Operating Protocols of a Community Treatment Center for Isolation Of
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Operating Protocols of a Community Treatment Center for Isolation of Patients with Coronavirus Disease, South Korea EunKyo Kang,1 Sun Young Lee,1 Hyemin Jung, Min Sun Kim, Belong Cho, Yon Su Kim beds. Because of limited medical resources and the Most persons with confirmed coronavirus disease (CO- COVID-19 epidemic curve, concerns grew that new VID-19) have no or mild symptoms. During the COV- facilities would be needed to isolate and care for pa- ID-19 pandemic, communities need efficient methods to tients in South Korea. monitor asymptomatic patients to reduce transmission. The National Health Insurance System (NHIS) of We describe the structure and operating protocols of a community treatment center (CTC) run by Seoul National South Korea offers complete access to healthcare for University Hospital (SNUH) in South Korea. SNUH con- the entire population (13). South Korea’s medical uti- verted an existing facility into a CTC to isolate patients lization rate is the highest, 16.6 outpatient visits per who had confirmed COVID-19 but mild or no symptoms. capita per year, among Organization for Economic Patients reported self-measured vital signs and symp- Cooperation and Development (OECD) countries toms twice a day by using a smartphone application. (14). Citizens of South Korea have high access to med- Medical staff in a remote monitoring center at SNUH re- ical services. Before the COVID-19 pandemic, no one viewed patient vital signs and provided video consulta- in the country anticipated a situation in which hospi- tion to patients twice daily. The CTC required few medi- tal admission would be denied. South Korea has 2.6 cal staff to perform medical tests, monitor patients, and times more hospital beds than other OECD countries, respond to emergencies. During March 5–26, 2020, we 12.3/1,000 population. However, the country only admitted and treated 113 patients at this center. CTCs could be an alternative to hospital admission for isolating has 1,027 negative-pressure isolation beds, and these patients and preventing community transmission. are not distributed across all regions. When the COV- ID-19 pandemic reached South Korea, the number of ince the first suspected case was reported in De- available negative-pressure isolation beds decreased, Scember 2019 (1,2), the number of coronavirus and patients could not be admitted to the hospital be- disease (COVID-19) cases has risen steeply world- cause of the shortage of medical facilities, especially wide (3,4). In South Korea, COVID-19 outbreaks oc- in regions where outbreaks mainly occurred. curred at religious facilities and the number of cases When an imbalance between the demand and increased drastically, especially in Daegu City and supply of medical resources exists, adequate triage the North Gyeongsang Province, and the number of patients is critical for allocating limited resources of patients with asymptomatic or mild symptoms to patients who can benefit the most (7). In a large- increased exponentially (5,6). In the early stages of scale study from China, Wu et al. (8) suggested that the COVID-19 epidemic, all patients with diagnosed ≈80% of COVID-19 symptomatic patients were re- COVID-19 were hospitalized in negative-pressure ported to have mild upper respiratory infection isolation units to treat the disease and prevent the without hypoxia, and only 20% of infected patients spread of infection. However, because the infection needed medical services. Until March 25, 2020, the spread rapidly, the number of patients exceeded crude mortality rate in South Korea was 1.4%, and the number of available negative-pressure isolation estimates suggested the severity of COVID-19 in the country would not be high (9). However, considering Author affiliation: Seoul National University Hospital, Seoul, asymptomatic carrier transmission (10), the high re- South Korea productive number (R0 = 2.2) (11), and the possibility DOI: https://doi.org/10.3201/eid2610.201460 1These first authors contributed equally to this article. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 10, October 2020 2329 SYNOPSIS of sudden deterioration (12), even patients with mild a CTC. Medical staff assessed patients and excluded or no symptoms should be isolated and monitored. persons at high-risk for deterioration from CTCs and On March 2, 2020, the government of South Ko- recommended hospitalization. rea started operating community treatment centers (CTCs) to provide quarantine, regular examination, Criteria for Discharge from the CTC and monitoring for asymptomatic and mildly symp- KCDC has 2 criteria for releasing patients from tomatic patients with laboratory-confirmed COV- quarantine. Symptomatic patients can be discharged ID-19. By March 25, a total of 17 CTCs were serving if symptoms disappear and they have negative re- patients with mild symptoms nationwide. The CTC sults on 2 reverse-transcription