Suggestions of management on emergency responses to epidemic outbreaks in outpatient or emergency departments of tertiary teaching hospitals

Graphical abstract

Background

Patients infected with the alpha, beta, and delta strains of coronavirus disease 2019 (COVID-19) usually exhibit fever, dry cough, nasal congestion, sore throat, loss of taste or smell, runny nose, conjunctivitis, fatigue, myalgia, diarrhea, and other symptoms,^[1] while patients infected with the omicron strain present mild symptoms, including nasal discharge, sore throat, sneezing, headache, and cough.^[2] Some patients deliberately conceal the relevant medical history, which makes it difficult to find in the pre-examination screening in outpatient or emergency departments. Outpatient and emergency buildings are usually linked to each other, and some older floors are poorly ventilated. Once patients with COVID-19 see a doctor in an outpatient or emergency building, especially patients infected with the omicron strain, an outbreak of the epidemic in a large area is easily possible.

Therefore, according to the relevant regulations and requirements of the State Council of China on the issuance of the notice on the prevention and control of 2019 novel coronavirus pneumonia (8th Edition),^[3] based on recent developments in the prevention, control, and treatment of COVID-19 nucleic acid-positive patients in medical institutions in China, and practices evidence of >10 hospitals in Shenzhen identifying COVID-19 cases in outpatient or emergency settings. We organized experts to put forwards relevant management measures for the temporary medical control of three-level public medical institutions. The purpose of these measures is to provide recommendations for the temporary control of medical institutions, to limit the spread of the epidemic to the greatest extent, and to further coordinate the contradictions between hospital management and patients’ medical needs.

Management Principles

To further improve the prevention and control of the COVID-19 epidemic accurately, efficiently, and scientifically, the committee members met to review and discuss the contents on January 12, 2022. Based on the general principles of the classified and divisional prevention and control strategy^[3] and through the comprehensive implementation and control of all kinds of prevention and control measures, the creation of a “1–1–9” team work (1 temporary leadership group, 1 special working shift, and 9 task forces) is recommended to strive to classify and control epidemic-related personnel with a minimum expenditure of time, and implement the most effective environmental disinfection and monitoring.

The second key principle involves the “520” management strategy, which includes 2 kinds of construction systems (organization construction and system construction), 2 kinds of quality control systems (linking quality control and final quality control), 2 types of populations (hospital staff and patients), 2 kinds of relationships (governments and medical institutions, hospitals and departments), 2 kinds of contradictions (daily treatment and routine examinations for hospitalized inpatients, hospital staff isolation and recovery of medical needs), and finally achieve 0 potential accidents.

Rapid Responses at Government Level

A temporary leadership group is led by the municipal health administration commission, on the support of the expert team with extensive experience in epidemic prevention and control, and is coordinated by the district epidemic prevention and control office, the people's government of the street office where the medical institution is located, the ministry of public security, industry, and information technology and public health. Determining the specific populations isolation measures and the principles of environmental sterilization is the primary task of epidemic prevention and control for emergencies occurring in medical institutions, which is recommended by the headquarters to be made within 30 min after a full investigation.

Specific control measures

• (1)Close contact and secondary close contact personnel should be controlled according to the specified requirements.^[3]
• (2)Home self-isolation should be implemented for 7 days and self-health monitoring should be performed for another 7 days. COVID-19 nucleic acids should be evaluated on days 1, 2, 3, 5, 7, and 14.
• (3)Home health management should be implemented for 7 days, which indicates COVID-19 nucleic acid detection three times over the course of the 7 days, and self-health monitoring for 7 days.
• (4)Home health management should be implemented for 3 days, which indicates nucleic acid detection two times over the course of the 3 days, and self-health monitoring should be implemented for 11 days.
• (5)“Two points and one line” work-life model without public transportations should be implemented, and COVID-19 nucleic acid detection should occur seven times over the course of 7 days.
• (6)The location involved in the epidemic should be off duty for 3 days. The final disinfection should be carried out after the environmental surface is sampled, and the sampling and monitoring should be carried out for 3 consecutive days.

