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Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 16-24

COVID-19 pandemic preparedness and mitigation plan: Department of internal medicine experience from a clinical perspective


1 Department of Internal Medicine, College of Medicine and King Saud University Medical City, King Saud University; Obesity Research Center, College of Medicine, King Saud University; Strategic Center for Diabetes Research, College of Medicine, King Saud University; The Strategic Technologies Program of the National Plan for Sciences and Technology Innovation in the Kingdom of Saudi Arabia, Riyadh, Saudi Arabia
2 Department of Internal Medicine, College of Medicine and King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
3 Obesity Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
4 Department of Internal Medicine, College of Medicine and King Saud University Medical City, King Saud University; The Strategic Technologies Program of the National Plan for Sciences and Technology Innovation in the Kingdom of Saudi Arabia; The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
5 Department of Orthopedics, College of Medicine and King Saud University Medical City, King Saud University, Saudi Arabia
6 Trauma and Acute Care Surgery Unit, Department of Surgery, College of Medicine and King Saud University, Saudi Arabia
7 Department of Internal Medicine, College of Medicine and King Saud University Medical City, King Saud University, Riyadh; Oncology Center, King Saud University Medical City, Saudi Arabia

Date of Submission09-Sep-2020
Date of Decision18-Oct-2020
Date of Acceptance28-Oct-2020
Date of Web Publication06-Jan-2021

Correspondence Address:
Assim A Alfadda
Department of Internal Medicine, College of Medicine and King Saud University, Medical City, Obesity Research Center, College of Medicine, King Saud University, Strategic Center for Diabetes Research, College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsm.jnsm_109_20

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  Abstract 


During the current COVID-19 pandemic, timing and preparedness for healthcare facilities are fundamental. This descriptive article narrates the Department of Internal Medicine at the College of Medicine and King Saud University Medical City (KSUMC) response before and during the COVID-19 outbreak by focusing on the preparedness and mitigation plans the department implemented for its clinical services. A COVID-19 taskforce was created to implement the pathways for healthcare workers' workflow organization, plan the effective use of isolation facilities and personal protective equipment, and enhance liaisons between departments in the medical city. Telehealth was utilized for outpatient services, and medications were delivered to patients via courier. Aerosol-generating procedures were conducted after thoroughly reviewing the clinical indications and time-related risks. Medical day unit services followed a strict multistep screening protocol and rescheduled nonurgent investigations and therapeutics when possible. The Department of Internal Medicine prepandemic preparedness helped significantly mitigate the pandemic impact on KSUMC. Prioritizing in-hospital clinical care according to the patients' conditions, full adherence to infection control measures, clear and efficient communication between departments, and utilizing telehealth were the key elements in maintaining state-of-the-art clinical care during the pandemic.

Keywords: COVID-19, department of medicine, mitigation, pandemic, preparedness


How to cite this article:
Alfadda AA, Albilali A, Alqurtas E, Alharbi A, Ekhzaimy A, Muayqil T, Bedaiwi M, Barry M, Azzam N, Aljebreen A, Isnani A, Bahammam A, Nasser AB, Nouh T, Alzahrani M, Alsaleh K, Alfaadhel T, Alotaibi N, Alayed K, Alkhowaiter M. COVID-19 pandemic preparedness and mitigation plan: Department of internal medicine experience from a clinical perspective. J Nat Sci Med 2021;4:16-24

How to cite this URL:
Alfadda AA, Albilali A, Alqurtas E, Alharbi A, Ekhzaimy A, Muayqil T, Bedaiwi M, Barry M, Azzam N, Aljebreen A, Isnani A, Bahammam A, Nasser AB, Nouh T, Alzahrani M, Alsaleh K, Alfaadhel T, Alotaibi N, Alayed K, Alkhowaiter M. COVID-19 pandemic preparedness and mitigation plan: Department of internal medicine experience from a clinical perspective. J Nat Sci Med [serial online] 2021 [cited 2021 Apr 17];4:16-24. Available from: https://www.jnsmonline.org/text.asp?2021/4/1/16/306257



The term “pandemic” originates from the Greek term “pan,” meaning “all,” and “demos,” meaning “the people;” therefore, a pandemic can simply be defined as the worldwide spread of a new disease.[1] The most devastating pandemic in the human history was the H1N1 Spanish influenza of 1918, which killed between 50 and 100 million people worldwide. For more than a century, no unprecedented pandemics have caused such devastation until coronavirus disease-19 (COVID-19). With its high transmissibility and attack rate (R0) of 2.5, COVID-19 has spread to more countries than any other previous pandemic.

