RHUH experience during Covid-19

21/10/2020

Rafik Hariri University Hospital (RHUH) Experience during COVID-19 Pandemic

Objective:

Being the first governmental hospital to respond to COVID cases, although the economic problems we are struggling in, was a real fight. Our response was rapid. We have done a significant adaptation in 24 hours to meet the very specific needs of our population during the pandemic and since then we keep integrating new knowledge day after day.

Sharing our clinical experience and our staff engagement and suffering in managing cases of Coronavirus disease, is a salute to our heroes, a success story and a lesson to be learned by healthcare policy makers in the context of dramatic pandemics. 

Situation:

On the 21 of February 2020, Lebanon disclosed the onset of the first positive COVID-19 patient, transferred directly from Rafik Hariri International Airport and admitted to RHUH isolation unit. The patient was coming back to Lebanon through a direct flight from Iran (Koum area).

RHUH being the referral governmental hospital called by the Lebanese Ministry of Public Health for the management of very contagious cases was immediately engaged to carry out rapid response actions and to track all needed arrangements and provisions.

This was an unprecedented challenge to all RHUH staff. It perfectly affected the physical and mental wellbeing of our Health Care Workers especially frontlines.

From February till October 2020, 49744 persons have been tested positive for COVID-19 in Lebanon. We have traced 21625 recoveries, 439 deaths during this 8 months period (Figures are subject to increase by time).

Among these 782 patients infected with COVID-19 were admitted to RHUH dedicated Corona Wards, 59 patients infected with COVID-19 died in RHUH, 482 patients infected with COVID-19 were cured and discharged. Some other patients presented to RHUH Emergency Room for testing and assessment, and have been found well enough to be discharged and advised to self-isolate themselves, take prescribed medications and instructions and monitor their symptoms at home.

Preparedness:

The hospital had in place one dedicated isolation unit of 4 intensive care beds fully equipped and some of our staff were already trained on the management of contagious disease but there was an imminent need to tackle expected increased workload in an ever-evolving situation. 

1. Physical settings, access paths and patient flow:

At the very beginning of the pandemic, in order to minimize the spread of the disease, and in addition to the Ground Floor isolation unit, we converted conventional wards to isolation areas without suspending any essential clinical services: 4 wings at third floor of the main hospital building were capable of providing 24/24 care to 128 patients. A triage system with a separate pathways for suspected cases was developed with a fully equipped emergency room for COVID patients’ assessment and admission. By the evolution of the disease and the increase in demand, later additional units were prepared:

• A ward in basement one with total of 20 beds,

ICU 1with a total of 11 beds (after transferring non COVID cases to CCU unit),

ICU 3 with total of 8 beds,

6 ICU beds for in-patients staying in COVID ER (due to lack of places in COVID ICU beds),

8 ICU beds (inside the operating theater which was restructured in collaboration with UNHCR),

4 COVID NICU beds.

• Entrance to all these areas was restricted to two elevators near COVID ER door. The first elevator was labeled for clean items only and the second one for soiled items only.
• Gibson boards’ doors were installed to close all possible entries to the new hospital units henceforth called Corona hospital.
• An operating room for urgent surgeries as well as one room for Normal vaginal delivery were prepared in COVID emergency department for suspected/confirmed COVID cases.
• Dialysis sessions for patients in need were provided in ICU 1 rooms.
• Specific measures to prevent nosocomial infections were implemented including regular screening and symptom checking of all individuals entering the facility buildings with administrating a questionnaire of symptoms and travel history, mask wearing, use of hand sanitizer, regulation of traffic using one way controlled gate and social distancing for staff. 

