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

Hospitalists care for the majority of medical inpatients across the United States,¹³ and as such, they currently, and will increasingly, play a major role in the US COVID-19 response. This is the case at the UCSF Helen Diller Medical Center at Parnassus Heights (UCSFMC), a 600-bed academic medical center. To learn from other’s early experiences with COVID-19, UCSF Health System leadership connected with many outside health systems including NUH. As one of its multiple pandemic responses, they engaged the UCSFMC Division of Hospital Medicine (DHM), a division that includes 117 hospitalists, to work with hospital and health system leadership and launch a respiratory isolation unit (RIU) modeled after the NUH pandemic ward. The aim of the RIU is to group inpatients with either confirmed or suspected COVID-19 patients who do not require critical care.

An interdisciplinary work group comprising hospitalists, infectious disease specialists, emergency department clinicians, nursing, rehabilitation experts, hospital epidemiology and infection-prevention leaders, safety specialists, and systems engineers was assembled to repurpose an existing medical unit and establish new care models for the RIU. This workgroup created clinical guidelines and workflows, and RIU leaders actively solicit feedback from the staff to advance these standards.

Hospitalists and nurses who volunteered to work on the UCSF attending-staffed RIU received extensive training, including online and widely available in-person PPE training delivered by infection-prevention experts. The RIU hospitalists engage with hospitalists nationwide through ongoing conference calls to share best practices and clinical cases. Patients are admitted by hospitalists to the RIU via the emergency department or directly from ambulatory sites. All RIU providers and staff are screened daily for symptoms prior to starting their shifts, wear hospital-laundered scrubs on the unit, and remain on the unit for the duration of their shift. Hospitalists and nurses communicate regularly to cluster their patient visits and interventions while specialists provide virtual consults (as deemed safe and appropriate) to optimize PPE conservation and decrease overall exposure. The Health System establishes and revises PPE protocols based on CDC guidelines, best available evidence, and supply chain realities. These guidelines are evolving and currently include surgical mask, gown, gloves, and eye protection for all patient interactions with suspected or confirmed COVID-19 and respirator use during aerosol-generating procedures. Research studies (eg, clinical trials and evaluations), informatics efforts (eg, patient flow dashboards), and healthcare technology innovations (eg, tablets for telehealth and video visits) are continually integrated into the RIU infrastructure. Robust attention to the well-being of everyone working on the unit includes chaplain visits, daily debriefs, meal delivery, and palliative care service support, which enrich the unit experience and instill a culture of unity.

The structures and systems born out of the 2003 SARS experience and the “test, trace, and isolate” strategy were arguably key drivers to flatten Singapore’s epidemic curve early in the pandemic.³ Even with these in place, Singapore is now experiencing a second wave with a significantly higher caseload.¹⁴ In response, the government instituted strict social distancing measures on April 3, closing schools and most workplaces. This suggests that the COVID-19 pandemic may fluctuate over time and that varying types and levels of interventions will be required to maintain long-term control. The NUH team describes experiencing cognitive overload given the ever-changing nature and volume of information and fatigue due to the effort required and duration of this crisis. New programs addressing these challenges are being developed and rapidly deployed.