|Year : 2022 | Volume
| Issue : 2 | Page : 144-149
Preparing a teaching hospital and university campus for the COVID-19 pandemic: A Saudi University hospital experience
Wajdan Al-Assaf1, Mohammed Al-Raye2, Mercy Joseph2, Ahmed Al-Anazi3, Sabarina Jumat4, Hisham Al-Zughibi5, Aseem Allam2, Abdulkareem Al-Suwaida6
1 Emergency Medicine Department, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
2 Infection Control Deparment, Department of Medicine, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
3 Specialized Medical Center, Riyadh, Saudi Arabia
4 Nursing Department, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
5 Local Content and Government Procuretment Authority, Riyadh, Saudi Arabia
6 King Saudi University Deprtment of Medicine, Riyadh, Saudi Arabia
|Date of Submission||05-Dec-2020|
|Date of Decision||24-Aug-2021|
|Date of Acceptance||13-Jan-2022|
|Date of Web Publication||28-Apr-2022|
College of Medicine, Princess Nourah Bint Abdulrahman University, P O Box 84428, Riyadh
Source of Support: None, Conflict of Interest: None
Objectives: To outline the preparation conducted by King Abdullah Bin Abdulaziz University hospital, And princess Nourah Bint Abdulrahman university to deal with COVID-19 pandemic. This experience may assist other healthcare facilities (especially academic hospitals) in pandemic-related disaster planning and management. Methods: A descriptive study outlining the process of disaster preparedness and functional implication of this preparedness for a university campus and its related academic hospital to cope with the merging COVID-19 pandemic for the period from February 2020-October 2020. Results: The implemented measures in both the university and hospital helped in decreasing the rate of COVID-19 cross-infections between healthcare workers, admitted patients and university personnel. Resources were evenly distributed, and clear line of management, reporting and communication was established between the hospital and university. Conclusion : Integration between all stake holders in academic hospital and university leadership is the corner stone in pandemic and disaster management.
Keywords: COVID-19, pandemic, disaster preparedness
|How to cite this article:|
Al-Assaf W, Al-Raye M, Joseph M, Al-Anazi A, Jumat S, Al-Zughibi H, Allam A, Al-Suwaida A. Preparing a teaching hospital and university campus for the COVID-19 pandemic: A Saudi University hospital experience. J Nat Sci Med 2022;5:144-9
|How to cite this URL:|
Al-Assaf W, Al-Raye M, Joseph M, Al-Anazi A, Jumat S, Al-Zughibi H, Allam A, Al-Suwaida A. Preparing a teaching hospital and university campus for the COVID-19 pandemic: A Saudi University hospital experience. J Nat Sci Med [serial online] 2022 [cited 2022 May 21];5:144-9. Available from: https://www.jnsmonline.org/text.asp?2022/5/2/144/344204
| Introduction|| |
Novel coronavirus (COVID-19) is a new strain of coronavirus that was first identified in a cluster of pneumonia cases in Wuhan City, in the Hubei Province of China, in late 2019. The virus continues to spread; globally, as of 4:32 pm CEST, March 29, 2021, there have been 126,890,643 confirmed cases of COVID-19, including 2,778,619 deaths. On March 2, 2020, the first COVID-19 case was recorded in the Kingdom of Saudi Arabia (KSA).
Hospitals require special pandemic disaster preparation; however, this process is challenging because of the nature of the pandemic, the structure of the healthcare institution, and available human and material resources. Some checklists for disaster preparedness exist, such as the World Health Organization's checklist for pandemic influenza yet not all hospitals are ready for such a challenge. Prior studies have considered surge planning during pandemics to increase capacity and capability, resource utilization processes and procedures during influenza pandemics, including specific pediatric considerations as part of pandemic response preparation, and incident command center activation and utility during disasters before the pandemic However little research has considered a holistic approach to preparation that covers all aspects, from patient reception, management pathways, personnel preparation, and so on. A study from Schultz et al.—which details the process of preparing an academic center for the Ebola virus—is an exception. Literature delineating holistic hospital preparedness has only latterly begun to emerge and most have approached the preparedness procedure in a similar way to our paper, for example, the paper published by Gupta and Federman.
