Min-Hoe Chew1, Lester WL Ong1, Frederick H Koh1, Aven Ng1, YHA Tan1, Biauw-Chi Ong2
1 Department of General Surgery, Sengkang General Hospital, Singapore
2 Department of Anaesthesiology, Chairman Medical Board, Sengkang General Hospital, Singapore
On 11th March 2020, World Health Organization declared the coronavirus disease (COVID-19) outbreak a pandemic.  Over 509,164 people have been infected worldwide with 23,335 deaths . (case fatality-rate 4.6%)
The first imported case of COVID-19 in Singapore occurred on 23rd January 2020.  Local transmission was confirmed on 4th February 2020 and the Disease Outbreak Response System Condition (DORSCON) was raised (Orange) on 7th February 2020 [4-5]. As of 27th March 2020, there have been 732 cases in Singapore and 2 deaths.  Sengkang General Hospital (SKH) is a 1,400-bed hospital serving a population of 900,000. SKH confirmed its first case on 26th January 2020 and has managed 32 cases to date.  SKH Department of General Surgery (GS) has developed response measures to ensure all staff were ready to perform surgery for COVID-19 cases, reduce risks of nosocomial infection, and ensure continuity of care for patients. We describe the Preparation Phase in the initial outbreak, the Evolution Phase (DORSCON Orange), and Crisis Phase planning norms (DORSCON Red). [8-9]
Preparation Phasebegan before the first case was reported in Singapore. Cases were initially limited to China . Information was limited; thus, planning was based on experience with Severe Acute Respiratory Syndrome (SARS) outbreak in 2002 [11-12]. A departmental task force was formed to enforce measures implemented by the hospital and develop knowledge specific workflows. Importantly, besides fever and upper respiratory tract symptoms, COVID-19 patients could mimic surgical conditions and have diarrhoea and abdominal pain [13-15].
The task force ensured accuracy of information disseminated. This suppressed falsehood from social media and maintained morale. This also allowed rapid and effective communication between junior and senior staff, and obtained feedback regarding policies.
Internal surveillance measures
Staff conducted twice daily temperature monitoring. Temperatures were entered into web-based forms via personal smartphones. All staff had Radiofrequency Identification tags facilitating contact tracing should there be exposure. Staff who developed symptoms were to only seek medical consultation within the hospital staff clinic. This enabled symptomatic staff to be identified promptly.
Training and rehearsals
Hospital-wide refresher training on the use of Personal Protective Equipment (PPE) was conducted. This included N95 mask fitting as well as training on Powered Air-Purifying Respirators (PAPR) (CleanSpace® HALOTM, CleanSpace Technology Pty Ltd, Artarmon, NSW, Australia).
Business Continuity Plan (BCP)
The GS department split into two working teams. One team handled all inpatient services, which included emergency admissions, elective and emergency surgeries and ward rounds; the other team managed outpatient clinics and endoscopy procedures. Every seven days, teams would exchange duties.
The segregation of teams ensured that the department would remain functional should any team member fall ill. Under Singapore guidelines, close contacts of confirmed COVID-19 cases without adequate PPE, will serve a 14-day quarantine.  A seven-day cycle was appropriate in view of the reported mean incubation period of 5 days. 
This BCP was executed when Singapore raised the DORSCON level (Orange) on 7th Feb 2020.
Elective and emergency surgeries
Non-urgent, non-cancer surgeries were postponed. Time-sensitive surgeries, such as cancer-related work and limb salvage procedures, could proceed. Surgeons performed elective surgeries during designated weeks.
Outpatient clinics and endoscopy
Outpatient clinic patient volume was reduced by 30%. Non-urgent endoscopy procedures were postponed. Patients attending appointments had temperature checks and performed declarations of travel history and symptoms. Ill patients were diverted to the Emergency Department (ED).
There was a spontaneous reduction in hospital attendances. ED admissions to the surgical department fell 11% (from a median of 156 per week) initially. (Figure 1) OR utility for surgeries reduced by 13% (from a median of 155 per week). (Figure 2) Median outpatient clinic attendances also decreased by 22% compared to the same period (1674 per week in 2019), without any hospital-initiated postponement. (Figure 3)
However, between the fifth and seventh week, the number of emergency admissions increased by 7 to 14% compared to the past year. OR utility returned to normal and outpatient clinic numbers surpassed previous year numbers by 24% in the seventh week. This was likely due to increased public confidence in Singapore’s response. 
Team segregation was subsequently stopped for junior staff to meet manpower demands. Team segregation for senior staff continued.
Crisis Phase (Preparing for DORSCON Red)
In a Crisis phase, it would necessitate expansion of departments such as ED and Intensive Care Unit (ICU). The objective of Crisis Phase planning was to facilitate manpower allocation while maintaining essential surgical capabilities. (Figure 4)
Key aspects of the Crisis Phase plan are:
- Reducing OR workload to allow anesthetists to support ICU
- Reducing outpatient clinic and endoscopy workload to free staff for deployment
The course for the COVID-19 pandemic is likely to be protracted.  A surgical department must plan a stepwise reduction of elective work to allow for sustained deployment of manpower to frontline departments, and team segregation to allow for continuity of essential services.
