starting treatment. So the when you're talking about infections that are replicating, the faster we start treatments, the faster people get better. So the faster I have answers will help us to start the appropriate treatments, it also delays inappropriate treatments. So I don't have to think like, oh, maybe I should do this drug versus that drug. I can know what's the best drug at the earliest time frame. So I am the daughter of a tool maker and so I will talk about the toolbox and while I don't have a doctor's bag like this anymore. I think the concept is something I want to replicate to you and it's something I'll bring throughout this talk. So, thinking about understanding all the tools in our toolbox and how best to use them. So as I think about our laboratory, molecular testing, again, these are highly sensitive, we have a better negative predictive value. If you have a laboratory test that's negative, they're likely it's likely not there. I can detect infections at their earliest time point and at their lowest levels. And so that is helpful, especially in certain patient populations that I'll go into a little bit later. And it does not require repeated measures. So, if I don't have the opportunity or the ability to repeat testing, this is a really helpful ways I'll probably want to lean toward a laboratory molecular based test. Alternatively, our point of care testing, our antigen based testing is also highly sensitive and they're really great for ruling in a positive. And so I'll get asked. Well, I had a, I had a antigen test or a home test that was positive. Do I need to come for a PCR? No, this is a great rule in. And if you get a positive, you know exactly what to do, it's also again, detecting protein that's being produced. So it really helps to define when that infectious period is and the rapid turnaround is ideal for quick decision making. So when you're in the clinic or you're talking about infection control, these are great tools in our toolbox to help us with that measure. So I am a cough doctor, most of the people that I see will come to me for with cough. And what I think we have learned as a community in healthcare is that not all that cough is COVID. And so we'll talk a little bit about influenza like illnesses. So, respiratory infections and they come in different varieties. We'll all present very similarly in many contexts but the treatments are vastly different. So IOI is something, is a term influenza like illness or IOI is a term used by the CDC. and it's very not specific. So it's a syndrome and it's defined as fever and cough and, or sore throat. And so it encapsulates a lot of what we know about the players, not only COVID, but a lot of the pathogens and then viral and respiratory infections that we have been seeing for, for eon. So this includes influenza, both A and B, it includes RSV group A strep and again includes COVID to name just a few. So with that, I want to present some data we're talking about some of the best data we have on when do these pathogens come around? Really comes, I think out of the CDC looking at their percent of ED visits. So this is a percent of EDs visits through the CDC's website. It talks about over time of the last two years. the proportion of patients and at what time point they're showing COVID versus influenza versus RSV or respiratory sensation virus. And what you can see by this slide is, you know, there's periods where we see very low levels for all three and then there's periods that we will see very high levels for all three. There's some blips COVID has kind of been involving in terms of the different cohorts and when we might have surges. but the pattern has been such that many of these respiratory viruses are all hitting within the winter season. So for that, I am not a Game of Thrones fan, but we all know I'm a midwesterner, we know that winter is coming and we know what is coming with it. And so with winter on its way, we definitely anticipate that we will have more respiratory viruses upon us to which proportions, which is the predominant, we don't know, but we do anticipate history being a history that we will be seeing as winter approaches more respiratory viruses and a mix of respiratory virus is important. So this is also from the CDC. And again, it, it depicts the the timing of when viral season has come on. And so it shows us, I believe it's starting at around uh 48, 40 weeks, which is in October. We are currently, I looked it up. We're currently week 29 of the year here in July. So we have several weeks ahead of us before we hit what is traditionally our colds and flu and respiratory viral season and we can see it can come on at different times. But historically, it's all been relegated within those winter months. So we do expect that history will repeat itself and in the coming months, we will start to see respiratory viruses again. So how do we prepare? We know it's coming. We know that we have different tools in the toolbox. Again, I want to emphasize thinking about using the right tool for the job. And so with that, as I think, and, and make decisions for my hospital, I think, you know, you want to make it individualized for the patient population and the resources within your own given community. But I break it down into two buckets from. And so I'd like to share that with you. So one bucket is really on the professional side. So I asked myself, what is our goal of testing? Is it for infection control? Is it for treatment management? So, thinking about what the goal that you are trying to achieve is gonna be very helpful. Also thinking about what the types of tests are available, right? You want to use the best tools for the job, but maybe you don't have every tool at your discretion. So whether it's point of care, testing or lab based testing, thinking about which tool might be best and the best use of your resources will be helpful. And then finally, I think about what's the location of the point of care. So where are we caring for patients? This is a patient who's presenting to the ED and maybe potentially hospitalized. Is this an outside clinic? Is this a preprocedural area? or is this a community-based setting that's outside of our normal hospital system, just a community-based clinic within those realms. And then, so