The university hospital in this study has a current capacity of 192 beds (including 31 adult critical care, 17 neonatal intensive care unit [NICU], and 11 pediatric intensive care unit [PICU] beds) and intends to grow to a 300-bed capacity by the end of 2021. We have 607 medical staff, with a nursing staff of 557. In addition to the hospital, we prepared the entire university for the pandemic. The university campus covers more than eight square kilometers', with 600 buildings, 766 classrooms, 35 lecture halls, and 3 high-tech auditoriums. More than 40,000 students across 60 nationalities attend the university. When faculty and administrative staff are included, our population is more than 60,000 people.
Overall preparedness plan
We aim to explain the overall preparedness plan for our teaching hospital [Figure 1] and the university itself (campus, staff, administration buildings, and housing). This information can help other hospitals, especially in the university setting, prepare for the COVID-19 pandemic and for future epidemics.
Creation of a task force (command and control center)
In preparation for the influx of patients with COVID-19, a task force was created in February 2020. The nine task force members included the hospital's chief executive officer, a consultant for adult infectious diseases (who is the director of the infection control department), the chief medical officer, the chief nursing officer, the head of disaster management, the manager of infection control, the director of facility management and safety, and the director of supply chain. The task force started with weekly meetings, and daily meetings were conducted throughout March 2020 after the first reported positive case, a healthcare worker (HCW).
In these meetings, a snapshot of the daily census of cases, admissions, supplies, equipment, bed status, and available personnel was presented, as were all challenges faced during the previous day. All suggestions and input from hospital members were discussed to determine their feasibility, with all approved items implemented immediately. Given the dynamic status of COVID 19, all issues faced during the previous day requiring corrective action were addressed and memos were duly distributed to the entire hospital.
An introductory preparedness meeting was conducted with the CEO and stakeholders from the emergency department (ED), outpatient department, and university medical center which covered the following: preparation of urgent logistical items from the supply chain, visual triaging at all entry points of the facility for early identification of all patients with acute respiratory illness, guidelines for the management of COVID-19 patients and exposed HCW, admission allocation and pathways, staff awareness, preparation of an isolation/quarantine building, logistical issues related to support services (maintenance and housekeeping), and awareness on the university campus.
General administrative modification
The pandemic affected core daily practices across all institutions. Precautionary measures were implemented to decrease the risk of spread: electronic biometrics to capture staff attendance were discontinued, all staff returning from other countries had to undergo 14 days of home isolation monitored by the infection prevention and control team (IC) per the Ministry of Health (MOH) recommendations, employee leave was put on hold until further notice in clinical and patient-related areas unless the departmental manager believed that the leave of a specific employee would not affect work, in which case an exception was granted by their manager and the CEO; when the spread reached a critical stage in the KSA, all visitors and patients sitters were prohibited (unless their support in patient care was necessary and under the responsibility of the admitting physician).
Hospital staff members were asked to refrain from any kind of social gathering; hence, all hospital lounges were closed, and lunch/dinner times were scheduled.
Prehospital providers' preparedness
The scope of our emergency medical services section was response to medical calls from inside the university campus. Once cases were reported in the KSA, one ambulance was designated as the COVID-19 ambulance. The entire team underwent scheduled training sessions on infection control procedures, as well as donning and doughing, with monitoring of rounds performed by the infection control department. Multiple simulations were conducted for patient transfer procedures either to or from the hospital and to the quarantine building. Any call for respiratory or fever-related complaints was approached as a suspected case. The team followed hospital policy for dealing with patients with acute respiratory infections: wearing full personal protective equipment (PPE), following contact/droplet precautions with each transfer, using portable high-efficiency particulate air (HEPA) filters to minimize aerosol-generating procedures, offloading transported patients through the designated respiratory area where a new ramp was installed; these patients were moved directly to the ED respiratory zone. This complete segregation of the two offloading zones was associated with a higher level of comfort for the ED HCWs.
