Contents Page
1. Before Your First Fever Shi� 2. Star�ng Your First Fever Shi� 3. Computer Tips & Tricks 4. Swabbing Your First Pa�ent 5. FFA Workflow for Special Popula�ons 6. So Where Are All These Places
27/9/20 2
Acronyms and what they are SASH = Swab-‐and-‐Send-‐Home / Swab-‐and-‐go
– General term where pa�ents are swabbed and discharged. Offered in ED, polyclinics and some GPs.
HO = Hospital SIF = SASH Isola�on Facility
– HO-‐SIF = isola�on facility in hospital e.g. CGH HO-‐SIF at clinics ABCD CIF / CCF = Community Isola�on/Care Facility
– Well Covid posi�ves, e.g. Expo, Downtown D’Resort GQF = Government quaran�ne facility DIF = Dormitory Isola�on Facility
– Gaze�ed dormitories which can hold posi�ve and suspect cases
27/9/20 4
Overview of CGH Fever Facility Area (FFA) FFA-‐1 / FFA-‐1 EXT HO-‐SIF
Opera�ng Capacity – Operates all hours – 3x consult rooms + 1x makeshi� consult room – FFA-‐1 EXT about 22 chairs for holding pa�ents
Equipped with XR, swab room, resus room, mini-‐pharmacy *FFA-‐2 is closed as of 7 September 2020
Holding area for pa�ents who require isola�on while awai�ng COVID swabs Currently, following group of pa�ents: – Dormitory/non-‐dorm foreign workers – People work/live at communal se�ngs (Annex C) who
cannot self-‐isolate
Located at A&E Block, Level 2, Old Clinics A, B, C & D Manned by doctors from: – CHI and Radiology daily (Mon to Sun) from 8am to 5pm – A&E outside of these hours
3 Important Numbers CGH Op Centre 9645-‐0310
COVID enquiries à Check ID roster on CGH intranet
FFA Senior / Resus Senior 3 is your go-‐to best friend – Check Daily Roster at Triage before shi� starts – If no designated FFA senior, to call R3 – shi� change at 8am, 4pm, 11pm
27/9/20 6
Latest Workflow in FFA
The latest clinical pathways and “Swab-‐and-‐Send-‐Home” Workflow will be pasted on the walls of the consult rooms. You should also be receiving it in your Hmail. It describes what tests to order and disposi�on op�ons. Do refer to them regularly as you work through a pa�ent.
27/9/20 7
COVID-‐19 Daily Updated Informa�on
Go to CGH Intranet Homepage & click on “COVID-‐19” at Right hand sidebar You will reach a COVID-‐19 Resource Page Click on the respec�ve links for latest ”MOH Case Defini�ons and Workflows” and “Latest Documents” As there may be new / emerging clusters, as a rou�ne please ask about: – occupa�on and place of work – a�endance at any recent large scale events (e.g. weddings)
27/9/20 8
Overcoming Language Barrier
There are print-‐outs of ques�onnaires in Bengali, Tamil, Hindi, Sinhali in FFA-‐1 to help you take history You can access the website by the Chowdhury sisters on h�ps://�nyurl.com/covidbengali to play audio clips of ques�ons you want to ask Download a Google Translate app in your handphone and enable microphone access
27/9/20 10
Preparing to step in
Bring your own issued N95 and Goggles There are stethoscopes and pens in FFA areas Gowning area at ICA/observa�on MO sta�on area Full PPE – surgical cap, yellow gown, N95, Goggles, gloves Put your handphone in ziplock bags (you can get from FFA pharmacist) There are toilets and water dispensers within FFA-‐1
27/9/20 12
Your Basic Worksta�on
27/9/20 13
Latest clinical workflow and MOH clusters
Cases to review
Meds – tramadol, maxolon, steme�l, buscopan
Discharge Advices
Basic Opera�on Workflow -‐ Start New Case
Start shi� à report to triage nurse in FA
Similar to P2 queue, cases will be given in round robin – Find under “Comments” – Queue stops 1h before your shi�
ends See the pa�ent, order the
inves�ga�ons, send your own bloods
Bring the pa�ent folder to the NURSING COUNTER for ac�ons such as XR/ECG/Tx
Remind nurses to call for XR services
27/9/20 14
Basic Opera�on Workflow -‐ Disposi�on à Pass docs to Nursing Counter (admit/discharge/HO-‐SIF)
Admission Indicate in Bed Admission remark
– “PARI Ward” includes: ARI or pneumonia PSHN/ Dorm workers
– “Fever and for op” Febrile pa�ent + GS review in ED for op
– “COVID Ward GW/HD” for COVID posi�ve – Refer to latest workflow pasted on the walls
in FA consult rooms for admission criteria Order COVID swab when swabbers are around
i.e. daily 10am-‐6pm
Discharge checklist Medica�on prescrip�ons Appropriate Health Advisories
1. ARI pa�ents with no swab 2. “Swab and Send Home” and HOSIF
pa�ents MC
– Outpa�ent MC (not HL) – Inform pa�ent that they are required