those are the professional sides. But I also think about who are the patient populations that I'm caring for. And so with that, I think I in terms of respiratory viruses and, and testing, thinking about the presence or absence of symptoms. And so whether patients are having symptoms, and if they do, what is the timing of those symptoms? And then also thinking about my clinical suspicion. Is this a patient that really is fitting the categories of ILI and I wanna increase my testing or do I have a very low clinical index of suspicion? Secondly, I look at their immune status of our patient, as well as the immune status of the community that we're living in. So I'll think about high risk patients, immunocompromised patients, transplants, chemotherapy on immune compromising medications. Those may all impact the decision on how I'm going to develop. our, our work pathways for screening and testing. I also think about high-risk communities. So high-risk communities, nursing home, residents, dialysis centers, areas that may have a large, a large number of at risk members. We also may impact our decision on on how we test and how we treat. And then finally thinking about our patients access and follow up and again, I'm in the city but thinking I've also gone to rural and remote populations. Having people come for a lab test when they have to drive 5 to 6 hours to the clinic may not be possible. So we want to think about that. We also want to think about follow up of our patient population. Is this a population on domiciled communities would be a good example that I may not be able to get any additional testing or communicate that follow up and how will that impact my approach to testing these populations? So with that said, I'd like to just present some of the ideas or thoughts about how we might implement those and what is it is evolving within my my work process as well as what the CDC is evolving to so probably the most controversial of the topics. Um in IOI testing is the preprocedural screening. So I'll start with that. But I think the idea is to get people to think about what testing might be and what screening might be and the benefits of that. So when we talk about preprocedural screening, the first thing I would recommend is that we just start with screening for ILI on presentation. So when patients are coming in, they're filling out all the forms, we're gonna ask them. Do you have any fever? Do you have any cough? Do you have any sore throat? If the answer is no. but they're going to have a test. It does make sense to say, well, we'll just do a COVID POS or a COVID only point of care. And if it's positive, we're obviously going to take appropriate precautions then late rooms. But we can have a discussion on whether or not this procedure can be done safely for that patient if it's negative. Then it really helps us to know if we have a complication of a fever afterwards. Hey, they were negative when they came in. conversely when you have ILA on their positive screen, then we're gonna take precautions, move into your room. And then we might want to do a point of care testing with a Multivariate panel So looking for not only COVID but looking for other things that may cause um cause this. And if it, again, if it's negative for COVID and patients feeling, OK, there can be a medical decision on whether or not to continue with that procedure. but there can also be recommendations for repeat testing. So again, I think in this space, we want to think about the safety of our staff getting procedures completed safety safely. And how best can we integrate that in a reasonable measure? That is both health effective and cost effective for patients. And so the IOI screening and using COVID testing is how I approach the situation for my institution. Now, let's talk about outpatient clinics. So again, this is a pre screening for ILI on presentation is easy. It's done with our front desk. If it's negative, we're just gonna continue care and we don't really require testing for these patients. They may just be coming in for a routine measure. It's, it's we can move on with business as usual just with IOI screening as a a verbal report. If patients do report positive IOI symptoms, then I think this is the time that we can intervene and would like to mask our patients, put them in a room, take them out of our waiting area with the rest of our patients and we can also perform point of care testing for multiple pathogens if that is available. Again, if our point of care testing is positive, we're gonna go ahead and treat if it's negative, that's when you're gonna look at. Is this a high risk patient or household? and either sending a PCR based testing or quarantine and contact them when home tests are available. If it, it's not a high-risk patient, I might just say just repeat a COVID home test in 48 to 24 to 48 hours. And I'll give them instructions, call back in this period of time if we have any change in symptoms. But again, I think this is a reasonable approach to help keep all of our patients safe and have our streamline, our workflows. So what about the emergency department? So this is actually based off of CDC guidelines. And so CDC guidelines also recommend screening on presentation if there are no ILI symptoms, there's really no testing just when patients present to this into the emergency department, if they do have testing again, infection control measures for perform point of care testing. And the CDC's recommendation for your emergency department is just to test for COVID and influenza if it's a time when it's circulating. So if it's in those winter months or it's been reported that they're starting to have increased circulations, which you can find online. That is the time that you would want to do testing. So, if a pathogen is identified again, treats, if it's not, if they're being admitted there, the recommendation is actually to send a multiplex PCR. If they are not a high-risk patient or household and they're not being admitted again, you're gonna high-risk patients. We're gonna recommend sitting a PCR and then you're gonna recommend that they quarantine penny results, not a high-risk patient or household. We'll ask them to repeat the COVID testing at home in 48 hours or call their clinic or healthcare