key: cord-1048018-h4xm76gd authors: Manauis, Charmaine Malenab; Loh, Marvin; Kwan, James; Chua Mingzhou, John; Teo, Han Jie; Teng Kuan Peng, David; Vasoo Sushilan, Shawn; Leo, Yee Sin; Hou, Ang title: Bracing for impact: operational upshots from the National Centre for Infectious Diseases Screening Centre (Singapore) during the COVID‐19 outbreak date: 2020-06-19 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12134 sha: 7e2b72aea9e9c8acefc493e40012c482e139c4dc doc_id: 1048018 cord_uid: h4xm76gd To combat the ongoing COVID‐19 pandemic, Singapore has adopted a rigorous screening approach that involves aggressive contact tracing, rapid isolation of confirmed or suspect cases, and immediate ring‐fencing of emerging local clusters and hotspots. Our screening centre team has been involved in running Singapore's designated screening centre since the end of January this year. With a well‐defined blueprint and substantial pre‐outbreak preparatory work, initial operations at our screening centre commenced within a day on activation and full operational status was attained in 3 days. As of 8 April 2020, the screening centre had screened more than 14,000 patients. We have adopted a “whole‐of‐hospital” approach, enlisting the help from other departments and subspecialties to augment manpower. Meticulous infrastructure planning to facilitate patient flow and strict measures to prevent nosocomial transmission and occupational exposure were instituted to safeguard both the staff and patients. This paper aims to describe our key takeaways in the course of operations and discuss the challenges encountered. Strategies to combat the ongoing COVID-19 pandemic vary greatly. A proposal briefly floated in the United Kingdom involved an early transition from containment to mitigation. 1 Serious concerns have been expressed regarding this approach, citing the potential catastrophic loss of lives. Many countries such as China have imposed drastic measures such as strict travel bans and the complete lockdown of entire cities. 2, 3 These strategies are not sustainable in the long term due to its highly deleterious impact on the economy and livelihoods. 4, 5 This calls for a complementary solution as countries seek to lift their lockdown measures. Singapore has received significant attention with regard to its crisis management approach to the ongoing COVID-19 outbreak and is regarded as the "gold standard" by international researchers in a recent study. 6 Singapore diagnosed its first case, a tourist from Wuhan, China, on January 23, 2020. 7 On January 28, 2020, the Ministry of Health decided to activate the National Centre for Infectious Diseases Screening Centre. On January 31, 2020, the country's designated screening centre was fully operational. The screening centre is housed in National Centre for Infectious Diseases, adjacent to its partnering hospital, Tan Tock Seng Hospital. As the national screening centre, it receives patients referred from primary health care clinics nationwide, walk-ins, immigration checkpoints, home quarantine, and Government Quarantine Facilities. The screening centre is operational round the clock and is run by the Tan Tock Seng Hospital Emergency Department (ED), in collaboration with National Centre for Infectious Diseases's Infectious Diseases Department. As of 8 April 2020, the screening centre had screened more than 14,000 patients, with daily attendances ranging from 50-500 patients. This paper aims to describe our experiences in running the screening centre including the pre-outbreak preparatory phase, infrastructure planning to facilitate patient flow, and coordinating a "whole-ofhospital" approach to support our wide-net surveillance efforts. We will discuss the challenges encountered in the course of operations and solutions used. The Severe Acute Respiratory Syndrome coronavirus (SARS-CoV) outbreak in 2003 had previously been considered as the biggest health care crisis in Singapore. A total of 238 probable SARS cases were identified, with 33 reported deaths (14% case fatality rate). A total of 97 (41%) health care workers were also infected over the course of the outbreak. 8 The valuable insights gained from tackling the SARS crisis have been factored heavily into our evolved response for future emerging infectious diseases. This includes the importance of a widenet surveillance strategy, early identification and isolation of confirmed cases, preventing nosocomial transmission, and occupational exposure as summarized in a previous review. 9 However, the screening centre team is cognizant that although it is important to incorporate these lessons, it is just as important to pay attention to the unique dif-ferences of COVID-19, particularly its increased transmissibility, 10, 11 albeit decreased fatality rates. One of the key lessons from combating the SARS and the 2009 H1N1 outbreaks is recognizing the need for a facility dedicated to the containment of infectious disease outbreaks. The National Centre for Infectious Diseases was built and conceptualized for this purpose. It is a 330-bed facility with 5 negative pressure wards and 2 intensive care wards. 12 The National Centre for Infectious Diseases also houses a large screening centre that is used for small, medium, and large scale outbreaks and the National Public Health Laboratory equipped with a biosafety-level 3 containment facility. The screening centre has a capacity for 22 trolley beds and 99 ambulatory patients when chairs are spaced 2 metres apart. Seating capacity can be increased to 181 when chairs are spaced 1.5 metres apart instead. This is in line with local and international guidelines on droplet precautions. 