In 1999, the World Health Organization (WHO) developed a six-phase approach to new contagious disease to easily incorporate new recommendations and approaches into existing national preparedness and response plans.[2] Phases 1–3 focus on preparedness, containing capacity development, and response planning activities, whereas Phases 4–6 indicate the requirements for response and mitigation efforts.[2] Phases 5 and 6 reflect widespread human infection and indicate a pandemic alert in which transmission occurs in at least two regions simultaneously. Moreover, a revision in 2005 included periods after the first pandemic wave to facilitate postpandemic recovery activities.[2]

The current COVID-19 pandemic began in December 2019 in Wuhan, Hubei Province, China. Most of the initially confirmed cases had visited a local fish and wild animal market in the previous month before symptoms appeared.[3],[4] Subsequently, on March 11, 2020, the WHO declared that “after making the necessary assessment, COVID-19 can be characterized as a pandemic.”

Saudi Arabia is one of many countries that have been affected by the worldwide COVID-19 pandemic. On March 2, 2020, the Ministry of Health confirmed the first case in Saudi Arabia. Since then, many regions in Saudi Arabia have reported an increasing number of COVID-19 cases. In King Saud University Medical City (KSUMC), several departments collaborated to manage COVID-19 cases, with the Department of Medicine being the driving force for most of these efforts. Between March 22 and September 30, 2020, a total of 4041 (11%) out of 36,764 tested patients in KSUMC were confirmed to have COVID-19 by reverse transcription polymerase chain reaction (RT-PCR), of which 821 (20%) were healthcare workers (HCWs). Of the total 4041 confirmed cases, 840 (21%) required hospitalization, of which 126 died (mortality: 15% of hospitalized and 3% of all infected patients).

Scope of service of the Department of Medicine

The Department of Medicine (herein referred to as the Department) is considered one of the largest departments in KSUMC. This Department oversees many clinical services and educational and research activities. The Department is clinically organized into specialized divisions and units that provide different medical services. The Department is comprised of ten clinical divisions and units: general internal medicine, pulmonology, endocrinology, gastroenterology, infectious disease, rheumatology, neurology, nephrology, sleep medicine, and the medical day unit (MDU). The Department employs 62 full-time attending physicians, 98 medical residents, and 28 fellows. Medical services provided by the Department include inpatient care, inpatient consultation service, outpatient ambulatory care, medical care unit, dialysis unit, medical procedures (endoscopy, bronchoscopy, and pulmonary function test), and sleep studies. [Table 1] displays the number of patients served by the Department for each service in 2019.
Table 1: Number of patients served by the department for each clinical service in 2019

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The Department's medical services are monitored and evaluated continuously to ensure that these services deliver high-quality care and are effective and safe for patients. Furthermore, these services are subject to continuous evaluation based on the demand for each service and the capacity and availability of the Department resources. New medical services can be established, and existing services can be expanded or modified based on the new demands and resource availability. The Department had recognized the importance of preparedness and reprioritizing its services before the beginning of the recent COVID-19 pandemic.

The importance of preparedness before and during a pandemic

Rapidly evolving pandemics can result in a high influx of patients into the healthcare system, stressing clinical and human resources.[5],[6] While pandemics are expected to occur, we remain oblivious to their timing. The difficulty in predicting their occurrence and the limited time available to organize a response after they commence make the issue of pandemic preparedness of utmost importance.[5],[6]

Preparedness for a pandemic is a necessity. The pre-established presence of patient isolation facilities, sterilization tools, personal protective equipment (PPE), and specialized HCWs is crucial to handle the sudden increase in demand for healthcare resources.[6] Having PPE readily available in preparedness for a pandemic will allow better protection for HCWs because shortages can occur quickly.[5],[7] Similarly, a preplanned system allowing for smooth transition of HCWs through shift-work, and providing rapid back-up for staff who cannot attend work due to suspected or confirmed contraction of illness, would help curb the impact of an unexpected outbreak.[6],[8] In addition, having a plan to reduce nonurgent admissions and procedures, strict triaging protocols, and telemedicine systems will quickly aid in decreasing the number of patients trafficking through healthcare facilities.[6],[9],[10] The benefits of these preparedness measures will also help reduce the negative impact on society in the postpandemic period.[5]

Trained personnel in leadership roles familiar with the pandemic management strategies are a major asset in coordinating inter-hospital transfers, establishing communication pathways with other allied healthcare services, facilitating resource allocation, and efficient patient sorting.[6],[7]

