Singapore's experience in ensuring continuity of outpatient care during the COVID-19 pandemic.

Abstract

In response to the COVID-19 pandemic, Singapore had raised the Disease Outbreak Response System Condition (DORSCON) level to Orange—mandating that large-scale events be deferred or canceled, daily health checks and business continuity capability plans enacted, and additional protective measures taken within vulnerable groups.1, 2 Even with soaring numbers of COVID-19 cases worldwide, Singapore has managed to curb rampant community spread and emerged as one of the model countries in battling COVID-19, earning commendation from World Health Organization (WHO).2-4 Hospitals worldwide are prioritizing resources to support front-line and inpatient care. In some countries, outpatient clinics are suspended to deter the spread of COVID-19, but in so doing, have inadvertently restricted access to outpatient care. Our Chronic Program is staffed by 33 medical subspecialists from 15 medical disciplines and 2 surgeons who serve a large volume of patients with chronic diseases at our Integrated Care (iCARE) Clinic. We describe the measures taken in a tertiary hospital in Singapore to mitigate the risk of infection in the outpatient setting, while maintaining near-full clinic operations. Clinicians are segregated into "Hot" and "Cool" teams, with the latter being further subdivided into two teams for contingency purposes. All teams operate within separate physical space, and reporting workflows. The "Hot" team cares for confirmed and suspected COVID-19 cases in critical care and isolation wards, while "Cool" teams manage the general wards and outpatient clinics. In the clinic, staff are divided into two sites and each doctor is paired with one assistant consistently. Patients who warrant in-person consultation are screened via telephone 3 days prior to appointment by service associates for travel history, fever and respiratory symptoms, and contact history with COVID-19 patients. Patients are screened on arrival at the hospital and once more in the clinic by nurses. At every patient touchpoint, staff are required to wear surgical masks and social distancing measures are enforced. A telemedicine service or virtual care (vCare) clinic is rapidly operationalized to allow video consultation between clinicians and patients. Pre-consultation laboratory tests can be performed in community clinics near the patients' house. For those unfit or frail, community nurses are available to perform house visits for phlebotomy. Test results can be viewed via the national electronic medical records. Prescribed medications are either self-collected or couriered. Patients desiring to defer appointments are offered vCare or allowed medication refills. These essential steps are orchestrated by our hospital command center and executed rapidly in response to the evolving situation to ensure “business” continuity, minimize spread, and staff protection. As healthcare systems worldwide are beginning to bend under the pressure of the COVID-19 pandemic, it is easy to forget that the disruption of outpatient care for patients with multi-morbidities may result in inadvertent exacerbation of their chronic illnesses leading to unwarranted hospitalizations, further stressing inpatient resources. We hope that by sharing our strategies and experiences in ensuring the continuation of timely and appropriate outpatient care, we can avoid this potential disaster. We acknowledge the effort and dedication of all our colleagues and the Alexandra Hospital vCare clinic staff. Authors have no conflict of interest to declare.