Understanding the Singapore COVID-19 Experience: Implications for Hospital Medicine

The NUH is a 1,200-bed public tertiary care academic health center in Singapore. Before the first COVID-19 case was diagnosed in Singapore, NUH joined forces with its broader health system, university resources (schools of medicine and public health), and international partners to refine the existing structures and systems in response to this new infectious threat.

One of these structures included the existing NUH ED negative-pressure “fever facility.” In the ED triage, patients are routinely screened for infectious diseases such as H1N1, MERS-CoV, and measles. In early January, these screening criteria were evolved to adapt to COVID-19. High-risk patients bypass common waiting areas and are sent directly to the fever facility for management. From there, patients requiring admission are sent to one of the inpatient isolation wards, each with over 21 negative-pressure isolation rooms. To expand isolation capacity, lower-priority patients were relocated, and the existing negative- and neutral-pressure rooms were converted into COVID-19 pandemic wards.

The pandemic wards are staffed by nurses with previous isolation experience and Internal Medicine and Subspecialty Medicine physicians and trainees working closely with Infectious Diseases experts. Pandemic Ward teams are sequestered from other clinical and administrative teams, wear hospital-­laundered scrubs, and use PPE-conserving practices. These strategies, implemented at the outset, are based on international guidelines contextualized to local needs and include extended use (up to 6 hours) of N95 respirators for the pandemic wards, and surgical masks in all other clinical areas. Notably, there have been no documented transmissions to HCW or patients at NUH. The workforce was maximized by limiting nonurgent clinical, administrative, research, and teaching activities.

In February, COVID-19 testing was initiated internally and deployed widely. NUH, at the time of this writing, has performed more than 6,000 swabs with up to 200 tests run per day (with 80 confirmed cases). Testing at this scale has allowed NUH to ensure: (a) prompt isolation of patients, even those with mild symptoms, (b) deisolation of those testing negative thus conserving PPE and isolation facilities, (c) a better understanding of the epidemiology and the wide range of clinical manifestations of COVID-19, and (d) early comprehensive contact tracing including mildly symptomatic patients.

The MOH plays a central role in coordinating COVID-19 activities and supports individual hospital systems such as NUH. Some of their crisis leadership strategies include daily text messages distributed countrywide, two-way communication channels that ensure feedback loops with hospital executives, epidemiology specialists, and operational workgroups, and engendering interhospital collaboration.¹¹

In the United States, the Joint Commission provides structures, tools, and processes for hospital systems to prepare for disasters.¹² Many hospital systems have experience with natural disasters which, similar to Singapore’s planning, ensures structures and systems are in place during a crisis. Although these are transferable to multiple types of disasters, the US healthcare system’s direct experience with infectious crises is limited. A fairly distinctive facet—and an asset of US healthcare—is the role of hospitalists.