Department emergency response measures

Each department should implement various emergency response measures in an orderly manner according to the division of responsibilities. The responsibilities of each department are as follows:

• (1)The municipal health administration departments are responsible for the overall scheduling of an emergency response, including classifying epidemic-related personnel, guiding medical institutions in fully implementing epidemic prevention measures, coordinating relevant units to cooperate with the emergency response, mobilizing more medical personnel from other medical institutions to support the epidemic prevention efforts when necessary, and reporting the resolution progress to the municipal epidemic prevention and control command office in a timely manner.
• (2)The district epidemic prevention and control command office should coordinate the supply of materials to the medical institutions, ensure the point-to-point transfer of medical institution personnel by private car, and coordinate and solve other difficulties of the medical institutions.
• (3)The street offices should help arrange volunteers for the hospital to assist in emergency resolution, when necessary, and coordinate with the staff and volunteers in the community where the temporarily controlled personnel are located to provide necessary assistance to family members, and to explain and resolve contradictions and disputes related to the event.
• (4)The ministry of public security is responsible for organizing police and security forces to ensure an effective peripheral related work of the medical institutions involved in the epidemic and to cooperate with the internal security of the medical institutions.
• (5)The ministry of public health is responsible for screening close contacts, secondary close contacts, key populations, and general populations, providing guidance on populations classification and management and guiding the terminal disinfection of the areas involved in the epidemic; The Ministry of Industry and Information Technology should assist the Ministry of Public Health and Public Security in epidemic investigations. The confidential contact verification should be completed within 2 h, and the secondary confidential contact verification should be completed within 4 h.

Rapid Responses at Hospital Level

One special working shift is composed of the leading group of the institute, and each leader is responsible for two working groups administration and management. The special working shift holds problem-oriented meetings and ensures a seamless and hermetic process for epidemic prevention and control. Their responsibilities include issuing medical guidance, implementing personnel and site management, carrying out nucleic acid testing, implementing strict cleaning and disinfection protocols, strengthening logistics support, completing safety guarantees, controlling publicity, and providing guidance to ensure the treatment of patients with acute and critical diseases and ensure medical services and medical safety.

Nine task forces will provide infection control and sterilization, nucleic acid sampling and detection, logistics support, medical treatment, health management, comprehensive secretaries, public relations, public opinion monitoring, and humanistic care. Each group should ensure the orderly and efficient operation of the links and final operations of each policy process within the group.

Preventing transmission in healthcare settings

Infection control and disinfection group

According to the requirements of the management specification of air cleaning technique in hospitals, the prevention and control of 2019 novel coronavirus pneumonia (8th Edition),^[3] and the guidance of the Disease Prevention and Control Department, environmental sampling and disinfection should be carried out for the incident containment site, especially the terminal disinfection of medical instruments, materials used by the patient, and the patient's diagnosis and treatment environment, which may contain respiratory secretions, excreta, and vomit.

• (1)The manpower and total dose of disinfectant required should be estimated according to the size of the areas involved in the epidemic and the number of tables.
• (2)Disinfection and sterilization personnel should be instructed to use disinfection and sterilization agents correctly. Then, 10–30 mL/m³ of 3% hydrogen peroxide should be used for the air. After being closed for 1 h, the windows should be opened for ventilation for 2 h. The objects surface and grounds should be disinfected with 1000 mg/L of a chlorine disinfectant and cleaned with clean water after 30 min. Special attention should be given to the disinfection of air conditioning exhaust outlets and air disinfectors.^[[4], [5], [6]^]
• (3)Fixed infection control staff should monitor the work of disinfection personnel in real-time to ensure whether the whole disinfection process is a standard shield and whether the personnel is under closed-loop management.
• (4)The areas involved in the epidemic should be disinfected at least once a day, and samples should be taken again, after disinfection and sterilization for 3 consecutive days. The key parts of sampling are the objects and related medical devices that patients may have contact with at a high frequency. The sampling quantity should be determined by infection control professionals according to the size of the incident area.
• (5)The COVID-19 nucleic acid results of environmental samples before and after disinfection and sterilization should be evaluated every day. If the environmental COVID-19 nucleic acid test result is positive, it is necessary to increase terminal disinfection and sterilization.
• (6)A list of disinfection and sterilization population, air, tables, grounds, equipment, environmental sampling nucleic acid reports, and other work checklists should be established to ensure that all process indicators and final indicators are qualified, and the linking quality control and final quality control of environmental disinfection.

Nucleic acid sampling and detection team group

According to the nucleic acid detection requirements specified by the headquarters, the key population and key environment should be determined according to the zoning and hierarchical management requirements, their nucleic acid results should be produced within 4 h, and other samples within 6 h,^[7] and the required staff should be estimated.

