Clinical bulletin: COVID19
Lessons from an obstetrics and gynaecology unit in Singapore
The International Society of Ultrasound in Obstetrics and Gynaecology (ISUOG), has helpfully hosted series of recent webinars of the management of the COVID19 crisis. They are a professional body representing health care professionals using ultrasound in obstetric and gynaecologic practice across the world.
In the west we are currently in the midst of the COVID19 epidemic. But in many parts of the east, the infection numbers have levelled off and are in decline. What can western healthcare professionals practicing in the women’s health setting learn from the experience of colleagues from the east?
Protection of staff
One of the key issues is the protection of staff. This ensures a viable workforce throughout the crisis. It is to be expected that a proportion of healthcare professionals who, as yet, have no immunity to COVID19, will become infected as they treat infected patients. But how can we minimize the numbers?
In this review we share the insights from an ISUOG webinar presented by Dr. Jill Lee, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital in Singapore.
Singapore is a peninsula with a population of 5.7 million people, of whom 1.6 million are foreigners. This implies that there is a very high degree of international travel associated with the country. Dr. Lee’s hospital, the KK Women and Children’s Hospital houses the largest obstetrics unit in Singapore, delivering 12,000 babies annually.
In terms of COVID19 infection in Singapore the key statistics at 16 March were:
- Confirmed cases = 226 (UPDATE: 683 on 26 March)
- Recovered cases = 105
- Still in hospital = 121
- Critical condition in ICU currently = 13 (UPDATE: 17 on 26 March)
- Deaths = 0 (UPDATE: 2 by 26 March)
- Confirmed cases affecting pregnant women: 0
- 5244 close contacts quarantined, with 3532 completed quarantine.
This indicates that Singapore is coping well with the COVID19 crisis, and Dr. Lee believes this is a function of two things:
- The aggressive approach to managing the outbreak immediately implemented by the Singaporean government. Particularly early home quarantine measures for people who came in contact with index COVID19 cases.
- Healthcare professionals taking precautions and reducing the chances of becoming infected themselves in the hospital setting, allowing them to be on hand to manage the epidemic.
The initial precautions taken by staff at the KK Hospital included the following general instructions:
- Maintain good personal hygiene
- Implement social distancing during COVID-19 epidemic period
- Reduce participation in gatherings where a minimum distance of 1m between individuals cannot be maintained
- Perform hand hygiene frequently with an alcohol-based hand rub (with 70% alcohol concentration)
- Avoid touching eyes, nose, mouth
- Implement respiratory hygiene: cough/sneeze into bent elbow or tissue, then dispose of the tissue immediately
- Use masks: wear a 3-ply surgical mask when visiting a hospital or other high-risk areas
- Seek medical assistance promptly for timely diagnosis and treatment when experiencing symptoms like fever and cough.
Triage of patients
Another key initial measure was to triage all patients and visitors where possible at the hospital and to have them screened via a questionnaire.
The screening questionnaire provided prompts for specific actions.
- Patient has respiratory illness symptoms of any kind: all patients in this category are issued with a mask to reduce the risk of aerosol droplets.
- Frontline screening staff: all screening staff should maintain a 1m distance (where possible) and adopt a 3-ply surgical mask (ideally the N95 model) and gloves.
- Patients with symptoms that match COVID19: these should be immediately isolated in a negative pressure isolation room.
Dr. Lee emphasised that it was important that ALL hospital staff, not just the frontline professionals took part in controlling the infection. With that in mind her hospital issued instructions for all auxiliary staff (such as cleaners) to don surgical masks, gowns, heavy duty gloves, eye protection (if at risk from splashing from organic material or chemicals) and wear closed footwear.
Specifically, for O&G patients, after screening, the KK Hospital implemented separate healthcare teams for looking after confirmed/probable/suspected COVID-19 patients. Dr. Lee admits that this will not be possible in every healthcare situation, but her hospital achieved it by cancelling non-urgent procedures and moving staff from those areas into the front line against COVID19.
Personal Protection Equipment(PPE)
In terms of Personal Protection Equipment(PPE) for staff in the front line, the KK Hospital stipulated the following:
- Goggles or full-face visor
- N95 mask (or superior)
- Closed footwear
N95 mask compulsory
In particular the N95 mask was deemed compulsory for procedures where aerosols might be generated. These procedures included:
- Tracheal intubation
- Non-invasive ventilation
- Manual ventilation before intubation
- Sputum induction
- Collection of nasopharyngeal swab
- Vaginal delivery
- Surgery, including caesarean section.
Vaginal delivery is considered an aerosol procedure in this case, because it is not appropriate to expect a mother to wear a mask during the second half of the delivery procedure.
Occupational health log
Another feature of the KK Hospital’s response in terms of protection for staff was the creation of an occupational health log for each staff member that detailed PPE training, mask fitting size, travel plans and, importantly self-reported temperature readings (taken twice per day).
However, even with robust procedures in place it is inevitable that a proportion of healthcare workers will become ill with COVID19 and also with other illnesses that service as a result of working at the front line.
Back in 2002, 21% of SARS cases (1,707) were healthcare professionals, and the KK Hospital were keen to avoid a repetition of that scenario with the even more infectious COVID19. They identified four factors that increase risk of transmission to healthcare professionals:
- Inadequate personal protection use at the beginning of the epidemic
- Long-time exposure to large scale of infected patients
- Shortage of PPE
- Insufficient training of frontline staff for infection prevention and control.
This was addressed in advance of the COVID19 crisis mainly by increasing training for staff in terms of PPE and infection control training. However, because it became clear that initial COVID19 infections in staff did not originate in the hospital but were related to staff activities outside of the hospital, additional measures were implemented.
- Restriction of travel, especially to highly affected areas
- 14-day quarantine for staff who have exposure/significant contact with confirmed cases, or travel to highly affected areas
- Onus on staff to inform supervisors of ANY travel (i.e. to non-affected areas), and use of surgical masks for 14 days if returning from travel
- Setting up of a staff clinic, with testing facility for COVID19
- Funding and leave allowance to support healthcare workers affected.
Dr. Lee provided details of the welfare programme that was initiated in the O&G isolation unit during the crisis. Firstly, staff were asked to fill in a survey related to emotional resilience.
– 52% felt worried about being asked to work in the isolation unit
– 85% worried about the wellbeing of their family
– 58% felt that working in the isolation unit created emotional pressure.
The unit therefore implemented WHO recommendations for dealing with staff stress during the epidemic:
- Reassure staff that stress is not a reflection on ability to do their job
- Make sure that staff take care of basic needs: that they rest, eat sufficiently, and undertake normal physical activity
- Provide opportunities for staff to stay in contact with family & friends (use digital methods when at work)
- Employ coping strategies, and allow staff to share concerns and fears with colleagues and managers who understand the situation they are in.
Utilising these strategies paid dividends in terms of emotional resilience: all staff in the isolation remained at the normal level, with some males approaching high resilience.
In summary, Dr. Lee suggests that the transmission rate amongst frontline healthcare workers appears to be controllable with use of protective equipment and good infection control training. She says it is important to realise that healthcare professionals will get sick, even as we minimise it by taking sensible precautions. It is therefore necessary to have established workflow and manpower plans to prevent collapse of services. Finally, to prevent burnout mental and social health strategies should be employed to support colleagues.
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