Emergency Responses to Covid-19 Outbreak: Experiences and Lessons from a General Hospital in Nanjing, China

In general, the emergency responses of our hospital were sequentially practiced in three major phases according to the Covid-19 situation in Nanjing and China (Fig. 1) (Table 1).

Phase I: It was initially launched on January 16, at the time of the declaration of its potential for human-to-human transmission by Professor Nanshan Zhong, the appointed leading advisor in the epidemics. The number of confirmed cases quickly increased to 600 nationwide, with a continuous spreading potential, and thus Chinese government soon officially ranked Covid-19 as category B infectious disease, which was managed as category A. Structural and political alteration and improvement was our essential content in Phase I under the guidance of WHO and Centers for Disease Control and Prevention (CDC). These efforts in Phase I acted as a fundamental footstone throughout the time.

Phase II: With a progressive national outbreak in China and unfortunately an increasing number of confirmed cases in other countries, the WHO-convened second meeting of the Emergency Committee decided on the determination of a Public Health Emergency of International Concern. The heavy Chinese New Year travel further challenged the healthcare facilities. All preliminary measures that were taken in Phase I were immediately upgraded since the first case reported in Jiangsu and Nanjing on January 22 and 23 sequentially.

Phase III: With a prospection of the first wave of population movement after the national holiday, Phase II covered the entire Chinese New Year week and 14-day observational isolation until February 14. In China, Covid-19 in the regions other than Hubei Province showed a substantial control. However, the possibility of imported infection and transmission was higher than before. On the other hand, we were aware of the accumulation of patients waiting, especially those with semi-elective diseases, and the necessity for work resumption. Therefore, in Phase III from February 14, consultant clinic gradually reopened, and elective operations were allowed only for Covid-19-negative patients, while all the previous protocols still being effective.

Emergency Leadership Committee—As a quick response to the outbreak of SARS-CoV-2, the Emergency Leadership Committee was launched on January 21. The committee, chaired by the President of Zhongda Hospital, included representatives from Administrative Board, relevant specialists, and logistics. This is the headquarter in responsibility for risk-assessment, decision-making and coordinating for the preparedness. An Emergency Response Plan was also established to clarify the responsibilities of each department to deal with potential internal and external emergencies. Figure 2 shows the organizational structure of the board. The Supporting Team and the Media Team were directly led by the Coordinating Team.

The Committee consists of: (1) Coordinating Team, to ensure the reallocation of personnel and resources for the potential large demand, responsible for the communication within the hospital, and with other healthcare institutions and governmental health authorities. (2) Multiple Disciplinary Team (MDT), to facilitate the quick decision making for suspected patients through either offline or online (web conference) consultation. It is composed of qualified experts from Emergency, Critical Care Medicine, Infection Prevention and Control, Respiratory, Laboratory services, and Medical Imaging. (3) Infection Prevention Control (IPC) Team, based on a specified policy. IPC team works to prevent nosocomial infections through enhanced surveillance, comprehensive evaluation, development of tailored procedures for each department, staff education, medical waste management, etc. (4) Supporting Team, to support the activities including procurement, transport, warehousing, stock monitoring and recording. Experiencing from the material shortage in Phase II, the access for public donation was immediately opened. All donations were strictly approved and were carefully examined to be qualified. (5) Public Media Team, to release daily real-time information through our own social media account, including knowledge update, operational information, highlights and achievements, psychological comfort, etc. The rapid release plays an important role in educating the public, avoiding patients' gathering, reducing the chance of in-hospital cross-infection and relieving social anxiety.

Fever Clinic—“Fever Clinic” is specifically designed as the first pass for the suspected outpatients who visit hospital with fever. The ventilation system was reorganized to prevent air backflow in the Fever Clinic. Contaminated (meeting patients), buffer corridor (donning and removing PPE) and hygiene (resting) blocks were separated. Two single-way inter-block paths were clapboarded, in such a way as to avoid the spread of pathogens efficiently. An isolated pedestrian connecting the Fever Clinic and quarantine unit was set.

Quarantine Unit—Any individual with fever, chest CT abnormalities, or epidemic contact with Covid-19 were guided to a remote quarantined unit (Fig. 3, green area). This unit was remolded from a regular day-care unit, with an enhancement in isolation, ventilation and sterilization. We estimated an outbreak with a similar mass of patients and suspects in Nanjing, as such current quarantine ward would be in significant shortage. For this, additional spaces (Fig. 3, yellow and red areas) were prepared for backups if needed. The internal building in the figure refers to the building only for in-patients in internal medicine unit.