provider or whatever your policy is for your ERs to do follow ups for that. But that is ILI testing in the emergency department. So what are the CDC guidelines? This is a slide that kind of exemplifies what the recommendations are of current CDC for patients coming to outpatient clinics or EDS And again, I reviewed those. So this is when SARS CoV-2 and influenza are co circulating Basically the discussion is if someone's coming in, implement with, with IOI implement, masking isolation ventilation and your air quality is also an important factor for this specimen collection for the CDC. So if they are symptomatic from IOI and it's circulating COVID testing, either doing uh NAAT or antigen testing is recommended influenza testing as well. And they also could the caveat multiplex testing if available. So if you have the capacity to multiplex text multiplex testing, it is a CDC recommendation for patients presenting to outpatient clinics or EDS um with IOI treatment pending results. And then the CDC also will recommend to for completeness sake, recommending a vaccination schedule based on those reportings. So as I precluded, I am a practicing clinician. and you know, I think I always think about like, oh, what, how does this, how would this work in real life? And so, this is a recent patient of mine back from the spring, who was seeing me, this is an 80 year old who I've seen many times who prevents presented to my clinic. coming in with an acute onset of symptoms for the last three days, specifically reporting runny nose, sore throat and fever patient has typically had a cough. The cough was slightly more. They were recently with his wife, visiting the grandkids, they had no known sick contacts, but his wife is starting to feel sick as well. This patient, I actually went to our, one of our immediate care clinics the day prior and got testing. But since the results weren't back, proceeded to come to my clinic because uh they didn't want to miss their appointment with me. So what did we do? So, at presentation, the patient reported active IOI symptoms. So we massed them and immediately placed them into a clinic room to take them out of our waiting room. My team called the lab. We checked to see if their results from yesterday were available and they were not. So we have a couple of options that we have in my clinic. We offer point of care testing just for COVID. It's about 15 minute turnaround time. We also have multi COVID flu RSV. However, that takes that panel takes probably closer to 30 to 60 minutes. And we have capacity to repeat the testing that was done yesterday the day prior. And so that's PCR with a 2420 plus panel, respiratory viral panel. And again, those reports can take 24 hours to come back. So we decided to warm point of care just for COVID. It came back positive within a few minutes. And so was able to walk in fully masked in full PPE to tell a patient. Yes, you have COVID. We got them set up on an antiviral with education about household and screening for contacts. The last thing I'll just report is, you know, we adjust our room turnover to prevent spread to other patients or staff. So whether that is a time when there is a known exposure in a room and turno air turnover time or having filters air quality filters placed in rooms. But again, if you have a known exposure, making sure patients that are using patients and staff that are using that room subsequently are not exposed. So that also is part of our clinic's protocol on how we approach this. So hopefully, at this point, you know, we have talked about some take home points of how we might use these. So specifically respiratory patterns, respiratory pathogens are an important source of acute contagious illnesses, especially found during the winter months in our current state. testing for multiple potential infections may be helpful to make our accurate treatments, diagnoses and implement both infection prevention and treatment courses early on. making sure we understand what is the pathogen and how best we treat it and isolate for it. Fully at this point point of care testing, we recognize as a valuable tool in our toolbox to help with accurate rapid on-site medical decision making that can really enhance our practice, patient care and workflows. And then we thought through screening protocols and how they should be targeted to maximize outcomes considering both our available resources as well as patient factors. And again, how we might use them within our clinics. to help patients do the best work possible. With that being said, I BD is one of the sponsors of this talk today. And so I did want to just show there multiplex multi analyst system. And so this is the BD VR plus system. I think there's uh a couple full disclosure. I have not done any of these, you know, I don't do a lot of of lab testing, but I think when I look at any of the things that we think about for our hospital, I think about some components and what I like about the BD system is that it's small, it's portable. There is a very fast turnaround time. It has a visual output screen. So there's no question of is there a line or not? It actually comes up in a text based digitally interpreted results. And it's fast and so we can plug it in, get a patient sample. It's kind of the Ron Popiel, you know, plug it in and it's done. And it's uh an easy thing that can be done in clinics, public health offices and other places. And so with that, I am happy to take any questions. Thank you so much, Doctor Prickett. We do have a few questions that have come in. Just the first one here is what immediate thoughts or projections do you have about the upcoming Us Respiratory season? And maybe some some thoughts on what health care providers could do to prepare. Yeah. I think if history repeats itself both from historical basis and we, we know that we're gonna be seeing an upsurge of respiratory cases coming the winter months. So I think we know at least the old players that are coming. I think the thing that is also there's always the possibility. So there was a good example of that, of having a new a new player. So knowing what we are aware of and know what might be coming, I think winter is definitely a time where we see most of these. So the other question was what can healthcare providers