Previous experience in our institute in a similar situation

Saudi Arabia has had a recent similar experience with the Middle East respiratory syndrome coronavirus (MERS-CoV).[11] This has helped us prepare our hospital and other hospitals in the country to face the COVID-19 pandemic. MERS-CoV[12] is another betacoronavirus that genomically has 50% resemblance to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the causative agent of COVID-19. The former infection has a higher case-fatality rate (35%) compared with COVID-19 (2%).[13],[14] The MERS-CoV epidemic in Saudi Arabia led to the development of a nationwide disease surveillance program with a reporting infrastructure.[15] The Saudi Central Board for Accreditation of Healthcare Institutes[9] revised their infection control policies and procedures and concluded that hospitals should report their negative pressure room to regular hospital room ratio with periodic audits of infection control practices.

During the MERS-CoV epidemic in Saudi Arabia, our medical city managed infected patients and developed the infrastructure and skills necessary to face this respiratory infection. However, outbreaks within the hospital were not always successfully prevented. One of these outbreaks occurred in the spring of 2015, when an unidentified MERS-CoV index patient caused a hospital outbreak involving 23 cases, 13 of whom were HCWs and the remainder were inpatients.[16] Based on this experience, we provided further support to the infection control unit within the hospital and revised our hospital-wide policies and procedures to emphasize the infection control practices. This experience, combined with the national regulatory changes in response to the MERS-CoV epidemic in Saudi Arabia, has helped prepare our medical city to respond to the COVID-19 pandemic.

In the present paper, we document our department's experience with the COVID-19 outbreak, particularly in relation to preparedness and mitigation measures that have been taken to face this disease. Our experience indicates that despite the rapid increase in COVID-19 cases in our region, stringent measures enhanced by clear and effective communication are instrumental in protecting our HCWs while delivering high-quality medical services to our patients. We believe that despite the far-reaching negative implications of the COVID-19 outbreak, there are many positive lessons. We share these lessons to guide those who must respond to similar outbreaks in the future.


  Preparedness and Training Top


Establishment of a COVID-19 taskforce and its duties

Since the beginning of the pandemic, the Department had created a COVID-19 taskforce that was concerned with planning clinical services for patients with COVID-19, enhancing communication within the Department, and coordinating with other clinical services in KSUMC. The taskforce is composed of the Department's chair, vice-chair for clinical affairs, head of the general internal medicine unit, supervisor of the medicine residency program, and two attending consultants specialized in infectious diseases and hematology. The taskforce ensures that all department staff had received the required training in infection control measures and PPE usage. The taskforce is responsible for organizing the workflow in the medical teams covering the COVID-19 wards to ensure the availability of beds, patients' monitoring equipment, trained nursing staff, and a sufficient number of physicians. The taskforce regularly reviewed the guidelines and new literature in managing COVID-19 cases, and it considered any comments or suggestions sent to the department to improve medical care for patients.

Training and support of departments' staff

All departments' medical staff had attended a mandatory course to ensure that they learned the proper use of PPE, donning and doffing, crash cart, and airway and critical care management. Our Department runs the internal medicine residency program, which is among the largest in the Kingdom of Saudi Arabia. When the COVID-19 pandemic started, our residency program included 100 residents. Since the beginning of the pandemic, an utmost priority has been placed on the physicians' safety. This was reflected in a series of actions that were coordinated in a timely manner between the department, residency training committee, medical city administration, and infection control department. A plan was established to ensure that all physicians had a respirator fit test with the proper N95 or a similar respirator using qualitative and/or quantitative fit methods.[17] Moreover, challenges of commuting to and from the hospital arose immediately after the government announced a curfew law. Thus, an electronic system was used so that the physicians could upload their names, residential addresses, and working duties information to obtain permits from the government.

The psychological impact of the crisis on many HCWs has been paramount. A recent hospital survey showed that the anxiety level from COVID-19 was significantly higher than that from the previous MERS-CoV epidemic.[18] An initiative from the department of psychiatry in our institute was constructed to help with stress management, coping with COVID-19, and teaching HCWs on how to support their families and kids.