by law to stay home – If swab: 3 days – No swab and ARI: 5 days
SOC / TCU if required – Inform pt to go a�er swab results
known or recovery of symptoms – If FW: indicate “To see in SOC Clinic J”
27/9/20 15
PARI admission Admit under ICU/HD Internal Med or specific non-‐medical specialty GW Specific Specialty as required otherwise Internal Medicine COVID +ve admission Admit under ICU/HD Internal Med or specific non-‐medical specialty GW Specific Specialty as required otherwise Infec�ous disease
MC example
27/9/20 16
✅
✅
If digiMC then no need to check this
3⃣ or 5 ⃣
Type here if diagnosis needs to appear in MC for insurance
✅ ➡
Discharge Advisory for Patients with Respiratory Diseases Swab-and-Send-Home (SASH)
Dear Sir / Madam,
You have symptoms of upper respiratory tract infection and this is most likely due to a viral illness. Our doctor has examined you on ________________________________ (date), and determined that you do not require admission. We have taken a sputum/throat specimen from you. Starting from the date your MC is issued, you must not leave your home for the duration of your MC, or until you receive a negative COVID-19 swab test result, whichever is sooner. Result notification
If you are a Singaporean/Permanent Resident, you can get the test results via the Health Hub app or https://www.healthhub.sg with your SingPass within 48 to 72 hours. We strongly advise that you make your way home directly from the hospital’s Emergency Department and self-isolate as you await the results of the test. Legal requirement to stay home during MC period
The doctor has issued a medical certificate (MC) for you to recover at home. In view of the ongoing COVID-19 situation, you are required by law to stay home for the duration of MC issued for this episode of illness unless you receive notification of a negative COVID-19 swab test result. Persons who do not comply will be liable to a fine of up to $10,000, or imprisonment up to six months, or both, under the Infectious Diseases Act. You should only leave your home to seek medical attention. If you need to go for any outpatient medical appointments prior to the confirmation of your swab test result, please inform the medical staff that you were recently screened for COVID-19. While awaiting the results of the swab test, it is very important that the following precautions be observed to protect others from being exposed to possible COVID-19 infection.
To travel home from the hospital’s Emergency Department after your consultation and evaluation: Please avoid taking public transport; Take your own private transport or a taxi / private hire car.
If you are being driven, please wear a mask and sit alone in the back seat. The windows of the car should be wound down and the air-conditioning switched
off. Please scan the SafeEntry QR codes and obtain taxi / private hire car receipt for
the journey, for contact tracing purposes in the event of a positive swab test.
Health Advisory -‐ SASH or HOSIF pa�ents
27/9/20 17
Only the posi�ve pa�ents will get informed. Pa�ents to access HealthHub SG mobile
app with SingPass for their own results.
Health Advisory -‐ ARI pa�ent with no swab
(<13yo)
27/9/20 18
Where to find advisory (Other languages available)
FFA-‐1 Layout (Not to scale)
27/9/20 19
WAITING AREA 1
STAFF/
PATIEN
T EN
TRAN
CE
CONSULT ROOMS 1 & 2
WAITING AREA 2
XRAY
NURSING COUNTER
ISO / RESUS ROOM
EXIT TO FFA-‐1 EXT
993 AMB ENTRANCE
TRIAGE / PSA
PHARMACY
CONSULT ROOM 3
Pneuma�c tube = Where to send bloods Racks to place swabs
Make-‐shi� CONSULT ROOM 4
FFA-‐1 EXT Layout (Not to scale)
27/9/20 20
NURSING COUNTER CONSULT STATION
ENTRAN
CE/EXIT
WAITING AREA
To F
FA-‐1
3. COMPUTER TIPS & TRICKS
A) Ordering COVID swab B) Ordering CXR for faster repor�ng C) Requirement to update CDLENS D) Acronym expansion E) Previous COVID serology/PCR posi�ve (coun�ng day of illness) F) Pre-‐consult ques�onnaires
27/9/20 21
A) Ordering COVID Swab Search “COVID” and fill the fields: Priority**
– “STAT” for HO-‐SIF (swab & hold) and use RED biohazard bag
– “Rou�ne” for the rest (swab & send home) and use TRANSPARENT biohazard bag
Indica�ons – select appropriate clinical indica�ons
Specimen site – select “Nose & Throat Swab”
27/9/20 22 **Please make sure you do this for faster processing of HO-‐SIF pa�ents.
