TTSH, NCID battle plan passes test

ON JAN 2, 2020, Tan Tock Seng Hospital (TTSH) started screening patients, who showed up at the Emergency Department (ED) with fever and symptoms of acute respiratory infection (ARI), for the disease we now know as Covid-19.

Then, reports were coming out of China describing a novel coronavirus, and TTSH began actively looking for cases who came to the ED with a history of travel in Wuhan, coupled with symptoms of ARI.

This was Singapore healthcare's very first step in what was to become its outbreak response, a period that marked the Emerging Phase of the outbreak at TTSH as the hospital prepared for this new threat.

In those early days, a test kit was already being developed, in anticipation that reliable testing would be key in confirming diagnosis. Called Fortitude, the Polymerase Chain Reaction (PCR) test kit was developed by TTSH's Department of Laboratory Medicine together with the Agency for Science, Technology and Research (A*Star). It also ensured that Singapore had a reliable local supply of test kits.

Suspect cases then were tested at TTSH ED and conveyed to the National Centre for Infectious Diseases (NCID) across the road for isolation. This was done via a specially designed double-deck bridge connecting the two buildings. Laboratory testing using PCR analysis by the National Public Health Laboratory (NPHL) was subsequently transferred to TTSH's Department of Laboratory Medicine (DLM) to better support and scale up clinical testing capacity to 24/7 for NCID and TTSH. (Today, testing for Covid-19 is done across public and private laboratories in support of efforts to contain the outbreak.)

On Jan 22, the Ministry of Health declared Disease Outbreak Response System Condition (DORSCON) Yellow. The next day, Singapore's first imported Covid-19 case was confirmed at the Singapore General Hospital, on Jan 23. The day after, the country's second imported case was confirmed at NCID.

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TTSH and NCID immediately moved into the Containment Phase of the outbreak, focusing on efficient screening and isolation.

By Jan 27, three contingency outbreak wards at NCID were opened to provide isolation beds for suspect and confirmed cases.

With numbers expected to rise, the hospital set up its Integrated Operations Coordinating Platform (IOCP) comprising leadership across TTSH and NCID, and started joint command operations.

Jan 28 was set as the date to kick off TTSH's augmentation for the outbreak response at NCID - that is D-Day in the hospital's Outbreak Disease Preparedness Plan.

To do this, TTSH had to reduce its Business-as-Usual (BAU) operations to make available manpower and resources for its Covid-19 response. Arrangements were made to quickly triage clinic appointments and postpone elective and non-urgent cases. Non-Covid-19 patients warded at NCID needed to be moved to TTSH so that the vacated wards could be readied to hold Covid-19 patients.

Upon 24-hours activation, TTSH ED transferred Covid-19 screening operations across the road to the purpose-built Screening Centre at NCID. A total of 1,266 staff were transferred from the main hospital to augment the 687-strong NCID and ramp up NCID's capacity, and open a 24/7 Screening Centre.

Ten days from D-Day activation, this Phase 1 ramp-up of NCID from 150 to 330 operational beds was completed, by Feb 7, just as MOH declared DORSCON Orange.

During the Sars outbreak in 2003, TTSH was locked down and designated the Sars hospital. That experience shaped the hospital's planning and development of NCID to become Singapore's vanguard against infectious diseases. NCID, officially opened on Sept 7, 2019, merely months before Covid-19 landed in Singapore, was ready just in time.

With the understanding that no two outbreaks were identical, a contingency had been built into NCID by design to be able to increase beds up to 586 with ready-oxygen points. On March 15, MOH approved TTSH's further augmentation plan to increase NCID's total beds from 330 to 586 beds.

This Phase 2 ramp-up saw an additional 422 staff being deployed to NCID. This brought the total headcount deployed from TTSH to NCID, to 1,688 staff in Phase 1 and 2, including 107 staff seconded from other public health institutions.

As the Covid-19 outbreak began to worsen after March, TTSH moved into a third phase, significantly scaling up its Covid-19 capacity beyond NCID.

On April 14, TTSH opened its first overflow Covid-19 ward back at the main hospital. At peak capacity in the middle of May, some 1,475 beds were operationalised for Covid-19 across the TTSH campus. This was on top of operating 729 beds for TTSH's BAU patients then.

During the outbreak, TTSH and NCID were managing about 50 to 70 per cent of the national workload for Covid-19 patients who required hospital care. As of June 1, we had screened more than 30,000 and admitted more than 9,000 patients for isolation and treatment.

Today, Singapore has come out of the Circuit Breaker Period, and so begins a slow and carefully calibrated transition to the Recovery Phase of the outbreak for Singapore.

