April 2020

4/1/2020 | BY Elhanan Bar-On, MD, MPH

Israel - COVID-19 Response at Sheba Medical Center

Operation of an isolation and treatment center in an existing hospital during a contagious outbreak.

Lessons learnt from the COVID-19 pandemic
*I can also share with you a ppt file (on wetransfer which includes useful photos)

Abstract
Following the outbreak of COVID-19, a facility for isolation and treatment was established in Sheba Medical Center (SMC) with the goals being early triage and identification of potential COVID-19 patients, prevention of the spread of the disease, provision of high level care while maximizing protection of medical and logistic staff from possible infection and prevention of contamination of the SMC main campus in order to ensure operational continuity. The facility was established in a complex serving as staff accommodation, situated remotely from the main SMC campus, which was adapted to serve as a hospital. It contained 40 beds, 4 of which had intensive care unit (ICU) capabilities, a point of care (POC) laboratory, mobile radiography, ultrasonography and computed tomography (CT). Patients were classified as suspected or confirmed COVID-19 and the facility was divided accordingly into clean, contaminated and intermediate zones. Operational principles included complete patient isolation from the surroundings, unidirectional motion from clean to contaminated zones and no direct contact between patients and caregivers except in emergencies. This was achieved by strict adherence to standard operational procedures (SOP) governing all activities, use of personal protection equipment (PPE), installation of double-door cubicles for delivery of food and supplies, laundry and garbage disposal and for nasopharyngeal swab testing. A multimodal telemedicine system was installed, enabling treatment to be delivered remotely while restricting patient-caregiver physical contact to emergencies. The advanced capabilities of the facility avoided the need to transfer patients to the main SMC campus.

During the first 23 days of operation, 43 patients were treated in the facility. No patient required transfer to the main SMC campus and no team member was infected by COVID-19, thus achieving the goals of the facility.
 
 
Introduction
The novel Coronavirus Disease 2019 (COVID-19) first appeared in Wuhan, China at the end of 2019 and rapidly spread to other areas in China and subsequently to other countries worldwide [1]. On March 11, 2020, The World Health Organization (WHO) officially declared COVID-19 as a pandemic.
COVID-19 is associated with febrile respiratory disease and in the largest case series published so far 26% of the patients required ICU admission with a mortality rate of 4.3% in the general population and higher amongst elderly patients [2] The virus is highly transmissible with an estimated basic reproductive number of R0 2.24-3.58 [3] , and may persist on inanimate surfaces for up to 9 days [4] . Hence it may spread rapidly within healthcare facilities and in the same case series, 41.3% of the cases were acquired in the same hospital, mostly by healthcare workers [2]. This emphasizes the importance of implementing infection control measures and the need for isolation of any suspected patient at the very beginning of admission.
 
Narrative
Sheba Medical Center (SMC) is a quaternary referral center, and houses the Israeli national virology laboratory – the only laboratory in Israel currently capable of performing polymerase chain reaction (PCR) tests for identification of the COVID-19 virus. It also houses The Israel Center for Disaster Medicine and Humanitarian Response (IDHM) which has a 50 bed rapidly deployable tented field hospital. SMC is situated in Ramat Gan which is part of the Dan metropolitan area (DMA) - the largest population concentration in Israel, counting 3.7 million inhabitants constituting 40% of the national population. In addition, SMC is the nearest medical center to Ben Gurion international airport through which the vast majority of travelers enter the country. Due to all the above factors, we anticipated that SMC would be in the frontline of receiving potential COVID-19 patients and therefore, as soon as the outbreak emerged, a task force was created which included representatives from hospital management, the center for disaster medicine (IDHM), the departments of emergency medicine, internal medicine, infectious diseases (ID), infection prevention and control (IPC), medical informatics (MI), telemedicine, logistics, human resources (HR) and public relations (PR). The task force embarked on formulating a contingency plan based on principles outlined in the WHO directives for Hospital Preparedness for Epidemics [5] and Operational detail of the WHO field hospital layout for Ebola treatment center [6].
 