• (1)The principles of single and mixed collection of nucleic acids should be determined. Key populations and environments should use a single collection, while the 10-in-1 or 20-in-1 test should be used for others.[7], [8] The key population includes the outpatient and emergency department involved in the epidemic, while the non-key population includes companions and other staff. The key environment refers to the environment involved in the epidemic.
• (2)A nucleic acid sampling team should be set up to determine the sampling location of different classes of people and the protective shield of the staff who collect samples. Medical workers in the inpatient department should collect samples by themselves, and other personnel should collect samples in the specified area.
• (3)Priority testing should be ensured for key groups, key environments, emergency surgery patients, and outpatients with fever.
• (4)If the testing quantity of the incident medical institution cannot be met, the samples should be sent to a third party for testing timely.

Logistics support group

Ensure the supply of protective materials and living materials.

• (1)Sufficient personal protective articles, disinfection drugs and instruments, and environmental disinfectant and sterilization drugs should be ensured according to the size of the affected areas and the number of personnel involved in the fight against the epidemic.
• (2)Planning and scheduling of basic living needs (such as diet, accommodations, etc.) should be performed quickly according to the number of personnel involved in the epidemic.
• (3)Meal delivery personnel should be coordinated and dispatched according to the number of inpatients, companions, and staff. Canteen staff or volunteers should provide meal delivery services, necessary water, daily necessities, and protective articles.
• (4)According to the requirements of epidemic prevention and control, identification signs related to diagnosis and treatment should be provided, and disinfection and sterilization should be supervised.
• (5)Transportation, patient transfers, and bayonets setup should be coordinated.

Operations management

Medical treatment group

Organize and coordinate patient diagnosis and treatment and relevant management regulation issues.

• (1)The opening of internet hospitals should be coordinated to provide diagnosis and treatment for patients and guide patients to seek medical treatment.
• (2)The daily treatment of inpatients, triage of outpatients, and follow-up diagnosis and treatment of outpatients and emergency patients should be coordinated, and emergency and elective surgery should be ensured.
• (3)Diagnosis and treatment regulations related to the epidemic situation should be announced.

Health management group

Responsible for the daily health monitoring of personnel, guiding personnel involved in the epidemic to complete health monitoring, and implementing personnel closed-loop management.

• (1)The list of personnel requiring health monitoring at different levels and areas should be managed, the state and emotions of personnel involved in the epidemic should be managed and give timely feedback should be provided.
• (2)The information of personnel involved in the epidemic should be accurately counted and then submitted timely to the disease prevention and control department to assign the control and regulation code.
• (3)The daily nucleic acid detection of each department should be counted.

General secretary group

Announce external information and report official documents.

• (1)The notice of internal hospital meetings should be released and meeting minutes should be taken. The relevant information about patients in the closed and controlled period from the official website should be released.
• (2)The superior competent department should be communicated with and the progress of the epidemic situation resolution in the hospital should be reported.
• (3)Data should be summarized, sorted, stored, and archived; confidential information should be recorded.

Public relations group

Coordinate the close cooperation between the hospital, the street office, and the Ministry of Communications and Public Security.

• (1)The street office should be coordinated to administrate and control the periphery of the hospital and optimize routes for patient treatment and employees who are returning to work.
• (2)The isolation control of epidemic-related personnel and their families should be coordinated.
• (3)The outward transport of patients in an area involved in the epidemic.

Psychosocial stress management of patients and healthcare workers

Public opinion monitoring group

Publicize and collect information on anti-epidemic-related events.

• (1)Online epidemic-related problems should be dealt with in a timely manner and touching anti-epidemic events should be publicized.
• (2)Anti-epidemic-related pictures and videos should be extensively collected.
• (3)The healthy development of public opinions should be guided.

Humanistic care group

Accurately grasp the situation of personnel involved in the epidemic and solve their difficulties in work and life.^[3]

• (1)Psychological consultants should be organized to provide individualized and accurate psychological assistance to the personnel involved in the epidemic.
• (2)Timely and accurate condolences should be given and concern and greetings should be conveyed.
• (3)Volunteers should be organized to solve difficulties for the personnel involved in the epidemic.

Funding

This work was supported by grants from the Sanming Project of Medicine in Shenzhen (Grant Number: SZSM20162011) and the Shenzhen Second People's Hospital Clinical Research Fund of Guangdong Province High-level Hospital Construction Project (Grant Numbers: 20173357201815, 20193357003, and 20203357014).

Conflicts of Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Managing Editor: Jingling Bao