As a result of the collective efforts of the whole community to flatten the curve, healthcare capacity has been safely conserved, especially with the massive opening of community care facilities for recovering Covid-19 patients. This recovery phase has been called a dance with the need to calibrate the resumption of hospital services versus our continuing vigilance to respond to any resurgence of cases in the community. It will be prolonged as we strive to keep the curve flat, transit to a new normal, and await the development of a vaccine for establishing herd immunity.

WHAT WE LEARNT IN OUTBREAK MANAGEMENT

At TTSH, we learn that outbreak management at the hospital level has to be nimble; to quickly take on various postures and effectively tackle the fast-evolving situation, in tandem with public health efforts at each phase of the outbreak.

We have to be ready, respond, and recover, only to be ready again.

Here, we outline key leadership considerations in a Hospital Outbreak Management (HOM) Framework.

State of Response

In the thick of the outbreak response at ground zero, there are five key leadership considerations.

Safety: Protect our healthcare workers so that they will protect one another and their families, and keep our patients safe. The key to safety is strong infection control and prevention. It starts with universal precautions, hand-washing and the appropriate Personal Protective Equipment (PPE) for each role and location.

Safety is also achieved by design, with facilities planning for the segregation of staff and patient flows, and clean and dirty flows. Negative pressure rooms with areas for donning and doffing PPEs need to be provisioned. Safety is also a culture. From voluntary incident reporting to quality assurances, it allows for continual improvements with psychological safety and a just culture for those involved.

Systems: Taking a systems approach to support ground operations enables a concerted hospital-wide response. A Command, Control and Communications (C3) system was recently commissioned at the 24/7 TTSH Operations Command Centre. It provides real-time visibility of patient flow and resource management.

The C3 system is a game changer, with the ability and agility to scale an outbreak response from a single hospital to a national strategy across hospitals.

Scalability: This is essential for the hospital to switch from "peacetime" mode to "outbreak" mode in as short a time as possible, and scale accordingly to the fast-evolving situation. It pertains to three key aspects - capacity (such as beds), capability (such as lab testing) and manpower. Scalability allows the outbreak response to be titrated one step ahead of the situation so as to respond effectively, but not too far ahead such that there is disconnect with reality on the ground. It enables the hospital to manage peaks and troughs in demand, and rest manpower in between peaks. It also allows for capacity to be balanced between BAU and outbreak response. This was a key factor in planning for NCID to be integrated with TTSH for a full outbreak response; for capacities, capabilities, and manpower to be supported by the main hospital in a scalable way.

Surveillance: While watching the front door during an outbreak, the hospital must keep an eye on the back door, as there is always the risk that hospital staff and BAU patients could bring in the infection from the community.

TTSH's Department of Clinical Epidemiology oversees hospital surveillance. Doing "sweeps" across the hospital at the beginning of an outbreak is key to the containment strategy prior to commencing screening of new admissions and visitors into the hospital. High-risk patients who may present for other conditions are identified for their susceptibility and actively isolated for treatment and safety. Staff surveillance covering sickness, twice-daily temperature monitoring, and staff movement is reinforced to facilitate efficiently any hospital-based contact tracing.

Technologies used range from the simple to the sophisticated; from Staff Roll Calls to Real-time Location Tracking Systems (RTLS); from Closed Circuit Televisions (CCTVs) to Video Analytics. All these are integrated into the C3 at the hospital's Operations Command Centre.

Sustainability: This is a key consideration for manning, especially with a prolonged outbreak situation.

The hospital needs to last the fight and not exhaust its workforce before the battle ends; there are peaks and troughs to contend with throughout. Measures to preserve the workforce include reducing non-essential activities, managing staff leave and redeploying staff.

Communications and engagement are challenging in a big hospital with more than 10,000 staff and even more so with this outbreak's critical need for safe distancing. TTSH has taken engagement online with its intranet as a single source of truth for all updates and revisions to hospital policies. TTSH's Kampung Online Application, utilising Workplace from Facebook, is the key engagement platform for team discussions and timely updates anytime anywhere. Other technologies adopted include secure messaging, chat bots, teleconferencing, and micro-learning applications.

Last but not least, equity issues do arise among groups of staff, pertaining to support, training and work schedules. Mindful that the constant heightened vigilance and increased workload may lead to both physical and mental fatigue of staff, Staff Support Staff (3S) programmes have been ramped up to focus on staff's mental well-being and welfare.

Besides the hotline, there are energising campaigns like #HealthcareHeroes and #SpreadASmile to encourage and recognise staff for their efforts. A Kampung market was also set up to share in-kind donations and goodwill by our community especially for lower-income staff. Enhanced staff policies were introduced to address issues from alternative accommodation to safe management practices. Titrated leave management ensured that as many staff as possible could take turns to rest.

