Lessons from SARS
Hospital outbreaks of SarsCoV2 are considered important ‘milestones’ on the road from an unpleasant but manageable regional SarsCoV2 outbreak, to a major healthcare disaster with overcrowded hospitals and excess mortality. Once out of control, hospitals tend to act as super-spreaders and contribute to, rather than help contain the infection chains. Preventing hospital outbreaks, thus, is among the most important individual measures to contain the SarsCoV2 pandemic.
It will be impossible to prevent every single SarsCoV2 infection in a hospital. But there are options to reduce the likelihood of major hospital outbreaks, most importantly minimise the risk of infection and transmission, and optimise the way an infectious or potentially infectious patient is dealt with within an institution. Digital tools are important elements in this agenda, said Benedict Tan, chief digital strategy officer at SingHealth, one of the biggest healthcare providers in Singapore during a HIMSS webinar.
SingHealth is running four hospitals with around 250,000 in-house patients per years. The organisation also takes care of several million outpatients annually.
Algorithms check temperature of staff members
The most important factor for outbreak prevention, according to Tan, was staff surveillance, since it is usually members of staff, not patients, who carry the virus from ward to ward and from patient to patient. SingHealth hospitals perform laboratory screening on their staff, but they have also implemented a digital temperature measurement scheme. Every staff member is obliged to take their temperature two to three times per day. The value is stored in a surveillance system automatically, and algorithms analyse the fever curves and generate an alarm when the value exceeds the normal variation.
“We do that in order to identify fever clusters on wards as early as possible,” said Tan. It has been shown that such a temperature screening is not totally reliable, since there are infected persons who transmit the virus before becoming symptomatic. However, 100% safety is not what these types of measures are about. Measures like taking temperatures are about decreasing, not eliminating risk, and thus about reducing the likelihood of a disastrous hospital breakdown.
Want to visit? Ask the automated visitor management system first!
SingHealth hospitals also use IT systems for decreasing the risk of transmission on the side of patients and visitors. In the emergency units, every patient who is capable of doing so completes an online questionnaire in order to document symptoms and the individual medical history. This information is immediately available to the ER doctor or ER nurse as part of the electronic medical record. According to SingHealth chief medical informatics officer Goh Min Liong, this policy reduces the contact time between staff and patients and thus – again – mitigates the risk of virus transmission from patient to staff member.
Another key application, according to Liong, is an automated visitor management system (AVMS) that was developed in recent years as a direct learning from the 2003 SARS epidemic. In contrary to policies in many other countries, Singapore generally allows visiting friends and relatives in a hospital during the pandemic. But everyone has to register at the AVMS before entering the hospital.
Visitors fill in a questionnaire on symptoms and risk factors, and they have a temperature check. The AVMS then calculates a risk score. A low-risk visitor can enter the hospital pretty quickly, wearing only a face mask. A higher-risk individual will be given additional personal protective equipment first. The AVMS also makes sure that no more than two or, in less critical times, four people visit a ward at the same time. This makes it possible for ward staff to keep an eye on every individual visitor.
Two IT departments are better than one
Since the digital infrastructure has to work as reliably as possible in times of a pandemic, 24/7 availability of qualified IT staff is another success factor to keep a hospital running. This is why the SingHealth IT department has switched to a specific staff roster for the time of the pandemic. In essence, there are two separate teams, members of which work from different locations and do not mingle at all. This will help to offer IT services even in situations in which there is an outbreak within the IT department that results in quarantining of staff members.
Measures like the ones mentioned above have been copied by hospitals in many places all around the world now. The team-based approach to staffing, for example, is used in a lot of ER units and surgical departments in regions heavily affected by COVID-19. There is also an increasing number of digital infection management tools that help hospitals recognise and track infection chains should they occur despite all preventive efforts.
Three German university hospitals in Göttingen, Hannover and Berlin, for example, are currently piloting a computer-based early warning system for infections and suspicious cases called ‘SmICS’. SmICS is short for Smart Infection Control System. It was developed in the context of the ‘Medical Informatics Initiative’, a government funding program for healthcare informatics. SmICS brings together data from the medical history of patients, virus and laboratory information, and data on the movement of patients and staff. Algorithms are analysing cases daily, and visualisations are used to backtrack contacts of infected patients. SmICS is a tool that was available before the COVID-19 pandemic already. It could be adapted to SarsCoV2 with its specific characteristics within weeks – another useful example for how a pandemic virus is driving healthcare IT innovation.
In summary, digital tools offer huge opportunities for helping in the containment of the SarsCoV2 virus and other future infectious disease outbreaks. Discussions in recent months have largely focussed on tracing apps, but there is much to win in other areas, too, specifically IT solutions that make the management of infected persons and contact persons more efficient. Whether, beyond process management, a digital surveillance of quarantine is desirable is a question for which different societies will find different answers. Democratic societies should probably work towards voluntary tools with a strong focus on privacy to boost acceptance and supplement non-digital contain efforts.