Emergency Department and Outpatient Clinic—We re-allocated the Department of Emergency and Respiratory and doubled the areas. A case with respiratory symptoms such as coughing, with or without sputum, but no fever can be instantly evaluated by a respiratory professional. The triage center takes full responsibility to collect the epidemiological history of every one of the visitors before entering the clinics. Though the senior physician clinics were temporarily closed to avoid extensive saturation of outpatients, regular clinic was guaranteed. Online consultation and prescription system were particularly recommended for non-emergencies.

Inpatient Ward—Ward facilities and capacities were thoroughly assessed and maintained. Prominent description of Covid-19 with infection indications and notice for mask-wearing and hand hygiene were posted. For cases for semi-elective surgeries such as malignant tumors, an isolation section with single-bed rooms was prepared.

Post-operational quarantine is granted until SARS-CoV-2 tested negative. This policy is still in effect for elective and semi-elective patients, despite that Covid-19 was relatively under control recently.

Laboratory and Medical Imaging—Clinical Laboratory and Radiology worked closely for SARS-CoV-2 screening. During the initial period, virus RT-PCR test was only provided by Jiangsu CDC. In Phase II, a RT-PCR for the virus in biosafety level two modification in the hospital was quickly set up to meet the subsequent national outbreak, complying with national and WHO Laboratory Biosafety Manual [4]. Collaboratively, an isolated CT room near the Fever Clinic and Emergency was assigned, in such a way to control the in-hospital transfer and thus reduce transmission risks (Fig. 3). Air sterilization with ultraviolet light for 10 min and medical sheets were replaced after each scanning.

Operating Room—In principle, surgeries were performed in a positive pressure operating theatre, which has been proved protective to staff and surgeons from cross-infection [5]. Negative pressure operating room was proposed during 2003 Severe Acute Respiratory Syndrome (SARS) pandemics, which was suggested as an alternative and enhanced protection to surgical staffs, as it provided a satisfactory airborne precaution [6]. One out of 17 operating rooms in the main block was a negative pressure theatre, and it was the priority choice for all emergent surgeries without RT-PCR nucleic acid tests. Regular positive pressure theatres were available for elective surgeries, with full personal protection equipped for all staff.

Workflow for Outpatient Service—As shown in Fig. 4, patients with fever, respiratory symptoms or epidemic history would be transferred to the Fever Clinic. Chest CT, together with a blood test and Covid-19 nasopharyngeal swab (NS), was performed. Highly suspected patients with positive Covid-19 test and CT scan were further quarantined in the Isolation Unit for re-test by CDC. Double confirmed cases were immediately transferred to Nanjing Public Health Center, the only official hospital for Covid-19 treatment. MDT professionals were involved in evaluation and diagnosis.

Workflow for Hospitalization and Surgery Service—All in-patients went through the SARS-CoV-2 screening process to eliminate in-hospital transmission. Figure 5 Shows the screening process for hospitalization and surgery. In principle, only those with normal temperature and chest CT with negative findings were allowed for hospitalization. The notice should be taken for special scenarios such as other infectious diseases causing fevers and CT abnormalities. MDT, therefore, played an irreplaceable role in strategy making. Upon admission, patients were under individual isolation for compulsory virus screening. For those with SARS-CoV-2 positive, further management would be carried out upon CDC's re-examination.

A quick pass was applicable to emergent cases. Lacking evident exclusions, operations were allowed only in the negative pressure theatre. All surgeons and medical staffs were essentially equipped with a cap, goggles, N95 mask, shoe covers, and disposable surgical gown and single-use gloves. Special concerns arose in patients with microscopic surgeries like neurosurgeries because it is impracticable to operate under a surgical microscope with goggles or face shield. All medical wastes were collected in a SARS-CoV-2-labeled double-layer bag and handled with Clinical Waste Management Procedures. Decontamination procedures were then operated to the highest standard, and air within the theater was tested by IPC.

Training for Healthcare Providers—All staffs must finish certain courses to learn about the Clinical Practice Guidelines: National Guideline for Management of Novel Coronavirus Pneumonia Infections, and the standard operating procedures of our hospital on January 20. During Phase II, we applied online training sessions to ensure that healthcare providers updated knowledge of the latest national clinical practice guidelines and hospital emergency response plan. Several questionnaires concerned with the hospital's operational performance were designed to investigate staff satisfaction and knowledge acquirement. As the epidemic continues, due attention is paid to the physical, mental and emotional needs of doctors and nurses, and psychological intervention is available.

Training for non-medical personnel—Non-medical personnel in the hospital, including logistics, security and volunteers received the same level of personal protection from infection. They participated in skill training on hand hygiene, wearing isolation gowns, environmental disinfection, to enhance their ability to fulfill their roles in implementing emergency responses. Their regular exercises and activities were supervised by the IPC team.

Patient and visitor management—Patients and people who accompany them in general wards were required to wear (at least) surgical masks. Similar risk assessment of visitors was taken by senior nurses, and visitors from Hubei Province were forbidden. Only one single visitor at a time wearing a mask was allowed to visit a patient.

