3 lessons and a silver lining from my stint as a doctor at a Covid-19 community care facility

I was among the first batch of medical administrators who volunteered to manage SingHealth’s Community Care Facility (CCF) at the Singapore Expo in late April.

The brief was simple — a two-week rotation shift, four halls, 60 doctors, 200 nurses and allied health professionals within SingHealth to care for 3,200 Covid-19 positive patients.   

After just one day of planning and one day of shadowing our colleagues from the Woodlands Health Campus and the Singapore Armed Forces who had been managing the first halls since March, we took over and managed the facilities from May till July.

In all, we cared for more than 7,000 patients.

THREE LESSONS

From my one-month deployment at the CCF, I have gleaned three valuable lessons.

First, it is imperative to prevent overwhelming the hospitals so that they can continue to care for non-Covid-19 patients, and have the capacity to respond to other emergencies. 

Singapore adopted a containment strategy at the start of the pandemic.

It quickly became apparent that if we tried to contain the virus by admitting every Covid-19 patient into hospitals as we did during the severe acute respiratory syndrome (Sars) outbreak in 2003, we would rapidly overwhelm the nation's healthcare infrastructure, especially with the massive spike in dormitory cases.

Singapore had around 11,000 beds, including 1,100 intensive care units, in acute hospitals before Covid-19 struck.

To cope with the fast growing numbers, isolation facilities such as the CCF at the Singapore Expo were set up across the country to house Covid-19 patients who were at low risk of requiring acute hospital care.

Secondly, by leveraging technology, a massive facility like the CCF can operate effectively with a relatively small team of healthcare workers.

At steady state, the four halls could hold up to 3,200 patients with round the clock medical care.

We managed this with just 12 medical administrators, 26 doctors and 72 nurses and allied health professionals rostered on-site every 12 hours.

To ensure sustainability, the CCFs were designed to operate as a shared-care facility where patients within each hall were responsible for their own wellbeing and had to seek medical attention for any acute medical issues or chronic disease management. 

The Vital Signs Monitoring system was introduced to detect early signs of deterioration in patients.

Patients were instructed to measure their own vital signs — blood pressure, heart rate and oxygen levels — at designated self-service stations located throughout the hall over several time-points daily.

We had roving teams to ensure patients knew how to use the machines. We also deployed a robot for teleconsultation to reduce the manpower required at night so that staff were well rested.

Thirdly, medical professionals need to think out of the box during unprecedented times and adapt quickly during any pandemic.

The doctors deployed at Expo were used to providing specialist care where each patient was managed by a small team of healthcare professionals in hospitals.

The notion that a patient is not seen by at least two doctors, an army of nurses or had his vital signs measured at least six times daily was hard for us to accept.

A huge mind-set change was required.

To ensure patients’ social, mental, dietary and psychological needs were addressed, a patient experience team was created.

They implemented various initiatives such as adjusting the intensity of the lights in the halls for a good night’s sleep, and providing electronic hair clippers and combs so that patients could be one another’s barber. 

Unfortunately, few patients had formal barber training and fewer could cut straight.

Many friendships were broken or forged over the clippers as a result. Nevertheless, it was hugely oversubscribed, as most were desperate for a trim.

I have never seen so much glee and joy from getting a bad haircut. 

TWO REASON FOR SUCCESS

The success of our facility and Singapore’s response to the pandemic can be attributed to two key factors.

First, the ability to conserve our resources and maintain a low healthcare worker to patient ratio.

Second, our collective memories of Sars. 

At the start of the pandemic, we learnt from senior doctors who shared their experience battling Sars 17 years ago.

Quarantine orders, contract tracing or Infectious Disease Act updates were all hard-earned lessons from the 33 lives Singapore lost then.

Some may argue that we might not have needed to go through the circuit breaker or that it was unnecessary. But I believe otherwise.

A look at the European and North American death rates and their resistance to wearing face masks should convince the most hardened cynic.

Without implementing measures like the circuit breaker and setting up CCFs, our healthcare services would not have been able to cope with the outbreak.

Singapore’s Covid-19 pandemic experience would have been vastly different had we not experienced Sars and remembered the lessons it taught us.

A mention must also be made of the dedication of Singapore’s healthcare workers.

At the start of the pandemic, some healthcare workers were shunned and at times vilified in public. Yet, they remained disciplined and focused on fighting the pandemic.

I saw this first hand too at the CCF at Expo.

Even before the first team of 12 of us walked the halls, many ground staff, who were meeting each other for the first time, were ready to plunge themselves into a different work environment.

We also received tremendous support from our headquarters at Singapore General Hospital.

Many healthcare workers who were not deployed at the CCF chipped in to get the facility off the ground, all while maintaining their day-to-day workload.

ONE SILVER LINING

While the nation's response to the pandemic wasn’t perfect, we have so far avoided a second wave and the Government is now talking about the possibility of moving into Phase Three of opening up the economy.

Sars was deadly but less infectious; Covid-19 is more infectious but not as fatal.

The next pandemic may be a combination of both.

Our silver lining comes from the fact that we were given two lessons 17 years apart on dealing with deadly (Sars) and infectious (Covid-19) pandemics separately.

While no one can tell when the next pandemic will be and what it will look like, a few core issues will likely remain relevant.

The next pandemic will probably be airborne. It will likely require detection and isolation in the initial stages.

It is human nature that our heightened awareness and compliance to facemask precautions will wane over time.

Swabbing and the capacity to process the swab samples cannot be sustained indefinitely.

The new normal, as much as we like to believe otherwise, will not last, as our country’s infrastructure was not purpose-built for it.

To maintain the social distancing requirement of 1m, we would need to build more hawker centres, markets and shopping centres.

We would also require more public transport capacity.

But to support these, our current land area of about 725 sq km would need to expand magically or the population of 5.7 million must be reduced drastically. Both options are unpalatable.

Scientists are already working on the workflow process required to tackle the next pandemic.

Only by recognising what we learnt from past pandemics, can we then work out the unknown to derive the equation necessary to be ready for the next pandemic, and save lives. 

ABOUT THE AUTHOR:

Dr Jay Lim is a consultant at the Department of Urology, Singapore General Hospital.