2. Resources provisions:
   • Medical supplies and medications stocks were prepared with necessary PPEs.
   • Staff were called and scheduled to cover 24 hours presence in COVID units and were allocated additional increments. Psychological support was provide by experts to avoid burn out as result of constant physical and psychological tension.
   • Expanding tests capacity to a level comparable to that of international hospitals.
   • 24 hours PCR testing laboratory

3. Infection prevention and control:
   • Guidance on required infection prevention and control procedures including safe use of PPEs for crucial staff safety was made available in regular and COVID units. Restricted budget and scarcity of resources were the major constraint that forced us to search for solutions that are not scientifically tested such as rewashing of Tyvek
   • Continuous control of environmental cleaning and disinfection. Infection control team making regular rounds.
   • Immediate training by the infection control team to all staff who started their duties in the new Corona hospital (HCWs as well as security staff and orderlies). Written instructions, SOPs prepared, laminated and hanged in all floors.

4. Communication and health awareness:
   • Prevention and awareness brochures to provide guidance on COVID-19 surveillance in healthcare and community settings were prepared for patients under isolation in hospital or isolated at their home taking into consideration all possible concerns patients or relatives can have.
   • Communication channels among clinicians and between a range of different stakeholders both within and outside the hospital.
   • Wi-Fi connection and TVs stations were made available in all COVID units.
   • Hotline was created for rapid answer to all people concerns and questions (1214).
   • Daily informative newsletter was elaborated and sent by RHUH on daily basis.
   • Meetings with all staff in COVID units were maintained through zoom conference call.
   • Monitor and management of staff exposure to COVID-19 were followed.
   • Collection of all necessary data for further analysis and information was secured.

5. Treatment:
   • Treatment took place in isolation units as part of Solidarity trials with WHO.
   • The hospital has developed guidelines for cases management from admission till discharge including care documentation.
   • Specific SOPs for clinical management of COVID cases, food delivery, linen handling, laboratory testing, admission and discharge processes, obstetrics, dialysis and surgical cases were also written.

Success story:

Working stress, daily influx of patients to hospital, low hospital capacity and the insufficient ratio of nurses to patients have made the care more difficult.

By the time the pressure was increasing on RHUH frontlines, and the fear of contacting the virus among healthcare workers was also increasing, the first staff exposure was declared.

One of our leaders a nurse supervisor, 30 years old presented a symptomatic table in favor of COVID-19. While she was on duty in June 12 she felt tired, and noted a mild cough with rhinorrhea. She was advised by the infectious disease physician to do the PCR test. The second day, her test comes up positive. Her symptoms were aggravating and she needed admission.

She was suffering from a severe pneumonia that required O2 administration along with the Antibiotics and the standard COVID treatment. She was only discharged after 9 days of hospitalization, in June 21.

Although she has been very careful since the beginning of the pandemic, wearing all needed PPEs at work and quarantining herself and her family at home, she always had in mind that it could be her one day who might be positive.

The day when she noticed the signs was memorable:

“It started with chills, body ache, severe headache, dry cough and fever of 39 degrees. I called the infectious disease physician who told me that I need to be closely observed and admitted”.

“At this moment my first reaction was to concentrate on whom I could have transmit it”.

“My only thoughts were regarding my three children, my husband, my parents and the people I was obliged to see”.

“The first hours were awfully difficult”.

After tracking all people who were in contact with her, the physician believed our supervisor contracted the virus from her little girl who had a doctor visit to one of the hospitals.

Loneliness, fear, anxiety were embracing her during all her stay although she was monitored and supported by all colleagues:

“It was really a nightmare, I felt helplessness and loneliness. I was on my own, I didn’t know whether I will survive or no”.

“Now that I am recovered, I thanks my family and friends who continued to follow on my case throughout my whole recovery period and I urge all people to respect guidelines diffused by the Lebanese Ministry of Public Health protecting their lives and the life of others”.

After this first staff contagion, many other staff were tested positive, but without the need for long hospitalization.  Out of 124 nurses working with COVID-19 patients, 9 nurses have been exposed and managed individually according to their degree of exposure.

Conclusion:

Hope that sharing this experience will enhance preparedness for future possible pandemics and will highlight the many bottlenecks when drawing crisis plans. In addition, this could be a call for all healthcare stakeholders that nurses are the critical line of defense, countries must identify the need for nurses and consider how to find ways to support them to ensure we can respond to any crisis confidently, and increase nurses and hospital resilience in response to such crisis.

RHUH

Nursing  Team