Early clinical response to a high consequence infectious disease outbreak at the Royal Melbourne Hospital Emergency Department – insights from COVID-19

This is a preprint only. The final version of this article is available at:
https://www.mja.com.au/journal/2020/212/10/early-clinical-response-high-consequence-infectious-disease-outbreak-insights

Introline

This article describes the early approach of a metropolitan emergency department to COVID-19.

Introduction

Coronavirus 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), emerged in China in late 2019 (1). COVID-19 is one example of a high consequence infectious disease (HCID) that may present to an Australian hospital. These infections are uncommon in Australia and are almost always cases where infection was imported from overseas. Less frequently, there is onward local transmission, such as during the influenza A(H1N1) pdm09 pandemic (2009).

HCIDs present unique challenges to Australian hospitals. Their rarity leads to unfamiliarity and loss of institutional knowledge between events. Many hospitals operate at near maximal capacity between outbreaks and have limited surge capacity (2). Protocols designed to manage single patients require adaptation to situations where larger numbers of patients require isolation, assessment and testing for infection.

While every Australian hospital has a mass casualty or disaster protocol, these are developed for “All Hazards” and may not address problems specific to HCIDs: the need to rapidly identify and isolate potentially infectious patients to prevent nosocomial transmission; the complexity of rapid triage and assessment on frequently evolving epidemiological and clinical grounds; the difficulty of differentiating HCIDs from more common but clinically similar conditions (3); the absence of rapid diagnostic tests to aid clinical decision making; and the potential for a prolonged surge for weeks to months during which time the workforce may be affected by both infection and absenteeism.

Here we describe the strategic approach of The Royal Melbourne Hospital (RMH) to triage and screen patients who have presented at risk (or concerned that they are at risk) during the early phases of COVID-19. Our resources may be of value to other organisations refining their triage and clinical algorithms.

The Royal Melbourne Hospital Response

RMH is an adult tertiary referral centre and the designated state-wide provider for quarantinable diseases. The ED treats over 80 000 patients annually.

From 6 January 2020, we instituted tools to identify at triage those patients with risk factors for COVID -19 and rapidly isolate them. Initially there was capacity to assess patients in one of three existing negative-pressure rooms. On 25 January, the first patient with COVID-19 in Australia was confirmed, who had arrived in Melbourne on a flight from Guangzhou. The Victorian Department of Health and Human Services (DHHS) informed all passengers on the flight of their possible contact with the case, leading to a significant surge in presentations to RMH.

Table 1 (available in the PDF version) presents an overview of the challenges in managing HCIDs, and details of our coordinated approach. Key components that can be utilised by other services are detailed below.

Governance 

Unlike other major incident responses, which tend to be short-lived, response to an outbreak requires a sustained response that will inevitably impact other clinical services. A governance process that includes executive sponsors and senior clinical leaders is essential.  The RMH COVID-19 response leveraged existing Code Brown (external emergency) Pandemic Sub-plan and Clinical Code Yellow (internal infectious disease emergency) plans as a governance framework. A governance group including medical and nursing executives, and senior clinicians from ED, Infectious Diseases (ID), Infection Prevention Services (IPS) and Microbiology meet regularly.

A single ‘standard operating procedure’ exists on our hospital intranet that provides all clinically relevant information for frontline healthcare workers (e.g. Personal Protective Equipment (PPE) guidelines, current case definitions, patient assessment algorithms). It is updated frequently given the dynamic situation, and so functions as a ‘living’ document for staff. This provides 24/7 access to an authoritative source that supports junior and senior staff alike to feel confident in their practices and approach.

Infrastructure

Establishment of a “Fever Clinic”

A particular design feature that may be adopted by other facilities is the rapid establishment of an out-of-department “fever clinic”.  In response to the first surge of patients, we rapidly repurposed the nearby hospital transit lounge (which was closed for the weekend), into a fever clinic (see Figure 1, available in the PDF version). The clinic received its first patient within two hours of notification from DHHS of the first local case. In its first 7 days, we assessed 109 patients. We discharged over 90% of patients within 4 hours of arrival. We retain this model, as patient numbers continue to increase.

