key: cord-0949610-9vpsc8g1 authors: Noh, Ji Yun; Song, Joon Young; Yoon, Jin Gu; Seong, Hye; Cheong, Hee Jin; Kim, Woo Joo title: Safe Hospital Preparedness in the Era of COVID-19: The Swiss Cheese Model date: 2020-06-30 journal: Int J Infect Dis DOI: 10.1016/j.ijid.2020.06.094 sha: 371332502cdca5db9cf31da390b298721a62ce87 doc_id: 949610 cord_uid: 9vpsc8g1 Abstract Since the first emergence in December 2019, COVID-19 rapidly spread out worldwide. During the pandemic of an emerging infectious disease, it is very important to prevent nosocomial outbreak and operate hospitals safely to maintain their functions. In this article, we presented the strategies for safe hospital operation based on the experiences of the Republic of Korea during early COVID-19 pandemic. Each hospital should keep multiple layered defenses to prevent even small cracks in the hospital’s quarantine system. During the 2015 Middle East Respiratory Syndrome outbreak in South Korea, most cases were hospital-acquired infections, and 21% of them occurred among healthcare personnel (HCP) (Choi et al., 2016) . Based Control and Prevention, 2020). Only 1.4% of COVID-19 cases occurred in acute care hospitals, whereas more than 6% of cases occurred in the long-term care facilities and psychiatric long-term care hospitals (Korea Ministry of Health and Welfare and Centers for Disease Control and Prevention, 2020) . It is necessary to support and strengthen the infection control system of long-term care facilities, which could be places of unexpected outbreaks with higher case fatality rates (McMichael et al., 2020) . According to the report from International Council of Nurses, at least 90,000 HCP worldwide are believed to have been infected with COVID-19 (Nebehay, 2020) . This comprises about 6% of the 3.5 million cases of COVID-19 in the world, as of May 6, 2020. In South Korea, HCP accounted for 2.4% of the total patients with COVID-19, significantly lower than those (9.1-29.0%) in the foreign countries (Supplementary Figure 2 ) (Korea Ministry of Health and Welfare and Center for Disease Control and Prevention, 2020 , Team, 2020 , Wang et al., 2020 . It was possible to lower the infection rate of HCP by reducing the workload through efficient distribution of medical resources and providing sufficient personal protective equipment. The COVID-19 outbreak in hospitals will not only lead to missed opportunities of treating chronic diseases in patients with high-risk conditions, but it will also lead to high mortality rates if these patients are infected. Even patients with mild symptoms can spread J o u r n a l P r e -p r o o f SARS-CoV-2 to many people in the enclosed spaces of hospitals. Thus, each hospital should bear in mind the Swiss cheese theory to provide multiple layered defenses to prevent even small cracks in the hospital's quarantine system (Table 1 ). In addition to providing enhanced education and training, most hospitals made it mandatory for hospital staffs to wear masks, and only allowed visitors wearing masks to enter the hospital. In several hospitals of South Korea, if both medical staffs and patients wore masks, secondary transmission did not occur even when infected patients stayed in the hospital for a long time (Lee and Jeong, 2020) . Both wearing of face masks and strict hand hygiene are essential for preventing the hospital spread of SARS-CoV-2. The government has introduced a number of strategies sequentially to prevent COVID-19 inflow to hospitals and operate hospitals safely ( Figure 1) . First, as a quarantine measure for the patients suspected of having COVID-19, gate screening (strengthened triage at the emergency room and the main hospital entrance), specialized clinics and preemptive isolation of pneumonia patients were carried out from an early pandemic period (Kim et al., 2020) . Two kinds of specialized clinics are being operated at the outside of the main hospital building during this COVID-19 pandemic: febrile respiratory clinic and clinic for patients who have an epidemiological linkage with the COVID-19 outbreak. Second, the real-time polymerase chain reaction (RT-PCR) method was validated in collaboration with academia and industry, allowing each hospital to perform a large number of tests and enabling the efficient use of limited isolation rooms. Third, considering the possibility of cross-transmission when concentrated at large hospitals at once, the public health center's inspection function was strengthened, and a residential treatment center was introduced to manage patients with mild COVID-19. During late February 2020 in South Korea, more than 500 cases of COVID-19 were reported daily, which was expected to reach unacceptable levels for the hospitals (Korea Ministry of Health and Welfare and Centers for Disease Control and Prevention, 2020). Thus, the first residential treatment center was J o u r n a l P r e -p r o o f • Restricted number of hospital gates were opened. • Fever, respiratory symptoms, and epidemiologic relevance were screened at the entrance; fever detector, structured reporting paper or mobile application were used. Two specialized clinics were operated at the outside of main hospital building during the COVID-19 pandemic. • Clinics for patients under investigation who have epidemiological linkage with COVID-19 • Clinics for patients with fever or respiratory symptoms Preemptive isolation of pneumonia patients All patients with pneumonia were preemptively isolated, and released only after negative confirmation of SARS-CoV-2 RT-PCR. High throughput diagnostic testing (RT- The rapid testing enabled efficient operation of the insufficient isolation rooms. Strategies to reduce hospital workload for COVID-19 • Mild patients were guided to take SARS-CoV-2 RT-PCR tests at the public health centers, not at the hospitals. • Mild laboratory-confirmed patients with COVID-19 were cared for at residential treatment centers. Patients from COVID-19 outbreak areas were not permitted to visit the hospitals. Instead, they were counseled and prescribed medicine using telemedicine. 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