B) Ordering CXR
Under Special Instruc�ons, indicate “COVID-‐FA”
If you do this, your CXR gets reported faster
27/9/20 23
C) Requirement to update CDLENS
“Apps” > “ID No�fica�on” > “New Submission” When?
– For posi�ve cases that you swab and send home (SASH)
– Suggest doing when acknowledge results on SCM (usually on next shi�)
27/9/20 24
NO need to no�fy suspect covid cases any more NO need to no�fy pa�ents you admi�ed to ward if they turn posi�ve (ward will do that) NO need to no�fy if the pa�ent was diagnosed with COVID by someone else (CIF, dorm swabs etc)
D) Acronym Expansion Saves Time!
Preferences > Acronym Expansion Consider one for: URTI /
Fever / Covid Risk Factors Other �me-‐saving
templates such as: history / PE / return advice / MC documenta�on
27/9/20 25
E) Previous COVID PCR/serology posi�ve Coun�ng the days: Use calculator desktop app Where to Admit
< 28days: – Admit COVID Ward under ID – If in doubt, call ID physician to discuss
29-‐90 days: – If pneumonia or suspected re-‐infec�on
with COVID à discuss with PARI doctor for PARI admission.
– Do not need to swab in ED – If not any of above: to admit to GW
>90 days: – Treat as per pre-‐covid norms (as
if pa�ent never had COVID)
27/9/20 26
Covid Results Interpreta�on
Individual/ Pooled
Swab + Sero
PCR +, Sero +
Day 15 of illness
CCF/Hospital �ll
Day 21
Clean (dorm) Block
PCR +, Sero -‐
Day 1 of illness
CCF/Hospital
PCR -‐, Sero -‐
COVID naïve
PCR -‐, Sero +
Recovered MW
Clean (dorm) Block
CCF: Community Care Facility, e.g. Expo
Likely swab and HOSIF
S�ll always check with senior / CGH OC
F. Pre-‐Consult Ques�onnaires
Helps to reduce �me taken to obtain travel and contact history from pa�ents What happens
– Pa�ent registers in ED – Pa�ent receives SMS to fill up this form – Doctor can autopopulate the PCQ into provider note – Helps to save �me to type note and ask the ques�ons
27/9/20 28
If there are swabbers … Who are they? Allied health colleagues to
help our turn-‐around �me When? Daily, 10am-‐6pm
When the swabbers are not around, you have to do your own swabs for FFA discharges only (no need to swab admissions)
For FFA PARI admissions Order CPOE, put “PARI” in comments, print out label, put in transparent biohazard bag
1. Print admission documents 2. Pass file to swabbers / nurse counters
(This is to help PARI ward turn-‐around �me) For FFA discharges 1. Order COVID swab 2. Collect specimen to print s�ckers 3. Place s�cker in biohazard bag
– RED: HO-‐SIF (swab & hold) – Transparent: the rest (swab & send home)
4. Print rest of discharge materials 5. Pass to swabbers / nurse counters 27/9/20 35
Your Swab Kit Swab-‐and-‐Send Home Discharge Advice
27/9/20 36
Discharge Advisory for Patients with Respiratory Diseases
Swab-and-Send-Home (SASH)
Dear Sir / Madam,
You have symptoms of upper respiratory tract infection and this is most likely due to a viral illness. Our doctor has examined you on ________________________________ (date), and determined that you do not require admission. We have taken a sputum/throat specimen from you. Starting from the date your MC is issued, you must not leave your home for the duration
of your MC, or until you receive a negative COVID-19 swab test result, whichever is
sooner.
Result notification
If you are a Singaporean/Permanent Resident, you can get the test results via the Health Hub app or https://www.healthhub.sg with your SingPass within 48 to 72 hours. We
strongly advise that you make your way home directly from the hospital’s Emergency Department and self-isolate as you await the results of the test.
Legal requirement to stay home during MC period
The doctor has issued a medical certificate (MC) for you to recover at home. In view of the ongoing COVID-19 situation, you are required by law to stay home for the duration
of MC issued for this episode of illness unless you receive notification of a negative
COVID-19 swab test result. Persons who do not comply will be liable to a fine of up to $10,000, or imprisonment up to six months, or both, under the Infectious Diseases Act. You should only leave your home to seek medical attention. If you need to go for any outpatient medical appointments prior to the confirmation of your swab test result, please inform the medical staff that you were recently screened for COVID-19. While awaiting the results of the swab test, it is very important that the following
precautions be observed to protect others from being exposed to possible COVID-
19 infection.
