Virus prevention and mitigation strategies

Patient pathway

A patient pathway was developed starting from the emergency department (ED) to admission or discharge to provide the most efficient and safe care and to limit unnecessary exposure to HCWs (Fig. 2).

Fig. 2. Pathway of suspected and confirmed cases of COVID-19.

Task force teams

With the first reported COVID-19 case in the KSA, multiple task force teams were created by the IPCD to manage various essential operational functions (Fig. 3). The work dynamic of those teams was coordinated with oversight at the managerial level. Because it was beyond the capacity of the existent IPC staff to operate such emergency services, volunteer opportunities were announced to support the IPC team, which doubled the IPCD manpower from 30 to 60 HCWs. Volunteers from departments and programs that were downsized or those that held their services, such as the dental department and internship and academic programs, were recruited and trained to fulfill the required duties.

Fig. 3. COVID-19 governance and collaboration task force teams. Note. PCIA, Prevention and Control of Infection Administration; ICPs, infection control practitioners.

The task force teams were organized into 4 main groups:

1. 1. Surveillance and data management group. This group ensured that the flow of data and information would proceed in a smooth, timely, and effective manner among all groups as needed (Fig. 4).

   

   Fig. 4. COVID-19 test data flow.

2. 2. Registration team. As a national mandate and in compliance with the Saudi MoH reportable diseases notification process, any person tested for COVID-19 was registered in a national database called the Healthcare Electronic Surveillance Network (HESN). A team of public health inspectors and volunteers from the medical staff were trained to access the system and to enter required data.

3. 3. Results notification team. The results team tracked the results of registered COVID-19 test samples and entering them on a Google spread sheet that was accessible to all clinical areas. An algorithm for triaging suspected cases and testing for COVID-19 was developed based on a surveillance case definition and triaging system approved by the Saudi Center for Disease Control (Fig. 2). ⁴ Clinical specimens for COVID-19 screening (including nasopharyngeal swabs) were initially sent to a centralized national laboratory for polymerase chain reaction assay (PCR) testing. Later, testing was decentralized to many regional laboratories to increase testing capacity and to reduce turnaround time from 48 hours to 12 hours.

Driven by the royal order to offer COVID-19 testing and management as an unpaid service for all citizens and expatriates, accessibility to the services expanded. The number of COVID PCR tests increased from 10,000 tests per day to >100,000 tests daily. At KSMC, 41,916 COVID-19 samples were collected between mid-January and the end of December 2020.

1. 4. Notification and tracing teams. Proper contact tracing is an essential element in the containment of any infectious disease outbreak. Once a positive COVID-19 result was reported to the hospital, an e-mail was sent by the notification team to the concerned department(s). In parallel, the contact-tracing team tracked the pathway of hospitalized positive cases and interviews the nonhospitalized cases by telephone to identify close contacts among HCWs and patients. By the end of December, 4,914 positive cases had been traced. In addition, the notification team also communicated negative results by telephone.

Exposed personnel were also notified about their risk of exposure in order to apply the postesxposure protocol according to approved guidelines (Fig. 5). Exposure in the community (eg, household and workmates contacts) was traced and managed by the public health authority.

Fig. 5. COVID-19 healthcare worker management after exposure.

HCW postexposure management group

A special process was established for addressing HCW COVID-19 concerns. The HCW postexposure management group worked on this matter using 4 established subteams.

1. 1. Clinic team. In the beginning of the pandemic, to facilitate testing for COVID-19 and to spare the limited negative-pressure rooms, our negative-pressure ambulance was used by the clinic team to collect COVID-19 test swabs from hospital employees. The main indication for the swab test was returning from international travel.

As the situation evolved and local transmission incidents increased, a designated COVID-19 employee clinic with a broader scope of service involving family medicine physicians and internists was allocated for personnel testing in a well-ventilated noncrowded location near one of the hospital gates. This clinic serves HCWs returning from abroad, who were exposed to a positive case, and/or who presented with COVID-19 symptoms. The clinic processes aligned with national protocol for HCWs.

1. 2. Hotline team. Virtual consultation was accessible to respond to employee concerns via a hotline.

2. 3. The dormitory team. Uniquely in the KSA, the healthcare system depends on many expatriates who mostly live in a common housing building sponsored by the hospital. At KSMC, >2,000 female staff, mainly nurses, live in 3 housing buildings with ∼10 persons in each flat sharing the same kitchen and 2 bathrooms. One of those buildings has been designated for isolation of staff living in the dormitory whenever quarantine is indicated. A team was created to oversee the dormitory isolation facility, to initiate and discontinue isolation of staff living in the dormitory, to check isolated staff and meet their needs, and to ensure adherence of all staff in the dormitory to all the necessary preventive measures.

Continuous awareness and monitoring inside the dorm was conducted to minimize staff interaction and exposure between different flats by preventing social gathering in common lobbies. However, it was difficult to control the interactions inside each flat. Monitoring continued in order to detect and isolate any dormitory resident presenting with COVID-19 symptoms.