Staff availability and workflow reorganization

In response to the pandemic, medical staff vacation requests were postponed to make all staff available upon request. Only 50% of the Department's workforce was planned to remain actively working. In contrast, the others served as a back-up to minimize staff exposure and avoid losing the entire workforce in case of an internal outbreak. This percentage might change in response to heavy service loads on some occasions. We also significantly modified the daily routine rounds on patients. As an academic hospital, patient rounds usually involve the participation of an average of 8–11 persons (the attending physician, fellows, residents, interns, and medical students). To minimize the risk of inter-team disease transmission, we limited the team to three physicians (the attending physician, fellow or senior resident, and a junior resident). One physician saw a patient at a time and discussed the case with the team. The attending physician decided who among the team would see each patient based on the patient's condition. Furthermore, the physicians' lounge was closed, limited numbers of HCWs were allowed in a single nurse station, and social distancing was implemented between HCWs during meal breaks.


  Outpatient Services Top


Management of outpatient ambulatory services

The current pandemic has dramatically changed our outpatient healthcare delivery model. In 2019, we saw 35,797 patients in our outpatient ambulatory clinics. Given the high risk of disease transmission, the Department has taken initiatives to minimize exposure of patients and HCWs by implementing mandatory use of PPE at all times during clinics. Proper screening for all patients before entering the clinic area was initiated, which included measuring body temperature and completing a health-related symptom questionnaire for all patients. To maintain patients' access to healthcare during the pandemic, we initiated telemedicine clinics to assure rapid and effective communication with patients. Scheduled patients in the clinics were triaged by the medical team 2 weeks ahead of their appointments. Based on their clinical condition and their geographical location, patients were either seen virtually over the phone to obtain their medical history and discuss laboratory results and management plans, or they were asked to come in-person to the clinic.[19] Medical staff maintained proper documentation for all patients' visits, whether performed virtually or physically. By implementing the telehealth approach, we saw approximately 49% of our patients in virtual clinics. This not only minimized the risk of infection while visiting the hospital, but it also reduced patients' anxiety in commuting to the hospital during the curfew. The rapid implementation of this system in the department was a remarkable achievement given that telehealth was not well established in our medical city. [Figure 1] depicts a comparison of telemedicine use in different departments within the medical city. As shown, the Department of Medicine adapted quickly to the situation and was the highest among all other departments to implement virtual clinics.
Figure 1: The use of telehealth in outpatient ambulatory clinics in different departments within the medical city. Seen-in-person: The patient came to the clinic in-person; complete virtual visit: The patient was assessed virtually, investigations were reviewed, medications were prescribed, and the visit was documented in the electronic record system; incomplete virtual visit: Incomplete documentation of the virtual visit; cancelled/rescheduled: The patient visit was cancelled or rescheduled

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However, we faced several challenges in our outpatient ambulatory clinics. Part of these challenges was related to the curfew regulations, which restricted patients' transportation to the hospital to receive their prescribed medications. To overcome this obstacle, the Department utilized the medication delivery system implemented by the hospital in which a mail carrier delivered patients' medications to their homes. Patients received their new or re-filled medications delivered to their homes after talking to their doctors during the virtual visit. Furthermore, patients had the option to receive an electronic prescription if they preferred to obtain their medications from pharmacies nearby their homes. Another challenge was the delay we faced in getting the patients to perform their required investigations and imaging studies. This was partially due to not only difficulties in transportation but also to the patients' preferences to avoid the hospital during the outbreak. We managed this issue by prioritizing cases according to their medical condition and rescheduling all required tests.

Our experience with the use of telemedicine in providing healthcare services to our outpatients during the pandemic has been beneficial from different aspects. It helped maintain the patients' access to healthcare services, reduced the burden on patients to physically attend clinics, and opened the door to new policies promoting the effective deployment of telemedicine in serving our patients.


  Inpatient Services Top


Hospital admission limitations and prioritization

To prepare for the COVID-19 pandemic, our hospital attempted to accommodate the expected surge of cases in the medical wards and intensive care units by modifying the scope of care with a greater focus on COVID-19 patients. Limiting the admission criteria for non-COVID-19 patients to specific categories and rescheduling all elective medical and surgical admissions helped manage the bed status and free up some of the wards. We used the Canadian Emergency Department Triage and Acuity Scale to restrict the admission of non-COVID-19 patients in the emergency department to Categories I and II (Resuscitation and Emergency).[20] In addition to the allocation of resources, this restriction minimized the possibility of spreading the infection inside the hospital to non-COVID-19 patients. Our goal was to serve and accommodate more COVID-19 patients with appropriate, well-organized, and focused care, which we believe helps ease the load on the medical system in Riyadh city.

