Disease Outbreak Surge Response: How a Singapore Tertiary Hospital Converted a Multi-story Carpark Into a Flu Screening Area to Respond to the COVID-19 Pandemic.

Coronavirus disease 2019 (COVID-19), first documented in December 2019, was declared a public health emergency by the World Health Organization (WHO) on January 30, 2020 (https://www.who.int/westernpacific/emergencies/covid-19). The disease, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, has affected more than 9 million people and contributed to at least 490,000 deaths globally as of June 2020, with numbers on the rise (https://www.worldometers.info/coronavirus/#countries).Increased numbers of patients seeking medical attention during disease outbreaks can overwhelm healthcare facilities, hence requiring an equivalent response from healthcare services. Surge capacity is a concept that has not only been defined as the "ability to respond to a sudden increase in patient care demands" (Hick et al., Disaster Med Public Health Prep. 2008;2:S51-S57) but also to "effectively and rapidly expand capacity" (Watson et al., Milbank Q. 2013;91(1):78-122).This narrative review discusses how Singapore's largest tertiary hospital has encapsulated the elements of surge capability and transformed a peacetime multi-story carpark into a flu screening area in response to the COVID-19 disease outbreak.

Reorganising the emergency department to manage the COVID-19 outbreak.

BACKGROUND: The COVID-19 disease outbreak that first surfaced in Wuhan, China, in December 2019, has taken the world by storm and ravaged almost every country in the world. Emergency departments (ED) in hospitals are on the frontlines, serving an essential function in identifying these patients, isolating them early whilst providing urgent medical care. This outbreak has reinforced the role of Emergency Medicine in public health. This paper documents the challenges faced and measures taken by a tertiary hospital's ED in Singapore, in response to the outbreak. MAIN BODY: The ED detected the first case of COVID-19 in Singapore on 22 January 2020 in a Chinese tourist and also the first case of locally transmitted COVID-19 on 3 February 2020. The patient journeys through the patient reception area in the ED and undergoes fever screening before being shunted to isolation areas within the ED. Management and disposition of suspect COVID-19 patients are guided by a close-knit collaboration between ED and department of infectious diseases. With increasing number of patients, back-up plans for expansion of space and staff augmentation have been enacted. Staff safety is also of utmost importance, with provision and guidelines for personal protective equipment and team segregation to ensure no cross-contamination across staff. These have been made possible with an early setup of an operational command and control structure within the ED, managing manpower, logistics, operations, communication and information management and liaison with other clinical departments. CONCLUSION: With the large numbers of undifferentiated patients managed by the ED to date, more than 820 patients with COVID-19 have been identified in the hospital. Not a single member of the staff of the SGH Emergency Department has come down with the illness. The various measures undertaken by the department have helped to ensure good staff morale and strict adherence to safety procedures. We share the lessons learnt so that others who manage EDs around the world can benefit from our experience.

Containing COVID-19 in the Emergency Department: The Role of Improved Case Detection and Segregation of Suspect Cases.

OBJECTIVES: Patients with COVID-19 may present with respiratory syndromes indistinguishable from common viruses. This poses a challenge for early detection during triage in the emergency department (ED). Over a 3-month period, our ED aimed to minimize nosocomial transmission by using broader suspect case criteria for better detection and using appropriate personal protective equipment (PPE) for health care workers (HCWs). METHODS: All ED admissions with respiratory syndromes over a 3-month period were tested for COVID-19. The sensitivity and specificity of screening criteria in detecting COVID-19 were assessed. A risk-stratified approach was adopted for PPE usage in the ED, based on high-risk "fever areas" and lower-risk zones. When a case of COVID-19 was confirmed, surveillance was conducted for potentially exposed patients and HCWs. RESULTS: A total of 1,841 cases presenting with respiratory syndromes required admission over the study period. Among these, 70 cases of COVID-19 were subsequently confirmed. The majority (84.2%, 59/70) were detected at ED triage because they fulfilled suspect case criteria. Of these, 34 met the official screening criteria; an additional 25 were detected by the broader internal screening criteria. Over the 12-week period, the cumulative sensitivity of internal screening criteria was 84.3% (95% confidence interval [CI] = 73.6% to 91.9%), whereas the sensitivity of the official screening criteria was 48.6% (95% CI = 36.4% to 60.8%). Given the broadened internal criteria, the preexisting ED "fever area" was insufficient and had to be expanded. However, there were no cases of nosocomial transmission from intra-ED exposure, despite extensive surveillance. CONCLUSION: Frontline physicians need to be given leeway to decide on the disposition of cases based on clinical suspicion during an ongoing outbreak of COVID-19. If a broader criterion is used at ED triage, ED facilities and isolation facilities need to be readied to accommodate a surge of suspect cases. Usage of appropriate PPE is essential in minimizing nosocomial transmission.