As the number of asymptomatic carriers increased, standard precautions were applied for all transported patients, with terminal cleaning after each transport.
When the spread of the infection started to affect the EMS workforce, the number of quarantined personnel increased due to confirmed infection, contact with a confirmed case, or having viral symptoms and awaiting swab results.
We encountered multiple preparedness challenges:
- Human resources: Given the challenging situation, we hiring new team members was difficult, and so we sought external support from the hospital transportation department to assign ambulance drivers from their team to support our staff in their daily operations. The ambulance response crew consisted of a driver from the transportation department, a paramedic, and, for critical cases requiring external transport, a physician to accompany the patient. No changes were made to the number of staff allocated to each shift, or their working hours
- Equipment and supplies: A transportation capsule and an automated CPR machine were bought to decrease contact with infected patients, and the EMS department was the top priority area for PPE allocation. As there were shortages of N95 masks, alternatives were provided to the team (the only ones available were powered air purifying respirator)
- Communication: Due to the changing nature of the disease, and the uncertainty, there were multiple versions of case management protocols and initially even case definitions. The updated management algorithms prepared by the COVID-19 task force were sent immediately to the EMS section head who distributed them to the team via E-mails, printed papers, and through communication group (WhatsApp). The team was also connected with the medical commander who was our on-duty emergency medicine consultant and the infection control representative (assigned daily) to get directions related to patient care and disposition.
Hospital reception of patients
Since the ED is always the first point of entry, with open access for all patients, special attention had to be paid to the flow of patients to minimize the risk of cross-infections. This was achieved by segregating suspected cases from other patients.
Walk-in Patients. As the influx increased, the ED was split into two areas, the respiratory and nonrespiratory zones. The respiratory zone was for potential COVID-19 patients with a separate entrance door and consisted of a primary triage area, a waiting room, and triage rooms. At the triage area beside the door, every patient was asked about symptoms, risk factors, and case definition criteria as stated by the Saudi MOH, as well as checked for temperature, oxygen saturation, and heart rate. The separate waiting room was equipped with HEPA filters and chairs spaced 1.5 meters apart. Triage rooms, also equipped with HEPA filters, served as rapid assessment rooms where the physician examined patients. If the patient was discharged, a swab was done in the designated swab room to minimize patient movement. If the patient was sick, they were transferred through the back door of the rapid assessment rooms to the designated isolation respiratory ED area through an isolated, controlled corridor.
There was also a nonrespiratory zone to manage non-COVID-19 patients. Its primary assessment zone was located immediately in front of the door, with 24/7 nurse coverage, to screen and divert people with respiratory complaints or those who met the above criteria to the respiratory zone. When the number of cases and the percentage of asymptomatic carriers increased, additional infection control measures were implemented in the nonrespiratory zone. All patients were considered COVID-19 cases; accordingly, proper PPE was utilized and universal masking was reinforced in the area.
The number of working staff continued the same as in the pre-COVID era (1 consultant, two to three residents, 12 nurses). The nursing team was divided in each shift into two groups, one assigned to the respiratory area which consisted of three to four nurses (those who passed the N95 fitting tests and with no risk factors or comorbidities). No changes were made to the total working hours that remained; 8 h for physicians and 12 h for nursing and prehospital providers.
Infection control department staff and nursing supervisors conducted daily monitoring rounds in the ED to assess the adherence to infection control precautions, as well as the adherence to admission policies (addressed in the next section).
As the curfew and public fear of contracting the infection played a major role in decreasing the number of ED patients, the only issue we faced was related to overcrowding in the respiratory area. There were a limited number of respiratory zone beds and waiting room chairs for those who were hemodynamically stable. This was measured after the initial vital signs assessment, and in the case of overcrowding, patients were advised to wait in their cars until called by the team by phone.