13-15 It is further divided into 2 areas: a High Risk wing and a Low Risk wing ( Figure 1 ). The screening centre is located in the Central Region of Singapore, 16 providing easy access to members of the public for screening. Within promptly directed to the High or Low risk wing based on a rapid assessment of their different epidemiological risk factors as stipulated on the sorting form. Each patient is assigned a seat number that is recorded for contact tracing purposes. Contact tracing is also facilitated by a real-time location system 18 patient tracker tagged to each patient and closed-circuit television monitoring. Patients are instructed to remain seated and any patient movement within the screening centre is under strict staff supervision. Non-ambulatory patients conveyed by ambulances are placed in trolleys and are directly sited in consultation rooms after the initial sorting. These consultation rooms are also used for physical examinations as necessary, ensuring that patients' privacy is respected. Unstable patients are attended to immediately in the resuscitation room. All staff entering the screening centre are required to wear full personal protective equipment (PPE). This consists of a hair cap, goggles, N95 mask, disposable gowns with knitted cuffs, and gloves. 19 They are also tagged with real-time location system to facilitate contact trac- The key direction for the screening centre is to limit community transmission of COVID-19. This is particularly important due to the Close contacts, as identified by contact tracing teams from Ministry of Health working round the clock, are swiftly notified and instructed to practice self-isolation and social distancing; a proportion may be quarantined according to the risk assessment. They are also reminded to return to the screening centre promptly for evaluation and testing should they develop symptoms. As the country's designated screening centre, the National Centre for Infectious Diseases screening centre had screened more than 14,000 patients as of 8 April 2020, which is ∼70% of the country's screening workload. Rapid isolation of confirmed cases and close contacts limit community transmission, as part of efforts to "flatten" the epidemic curve and avoid an epidemic peak that overwhelms health care services. 20 We are of the belief that the wide-net surveillance approach has contributed to a ratio of 1.8 undetected cases for every detected COVID-19 patient, 1 one of the lowest in the world. The Tan cases started on January 2, 2020. As the number of patients increased, the ED overflow protocols were implemented. At its peak, ∼60 patients were screened at the ED per day in addition to the usual ED attendances. The decision was then made by Ministry of Health to activate the National Centre for Infectious Diseases Screening Centre on January 28, 2020 (D) once patient numbers met the threshold capacity. The screening centre commenced its operations on January 29, 2020 (D+1) and was fully operational by January 31, 2020 (D+3). The screening centre was able to attain full operational status within a short span of 3 days due to the pre-outbreak preparatory work and planning as laid out in Figure 3 . As early as the second quarter of 2018, the Tan Tock Seng Hospital ED, in collaboration with the various stakeholders, developed standard operating procedures in the following domains, including medical, nursing, operations, logistics, pharmacy, radiology, security, housekeeping, food and beverage, transport, and mortuary. As stipulated in To sustain round the clock operations, we adopted a "whole-of- Augmented medical personnel are assigned a 10-day rotation in the screening centre. Over the course of operations, the screening team encountered several challenges, mainly in the area of communications, surges in patient attendance, and staff morale. These challenges and the Daily attendances at the National Centre for Infectious Diseases Screening Centre (Information updated as of 8 April 2020) respective solutions used will be further elaborated on in the subsequent paragraphs. The Sudden increases in patient attendance ( Figure 4) when a new (large) cluster was identified in the local community, or the week after a travel advisory was issued for overseas Singaporeans to return. 22 Pre-planned contingency procedures were promptly enacted and manpower was augmented from our standby roster, which was made possible due to the "whole-of-hospital" approach that we adopted. Seating arrangements were revised (chairs spaced 1.5 meters apart instead of 2 meters) to increase seating capacity from 99 to 181. The leadership team is well aware of the potential psychological and physical stresses experienced by the screening centre staff during the outbreak. 23 In the past decade alone, the international community has experienced 2 major pandemics: the 2009 H1N1 pandemic and the current COVID-19 pandemic. With a population density of 8,358/km 2 , as well as her status as a major transport hub for international travel, Singapore is inherently vulnerable to the threat of infectious diseases outbreaks, similar to many major cities such as New York City (10,194/km 2 ), Paris (21,498/km 2 ), and Manila (42,857/km 2 ). 25 The importance of a swift and coordinated response to curb rapid transmission cannot be overstated. In our experience, the aforementioned strategies as summarized in Table 1 have been indispensable to our outbreak response. These include a pre-outbreak response plan with detailed standard operating procedures, a purpose-built infrastructure, meticulously designed layout and patient flow, a wide-net surveillance strategy, and a "whole-of-hospital" approach to manpower augmentation. Early data from a recent local study 26 have demonstrated the efficacy of these containment strategies whereby the 7day moving average of the interval from symptom onset to isolation declined significantly for both imported and local cases, from 9.0 and 18.0 days to 0.9 and 3.1 days. We hope these strategies and planning blueprints can be adapted for use by other countries in their outbreak response, especially densely populated cities that share similar demographic features as Singapore. The authors declare no conflicts of interest. 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