1. 4. Recovery team. A recovery team was assigned to guarantee proper and timely follow-up of HCWs affected by COVID-19 using the established return-to-work process and to ensure that manpower capacity was maintained to avoid staff shortages. Early in the pandemic, the KSA MOH regulation mandated that any positive case (including HCWs) either be admitted to the hospital or isolated in a designated quarantine hotel. Two consecutive negative PCR tests were required for release from isolation. In some extreme cases, this process took ∼6 weeks and required extended follow-up by the team. With guideline updates, home isolation was allowed if convenient, and positive HCWs were allowed to resume duty 10 days after their positive result date with symptom resolution.

Resources and services group

The resources and services group was responsible for support services and resources management and was composed of 4 subteams.

1. 1. Supply management team. The shortage of essential medical supplies was one of the major challenges faced by the healthcare system during the COVID-19 pandemic. Critical shortages were identified for PPE (mainly N95 respirators) and disinfection supplies. The supply management team was assigned to work closely with supply-chain stakeholders to oversee the inventory of critical PPE and other supplies, to calculate need and consumption, to evaluate new products, and to request the purchase of equipment and consumables required for infection control practices and COVID-19 prevention. A database was created that included items defined by the MoH as essential infection control supplies. The strategies implemented by this team were successful in optimizing PPE distribution and utilization.

New products were evaluated by IPCD and introduced by the team such as transportation capsules, HEPA filters, ultraviolet disinfection machine and powered air purifying respirators (PAPRs).

1. 2. Environmental services team. The healthcare environment and fomites can be contaminated with SARS-CoV-2, leading to possible healthcare-associated transmission to HCWs or patients. ^{Reference Pastorino, Touret, Gilles, Lamballerie and Charrel5} It is crucial to apply proper environmental disinfection to minimize risk of indirect transmission of COVID-19 infection. The environmental health team determined cleaning and disinfection protocols for patients’ rooms, utility rooms, nursing stations, offices, elevators, employee transportation buses, patient transportation capsule, public areas (eg, hospital garden and coffee shops). Selection of cleaning and disinfection products was based on approved effectiveness and compatibility according to national and international guidelines. ^{Reference Cimolai6}

Hydrogen peroxide (H₂O₂) fogging and ultraviolet light (UV) technology were used for the terminal cleaning of isolation rooms after discharge of positives cases as well as for scheduled mass cleaning of all rooms in certain hospital units. Impregnated quaternary ammonium wipes and chlorine spray were used for routine cleaning as appropriate. This team worked closely with the supportive services team conducting daily rounds to observe cleaning quality and other practices such as transportation of linen and medical waste. The frequency of waste collection was increased to meet the extra demand. To overcome the challenges of language barriers and lack of competency among poorly educated housekeepers, training was delivered to them using posters, videos, and practical demonstrations.

1. 3. Awareness and protocol team. Given the nature of this pandemic and the continuous changes in guidelines and protocols, the awareness team was tasked with keeping all HCWs updated “right on time” with current infection prevention and control information. Face-to-face education sessions and practical bedside training to address staff concerns were performed in the early stages of the pandemic, and these were soon replaced by remote education techniques. An e-learning certified course with competency assessment was launched for HCWs, especially those assigned to critical care units, emergency departments, and isolation units. Additionally, many virtual sessions were presented regarding specific topics such as the use of PAPR and protocols for PPE reuse and extended use.

Messages were circulated about preventive measures through the hospital portal. Other tools for education included messages displayed on computer screens and reminder posters located throughout the hospital, guiding HCW behaviors and providing information for the public when visiting was resumed with restricted numbers and shorter duration (after the pandemic curve flattened).

1. 4. Audit and policies team. The Central Board of Accreditation of Healthcare Institutions (CBAHI) a national accreditation body in Saudi Arabia (similar to The Joint Commission in the United States) issued a checklist consisting of 7 main standards for assessing healthcare preparedness for MERS-CoV and COVID-19. ⁷ Implementation of those standards was audited through scheduled and unscheduled leadership tours, which enhanced interaction with frontline staff, ensured compliance with the standards, and addressed personnel concerns. This team also worked closely with the quality management department to develop COVID-19 prevention policies including both the generic hospital-wide policies and specific services policies, such as dealing with COVID-19 in the operating room.

Frontline ICP group

This group consisted of 4 teams and covered different hospital units. Each team worked on enhancing the implementation of infection prevention and control measures through continuous monitoring of staff practices, immediate feedback and awareness, and checking the adequate distribution of required resources. Hand hygiene compliance was also monitored regularly by the teams using the World Health Organization observation form. ^{Reference Iversen, Stangerup and From-Hansen8}

A simplified monitoring tool for COVID-19 was created for the hospital including all preventive measures such acute respiratory illness monitoring for HCWs, social distancing, universal masking, hand hygiene, PPE practices, and environmental and equipment cleaning. The form also included a category for reporting of malpractices to the concerned supervisor, employing engineering parameters and a room-entry log book in isolation rooms (Appendix 1 online). The form was completed by infection control practitioners on all rounds that occur daily on the morning shift in all hospital units and are repeated on the evening shift in special care units including emergency department, critical care unit, and isolation wards.

Frontline infection control teams also consulted with treating teams to increase proper utilization of the isolation ward beds. This occurred through continuous joint rounds and shared decision making about discontinuing isolation and discharging suspected or confirmed COVID-19 cases.