The protection of healthcare staff is vital. Ng et al. reported 85% of 41 healthcare workers were exposed to a COVID-19 patient during an aerosol generating procedure . None acquired the infection even though not all were in N95. Standard hand hygiene practices remain important.
Our department statistics provide a snapshot of Singapore’s health-seeking behaviors. Postponing elective surgeries did not reduce workload and more patients were admitted as emergency cases.
We acknowledge that we have had a very controlled increase in the number of COVID-19 cases; much of this is a result of a national strategy of rapid detection and isolation of cases and aggressive contact tracing.  Nonetheless, it is challenging to strike a balance between complacency and overreaction. Premature implementation of drastic measures can lead to staff burnout and resource wastage. Indecisive action however, may result in nosocomial spread and a loss of confidence in hospital leadership. The department has benefitted from the hindsight of the SARS outbreak in 2002.
In the COVID-19 pandemic battle, there are multiple considerations in how a surgical unit functions. Phases of Preparation, Evolution and Crisis will require hard decisions, strong leadership and decisive communication. A robust BCP is essential to ensure that surgical patients continue to have quality care.
1. Ghebreyesus TA. World Health Organization. Coronavirus disease 2019 (COVID-19). WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020. March 11, 2020. Available at: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020. Accessed March 11, 2020.
2. WHO Coronavirus Situation Report 67. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200327-sitrep-67-covid-19.pdf?sfvrsn=b65f68eb_4. Accessed 28th March, 2020.
3. Abdullah Z, Salamat H. Singapore confirms first case of Wuhan virus. January 23, 2020. Available at: https://www.channelnewsasia.com/news/singapore/wuhan-virus-pneumonia-singapore-confirms-first-case-12312860. Accessed March 14, 2020.
4. Ministry of Health, Singapore. Confirmed cases of local transmission of novel coronavirus infection in Singapore. February 4, 2020. Available at: https://www.moh.gov.sg/news-highlights/details/confirmed-cases-of-local-transmission-of-novel-coronavirus-infection-in-singapore. Accessed March 14, 2020.
5. Ministry of Health, Singapore. Risk assessment raised to DORSCON Orange. February 7, 2020. Available at: https://www.moh.gov.sg/news-highlights/details/risk-assessment-raised-to-dorscon-orange. Accessed March 15, 2020.
6. Ministry of Health Singapore Updates on COVID-19 Local situation. Available on: https://www.moh.gov.sg/covid-19. Accessed March 28, 2020.
7. Channelnewsasia. 4th confirmed case of Wuhan virus in Singapore: MOH. January 26, 2020. Available at: https://www.channelnewsasia.com/news/singapore/4th-confirmed-case-of-wuhan-pneumonia-virus-in-singapore-moh-12339912. Accessed March 14, 2020.
8. Yeo C, Kaushal S, Yeo D. Enteric involvement of coronaviruses: is faecal-oral transmission of SARS-CoV-2 possible? Lancet Gastroenterol Hepatol. 2020 Apr;5(4):335-337.
9. Ministry of Health, Singapore. Ministry of Health Singapore pandemic readiness and response plan for influenza and other acute respiratory disaeses (revised April 2014). April, 2014. Available from: https://www.moh.gov.sg/docs/librariesprovider5/diseases-updates/interim-pandemic-plan-public-ver-_april-2014.pdf. Accessed on March 20, 2020.
10. Li Q, Guan X, Wu P, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020 Jan 29. doi: 10.1056/NEJMoa2001316. [Epub ahead of print]
12. Chow KY, Lee CE, Ling ML, et al. Outbreak of severe acute respiratory syndrome in a tertiary hospital in Singapore, linked to an index patient with atypical presentation: epidemiological study. BMJ. 2004 Jan 24;328(7433):195.
13. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395: 507-13.
14. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease, (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648. [Epub ahead of print]
15. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan. China. Lancet 2020; 395: 497-506.
16. Ministry of Health, Singapore. Multiple lines of defence to guard against local spread of COVID-19. March 13, 2020. Available from: https://www.gov.sg/article/multiple-lines-of-defence-to-guard-against-local-spread. Accessed on March 22, 2020.
17. Ipsos. Singaporeans are confident in the Government amidst fears of the COVID-19 outbreak. March 16, 2020. Available from: https://www.ipsos.com/en-sg/singaporeans-are-confident-government-amidst-fears-covid-19-outbreak. Accessed on March 22, 2020.
18. Tan A. Covid-19 likely to last till end-2020 at least: Experts. March 9, 2020. Available from: https://www.straitstimes.com/singapore/health/coronavirus-covid-19-likely-to-last-till-end-2020-at-least-experts. Accessed on March 22, 2020.
19. Ng K, Poon BN, Kiat Puar TH, et al. COVID-19 and the risk to health care workers: a case report. Ann Intern Med 2020 Mar 16. Doi:10.7326/L20-0175 (Epub ahead of print)
20. Wong JEL, Leo YS, Tan CC. COVID-19 in Singapore-Current Experience: Critical Global Issues That Require Attention and Action. JAMA. 2020 Feb 20. doi: 10.1001/jama.2020.2467. [Epub ahead of print]