COVID-19 inpatient wards' preparation and management

Dedicated wards were kept ready to admit patients with suspected or confirmed COVID-19. These wards can accommodate up to 24 patients in a single room. Each room was continuously supplied with full PPE (nonreusable gown, gloves, surgical mask, face shield, waste contamination container, and N95 mask upon request). Patients with suspected or confirmed COVID-19 were seen, assessed, and admitted under the care of the COVID-19 medical team. Once suspicion of COVID-19 was ruled out, the patient was transferred to another ward and managed by a different medical team. Patients who required more intensive care were transferred to the respiratory intermediate care unit, which is also supervised by the Department.

Several aspects were considered when creating COVID-19 medical teams, which are responsible for taking care of all suspected and confirmed cases. First, these teams must have only the minimum number of physicians required to deliver the service. This is important to avoid workforce loss in case an outbreak occurs or is suspected in the medical team. We determined the teams required an attending physician, a senior resident or fellow, and a junior resident. Second, each team covered a dedicated COVID-19 ward to avoid unnecessary rounds on other wards. Third, the number of teams increased with the increase in the number of admitted patients. When we had more than 138 patients admitted with the disease, five dedicated teams were running simultaneously. Attending staff and fellows from all medical subspecialties participated in the coverage. At one stage, we had asked residents from other specialties to join the COVID-19 medical teams to alleviate pressure on the medical residents.

Subspecialties consultation services

We attempted to minimize the physical interaction between inpatients who require subspecialty consultations and the medical staff of the consultation team to reduce the risk of spreading the infection between patients and medical staff. This strategy was performed by limiting the number of consultation team staff who visit the patient to one physician per visit, when medically feasible. We also encouraged the medical staff who provided subspecialty consultations to COVID-19–confirmed or suspected cases to reduce the time spent at the bedside and to utilize virtual inpatient consultations while still ensuring state-of-the-art evaluation and care. An infectious disease COVID-19 team was newly established to provide consultation services for all wards and intensive care unit inpatients, outpatients, and quarantined staff.

Liaising with other services

The medicine, emergency, and intensive care departments are the primary departments involved in managing COVID-19 patients. With our colleagues in the emergency department, we identified the roles and responsibilities of both departments and created a pathway for referrals. Direct communication between the chairmen of both departments helped facilitate the admission process and overcome any unexpected issues. We also communicated efficiently with the intensive care department to maintain the dynamics and workflow of transferred cases and provide appropriate patient care in a timely and efficient manner.

The need for surgical procedures for non-COVID-19 patients was assessed and individualized according to the patients' conditions. For example, when a procedure was deemed necessary in dialysis patients (e.g., arteriovenous fistula creation or peritoneal dialysis catheter insertion/removal), the nephrologist communicates with the surgeon for initial approval. The surgeon will then pursue final approval from the surgical committee in the department of surgery. Several peritoneal dialysis catheter removals and insertions were successfully and smoothly performed with excellent cooperation between both departments. Another example is collaborating with the department of radiology to perform urgent interventional procedures for patients. The team in the Department connects with their colleagues in interventional radiology to explain the indication and discuss the urgency, which allows the interventionist to prioritize the cases accordingly.


  Procedures and Special Services Top


Endoscopy

Disruptions in endoscopic services have been reported by up to 80% of scheduled procedures in multiple endoscopic units worldwide.[21],[22],[23],[24],[25] Most endoscopic procedures are aerosol-generating procedures, which are considered high risk and would expose HCWs to the risk of infection.[26] We realized the importance of adapting and implementing local hospital policies at the endoscopy unit. Therefore, a taskforce of four expert endoscopists was formed to establish policies and recommendations during the COVID-19 pandemic. Cases requiring endoscopy were divided into three categories: (1) routine cases: should be postponed and rescheduled, (2) emergency cases: life-threatening conditions in which the endoscopy procedure can be life-saving; these cases should be performed immediately; and (3) urgent cases: do not meet the criteria for routine or emergency procedures. These cases are individually evaluated by the attending gastroenterologist, according to the patient's condition. Examples for cases in each category and general guidance and recommendations for endoscopy procedures are included in Supplement 1.