do to prepare? we can have a plan so we can say we know it's coming. How are we gonna screen what works for my clinic? What are the resources I have? What are the staff that I need to educate? What are the policies and protocols to help again when patients present, which we know they will move them through the system quickly, effectively and minimize spread not only to the other staff in our clinic, but also the workers so that we're not having issues of workers um getting sick as well. Excellent, excellent See this person appreciates the speed and rapid turnaround time that antigen tests provide how can I improve the performance and reliability of antigen test results, given reduced sensitivity compared to PCR So great question. I think, you know, the just knowing how to use the tool and making sure the tool is used as how it's intended to be. So I think we know what the sensitivity is. but it's only if we use the test as they're intended to use. So that means we're storing them in the correct space, we're using them in the correct sequence. We're doing the appropriate controls within that and we're making sure they're not expired. So again, I think those are the reasonable things that we can do to really help us to reduce the to improve the reliability. The second is just understanding the limitations of antigen testing. And so we know it's not gonna be perfect. and if we do have a high clinical suspicion, doing a repeat test, whether that's like, hey, I'm not quite sure, let me do one right on site or have it repeated in, you know, within 24 to 48 hours to say we're really gonna have a confirmatory test. So those are two ways I think that are reasonable clinical interventions for low-cost test to ensure that we're making the accurate diagnosis to the best of our ability. Excellent, thank you. Let's see. We have another question here. This one this, this is another multi part question in your practice in your practice, have you noticed a reluctance or refusal by patients to get tests done at an external lab? I'll continue to read the whole thing and then we can break it apart if we need to. if a rapid antigen test for a symptomatic patient is done immediately at POC. And a negative result for COVID flu RFC is obtained. Would patients be more likely to comply with a laboratory referral? And what panel would you order in that situation? So let me break it up. We'll start with the first part. Have you noticed a reluctance or refusal by patients to get tests done at an external lab? I think it goes both ways to be honest with you. Some patients feel very much that they want to have a lab based test, like they trust it more because it's coming from a health care system. So that is, and I say, well, I don't really trust the home test. I'd like to do your lab. Conversely, I've had the opposite in my patient care experience as well. I've had patients say, do I really need to come in? Can't I just do the home one? So I think when you think about reluctance or refusals I think it comes in both things. So kind of talking to patients. What is your concern? of the other concern with lab base is sometimes in cost. And since it falls under, it may be under a hospital system, so some patients may take refusal because there's a copay involved with their insurance. So I think when I have that reluctance or refusal by patients that really want to understand and educate and speak to the concern at hand. But in my practice, it's come in both ways. So the second part of that is if a rapid antigen test for symptomatic patient is done immediately at point of care and a negative result for examples are COVID flu RSVS change, would patients be more likely to comply with a laboratory referral? And what panel would you order in that situation? I think if you tell them or when I told patients that the point of care is negative, they and we have a PCR that may detect more or have a higher sensitivity, it may be early on. Patients are usually very agreeable to that. So, for most patients, you know, knowledge is power and the kind of understanding what this is and what it isn't is very helpful. And if I have a negative point of care I typically it's especially a high risk patient or some of that's not fitting. I'm not quite sure. I think most patients have done the laboratory pa based testing without concern. I think your follow up question is what panel would I order in that situation? I think it kind of goes back to what is accessible to you at the time. So, and what is your turnaround time for that? So, in my hospital, we have we actually, we have multiple multiplex PC RS. We've had several platforms. I really don't get to pick. we but you can do your hospital based and you could do send outs to different like national based labs. They're all very similar in the testing that they're performing. It mostly has to do with what the turnaround time and what your delivery processes are like, how do I quickly can I get them to a lab? And how quickly can I get the results back is probably the bigger question as to the specifics of one are both lab versus another. Excellent. Well, we are going to leave the Q and A open. So if anyone else has any questions, please feel free to share those in the window to the bottom left of your screen. As we near the end of the hour though, I would like to thank you all for taking the time to join us today. And If you do have questions for the McKesson team there's a number there provided for you and a repeat of our disclaimer there. So for a full list of our upcoming events, I invite you to visit us at mms.mckesson.com slash learning dash webinars. You can register for a future webinar, you can share with your colleagues or sign up to receive regular updates on our webinar schedule. And once again, thank you all so much for your time today and especially thank you so much, Doctor Prickett for your time today. We really appreciate your expertise and especially your time. So thank you again. Be sure to check your inbox a couple of days. You should receive a recording of the presentation and slides from today. And with that, if you had any closing thoughts or anything, Doctor Prickett, no, thank you for having me. Excellent. Well, thank you so much. And thank you everyone out there. Have a great afternoon.