PCR (RT-PCR) tests is designed to monitor and isolate patients with mild >24 hours apart. KCDC recommended PCR ampli- conditions during emerging infectious disease out- fication of the viral E gene as a screening test and breaks. We describe the structure and operating pro- amplification of the RdRp region of the open read- tocols of a CTC operated by Seoul National Universi- ing frame 1b gene as a confirmatory test. RT-PCR ty Hospital (SNUH) during the COVID-19 pandemic. is considered positive only when all the genes are detected, based on the opinions of experts who de- Materials and Methods tected weak and nonspecific amplification in the clinical specimens of patients who received negative Study Setting in the SNUH-CTC results. Asymptomatic patients can be discharged if SNUH is a teaching hospital with 1,700 beds. The they have 2 negative RT-PCR tests >24 hours apart Mungyeong Human Resource Development (HRD) within 7 days of diagnosis. Center, 153 km from SNUH, is a 7-story, 100-room fa- We conducted our study in accordance with the cility with accommodations that is normally used for World Health Association’s Declaration of Helsinki training SNUH staff. SNUH converted Mungyeong (https://www.wma.net). The study was approved HRD to a CTC in cooperation with the government’s by the institutional review board of SNUH (IRB no. CTC operating policy and established a monitoring H-2003-163-1112). center inside SNUH. SNUH-CTC began operating on March 5, 2020 as the third CTC in the country. Results Admission and Discharge Criteria Overall Structure SNUH-CTC consisted of 2 centers: the patient center Screening Criteria for Patients for CTC in Mungyeong HRD, where patients were admitted, The Korea Centers for Disease Control and Preven- and the monitoring center in Seoul at SNUH, where tion (KCDC) classified the severity of COVID-19 into medical staff provided video consultation services very severe, severe, mild, and asymptomatic (15) (Figure 1). In the patient center, personnel from the (Appendix Table 1, https://wwwnc.cdc.gov/EID/ Ministry of Health and Welfare, local government, article/26/10/20-1460-App1.pdf). Mild COVID-19 hospitals, military, police, and fire agencies stayed is defined as alert and meeting >1 of the following and provided various services necessary for the op- conditions: <50 years old, >1 underlying conditions, eration of the CTC (Appendix Table 2). and temperature <38°C with antipyretic drugs. As- ymptomatic is defined as a patient who is alert, <50 Patient Center years old, has no underlying disease, is a nonsmok- We divided the Mungyeong HRD Center into a clean er, and has a temperature of <37.5°C without anti- area, in which medical and operating staff worked, pyretic drugs. Patients classified as severe or very and a contaminated area, where patients lived. Each severe were admitted to hospitals; CTCs only ac- area had a designated entrance separate from the cepted patients classified as having mild or asymp- other. We designated an area between the clean and tomatic COVID-19. contaminated areas as a gray zone in which person- Patients with mild COVID-19 met >1 of the fol- nel could remove personal protective gear or perform lowing criteria for CTC admission: they did not nec- other required activities, such as collecting patient essarily require hospitalization; they only required samples or removing waste (Figure 2). monitoring; they were unable to properly self-isolate Mungyeong HRD Center had internet service (for instance, they had no suitable place to live or lived and SNUH installed an additional network to access with persons in a high-risk group); or, as determined the hospital’s electronic medical record (EMR) sys- by local government, they needed to be admitted to tem. Supplies for conducting RT-PCR tests, such as 2330 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 10, October 2020 Protocols of a Treatment Center for COVID-19 Figure 1. Overall structure of the SNUH community treatment center (SNUH-CTC) for isolating mildly symptomatic or asymptomatic patients with coronavirus disease, South Korea. SNUH-CTC was divided into a monitoring center at SNUH in Seoul and a patient center 153 km away in Mungyeong. Boxes indicate various agencies and organizations the provided staff to help run SNUH-CTC and support operations. Arrows indicate direction of information, services, or patient transport. RT-PCR, reverse transcription PCR; SNUH, Seoul National University Hospital. swabs and a refrigerator, and a mobile radiography symptoms, the medical director checked the staff bus were placed next to the building. According to member and provided a RT-PCR test if necessary. the national guidelines for COVID-19, physicians col- Each room of the Mungyeong HRD patient cen- lected RT-PCR samples on a 2-day cycle for negative ter was equipped with an automatic blood pressure cases and on a 3- or 7-day cycle for positive cases and monitor, digital thermometer, and pulse oximeter so sent the samples to SNUH to be tested.