Achieving Zero COVID-19 : From a Non-Covid Emergency Department’s Perspective

Introduction

Coronavirus disease 2019, or famously known as COVID-19 has been with us for the past few months, since it was first reported to World Health Organization (WHO) on December 31, 2019. The causative organism; a novel virus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or formerly known as 2019-nCoV, was first identified in Wuhan City, Hubei Province, China¹. Since then, it has grown out of control, causing respiratory infection in most parts of the world. On January 30, 2020, the WHO has declared COVID-19 outbreak as a global health emergency^2,3, and almost two months later, on March 11, 2020, it has been declared as a global pandemic⁴. The year 2020, as we all Malaysians has been accustomed to as a year of modernization, will never been the same anymore.

COVID-19 has become a real public health problem in many countries, and our country Malaysia, is not spared. Our Ministry of Health (MOH) has become the main agency in fighting this deadly infection, alongside other ministries and agencies such as Ministry of Higher Education (MOHE), Ministry of Home Affairs, Ministry of Defence, Royal Malaysia Police as well as Malaysian Armed Forces. As part of MOH mitigation strategies, several health clinics and hospitals have been gazetted as COVID-19 screening and admitting facilities, respectively. In Kelantan, there are only four admitting hospitals dedicated for COVID-19 namely Hospital Raja Perempuan Zainab II (HRPZII), which is the state general hospital, Hospital Sultan Ismail Petra (HSIP), Hospital Kuala Krai (lama) and Hospital Tumpat⁵.

Hospital Universiti Sains Malaysia (Hospital USM) is the teaching hospital for USM Health Campus in Kubang Kerian, Kota Bharu Kelantan. Since its establishment in 1983, it has become one of the main referrals and tertiary hospitals, alongside HRPZII and HSIP. Hospital USM, being a teaching hospital under MOHE, is not gazetted as COVID-19 hospital, unlike the other three main hospitals under MOH. However, Hospital USM, especially through its Emergency Department, has been receiving all variety of cases through our doors, including severe acute respiratory illness (SARI) cases, which should be approached as potential COVID-19 cases, until proven otherwise⁶.

Hospital USM COVID-19 management guidelines: Emergency Department

In order to achieve this, Hospital USM has come out with its own guidelines on COVID-19 management. Our ultimate goal is to achieve “zero COVID-19 cases among our staffs and patients”. In other words, our aim is to strictly screen all patients and staff who are suspicious of COVID risk. This action is tremendously important to prevent cross infection to non-COVID patients and staff. It is our duty to ensure that appropriate patients are screened at our triage to prevent staff and other patients acquiring COVID-19 from infected patients. Our Emergency Department, being at the frontline, has been practising strict policies with regard to COVID-19 management, as mentioned below:

a. Strict adherence to Personal Protective Equipment (PPE)

“PPE is your life saver”. Each member in our emergency department are provided with specified PPE, depending on their working zone and exposure risk, as per MOH guideline. There is also a dedicated team in charge of PPE to ensure enough floor stock for the working staffs, as well as drafting the minimum requirement of PPE in each zone based on the available evidence plus Unit Kawalan Jangkitan dan Epidemiologi Hospital (UKJEH) recommendation. Our staffs are also being trained to utilize PPE appropriately including donning and doffing. It is vital to follow the recommendation, hence we can avoid contamination of self or the environment with the contaminated equipment. Used PPE are discarded with special system to ensure zero risk of infection to other staff.

b. Screen, screen and screen your patient

Patient screening is one of the most important aspect in COVID-19 management. Without a proper and systematic screening tool, potential COVID-19 patient (as we all called PUI or Person Under Investigation) may entered our clinical areas hence exposing other health care workers (HCW) to the infection. MOH has designed a simple checklist form to be used at triage counters for all patient and relatives attending emergency department. In Hospital USM Emergency Department, screening forms were placed at all patient entry points namely triage counter, and ambulance bay opening and handled by dedicated staffs with full PPE applied. Questions asked during screening are as followed:

1. History of fever or sore throat or cough or shortness of breath
2. History of travelling to foreign countries (within 14 days)
3. Attended an event associated with known COVID-19 outbreak (within 14 days)
4. History of close contact with confirmed COVID-19 patient
   • In the presence of individual suspected or being investigated or confirmed COVID-19 in enclosed air-conditioned room for more than 2 hours
   • Working in close proximity with individual suspected or being investigated or confirmed COVID-19 in enclosed space within 1meter for more than 15 minutes.
   • Travelling in same vehicle as individual suspected or being investigated or confirmed COVID-19 for more than 2 hours and within 2 seat distance.
   • Staying in same house as family member or tabligh member of same small group that is suspected or being investigated or suspected COVID-19

PUI is defined based on the presence of any symptom (in Question 1) plus any risk factor for COVID-19 (Question 2, 3 or 4)⁷.

