key: cord-0689002-4bsgqtsa
authors: En Tan, Glorijoy Shi; Hou, Ang; Manauis, Charmaine Malenab; Chua, John Mingzhou; Gao, Christine Qiuhan; Kiat Ng, Frank Kwang; Wong, Chen Seong; Ng, Oon-Tek; Marimuthu, Kalisvar; Chan, Monica; Leo, Yee-Sin; Vasoo, Shawn
title: Reducing hospital admissions for COVID-19 at a dedicated Screening Centre in Singapore
date: 2020-05-16
journal: Clin Microbiol Infect
DOI: 10.1016/j.cmi.2020.05.005
sha: ba9be641276dcdb811f3ae0dbc3bd87e7480f635
doc_id: 689002
cord_uid: 4bsgqtsa

nan

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The National Centre for Infectious Diseases (NCID) Screening Centre (SC) in Singapore was activated on 28 January 2020 to evaluate patients referred from institutions nationwide for COVID-19 disease (1). All suspect and confirmed cases seen were admitted for purposes of isolation to airborne infection isolation rooms, in line with a national containment strategy to limit community transmission. As the number of cases requiring admission increased, there was a need to develop a triaging algorithm to determine who could be discharged pending a confirmatory result. We describe a Swab-and-Send-Home ("SASH") strategy implemented on 7 February during this outbreak that has helped to reduce hospital admissions.

Patients who fulfilled case definition as defined by the Ministry of Health would undergo a chest radiograph. They would then be stratified into high-risk or SASH according to criteria. If any high-risk suspect criteria were met, the patient was admitted for evaluation ( Figure 1 ).

High-risk criteria were modified according to latest available epidemiological and scientific information on the global outbreak situation (Supplementary Appendix). In the SASH group, one nasopharyngeal swab for SARS-CoV-2 polymerase chain reaction (PCR) was taken immediately. Patients were sent home with surgical mask, standard advisory to observe personal hygiene, given seven days of hospitalization leave and asked to return if unwell. A clinic appointment five to seven days later was scheduled if SASH patients had acute respiratory illness with travel to areas of heightened vigilance or other countries with outbreaks, close contact with confirmed cases, prolonged ARI or visits to other hospitals overseas without pneumonia. No appointments were given for low risk patients. If the PCR result was positive, the patient was recalled immediately for direct admission to NCID. If the PCR result was negative, clinicians conducted a tele-health consult with patient via phone call after 4 to 6 days to assess resolution or persistence of symptoms. If symptoms had improved or resolved, and no other reasons for medical review, the scheduled appointment was cancelled.

Between 7 February to 24 March 2020, a total of 10,571 patients were evaluated at SC, of which 9153 (86.6%) fulfilled suspect case definition. Using the algorithm, 8089 (88.4%) were SASH and the rest admitted as high-risk suspects. Among those SASH, 3.1% were found to be positive and recalled for admission the following day regardless of clinical condition for purposes of isolation, compared to 10.2% positive in the high-risk direct admission group.

From 16 March, due to the high volume of follow up appointments, physicians initiated follow up tele-health consults via phone call to 793 SASH patients who had one negative swab result one day prior to scheduled clinic appointment. This resulted in the cancellation of appointments for 480 (60.5%) patients whose symptoms had improved or resolved. Overall, there were 14 (0.17%) SASH patients who re-attended SC or outpatient clinic within 14 days of initial negative swab for persistent symptoms and were found to be positive on repeat swab.

As COVID-19 cases increase globally, healthcare institutions are facing greater pressure to perform diagnostic testing and allocate resources to patients who need hospital care the most (2, 3) . Capacity to evaluate, test, admit or isolate persons-under-investigation for COVID-19 depend on healthcare resources available and case-loads which will vary from country-to-country and the degree of transmission in each. A "SASH" strategy followed up with a tele-health consult via phone call may be an effective intervention to optimize limited hospital resources. Nonetheless, given the constantly evolving nature of COVID-19 outbreak response and differing national resources, the SASH algorithm would need to be contextualized and may need to be modified to meet changing needs. 

National Centre for Infectious Diseases (NCID)

Fair Allocation of Scarce Medical Resources in the Time of Covid-19

COVID-19 mass testing facilities could end the epidemic rapidly

The authors would like to acknowledge Jievanda Ow Shu Ying, Estee Tan Yidi, Imrana Banu and Jasmine Teo Shi Min for their contributions to the data collection and analysis.

Study conception and design: GSE Tan