To minimize the risk of spreading the infection, new clinics and services were added to maintain the continuity of patient care without adding extra risk to the patients. To maintain patient care during curfew, the following procedures were implemented: A medication refill clinic was set up, where scheduled patients had a phone interview with the physician, who requested the refilled medications that were then delivered through the postal service. To decrease the load on the ED, a walk-in clinic for urgent employee complaints continued to operate. In addition, a dressing clinic for the assessment of postoperative patients was opened based on a surgeon's request, and virtual clinics were activated for all specialties. Given the unique situation of obstetrical services, the obstetrics services continued to allow patients to attend their clinics for high-risk pregnancies.
A flu clinic was initiated at the end of March based on the decision of the COVID-19 task force, where exposed and suspected cases that met the case definition of COVID-19 were swabbed. Contact tracing for all staff exposed to positive cases and swabbing for COVID-19 were conducted in the flu clinic by the infection control department and case assessment was done by family medicine physicians assigned to the flu clinic. Exposed staff members were either sent for admission or to the quarantine building for isolation based on the clinical assessment conducted by the family medicine physician. The situation of the flu clinic, including the number of cases, scheduling challenges, and staffing issues, were discussed daily in the COVID-19 task force meeting.
Awareness regarding COVID-19 was promoted through printed materials, roll-up banners, and electronic advertisements across the hospital and university medical center. HCWs were reminded to be constantly vigilant around patients. Education and protocols for triage and evaluation of potential COVID-19 patients were communicated and monitored in the ED triage and the flu clinic daily. Education and monitoring of environmental cleaning and disinfection procedures were carried out consistently to ensure they were carried out in compliance with COVID-19 safety guidelines. Inventory conservation steps were carefully performed for all PPE to prepare for an influx of patients with COVID-19. These steps ensured that PPE remained available. Even though supply chain staff worked to secure additional equipment and supplies, future demand could necessitate the implementation of an extended or reuse program for N95 masks.
Admission of (suspected/confirmed) COVID-19 cases
A COVID-19 floor (the 5th floor) was designated for patients with suspected or confirmed COVID-19 and included an intensive care unit (ICU) for critical COVID-19 cases. The cohort decision was to provide a dedicated health care team for those patients, as well as helping to maintain the supply of PPEs in the case of shortage (as extended use of PPEs) based on the WHO recommendation., The ward had a series of single rooms and a direct connection to the designated respiratory elevator from the ED. The ward was card-access controlled, with 24/7 security coverage at the doors to control access. No visitors or sitters were allowed. To decrease PPE consumption, stable patients talked with their medical team over the telephone while the team remained outside a glass-panel door, and staff entrance was minimized to one physician only to conduct the daily examinations. Vital sign checks were reduced to twice daily, and medications were given at this time if feasible. Some regular beds were converted to a step-down unit on the same floor to minimize patient movement across the hospital.
In the case of elective admission of a confirmed COVID-19 case, for infection control, both the ED and COVID-19 ward nursing team leaders were informed to activate the patient file by the infection control team, whereupon they assigned a room and informed the on-call physician to make the admission request. Upon arrival, the patient was immediately moved to a room on the COVID-19 ward after their vitals were assessed in the ED.
All admissions from the ED, whether suspected cases or not, were placed in the COVID-19 isolation ward, where they were swabbed upon admission (either in the ED or the ward if it was an elective admission) if their swabs came back negative, they were moved from the specialty ward. As obstetric cases required unique care, upon admission of any pregnant woman, a midwife was assigned to cover the COVID-19 ward until the patient was either shifted to a new ward or discharged. Those requiring emergency surgery (including cesarean section) were shifted directly to the designated operating theatre, which was equipped with two HEPA filters, where the operating team took airborne isolation precautions during the operation. Women presenting in active labor were shifted to the designated labor room, which was equipped with HEPA filters. The delivery team complied with the airborne isolation precautions. Delivered babies were placed in a designated separate nursery section until the mother's swab results were returned.