Bronchoscopy

Similarly, the pulmonary unit in the Department has established a bronchoscopy workflow based on the recommendations and expert opinions derived from observations made during prior respiratory viral outbreaks including SARS, MERS, and influenza.[27]

Bronchoscopic policy for case workflow states that all patients should be swabbed for COVID-19 within 48 h of the procedure, all elective procedures should be postponed and rescheduled, and the number of staff participating in any procedure must be limited to minimize the use of PPE and reduce known or occult exposure to infectious aerosol.[28] For procedures that cannot be deferred (e.g., massive hemoptysis, lung mass, foreign body removal, mediastinal adenopathy suspicious for cancer, and airway obstruction), recommendations of protective measures against infectious aerosols include the use of respirator-level respiratory protection and negative pressure rooms with a full complement of barrier PPE (gown, gloves, cap, and wrap around eye protection).[27],[28] Transmission may be reduced by using disposable bronchoscopes (in intensive care unit settings) in known COVID-19 patients. All bronchoscopic staff were trained on how to sterilize surfaces that might have been contaminated by respiratory secretions or droplets, proper removal of PPE, and hand hygiene pre- and post-procedure.[27],[29]

Dialysis

Patients on chronic hemodialysis are at risk of being exposed to carriers of COVID-19 in the community, which could lead to an outbreak in other patients and HCWs in the dialysis unit. Given this potential risk, several measures were taken in our dialysis unit: (1) patient crowding at the entrance of the dialysis unit was banned, with only one patient admitted to the unit at a time; (2) triaging was performed before entry by screening for fever, respiratory symptoms, and potential exposure to positive or suspected cases; (3) nurses were assigned to specific patients during each shift (cohorts) to limit potential exposure to other patients who might be asymptomatic carriers; (4) strict PPE measures were implanted while caring for patients; (5) patients wore face masks before, during, and after treatment; and (6) no companions were allowed with patients in the dialysis unit. Similar measures were implemented for patients receiving peritoneal dialysis. Moreover, admitted patients in need of renal replacement were dialyzed via portable machines. Specifically, patients admitted as suspected COVID-19 cases were dialyzed in isolated rooms with proper PPE.

Medical day unit

The MDU plays an essential role in facilitating patient care for multiple subspecialties. This unit is structured to provide inpatient care such as intravenous therapeutics and investigative procedures that do not require overnight hospitalization.

Given their background of autoimmune diseases and the known effect of receiving immunomodulators or biological therapies on raising their susceptibility to infections, most MDU patients were considered high risk during the pandemic. It was not feasible to screen all patients for COVID-19 before admission due to multiple factors, including the number of daily admissions, tight scheduling, and possible delays in management. Therefore, to navigate these unprecedented times without jeopardizing patient care and patient and HCW safety, multiple adjustments to the workflow in the MDU were implemented. All previously booked patients were reviewed at least 1 week ahead by the assigned medical team. Nonurgent therapies and investigations were postponed temporarily after contacting the patient via phone to assess their clinical status. The need for all booked therapeutics infusions was assessed by reviewing patients' charts and contacting them via phone. Accordingly, a medical decision was made to either continue their therapy, space the interval if clinically feasible, or shift therapy from intravenous to subcutaneous if an effective equivalent was available and would not jeopardize their disease control. It was important to help every patient decide their therapy and address their related concerns about its timing during this pandemic.

Triaging for COVID-19 was performed via three stages. First, preadmission through a phone call was performed at least 2 days ahead of the date of admission. Second, screening was conducted at the hospital gate on the date of admission. Third, screening was performed at the MDU reception area, which is separate from the clinical area. An admission registration desk was also placed at the MDU reception to minimize patient mobilization between hospital buildings and clinical areas. All admissions for patients who were suspected to have COVID-19 were postponed before the patients' arrival to the hospital.

Patient's companions or visitors were not allowed inside the MDU and were advised to wait in the waiting areas outside the unit, which were arranged to maintain social distancing. Waiting areas and the patient lounge inside the unit were closed. Thorough cleaning and disinfecting protocols were followed after every discharge. Medical equipment mobilization was limited, and strict infection control measures were followed in all aspects of clinical care.

Oncology center

Caring for cancer patients during the COVID-19 epidemic represents a special challenge. In one aspect, both conditions are potentially life-threatening; thus, delaying or closing oncology services is expected to directly affect patient health and survival. Conversely, cancer patients have been reported to have higher mortality and complications if they become infected with COVID-19. Severity and complications in patients with cancer and COVID-19 have been studied in several papers. Liang et al. evaluated 1572 patients with COVID-19, of whom 18 had a prior history of cancer. The patients with a history of cancer had a higher incidence of severe events, including admission to an intensive care unit requiring invasive ventilation, or death compared with other patients.[30] In another report by Dai et al. from Wuhan, COVID-19 patients with cancer were significantly more likely to require intensive care unit admission (odds ratio [OR] 2.84) and to have higher rates of severe/critical symptoms (OR 2.79).[31]

Most of the recommendations for managing patients with cancer during the pandemic were based on the expert opinions and health regulatory bodies. Two of the major oncology societies, the American Society for Clinical Oncology and the European Society for Medical Oncology, had prioritized cancer care interventions according to the patients' conditions.[32],[33] The oncology center at KSUMC continued to deliver cancer care during the pandemic while implementing strict infection control measures.

