:Experience of Asan Medical Center Jiwon Jung Department of - PowerPoint PPT Presentation

Preparedness and Response to COVID-19 :Experience of Asan Medical Center Jiwon Jung Department of Infectious Diseases, Asan Medical Center, Ulsan College of Medicine, Seoul, Republic of Korea

Epidemic curve of the world https://www.who.int/docs/default-source/coronaviruse/situation- reports/20200810-covid-19-sitrep-203.pdf?sfvrsn=aa050308_2

1000 Epidemic curve of South Korea 200 400 600 800 0 1/16 1/19 1/22 1/25 1/28 1/31 2/3 2/6 2/9 2/12 2/15 2/18 2/21 2/24 2/27 3/1 3/4 3/7 3/10 3/13 3/16 3/19 3/22 3/25 3/28 3/31 4/3 4/6 4/9 4/12 4/15 4/18 4/21 4/24 4/27 4/30 5/3 5/6 5/9 5/12 5/15 5/18 5/21 5/24 5/27 5/30 6/2 6/5 6/8 6/11 6/14 6/17 6/20 6/23 6/26 6/29 7/2 7/5 7/8 7/11 7/14 7/17 7/20 7/23 7/26 7/29 8/1 8/4 8/7 8/10

Asan Medical Center • 2,700-bed, tertiary care center, Seoul, Korea • Healthcare workers – 8,800 • Outpatient – 12,000 per day • Inpatient- 300 per day

AMC Response to COVID-19 Screening of Patient (1) Before visiting our hospital • Delay appointment of outpatient clinic or admission of patiens from high risk area or countries (e.g. China at Jan, Daegu City at Feb) (2) At visiting our hospital Questionnaire (epidemiologic link, symptom or sign of COVID-19) (3) During hospitalization Screening for pneumonia (GGO on chest CT) Periodic PCR follow-up in high-risk patients (from Daegu City or other epidemiologic risks)

Questionnaire for screening Daily update

Booth for specimen PPE collection donning Map of screening clinic room clinic1 Booth for specimen collection • Clinic 1: Patients planned for hospitalization with symptoms or Waiting clinic2 epidemiologic link room • Clinic 2: Outpatients with Reception epidemiologic link • Clinic 3: Outpatients with symptoms Clinic 3

2 CXR rooms Clinic 3 Specimen Clinic 2 collection booth Clinic 1 All rooms - negative-pressure

Blood sampling Sample collection booth - nasopharyngeal swab, sputum collection - UV - air change rate: 300/hour

Monitoring of fever at entrance using infrared thermometers (20 Jan~)

Restriction of visitors • Restriction of parcel service • Delaying students’ clinical training, and volunteer staff • Restriction of visit to wards and ICU • Restriction of go-out of in-patient

Universal masking Pt with COVID-19 Healthy person

Promotion of hand hygiene

Respiratory ER • Respiratory ER (1 st floor): Symptoms (fever, respiratory symptoms or pneumonia) or epidemiologic link  universal PPE (gown, FFP2 equivalent mask, gloves, face shield) • ER (6 th floor)

Caution with aerosol generating procedures • Nebulizer use: only after authorization by pulmonologist single room, proper PPE • CPCR, bronchoscopy and other AGP (BiPAP, CPAP, high flow O2 therapy, T cannula suction, et al.) – single-room, proper PPE (gown, gloves, FFP2 equivalent mask, face shield or goggle) • Bronchoscopy – universal PCR screening 1 day before bronchoscopy

Early PCR set-up • SARS-CoV-2 real-time PCR • Start at Jan 29 (within 10 days after first case in Korea) 1000 909 800 686 600 595 600 518 516 483 449 438 427 400 367 253 248 242 207 190 200 210 152 147 146 130 131 104 125 114 107 100 98 101 105 94 93 91 87 89 86 110 84 78 81 79 74 76 74 76 67 64 63 63 59 62 59 62 62 58 57 55 53 51 51 51 51 54 47 47 39 49 50 49 49 48 48 50 45 43 46 44 45 44 40 39 39 39 39 42 42 35 35 38 38 38 37 35 32 34 32 33 34 33 3416 27 30 27 27 27 29 27 27 28 25 26 25 22 22 20 23 18 18 19 16 19 17 13 14 13 12 13 15 13 12 8 9 11 86 10 10 10 9496 8324 2513 134 1 1 11 3 1 2 2 0 1/16 1/20 1/24 1/28 2/1 2/5 2/9 2/13 2/17 2/21 2/25 2/29 3/4 3/8 3/12 3/16 3/20 3/24 3/28 4/1 4/5 4/9 4/13 4/17 4/21 4/25 4/29 5/3 5/7 5/11 5/15 5/19 5/23 5/27 5/31 6/4 6/8 6/12 6/16 6/20 6/24 6/28 7/2 7/6 7/10 7/14