Team of human resource is in charge of arrangement and assignment of medical care providers. We faced a shortage in medical personnel throughout the time not only nationally but also in our hospital for two reasons. First, being less experienced, all the interns and junior residents were not called back and under strict self-isolation at home due to the Chinese New Year holiday. Second, twenty physicians and nurses were sent to participate in the medical team supporting Wuhan and Hubei Province, while additional medical team with 150 physicians and nurses being standby, which might further worsen the situation of staff shortage. Under such circumstances, the Human Resources took several measures. First, volunteers from the community and administrative staffs were assigned to assist the temperature measurement, epidemic history inquiry and triage the patients at the entry of the outpatient clinic. Right-on-time education and training were provided to the above personnel to ensure their qualifications during the first phase of preparedness. Second, some retired hospital staffs were included in the personnel reserve to assist clinical care when necessary. Each staff's health condition was strictly recorded. Third, psychological support to relieve the anxiety among staff was available.

To better understand and control the epidemics, several clinical trials were designed, registered and started. A randomized controlled trial was proposed by critical care medicine physicians of our hospital working in Wuhan, evaluating the safety and efficiency of a certain antiviral drug. Moreover, a large number of grants supported by various foundations such as National Natural and Science Foundation, local government, the university and hospital foundations were available to encourage more scientific researches on SARS-CoV-2.

Online Consultation and Prescription system—As a supplement to outpatient service, a free online consultation and prescription system was opened for all the specialties to reduce the cross-infection risk and decrease the workload for medical staff. The system supports real-time and appointed photo/video consultation, while payment could be accomplished online. The working site is a dedicated meeting room equipped with developed information and network communication technology.

Daily Data Report—Daily operational statistics, including outpatient numbers, suspected/confirmed cases, personnel, resources and material reserve, were all uploaded to the Office Automation system for authorized access. The management policy and procedure of the epidemics were dynamically updated and shared promptly. In addition, advices and suggestions from employees can be conveniently collected through mobile and analyzed by the committee.

Online Education and Meeting—To avoid gathering, staff training for SARS-CoV-2, weekly meetings for administrators, case discussions and lecturers were all carried out through live streaming on a mobile device.

Remote Union Consultation Platform—In response to the ongoing epidemic in Hubei Province, Zhongda Hospital joined a remote union consultation platform, which connects seven provincial-level hospitals with more than 100 experts designated for diagnosis and treatment of Covid-19. Through the platform, experts could conduct image reading and report writing, case discussion, and develop a personalized treatment plan.

Until March 4, 3879 CT scans and 2305 PCR tests were accomplished, of which 0.4% revealed abnormal image patterns and 0.1% PCR positive, distinguishing 16 suspected patients and 3 confirmed cases. No medical care provider was infected with Covid-19. There is also no case of hospital-acquired Covid-19 infection for those who received medical care in the setting of both outpatient and inpatient.

With the outbreak of Covid-19, daily reports consist of outpatients, surgeries, fever clinics and emergencies were displayed to assess the flow during the epidemics. Regular clinical services (Fig. 6A) and surgeries (Fig. 6B) maintained in Phase I had a remarkable decrease due to the clinical and elective surgery restrictions in Phase II and gradually increased in Phase III. Notably, emergencies and fever clinics were faced with a prominent peak rapidly in Phase I, with 317 patients in emergency (day 7, January 22) and 92 patients in the Fever Clinic (day 5, January 20). Considering the public panic in this period, additional health educations were provided by doctors and nurses to relieve patients' anxiety, which might contribute to the gradual decrease in patients in Fever Clinic and emergency in Phase II and even in Phase III when work resumption began (Fig. 6C).

Hospital staff may be particularly vulnerable to psychosocial distress as they faced a conflict between professional responsibilities and families. Questionnaires were designed to identify hospital staff members at high risk of suffering mental distress and other mental problems in the fight with Covid-19. Of all the valid questionnaires. 6.46% staffs suffered depression, and 9.87% had anxiety.

In addition, our infection control work was introspected through questionnaires to staff to feedback the suggestions and satisfaction. A comprehensive understanding of this novel coronavirus was displayed after training, with a scale of 95/100. Overall, most staff members (98%) were satisfied with the hospital infection control work, and excellent suggestions were provided.

Our hospital has received a total of 315,009 masks, 13,579 gowns, 125,800 gloves, 6448 goggles and 3404 face shields through public donation by March 2. Daily consumption of PPE dramatically increased, and the requirements for masks and gowns were 2.3 and 3.6 times that of last year, respectively (Fig. 7). Additional demands for goggles and face shields highlight the necessity of routine store in case of such emergency.