Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore

Abstract

The coronavirus disease 2019 (COVID-19) outbreak has been designated a public health emergency of international concern. To prepare for a pandemic, hospitals need a strategy to manage their space, staff, and supplies so that optimum care is provided to patients. In addition, infection prevention measures need to be implemented to reduce in-hospital transmission. In the operating room, these preparations involve multiple stakeholders and can present a significant challenge. Here, we describe the outbreak response measures of the anesthetic department staffing the largest (1,700-bed) academic tertiary level acute care hospital in Singapore (Singapore General Hospital) and a smaller regional hospital (Sengkang General Hospital). These include engineering controls such as identification and preparation of an isolation operating room, administrative measures such as modification of workflow and processes, introduction of personal protective equipment for staff, and formulation of clinical guidelines for anesthetic management. Simulation was valuable in evaluating the feasibility of new operating room set-ups or workflow. We also discuss how the hierarchy of controls can be used as a framework to plan the necessary measures during each phase of a pandemic, and review the evidence for the measures taken. These containment measures are necessary to optimize the quality of care provided to COVID-19 patients and to reduce the risk of viral transmission to other patients or healthcare workers.

Fig. 1

Personal protective equipment donning and doffing areas. Steps are colour-coded (A: blue for clean and red for contaminated) and marked in numerical sequence at designated areas just outside the OR, with posters to guide staff on the process. Step 1: Put on N95. Step 2: Donning PAPR (B). Step 3: Enter OR through scrub room. Step 4: Clean external surface of the PAPR face shield (C), remove surgical gown and outer gloves. Step 5: Doffing PAPR (D). OR = operating room; PAPR = powered air-purifying respirator

Fig. 2

Staff in powered air-purifying respirator (PAPR) during an aerosol-generating procedure

Fig. 3

High-touch equipment within the operating room are wrapped with plastic sheets to facilitate decontamination. A) Anesthesia workstation. B) Back of anesthesia workstation. C) Exposed surfaces wrapped with plastic. D) Laptop for nursing documentation

Fig. 4

Pre-packed sets of equipment

Fig. 5

Hierarchy of controls to control exposure to occupational hazards. The five layers can be implemented concurrently or sequentially. To control exposure to infectious diseases in the healthcare environment, elimination and substitution controls are often limited or not feasible. Effectiveness of control measures generally decreases down the layers

Fig. 6

Summary of the measures implemented in the operating room and anesthetic department to enhance infection prevention in a COVID-19 pandemic