Intensive care unit admissions
All patients requiring ICU admission, regardless of their COVID-19 status, were admitted to the ICU located in the isolation ward (our ICU consists of single-wall separated rooms), which was equipped with HEPA filters where the room was not a negative pressure room. As the number of ICU cases in the city reached a critical level, the regional command and control center started to move boarded ICU patients to us. When the hospital received the notification of an incoming ICU case, an ICU bed was assigned, and the ICU and ED teams were informed. The patient was offloaded through the respiratory pathway and immediately taken to the COVID-19 designated ICU.
Healthcare worker infection and psychological well-being
Multiple precautionary measures were applied to decrease the infection rate among HCWs (no social gathering, shifting of meetings to online versions, limiting the number of physicians attending patients with positive COVID-19 to one during daily rounds, and rescheduling of vital signs check timings to coincide with medication timing). As a result, the reported infection rate among HCWs was low (37) from March to July. Nurses and unit managers were instructed to schedule meals/break times to minimize the number in each group. Universal masking was mandatory throughout the hospital. Housing options were provided for those concerned about their families' well-being. Work attendance was limited to those on duty. Finally, psychological support channels were available through phone consultations provided by both psychologists and psychiatrists.
Personal protective equipment selection and training for hospital personnel
The infection prevention and control team started dedicated in-service training that was scheduled to cover the all personnel working in these areas, with tracking of attendees for monitoring for all clinical and nonclinical departments in the facility while prioritizing areas of greatest potential exposure (ED, critical care units, and the COVID-19 admission ward) based on risk analysis and WHO statements. These staff members received training on the proper implementation of infection control procedures, which included hand hygiene; the correct use of PPE (long-sleeved isolation gowns, gloves, and eye protection goggles or disposable face shields); proper donning and doffing of PPE; disposal of PPE, and the prevention of contamination of clothing, skin, and environment during the doffing process. Training was also delivered to nonclinical and housekeeping staff on respiratory and hand hygiene, including cough etiquette, the proper techniques for using alcohol-based hand sanitizers and washing hands with soap and water, the use of surgical facemasks, and social distancing.
The infection control department started to conduct monitoring rounds in all hospital areas, observing the process of infection control procedure applications. In the case of a breach of those procedures, the issue was referred immediately to the health care practitioner and their managers with an explanation of the appropriate way to perform them.
Logistics and supplies preparedness
The COVID task force maintained daily monitoring of logistics and the supply inventory in the facility, especially infection control-related supplies, to ensure sufficient supply levels in case of a major outbreak. All COVID-19-related supplies requested by clinical areas had to be approved by the infection control team (in terms of type and quantity) for additional control over the supply and demand. Part of the daily monitoring of supplies involved red-flagging any abnormal increases in consumption, which were investigated to determine whether there was a misuse of supplies and, if so, to address it immediately. Since the supply shortage was global, all supplies with low quantities were yellow-flagged and reviewed for alternatives.
Nursing staff were the cornerstone of this fight against COVID-19. In addition to their regular patient care duties, nurses were assigned to help in other areas of need. Nurses staffed screening stations by the main hospital door, other entrances, and the designated entrance gates for the university itself. Each person had an infrared digital temperature check, and those with high temperatures were prevented from entering. In addition to a temperature check and inquiry about any flu-like illness symptoms, everyone was asked to wear a mask (either their own or one provided by the nursing team) and to do alcohol-based hand hygiene. A group of nurses was assigned to the infection-control support team to supervise compliance with infection control procedures in patient-care areas and to conduct a massive fit test for N95 masks. These nurses were trained by the infection control team. Nurses worked together to support the infection control team in entering the swab requests into the national request database, following up with results, calling patients to check on them or inform them about their results, and calling patients to return for admission in case they were positive. They were also assigned to the hospital quarantine building for asymptomatic positive cases or suspected cases as part of the hospital beds' extension. Finally, nurses were involved as key stakeholders of the “Drive-Thru for COVID-19 swab” team within the university.