Any suspicious PUI patient will be managed in isolation room or sent straight away to screening facilities depending on their PUI categories. Patients who do not fulfilled PUI categories will then be categorized accordingly into acute respiratory infection (ARI), influenza like illness (ILI) or severe acute respiratory infection (SARI). All of them will be managed at Hospital USM. All SARI cases will be swabbed for COVID-19 and subsequently admitted to our dedicated SARI wards. Upon obtaining the result, negative COVID-19 patients will be transferred out to non-SARI ward accordingly, while positive patients will be transferred to the nearest COVID-19 admitting hospital, which is Hospital Raja Perempuan Zainab II.

USM had developed additional screening questions to all staff including USM students in order to achieve our aim towards “zero COVID-19 among patients and staff”. 

List of the questions are:

• History of recent (14 days) travel from Sabah / Sarawak
• History of recent (14 days) interstate travel from hot spots area
• History of attending large gathering involving many people from distant places (eg: kenduri, party, festivals)
• Close contact with a person recently (14 days) travelled overseas
• Recurrent presentation with unresolved RTI

c. Redefining AGP clinical practice

COVID-19 has been generally accepted to be transmitted via droplet. However, any aerosol generating procedure (AGP) has the potential to cause aerosol transmission hence increasing its risk to the HCW. Examples of AGP are nebulization, non-invasive ventilation (NIV), and intubation. Any HCW who attend ARI/ILI/SARI cases must wear full PPE at all time during AGP. In our setting, we have relocated our asthma bay from the yellow zone to our ambulance bay area, which is located outside the ED building. Nebulization is prohibited and for severe cases, intubation is mandatory. Instead, we use metered-dose inhaler (MDI) with modified spacer for all mild to moderate acute exacerbation of bronchial asthma (AEBA) patients. As far as NIV is concern, we avoid its usage for our SARI patient and proceed straight away with intubation for all indicated patient. Intubation process was also done with few modifications such as⁸:

• Restrict number of personnel to maximum three to four persons only
• All intubation must be done in ED isolation room
• Use of video laryngoscope
• Use of head box
• Emphasise on first pass success
• Dedicate one ventilator only for ventilated SARI patient (must be dual limb)
• Use of HEPA filters
• Avoid excessive bagging and suctioning if not necessary
• Incorporating point of care ultrasound (POCUS) for stable ARI/ILI

ARI and ILI are the milder forms of SARI. Both categories rarely need admission as the patients were usually stable. However, despite the benign nature of both illnesses, there are still a small risk of them being a potential COVID-19 case⁹. To address this issue, we have incorporated the use of bedside lung ultrasound (LUS) to re-stratify them according to their risk¹⁰. During LUS, we are looking for any presence of B-lines at bilateral anterior and posterior lungs. Those patient with abnormal finding on ultrasound or auscultation will be send for chest x-ray (CXR). Depending on the finding of their CXRs, they will be upgraded accordingly as SARI patient and were then be placed at our designated area in our red zone. Those who are deemed fit to be discharge (based on clinical assessment and CXR) will be given symptomatic treatment and oral antiviral therapy (Tablet Tamiflu).

Conclusion

In the nutshell, all emergency department, gazetted or not, must adapt to this new normal in order to win our battle against this invisible enemy. This fight against COVID-19 is far from over. It is interesting to see how this infection had changed our ways in managing acute and critically ill patients in ED. As quoted by General Sun Tzu in The Art of War; “If you know the enemy and know yourself, you need not fear the result of a hundred battles. If you know yourself but not the enemy, for every victory gained you will also suffer a defeat. If you know neither the enemy nor yourself, you will succumb in every battle”.

References:

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