Interventional radiologists from Singapore have shared their strategies for the preparation of IR services to cope with COVID-19 patients, emphasising the need for clear planning and cross-departmental working to tackle the spread of the virus.
Lessons from Singapore’s healthcare system were shared by Kiang Hiong Tay, head of the Department of Vascular and Interventional Radiology at Singapore General Hospital and Chow Wei Too, director of IR Ops at the hospital’s Division of Radiological Services, alongside Farah Irani, director for IR at Seng Kang Hospital, as part of a webinar organised by the Society of Interventional Radiologists (SIR), “Is your IR service ready for COVID-19?”.
The webinar is a part of a suite of resources available to the IR community aimed at assisting in the response to the COVID-19 outbreak. SIR has released a toolkit featuring best practice guidance and recommendations for approaching the virus while the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) is also working on a number of initiatives to share information, including a resource centre on the CIRSE website with useful articles, checklists and webinars.
Rajesh Shah, (Stanford Healthcare, Palo Alto, USA) urged IR teams to adopt the recommendations, warning that the USA is “just at the beginning” of its battle against COVID-19. “You don’t want to be implementing these [recommendations] when COVID-19 patients are coming through your door, you need to be implementing these much earlier. In some places that might be too late, but you have to start right away.”
Speaking during the webinar, Tay explained that Singapore’s response to the 2020 COVID-19 outbreak has largely been informed by lessons learned from the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS), which resulted in around 33 deaths, including those of two healthcare workers. “Because of this incident in Singapore, we have undertaken a number of changes to our system, to prepare ourselves for the next outbreak,” Tay explained. Significant post-SARS developments have included an increase in the number of negative pressure isolation rooms throughout Singapore’s public health system, as well as the establishment of a purpose-built National Centre for Infectious Disease, which itself has 330 negative pressure rooms.
Additionally, Tay explained, all public hospitals now have segregated inpatient and outpatient facilities, including in radiology departments, while the country also began a national stockpiling programme for personal protective equipment (PPE), including N95 respirator and surgical masks, to ensure it has adequate supplies to tackle future outbreaks. Singapore has also developed strong contact tracing capabilities, Tay said, which includes involvement of the police and criminal investigation bodies. “We also have a National Health Staff Surveillance System (S3) where we could survey the temperatures of all healthcare workers nationally. This would help pick up early fever clusters, before they spread out,” he added. “Importantly, we also had a major investment in biomedical science, with a significant focus in building expertise in infectious diseases.”
The strategy for tackling COVID-19 in Singapore has been one of containment, Tay noted, in order to ensure that the healthcare system can prevent itself from being overwhelmed by the number of cases coming in. “The key is to break the chain of transmission, and in Singapore we try to leave no stone unturned and with every single case, isolate them, and have rigorous contact tracing, and quarantining of the contacts,” he explained. Social distancing policies have also been introduced, and the Singapore government has emphasised the social responsibility for residents to remain in their homes, particularly if they begin to show symptoms of COVID-19.
At an institutional level, Tay commented that formation of a taskforce across departments is an important step in coordinating the response to an outbreak. “We meet daily to sort out any COVID-19 related issues. We review our manpower status, the sick leave and the temperature surveillance. We have an app that can easily enter this and staff are required to do this two times a day and this can be easily monitored,” Tay said. Other areas to be overseen by the taskforce include logistical issues, include monitoring PPE stocks, and ensuring that infection control practices are maintained on the ground.
Establishing segregated teams, comprising members of different sub specialities should also be considered, Tay suggested, so that essential functions can continue even if specialist staff are required to be quarantined, while elective cases should also be reduced. “For IR, the lessons learned from SARS are still relevant,” Tay remarked. “The concept is actually quite simple: you need to protect your patients, protect your staff and prevent intra-hospital transmission. Underbuilding all of this is strict adherence to infection control measures. We need to have business continuity plans because the likelihood of getting quarantined from exposure is high.”
Following Tay, Too Chow Wei outlined Singapore General Hospital’s approach from an IR operations perspective, noting that the institution had instigated a six-point plan for dealing with the virus.
The first step is patient segregation, Wei explained, with in- and outpatients separated into different areas or by time slots, so that there is no cross contamination between patients. “Here at Singapore General Hospital we have seven rooms separated into two levels, so that we can do an upstairs/downstairs space segregation. If you can’t, do it by time, finish [the] outpatient list in the morning before you are getting your inpatients in.” Reducing the workload of the hospital is also important, he noted. “Arbitrarily at the start of the infection we said that we wanted to reduce workload by about 50%. In reality it is probably closer to about 30–40%. We want fewer patients in the hospital as it is less likely they can overwhelm the system.”
The second part of the chain is staff segregation. Wei said that within Singapore General Hospital, the IR team has been split into two functional teams of doctors, nurses and radiographers, to keep certain functions running in case specialists need to be quarantined. A policy of social distancing, and staggered meal times has also been employed, to reduce the amount of social contact between staff, and potentially reduce the likelihood of infection. The institution has adopted a further policy of vetting and prioritising cases that are handled. “Non-urgent procedures have been given long waiting times,” Wei explained.
In addition, the hospital has sought to minimise the movement of isolated patients. “If we can treat by the bedside, we should do it by the bedside,” he said. This has necessitated the introduction of enhanced workflows, described by Wei as one of the most important parts of the strategy. “We reached out to our colleagues in anaesthesia, security, infection controls and we developed workflows. This is really a juggling act,” Wei said. The process involves ensuring that as a COVID-19 positive, or suspected patient leaves a ward en route to the IR centre, the area is cordoned off by security, so that a path can be found that minimises contact with other staff and patients. As the patient is moved, environmental services will clean down surfaces. “We need to bring everybody together just for transfer of the patients. We have simulations, rehearsals and after action reviews and we constantly improve our workflows,” Wei commented.
Alongside this, the IR room is prepared for the receipt of the patients. All equipment that is unnecessary for the procedure is removed, and the remaining equipment is wrapped in plastic sheeting. At the end of the procedure there is a wipe down of the equipment, with a disinfectant wipe, after which the walls and floor and other areas are cleaned with sodium hypochlorite solution at 1,000ppm. After this the room is then disinfected, either with ultraviolet c treatment or hydrogen peroxide vapour.
Offering his advice on putting a strong strategy in place for tackling the COVID-19 outbreak from an IR perspective, Wei posited: “You need to talk to different stakeholders in the hospital. Change has become the new constant. New workflows will need to be established, documented, rehearsed, reviewed and improved. Everybody plays a role, we really need to talk about infection controls. This is a labour intensive process, but training will pay off.”
Speaking after Wei, Irani outlined the Seng Kang General Hospital experience in having dealt with COVID-19 cases. Similar to the processes described by Wei, she sketched out the procedure for the movement of patients at Seng Kang, which seeks to minimise the risk of the spread of infection. This involves a similar level of coordination between departments, and within the IR department itself. Each member of the team has a defined role in handling the patient, and prepping the facilities for use.
After the patient has been moved on, there is a strict procedure for the removal and sterilisation of clothing and equipment. Safe removal of equipment is one area highlighted by Irani as being particularly important part of the process to prevent the spread of infection. “Doffing is more important than donning,” she said. “We always are very careful when we put on the equipment, but the time we will get infected is when we take off the equipment, and that is when we need to be really careful.”
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