From the start of the pandemic, the COVID-19 task force agreed to utilize one of the empty campus buildings as a quarantine building to serve the following groups: Patients and HCW who were awaiting swab results and did not have proper home isolation conditions, staff who arrived from abroad, as they were required to isolate for 2 weeks before returning to work, students living in campus dorms, hospital services staff (housekeepers, laundry employees, and maintenance teams), as all of them were outsourced services, and the housing provided by their employers was suboptimal.
The building served an additional role as a place to admit asymptomatic stable COVID-19 patients to minimize the pressure on hospital wards, as the national regulations required them to isolate in a quarantine building or hospital for 10 days until their symptoms resolved. A medical team consisting of two registered nurses was assigned to the isolation building. A mobile pharmacy containing simple medications, such as antipyretics and nonnarcotic pain relief medications, was stocked, and medical coverage was provided 24/7. Patients were checked through phone calls twice daily. Patients with complaints or concerns were able to call the medical team through a designated phone number. After the initial assessment, the team could make a phone consultation to the ED on-duty consultant, who could request transfers to the ED, using our EMS system. Some hospital housekeepers were reassigned to the isolation building, with in-house accommodation because they were trained in infection control measures and terminal cleaning.
The university campus was an integral part of our preparedness procedures. Several measures were implemented to prepare it for the upcoming pandemic. It started with site visits that were conducted by the IC team to assess high-risk areas (crowded or with less aeration). Based on its findings, wall-mounted hand sanitizing alcohol dispensers were provided to the university team with advice on the proper placement locations, and advice on social distancing and protective measures was shared via social media, E-mails, university TV screens, and printed pamphlets. Additionally, the university housekeepers were trained in the proper cleaning process and disinfection procedures in case they were needed.
A comprehensive university preparedness plan was created for dealing with suspected/confirmed cases on the campus: how to notify the hospital in case of a suspected/confirmed case, how to transport cases to the hospital (routes and precautions), the process of closing classes/colleges for disinfection after such cases, and contact tracing procedures (follow the class attendees, faculty schedules, and student schedules).
When the curfew was lifted, extra measures were implemented to maintain safety, including limiting campus entrances to five designated gates, morning screening to check all employee and student temperatures upon arrival, distribution of face masks, and enforcing hand hygiene. As cases increased, learning was shifted to distance learning, except for medical interns who were not included in this national plan. To minimize their risk of infection, attendance was limited to those on call, with clear instructions for social distancing, to protect and therefore ensure the availability of those working in critical areas like ED, ICU, NICU, and PICU. In addition, their duties were changed to active simulation-based sessions and active case discussion, where they were segregated into groups, and returned home when they finished.
An educational campaign was conducted at the university by the hospital health education affairs and vice rectorate of student affairs to increase awareness and facilitate the education process for all faculties in the university. When cases were initially reported in China, an educational class was conducted for the university's Chinese students via a translator to explain what protective measures they needed to implement and when to report to the hospital. Educational materials were distributed to all students and faculty, brochures and roll-up banners were placed with all the university faculties, and respiratory etiquette and COVID-19 information was displayed on the university TV screens and distributed via E-mail to all staff and students.
| Conclusion|| |
Pandemics pose extreme challenges for the health-care sector, which needs an integrated approach that includes HCW in addition to all the support services in a hospital. Adapting procedures to a university necessitates a full integration between major stakeholders to facilitate and unify the response.
IRB Log No. 19-0241, on Nov 26, 2019. Princess Nourah Bint Abdul Rahman University (PNU) IRB has been determined to be exempt from IRB review.
Financial support and sponsorship
This research was funded by the Deanship of Scientific Research at Princess Nourah bint
Abdulrahman University through the Fast-track Research Funding Program.
Conflicts of interest
There are no conflicts of interest.
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