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

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

Mar 13, 2024 23 likes •431 views

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

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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

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Epidemic curve of the world

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

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Epidemic curve of South Korea

200 400 600 800 1000 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

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Asan Medical Center

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

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Questionnaire for screening

Daily update

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Map of screening clinic

Reception

clinic1 clinic2 Clinic 3

Waiting room

Booth for specimen collection Booth for specimen collection PPE donning room

  • Clinic 1: Patients planned for

hospitalization with symptoms or epidemiologic link

  • Clinic 2: Outpatients with

epidemiologic link

  • Clinic 3: Outpatients with symptoms
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Clinic 1 Clinic 2 Clinic 3

Specimen collection booth

2 CXR rooms All rooms - negative-pressure

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Blood sampling Sample collection booth

  • nasopharyngeal swab, sputum collection
  • UV
  • air change rate: 300/hour
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Monitoring of fever at entrance using infrared thermometers (20 Jan~)

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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
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Universal masking

Pt with COVID-19 Healthy person

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SLIDE 13

Promotion of hand hygiene

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Respiratory ER

  • Respiratory ER (1st floor): Symptoms (fever, respiratory

symptoms or pneumonia) or epidemiologic link  universal PPE (gown, FFP2 equivalent mask, gloves, face shield)

  • ER (6th floor)
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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

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Early PCR set-up

  • SARS-CoV-2 real-time PCR
  • Start at Jan 29 (within 10 days after first case in Korea)

1 1 11 2513 134 3 1 2 2 3416 74 190 210 207 130 253 449 427 909 595 686 600 516 438 518 483 367 248 131 242 114 110 107 76 74 84 93 152 87 147 98 64 76 100 104 91 146 105 78 125 101 89 86 94 81 47 47 53 39 27 30 32 25 27 27 22 22 18 8 13 9 11 86 10 10 10 14 9496 13 8324 12 18 34 35 27 26 29 27 19 13 15 13 32 12 20 23 25 16 19 40 79 58 39 27 35 38 49 39 39 51 57 38 38 50 45 55 49 33 37 34 43 59 49 67 48 17 46 51 28 39 51 62 42 42 51 54 63 63 59 48 44 62 50 45 35 44 62 33

200 400 600 800 1000

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

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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

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  • 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
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  • 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…)

Preoperative screening at AMC

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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

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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

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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

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Healthcare workers and staff

  • Daily check symptoms and epidemiologic risk through App or

Intranet

Symptoms High risk places

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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

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Setting up guidelines for management of patients with suspected COVID-19

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

  • r 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….
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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

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Confirmed patients Highly suspected patients Environmental cleaning Patients with fever or pneumonia

Donning sequence Doffing sequence Indication

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Setting up guidelines for management or care of patients with confirmed COVID-19

  • Cleaning and disinfection of medical equipment
  • Management of deceased patients
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Preparedness for nosocomial

  • utbreak

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

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Education

  • Donning/doffing of PPE

Doctor, nurse, paramedic, cleaner, staff of facility department

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  • From Feb to Aug
  • 13 patients with COVID-19 were transferred from other hospital,
  • r 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
  • utpatient clinic of our hospital
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SLIDE 34

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

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

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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

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Mother of infant who shared the multipatient room with index

Jung J, et al. Clin Microbiol Infect 2020

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  • Considering the incubation period

Careful observation of development of symptom/sign of COVID-19 Immediate testing of SARS-CoV-2 PCR During first 2 weeks after admission

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Need for Advancement

Unmet need

(1) Fast contact tracing CCTV tracing: time-consuming, labor-intensive (2) Visitor tracing

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Thank you for your attention