The outpatient clinics were maintained for patients on chemotherapy or those who require close follow-up for possible recurrence. All other visits were rescheduled or conducted virtually. Whenever possible, patients were encouraged to obtain blood work at a local laboratory and to send their results to their physicians. Physicians then communicate with patients to discuss management plans and prescribe necessary treatment. Similar measures to those applied in the MDU were implemented in the day chemotherapy and radiation therapy units.

For inpatient service, plans were implemented to limit patients' and HCWs' exposure to the infection. Dedicated nurses were assigned to each oncology ward, all admitted patients were screened for COVID-19 2 days before admission, patients were admitted to single rooms whenever possible, patients and HCWs were asked to use appropriate PPE, and patients' companions were not allowed except for pediatric oncology cases. Specific treatment guidelines were adopted that would enable switching parenteral drug administration to oral therapy (e.g., changing parenteral 5-fluorouracil to oral capecitabine in patients with breast and colon cancer).[33] We communicated with the local hospitals of patients residing outside the Riyadh region to allow for the continuation of their chemotherapy without jeopardizing their care.

Immunocompromised patients (including HIV clinics)

Immunocompromised patients including people living with human immunodeficiency virus (PLWHIV) are considered highly vulnerable to severe COVID-19.[8] In one case series in Barcelona, Spain, 1% of intensive care unit admissions due to COVID-19 were among PLWHIV, all of whom were younger than 50 years and displayed clinical presentations similar to the general population. All patients were shifted to boosted-protease inhibitor antiretroviral therapy (ART), and all survived.[34] With the implementation of quarantine, social distancing, and community mitigation measures, there has been a reduction in routine HIV screening. This had compromised the UNAIDS 90-90-90 initiative and may have led to missed new infections. Hospital visits by PLWHIV have been reduced, and the continuation of ART has been hindered. Hence, the infectious disease unit at the Department communicated directly with all their PLWHIV to educate them about proper methods to avoid infection and highlight symptoms of COVID-19. They were recommended to immediately contact the unit if they develop any of those symptoms. Routine visits for stable patients with normal CD4 cell counts and suppressed viral loads were conducted via telemedicine, and their ART supplies, sufficient for at least 90 days, were delivered by mail carrier throughout the entire country. Those with low CD4 counts or nonsuppressed viremia who required hospital visits were instructed to wear a mask at all times and perform regular hand hygiene. They were screened for fever and acute respiratory illness at hospital points of entry and were given direct access to the doctor's office without mingling with other patients in the waiting area. As part of routine care, a nasopharyngeal swab for SARS-CoV-2 RT-PCR was added to their workup, with future planning for serological IgG testing for all patients. To date of this writing, none of our PLWHIV cohort has been infected with COVID-19.


  The Department Plan to Resume Regular Clinical Services Top


With the pandemic still ongoing, it is difficult to predict its course. Approximately 3 months after the announcement of the first diagnosed case of COVID-19 in Saudi Arabia, restrictions were gradually eased to allow some economic and commercial activities to resume. There is expected to be an increase in newly diagnosed COVID-19 cases. However, the Department recognizes that it is important to continue all strict infection control measures while gradually resuming its regular clinical services.

The Department highlighted the following considerations before resuming regular services: (1) daily updated statistics should be available on newly diagnosed and suspected cases in KSUMC and the diagnostic testing availability; (2) the reopening plan for services is a dynamic process subject to change based on the situation of the infection; (3) sufficient PPE and medical supplies should be secured in all wards, clinics, and procedure suites before resuming regular services; (4) workforce planning should be implemented before restarting services to assure that an adequate number of physicians are available on-duty and as back-up in case there is an outbreak; (5) rescheduling of clinical services must follow clear prioritization plans and protocols based on the patients' clinical conditions; and (6) adequate and efficient patient communication is essential.


  Lessons Learned, Recommendations, and Future Directions Top


Many lessons have been learned since the beginning of this pandemic. It became clear to us that early planning and reallocation of resources to accommodate the expected increase in the number of COVID-19 patients who require hospitalization and intensive care are crucial. Furthermore, implementing protective measures such as staff training in different infection prevention and control methods, including the proper use of PPE, minimizing elective admissions, reducing HCW gatherings during medical rounds and meetings, and using telemedicine, were found to help decrease the spread of the infection in our hospital and community.