In this model of care, patients are physically segregated from the rest of ED into a dedicated rapid assessment and treatment space from their arrival, limiting exposure to other patients. The main benefit of this approach is that cases yet to be identified can be an important contributor to nosocomial transmission, and so early separation and detection is vital (8) (9). However, immediate recognition of cases is difficult due to unfamiliarity with the disease, overlap in clinical presentation with more common illnesses, and due to patient wait times.

Our fever clinic model of care was based on the success of this model in Toronto and Taiwan during the SARS outbreak (4), where no transmission was reported in these facilities, despite hospital exposure being implicated in the majority of cases in these regions [e.g. the presumed source of exposure for 72% of patients in Toronto (5) (6)]. It has also been reported as an effective strategy for triaging patients in Wuhan for COVID-19 (7). Similar approaches appear to have been used in other countries, but detailed descriptions are not yet available in the literature. In Australia, segregation of major incident patients was exemplified by the Royal Darwin Hospital, which functioned as the forward receiving hospital for medically-evacuated patients during the 2002 Bali Bombings (8).

Benefits include:

1. protecting an existing environment for the maintenance of business continuity;
2. facilitating protocoled interventions for spatially-clustered groups of patients;
3. providing a physical location to send additional “disaster resources” without cluttering areas of core business;
4. enhancing record-keeping.

Limitations of our approach are the additional staffing required, operational impact of loss of transit lounge, staff unfamiliarity with the location of resources (such as resuscitation trolleys), and a slightly further distance from resuscitation bays if patients deteriorate. We were also concerned about the potential risk of stigmatisation of patients who are seen to be segregated from the main ED waiting room cohort.

Implementation of Electronic Self-Registration and Self-Screening

A surge related to an emerging infectious disease provided our clerking department with a confluence of unique administrative and logistical challenges.  These included:

• A high proportion of patients came from a non-English speaking background;
• Contact tracing and follow-up requires accurate registration and an extended suite of contact details, but usual disaster response medical records protocols generate only anonymised patient registrations;
• Non-clinical staff (ward clerks) unfamiliar with PPE would be required to extensively interview patients to confirm details at some point;
• Patients came in bursts, producing delays in registration;
• Manual screening paperwork and registration papers provide a potential fomite for disease transmission;
• Our ED is paper-free under usual circumstances.

We developed a novel solution to this problem, leveraging the fact that over 91% of Australian citizens, and over 96% of Chinese citizens own a smartphone (9) (10) and converted an initial paper-based bilingual screening tool to an online one. This is hosted using the REDCap™ electronic data capture tool (11) (12).

Patients are directed to a secure website optimised for use on a smartphone. The registration portal is free to use. They answer questions regarding their epidemiological risk (such as a detailed travel history, or being a healthcare worker), clinical risk factors (such as being immunocompromised) and symptoms. Results are immediately fed to remote clinical computers where ward clerks can register the patient without direct patient contact, and clinicians can see screening information prior to their clinical encounter.

While not yet tested under a pandemic scenario, we anticipate this method of self-registration may be particularly useful in the event of a significant surge in patient numbers. Triage sieve and sort of patients can be rapidly undertaken by clinicians who are fed real-time registration data. Compared with usual mass casualty principles, the inclusion of epidemiological data in the e-tool is valuable for triage in this setting to screen out the relatively high proportion of patients with perceived, but not actual epidemiologic risk factors.

Our REDCap infrastructure is available in appendix 1 (see PDF version) for adaptation by other health services.

Conclusion

The importation of emerging infections into Australia is rare, and onward transmission is rarer still. As RMH received a surge in patients who required screening for COVID-19 relatively early during the current outbreak, our recent observations may provide opportunities for other hospitals to enhance their preparedness and response plans. We prioritise prevention of nosocomial transmission (using a scalable, separated fever clinic) early planning for worsening surge (adopting scalable solutions) and clear clinical governance (providing malleable and accessible centralized resources) .

References

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