The goals of the plan were:
  1. Early triage and identification of potential COVID-19 patients (both suspected and confirmed).
  2. Prevention of the spread of the disease into the surrounding community.
  3. Treatment of patients maintaining the highest level of care, while maximizing protection of medical and logistic staff from possible infection.
  4. Prevention of contamination of the SMC main campus in order to ensure operational continuity.
Once the principles were formulated, several options were considered. These included:
  1. Designating one of the in-campus, hospital wards as a dedicated ward for treatment of COVID-19 patients.
  2. Establishing a tent-based field hospital designated for COVID-19 patients, either within the boundaries of SMC or in a remote location.
  3. Establishing a dedicated facility in a structure within SMC which is not routinely used as a medical ward, distant and separated from the main campus.
On Feb. 16th, 2020, the Israel Ministry of Health (MOH) requested SMC to be prepared for admission of COVID-19 patients. The specific trigger for the request was a government decision to bring back to Israel the Israeli citizens quarantined on the Diamond Princess cruise ship, docked in Japan. After analyzing the three above mentioned options, the third option was selected and the campus was surveyed in order to locate the most suitable location. The site selected was a complex serving as staff accommodation, situated on the inner periphery of the SMC campus, 1,500 m from the main campus medical facilities. The built area is 1,500 m2 containing 30 rooms and 300 m2 of open space.
The advantage of this site was its geographic location –within the SMC boundaries - enabling utilization of all hospital resources while being far from the main campus – minimizing the chance of hospital contamination. This distance also served to quell anxiety of hospital personnel regarding acquiring the disease from patients in the facility. Following site selection, a thorough survey of the complex and its infrastructure was carried out and a blueprint was produced, planning its adaptation to a facility suitable for treatment during an outbreak. We followed the principles outlined in the Operational detail of the WHO field hospital layout for an Ebola treatment center [6]:
  1. Isolating patients with suspected or confirmed COVID-19 from SMC and the community by cordoning the facility from its surroundings and confining the patients to the interior to the facility.
  2. Classification of patients into one of two groups: Group 1 –suspected patients based on a history of possible exposure, and group 2 – patients testing positive on PCR with complete physical separation between the two groups.
  3. Within group 1 – complete separation between individuals.
  4. Reducing to a minimum physical contact between patients and caregivers.
Operational Model:
  1. The whole complex was cordoned from the surroundings with 3 entrance/exit gates for personnel and logistic supplies. Three zones were defined (fig 1.):
  2. Zone C - clean: The open-air internal periphery of the complex in which a tented command and control center (CCC), staff living quarters and a logistic center were placed.
  3. Zone B - intermediate: includes an entrance lobby to the building.
  4. Zone A - contaminated: The area in which patients are accommodated.
Due to the fact that our initial group of patients included suspected unconfirmed cases, zone A was partitioned into two sections: zone A1 for group 1 suspected patients and zone A2 for group 2 confirmed patients. Zone A can also be used for patients with a high suspicion of infection pending confirmation.

The facility had 40 hospitalization beds in separate rooms and 4 in a space constituting an intensive care unit (ICU) with full mechanical ventilation capabilities. Adjacent to the ICU was a glass cubicle attached to zone B, enabling direct observation of the patients, and containing all patient monitor screens.
 
Workflow and PPE routine:
Standard operational procedures (SOPs) were outlined for all activities including patient care and flow, supply delivery and waste removal, according to the principles of isolation and protection. These SOPs were strictly adhered to and supervised by the IPC unit. PPE is donned in a tent in zone C before entrance to zones B and A. The workflow is unidirectional from zone C to B to A with exits back to zone C through a doffing tent (fig.1).

A set of cubicles was constructed in the partition wall between zones B and A with a door which on both sides. (fig 2.) These cubicles are used for delivering meals and personal supplies.

A garbage and laundry chute was constructed in zone A leading to a trolley which is sterilized and disposed daily by SMC logistic staff.

A swab-testing station was constructed consisting of a window with two holes to which long gloves were attached. (fig 3.). This station enables performing naso-pharyngeal swabs by a staff member without any contact with the patient. Adjacent to this station is a cubicle similar to the ones used for food delivery. The patients place their swabs or other specimens in the cubicle, to be removed through the external door by the staff.

A walkway was prepared outside the building connected to zone A enabling patients to exercise in the fresh air.

Mobile radiography and ultrasonography machines were placed in zone B and a mobile computed tomography (CT) machine was placed in zone C, thus avoiding patient transfer to the main campus for imaging.
 