Preoperative screening at AMC • At other hospital at Daegu (Feb 2020) Just after living donor liver transplantation, donor was confirmed to have COVID-19  Closed operating theater • High risk: aerosol generating procedure including intubation, Positive-pressure room

• 1,128 patients with confirmed COVID-19 (perioperative) • 30-day mortality: 24% • Pulmonary complication: 51% Discussion • In the future, routine preoperative screening for SARS-CoV-2 might be possible with rapid tests that have low false positive rates, but hospital-acquired infection would remain a challenge. • Strategies are urgently required to minimise in-hospital SARS-CoV-2 transmission and mitigate the risk of postoperative pulmonary complications in SARS-CoV-2-infected patients whose surgery cannot be delayed. Lancet. COVIDSurg Collaborative

Preoperative screening at AMC • Since Feb 24, PCR-based universal preoperative screening • Since April 1, pooling (5 specimens) • Feb 24~ Apr 24 positive rate 0% (0/9,099) (95% CI, 0.00-0.04%) We deferred elective operation of patients with high epidemiologic risk (Daegu citizens…)

Universal screening at admission • 4/29~ all patients • Epidemiologic link or symptoms (+)  screening clinic, wait until getting negative PCR results • Epidemiologic link and symptoms (-)  collect the specimen at walk-through screening centers admission without getting PCR results • Apr 29~ Jun 10 • Positive rate – 0% (0/13,132) (95% CI, 0.00-0.03%) ♣ Deferred hospitalization in patients with high epidemiologic risk

Management of materials and medical equipment • Global shortage of PPE especially masks • Need for checking stocks, always! • PPE Gown (surgical gown, coverall) Glove Mask (N95, FFP2 equivalent level (KF94), surgical masks) Goggle, face shield • PAPR hood • Isolation pod, negative pressure wheel chair • Ventilator, High flow nasal cannula, ECMO 음압 이송 장비

Healthcare workers and staff • Restriction of visiting high risk places or cities/countries with high prevalence of COVID-19 - Karaoke, theater, sauna, night club, pub… • Restriction of gathering • Any respiratory symptoms  SARS-CoV-2 PCR, restriction from working until symptom relieves • Sharing informations, news, guidelines regarding COVID-19 in the front page of intranet

Healthcare workers and staff • Daily check symptoms and epidemiologic risk through App or Intranet Symptoms High risk places

Guardian in the wards • In-patients always stay with their caregivers or guardians • Screening for caregivers, guardians – needed • Mobile questionnaire system (Jul 1th~ ) • Symptoms and visiting history of high risk places

Setting up guidelines for management of patients with suspected COVID-19 or those with symptoms with or without pneumonia

Setting up guidelines for management of patients with suspected COVID-19 or those with symptoms with or without pneumonia • Classified by epidemiologic link, pneumonia, and symptoms  9 levels • Isolation room designation (single room, negative-pressure room) • PPE • Number need to follow-up PCR • Time of release isolation….

Setting up guidelines for management or care of patients with confirmed COVID-19 • Proper PPE Coverall N95 mask +- PAPR double gloves goggle/face shield Apron boots

Patients with fever or Confirmed patients Highly suspected Environmental Indication pneumonia patients cleaning Donning sequence Doffing sequence

Setting up guidelines for management or care of patients with confirmed COVID-19 • Cleaning and disinfection of medical equipment • Management of deceased patients

Preparedness for nosocomial outbreak Setting up negative-pressure Ward/ICU • Zone 1 – Screening (6 rooms) • Zone 2 – ICU (6 rooms) • Zone 3 – general wards (16 rooms; 2 with anteroom) • Designate PPE Donning/doffing area Portable negative pressure generating machine

Education • Donning/doffing of PPE Doctor, nurse, paramedic, cleaner, staff of facility department

• From Feb to Aug • 13 patients with COVID-19 were transferred from other hospital, or community health centers  2 were died • 12 patients were diagnosed with COVID-19 at our hospital - 1 medical student - 6 at ER - 2 at general ward - 1 at screening clinic - 2 was diagnosed at community health centers before or after outpatient clinic of our hospital

Mar 31 • 9 year-old girl • 3/25 visited to other hospital (Hospital A) due to headache  intracerebral hemorrhage, intraventricular hemorrhage • 3/26 Trasnfer to our pediatric ER • She had no respiratory symptoms, no pneumonia on CXR • During staying in ER, fever developed  Neg SARS-CoV-2 PCR Jung J, et al. Clin Microbiol Infect 2020

Media release of nosocomial outbreak at Jung J, et al. Clin Microbiol Infect 2020 Hospital A

Contact tracing using closed circuit footage, interview - Parents of index - Hospitalized patients and their caregiver (guardian) - Discharged patients and their caregiver - Healthcare workers who visited the wards Jung J, et al. Clin Microbiol Infect 2020

Mother of infant who shared the multipatient room with index Jung J, et al. Clin Microbiol Infect 2020