To travel home from the hospital’s Emergency Department after your consultation and evaluation: Please avoid taking public transport; Take your own private transport or a taxi / private hire car.
If you are being driven, please wear a mask and sit alone in the back seat. The windows of the car should be wound down and the air-conditioning switched
off. Please scan the SafeEntry QR codes and obtain taxi / private hire car receipt for
the journey, for contact tracing purposes in the event of a positive swab test.
Your Swab Room Survival Tips for MO Print CPOE Label and bring to room Ask pa�ent to check name and IC on
label Paste label on swab bo�le then start to
swab Double gloves and stand to the right side
(not in front) of pa�ent Then explain what you are going to do
Survival Tips for Pa�ent Look up to opposite ceiling (45-‐70 degree
head �lt) Throat swab – say “Aahhh” to minimise
gag Nose swab – most painful, breathe
through mouth during swab
27/9/20
Official Swab Instruc�on
27/9/20 39
Single RED biohazard bag for Dormitory Foreign Workers Single TRANSPARENT biohazard bag for other popula�on
5. FFA WORKFLOW FOR SPECIAL POPULATIONS
A. PUIO/PUQ/SHN B. HO-‐SIF (swab-‐and-‐hold) Pa�ents C. Cat A and B and NH
27/9/20 40
A. PUIO/PUQ/SHN -‐ Summary
Will usually be wrist-‐tagged but remember to confirm! All tagged cases = mandatory COVID swab = inform CGH Ops center prior to discharge Place discharge documents in nursing tray and will be duly reminded
27/9/20 41
A. Transport for discharged PUIO/PUQ/SHN
PUIO/PUQ Pa�ent’s documents will have
an extra label that states “PUQ”. Pa�ent will wear a coloured wrist tag.
Inform CGH Ops Centre on pa�ent discharge
Cannot go home via personal / public transport
PSHN (more details in next slide) From Hotel: Ask pa�ent or
look for hotel memo. If present, call CGH Ops center on discharge
From Home: Pa�ent to call People’s Associa�on (Tel: 63448222) to request for assistance in transporta�on advice /arrangements
27/9/20 42
Note: PUIO, PUQ, PSHN etc. cannot AOR àà face a problem = call CGH Ops Center
About PSHN They may come to you if
unwell, from: – border entry (with ICA memo) – from SHN Designated Facility
e.g. hotel (with SDF/ICA memo)
– own residence (by 993) – exit swab facili�es
Disposi�on – If admi�ng, please admit to
PARI. – If discharging, call CGHOC to
determine swab need and transport
27/9/20 43
Info required by CGHOC usually in this memo (all PSHN should have something like this from ICA)
Generally pa�ents can be on 7 or 14 day SHN or swab on arrival (deemed SHN �ll arrival swab out) depending on country of origin.
May be asked to swab them. If in doubt, just ask CGHOC.
B. HO-‐SIF (swab-‐and-‐hold) Pa�ents
Some of our dormitory foreign workers may not have isola�on facili�es at where they stay. Hence, we need to swab and hold them �ll results are out. They will be held in CGH Fever Holding Area (HO-‐SIF) under A&E care or designated external SASH Isola�on Facili�es (SIF). HO-‐SIF can also cater to non-‐dormitory FW and people at communal se�ng (e.g. CGH staff) who cannot self-‐isolate at home.
27/9/20 44
B. HO-‐SIF (swab-‐and-‐hold) Pa�ents
Ideally, we want to speed up the processing of HO-‐SIF pa�ents.
This affects our:
1. CPOE COVID Swab Order (STAT Order) 2. Swab specimen management (Red Biohazard Bag) 3. Disposi�on on EMD Provider Notes
27/9/20 45
C. Cat A/B and NH residents Pa�ent Groups Fit for discharge? Swab where Hold where
Cat A = prisoners and SAF DB detainees
Yes (Rule out pneumonia) *For CAT A non-‐prisoners (i.e. NOT in jumpsuits): check if able to isolate in police-‐lock up, otherwise to admit
Send back prison service/DB with memo to swab and isolate.
Not applicable
No
Admit. PARI holding
Cat B Yes Obs extension or FA FFA 1 ext or BID room if needed.
No Admit. Swab in ED FA during swabbing hours
PARI holding or FA
Nursing Home Yes *Confirm with NH if able to isolate un�l result is out, otherwise to admit
Obs extension or FA PARI holding or FA
No Admit. Swab in ED FA during swabbing hours
PARI holding
27/9/20 47 Cat B and Nursing Home swabs need to ordered as URGENT i.e. STAT and RED bag