Personal protective equipment (PPE) policy:
Four risk levels were determined with PPE policy determined accordingly:
  1. No risk: - zone C: All personnel dressed in hospital scrubs.
  2. Low risk - Zone B: 2 gowns, N-95 mask, shoe covers, hair cover, face shield, gloves.
  3. High risk – zone A: Hooded coverall, N-95 mask, shoe covers, face shield, double gloving.
  4. Logistic teams: Similar to “3” but made of more robust materials.
Our PPE policy was more stringent than that recommended by the WHO [8]. Due to a worldwide shortage of PPE, and as we learnt more about the COVID-19 viral spread, central stock monitoring and control was implemented in SMC and policies were adjusted according to specific activities in order to conserve stocks while maintaining adequate protection levels and WHO standards.
  • Telemedicine utilization:
A command and control center (CCC) was set up in an inflatable tent. It contained multiple systems enabling remote monitoring, communication and examination of patients. Auxiliary equipment was placed in the patients’ rooms. The systems included:

Communication
  • A telephone including a direct press button to the CCC and a cellular phone
  • Uniper ©  - a simple TV box turning the television to an interactive platform enabling video communication, as well as virtual group meetings between the patients and the CCC using the television and a very simple-to-use remote control which includes a built-in microphone
  • An Intouch medical© telepresence robot and a two way walkie-talkie were placed in the ICU, enabling communication with the CCC in case of an emergency forcing the staff to treat patients in zone A.
  • A public address (PA) system with loudspeakers which can be heard throughout the complex, enabling rapid emergency announcements to all patients
Monitoring equipment:
  • A thermometer, pulse oxymeter and blood pressure cuff in each room for self-measurement of vital signs
  • Earlysense © - a wireless bed sensor which continuously monitors heart, respiratory rate and motion while the patient is in bed and includes an artificial intelligence algorithm that can predict deterioration in case of secondary sepsis [7]
  • Biobeat© - a wireless sensor applied to the patient's chest which continuously mointors blood pressure, pulse rate, oxygen saturation, one-lead electrocardiograph, cardiac output, stroke volume, heart rate variability and skin temperature. This sensor is used for moderate to severe patients
Physical examination:
  • Tytocare©  - a device which enables remote physical examination of the heart, lungs, throat and ears, as well as measurement of vital signs as fever and heart rate. For easier use of this system, a tablet with the Tytocare© app was given to the patients, for simple use, in order to avoid the need  to download the designated app to their cellphone.
  • The whole facility was covered by cameras enabling observation from the CCC. Patients are counseled regarding the necessity of the camera for their safety but can request it to be disconnected.
Medical informatics:
  • Acess to the Electronic Medical Records (EMR) used by SMC (Chameleon, Elad©) and the SMC picture archiving and communication (PACS) system through computers in the CCC. 
 
All routine contact with patients is carried out through these systems. (fig. 4). This includes history taking, vital signs recording, daily rounds and all other communication. In addition, physiotherapy and psychosocial support activities were initiated, both in individual and in group sessions.
In case of emergencies or the need for direct contact with patients, staff enter zone A with appropriate PPE (fig. 5) and communicate with the staff in the CCC through the robot and walkie-talkie.
  • Personnel and organizational structure:
The center for disaster medicine and humanitarian response in SMC has a core of personnel and a roster of SMC staff members well experienced in field hospital operation in austere environments and in a wide range of scenarios. Based on this core, and realizing that working in the COVID-19 facility will require a large team with appropriate expertise and mindset, we selected a team from the large pool of SMC personnel. These included hospital directors and administrators, physicians, nurses, ID and IPC experts, psychosocial caregivers, logisticians and telemedicine experts. All team members voiced consent to working in the contagious environment and were then removed from their routine work roster and were subsequently totally dedicated to working within the All team members underwent a detailed briefing by the IPC unit specialists. This included principles of functioning in outbreaks, staff protection routine, use of protective personal equipment (PPE), patient handling, and patient transport. A model of the facility was constructed in our simulation center and the team was trained in various scenarios including patient and workflow routines and operation in various emergency situations using PPE and mannequins.
  • Patient flow:
When possible, phone contact is made with the patient before arrival and initial information is obtained. Upon arrival, the patient is met by a physician in full PPE and a short history is taken to assess his/her status. The patient is then allotted a bed appropriate to his/her condition. Asymptomatic patients are accompanied to the room and given a short explanation of the telemedicine tools and then the physician exits zone A. Symptomatic patients are examined and blood samples are obtained.