State of recovery

As Singapore moves to a post-Circuit Breaker period, the hospital too has to prepare for its road to recovery. However, BAU will not be the same as before. The road to recovery from a crisis goes beyond the opportunity to re-group and re-charge. It is important the focus of recovery is ultimately on the renewal of the organisation and its workforce towards the new normal that lies ahead.

Continuing measures: We need to continue to keep the curve flat. Measures include robust healthcare actions from testing to contact tracing to containment of any resurgence of cases; new habits such as mask-wearing, eating alone in pantries and safe distancing at the hospital and during commute to and from home; and raised hygiene measures at the workplace and in the community. For the hospital, continuing hospital surveillance, strict infection control and enhanced cleaning routines will be the new normal. The hospital has adopted new technologies like machines with ultraviolet and hydrogen peroxide disinfection capabilities to assist in terminal cleaning and to keep our cleaners safe in doing so.

Community health: A population health and systems approach ensures a full recovery from the outbreak and resilience for the next. There are three aspects: vaccinations to create herd immunity, vulnerable populations that need added protection (e.g. those living in communal settings, elderly), and vigilant public health intelligence.

The hospital supports mass testing and mass vaccinations in the community, prioritising vulnerable populations. Vaccinations against other viruses like influenza also play a part to reduce the "noise" of ARI symptoms in the community. Working closely with our community care partners, the hospital helps to train staff and ensure that vulnerable populations in nursing homes are kept safe. The hospital is also a key safety net to catch the index case of a potential cluster in the community and support contact tracing and testing for close contacts.

Changing care models: We must incorporate lessons learnt during the outbreak to future care models to build up our healthcare resiliency. During this outbreak, TTSH kept one-third of its beds and clinics for BAU operations to ensure that patients have continued access to emergency and urgent care. TTSH transited the care for appropriate patients to its community care partners who are part of its integrated care network. These integrated care partnerships not just serve the hospital's patients during "peacetime" but are also vital during an outbreak for business and care continuity.

Post outbreak, TTSH will continue to shift care beyond the hospital into the community to build longer-term care relationships with patients. The hospital will not only look after patients who come through its doors but also serve the population that lives within its catchment area.

Digital health will play a transformative role in enabling care beyond the hospital's walls. It has been accelerated with shifts to telehealth and online ordering for home delivery of medications during the Circuit Breaker Period.

State of readiness

After the outbreak, the hospital will transit to a state of readiness for the next outbreak. It has to quickly incorporate lessons to be ready for the next one that can happen at any time.

Planning: Planning is key to making an outbreak a known unknown. It includes capacity planning, capability development, and manpower planning and development. Every outbreak is different. We learn with every outbreak and make plans that are modular and flexible to meet emerging threats of different virulence and infectivity.

Preparedness: The hospital conducts regular exercises to test response systems, continual staff training in PPE to build confidence, and reviews of the hospital's supply chain to ensure robustness. This is a continual learning process as what happens in between an outbreak is the difference in our ability to respond well to the next one. For the supply chain, we need to move beyond stockpiles to resiliency to trust. A system approach to supply chain management across our health system, public-private partnerships and real-time visibility of stocks and burn-rates provide assurances for all actors in the system.

People: It is proven time and time again that no plan is ever followed to a tee in an actual outbreak, and no amount of preparedness will fully suffice for the next outbreak. It is about planning, more than having a plan.

The process of planning establishes understanding and builds relationships. Preparedness extends planning to all levels of the hospital. Ultimately, it is always about people. TTSH has invested in a leadership and organisational development framework that is anchored in collective leadership across the hospital and with community partners. At the individual level, it focuses on engagement tools to build relationships. At the team level, it looks into tools to enhance teamwork. And at the organisational level, it develops networking tools to enable staff to work across teams and organisations to build partnerships. This is the essence of a future-ready organisation that can also respond in times of crisis.

To be ready is to build relationships in between crisis. Relationships are the foundation of the deep learning cycle within the organisation; the gel which brings people together to work as a system in readiness for the future, come what may.

Healthcare is first into the outbreak, last out of the outbreak and always in between outbreaks. A continual learning approach is key for hospitals to respond, recover and be ready for the next outbreak. To do so, we must re-learn, renew and build relationships. It is an unfinished framework that every hospital can build upon with lessons learnt from every outbreak. These leadership lessons go beyond hospitals to other organisations, especially those in the frontline and service industries as our new normal in readiness for the next outbreak.