Looking into the near future, this pandemic is likely to continue for at least several months, and thus, we must implement measures to minimize system fatigue and overcome financial burdens. Our future goals should focus on the slow returning and reopening of our medical services that have been affected by the pandemic. Simultaneously, we must continue to implement preventive measures to halt the spread of this infection among our community and HCWs. This can be achieved by scaling up our active surveillance and testing, using efficient contact tracing tools, and precautionary self-isolation of contacts or symptomatic individuals. Furthermore, monitoring and improving hygienic practices and encouraging all staff to wear appropriate PPE while at work are critical to reduce the number of new cases during the reopening of clinical services.

Acknowledgement

The authors would like to acknowledge the Medical Director Office, KSUMC, for help with collecting the virtual clinic data presented in [Figure 1]. The authors would like to thank the Deanship of Scientific Research and Researchers Support and Services Unit for their technical support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Supplement 1: General guidelines and recommendations for endoscopy procedures in response to COVID-19 pandemic Top


The COVID-19 disease pandemic caused by the novel coronavirus-2 (SARS-CoV-2) has led to significant stress on healthcare systems.[1],[2] The disruption to endoscopic services has been reported by up to 80% in multiple endoscopy units worldwide.[3],[4] Most of endoscopic procedures are aerosol-generating procedures which considered as high-risk procedures that would expose healthcare workers to the risk of infection.[5] We realized the need for local hospital policy to be adapted and implemented at the endoscopy unit, King Saud University Medical City (KSUMC). A taskforce team of four expert endoscopists at GI unit was formed, and the following recommendations were created.


  Practice of Endoscopy at King Saud University Medical City Top


  1. All staff should be oriented and trained on the unit's COVID-19 protocol including strict infection control measures which includes hand hygiene, proper PPE donning and doffing technique, location within the unit of replacement PPE, and proper disposal
  2. Junior fellows will not be allowed in the endoscopy room to limit exposure, and all procedures will be done by consultants and senior fellows to reduce the time of exposure
  3. Strategies to triage and assess risk of patients with suspected or confirmed COVID-19 before endoscopy are mandatory using the Ministry of Health screening checklist
  4. Creation of two negative pressure rooms at endoscopy unit to perform endoscopies for all suspected or confirmed inpatients cases of COVID-19
  5. Caregivers and relatives of the patients are strictly prohibited to enter the endoscopy room
  6. Biopsies will be taken only if needed and will be labeled as a biohazard sample for all cases and handled carefully as per protocol by our staff and the laboratorty staff
  7. Disinfection policy for the scopes and accessories should be strictly followed as per the KSUMC infection control recommendations.



  Cases Prioritization Top


Emergency cases where the endoscopy procedure can be a life-saving should be done; however, all routine cases should be postponed. Cases which do not meet criteria for routine or emergency procedures are considered as urgent cases should be reviewed by the consultant on-call and decision will be made case by case based on the condition of the patients. [Table 1] shows classifications of cases as routine, urgent, or emergency as per the Saudi Gastroenterology Association position statement.[6]




  References Top


  1. Fauci AS, Lane HC, Redfield RR. COVID-19-Navigating the uncharted. N Engl J Med 2020;382:1268-9.
  2. Ranney ML, Griffeth V, Jha AK. Critical supply shortages-The need for ventilators and personal protective equipment during the COVID-19 pandemic. N Engl J Med 2020;382:e41.
  3. Thompson CC, Shen L, Lee LS. COVID-19 in endoscopy: Time to do more? Gastrointest Endosc 2020.
  4. Hollander JE, Carr BG. Virtually perfect? Telemedicine for COVID-19. N Engl J Med 2020;382:1679-81.
  5. Zhang Y, Zhang X, Liu L, Wang H, Zhao Q. Suggestions for infection prevention and control in digestive endoscopy during current 2019-nCoV pneumonia outbreak in Wuhan, Hubei province, China. Endoscopy 2020;52:312-4.
  6. Almadi MA, Aljebreen AM, Azzam N, Alammar N, Aljahdli ES, Alsohaibani FI, et al. COVID-19 and endoscopy services in intermediately affected countries: A position statement from the Saudi Gastroenterology Association. Saudi J Gastroenterol 2020;26:240-8.




 
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