Once the patient is settled in the room, telemedicine contact is established (mainly via Uniper©), a thorough history is taken and a detailed explanation is given regarding further usage of the telemedicine equipment. From that moment, all routine patient – caregiver contact is performed remotely or across a transparent barrier when taking swabs. All patient activities are timed and controlled by the CCC in order to minimize contact between patients. Initially this was of utmost importance due to the presence of unconfirmed patients. Once these were discharged patient contact was enabled.
Activities include collection of food and supplies, garbage disposal, swab testing and exercise in the outdoor walkway.
  • Patient Load:
During the first 23 days of operation 43 patients were admitted. 39 were mildly symptomatic and 4 were seriously ill. No patient required endotracheal intubation and there was no mortality.
 
Discussion
Whereas the primary goal of a medical facility in routine times is providing optimal care to patients, in the contagious outbreak setting, the additional goals of preventing the spread of the disease and staff protection gain utmost importance. When the facility is established within an existing medical center, the need to protect this center and to ensure its operational continuity becomes another major goal governing its operational mode.

When SMC was given the mission to establish a COVID-19 treatment center, we set out on this mission bearing in mind the above goals. The chosen site was a building within the boundaries of SMC but remote from the main campus. This enabled utilization of all SMC resources, however the remoteness of the facility enabled ample separation and protection of the campus. In an urban setting this spacing may not be possible and such separation may pose a major challenge. This remoteness also served to quell the anxiety of hospital staff due to the presence of COVID-19 in the hospital grounds.
The conversion of the facility to a hospital, taking into account the unique needs arising during a contagious outbreak was a major challenge. This was accomplished rapidly by our logistics section and emphasizes the importance of a strong logistic force in this scenario.  

Rapid team building is of utmost importance in this scenario. This was achieved by forming an organic dedicated team based on the core of the IDHM personnel with its vast experience in disaster scenarios and augmenting it with members of the large SMC staff who were dedicated to the facility. 
The SOPs governing operational routine and patient flow as well as logistic activity were developed and modified on a daily basis as we went along, adhering to the principles of isolation, treatment, and protection. The challenge of staff protection was addressed by combining meticulous adherence to SOPs and PPE usage, and the extensive use of telemedicine technology, part of which was not used by the clinicians prior to the event. The implementation of telemedicine technologies without prior training and therefore the need to train the patients remotely, posed a significant challenge. However, once this was achieved, these technologies enabled comprehensive treatment of all the patients’ physical and emotional needs, while minimizing patient -caregiver contact. The fact that no staff member tested positive for COVID-19 at the end of their deployment supports the effectiveness of these measures. 

The operational continuity of SMC was preserved throughout the period of operation. At the time of writing no patient required transfer from the COVID-19 facility to the main campus and no alterations were made in SMC activity.
 
Conclusions:
The COVID-19 outbreak which started in late 2019 posed multiple challenges to the healthcare community worldwide. The virus was previously unrecognized and initially there was a paucity of information regarding its mode of spread, its virulence and the diagnostic methods required. The staff of SMC is highly experienced both in advanced medical care and operation in disaster zones and austere environments as well as in outbreaks, but this experience, as well as most published directives, refer to operation in isolated facilities and not in a major medical center requiring protection.

Establishing this facility within a quaternary referral center posed a major challenge of ensuring the center’s operational continuity while fulfilling all goals of the COVID- facility. This was addressed through resourceful out of the box thinking, planning and execution with strict adherence to infection prevention regulations and the utilization of novel telemedicine technologies.

 At the time of writing, the COVID-19 crisis is ongoing, spreading to more countries and has been recognized as a worldwide pandemic necessitating treatment of large numbers of patients, some of them requiring advanced treatment, in a complex scenario previously unfamiliar to the medical community.

During our operation we have encouraged consultations and visits by healthcare professionals and administrators from other centers in Israel and in the Palestinian Authority in order to share our experience and disseminate this knowledge. We hope that the lessons learnt during the establishment and operation of our facility will serve the world healthcare community in overcoming this outbreak.
 
 
 References:
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  6. WHO/EVD/Manual/ECU/15.1: Manual for the care and management of patients in Ebola Care Units/ Community Care Centres Interim emergency guidance. Accessible at: https://www.who.int/csr/resources/publications/ebola/patient-care-CCUs/en/
  7. WHO 2020 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Accessible at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection-prevention-and-control