Quah et al.

International Journal of Emergency Medicine (2020) 13:32

https://doi.org/10.1186/s12245-020-00294-w
International Journal of
Emergency Medicine

STATE OF INTERNATIONAL EMERGENCY MEDICINE Open Access

Reorganising the emergency department

to manage the COVID-19 outbreak
Li Juan Joy Quah1* , Boon Kiat Kenneth Tan1, Tzay-Ping Fua1, Choon Peng Jeremy Wee1, Chin Siah Lim1,
Gayathri Nadarajan1, Nur Diana Zakaria1, Shi-En Joanna Chan1, Paul Weng Wan1, Lin Tess Teo1, Ying Ying Chua2,
Evelyn Wong1 and Anantharaman Venkataraman1

Abstract
Background: The COVID-19 disease outbreak that first surfaced in Wuhan, China, in December 2019, has taken the
world by storm and ravaged almost every country in the world. Emergency departments (ED) in hospitals are on
the frontlines, serving an essential function in identifying these patients, isolating them early whilst providing
urgent medical care. This outbreak has reinforced the role of Emergency Medicine in public health. This paper
documents the challenges faced and measures taken by a tertiary hospital’s ED in Singapore, in response to the
outbreak.
Main body: The ED detected the first case of COVID-19 in Singapore on 22 January 2020 in a Chinese tourist and
also the first case of locally transmitted COVID-19 on 3 February 2020. The patient journeys through the patient
reception area in the ED and undergoes fever screening before being shunted to isolation areas within the ED.
Management and disposition of suspect COVID-19 patients are guided by a close-knit collaboration between ED
and department of infectious diseases. With increasing number of patients, back-up plans for expansion of space
and staff augmentation have been enacted. Staff safety is also of utmost importance, with provision and guidelines
for personal protective equipment and team segregation to ensure no cross-contamination across staff. These have
been made possible with an early setup of an operational command and control structure within the ED,
managing manpower, logistics, operations, communication and information management and liaison with other
clinical departments.
Conclusion: With the large numbers of undifferentiated patients managed by the ED to date, more than 820
patients with COVID-19 have been identified in the hospital. Not a single member of the staff of the SGH
Emergency Department has come down with the illness. The various measures undertaken by the department have
helped to ensure good staff morale and strict adherence to safety procedures. We share the lessons learnt so that
others who manage EDs around the world can benefit from our experience.
Keywords: COVID-19, Emergency department

* Correspondence: joy.quah.l.j@singhealth.com.sg
1
Department of Emergency Medicine, Singapore General Hospital, 1 Outram
Road, Singapore 169608, Singapore
Full list of author information is available at the end of the article

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Quah et al. International Journal of Emergency Medicine (2020) 13:32 Page 2 of 11

Background The first indication of the COVID-19 disease outbreak

The COVID-19 disease outbreak that first surfaced in was in the city of Wuhan, Hubei Province, on 31 De-
Wuhan, China, in December 2019, has taken the world cember 2019 when the Chinese government informed
by storm and ravaged almost every country in the world the WHO China country office about a cluster of 41 pa-
[1]. Emergency departments (EDs), in most countries, tients with a new respiratory infection. On 2 January, the
have been on the frontline, meeting the undifferentiated Ministry of Health (MOH) in Singapore issued a health
patients presenting with a variety of complaints that rep- advisory and implemented temperature checks for pas-
resent the disease. Serving an essential function in iden- sengers arriving at her international airport from Wuhan
tifying likely patients with the infection and isolating [6]. On 11 January 2020, the Chinese authorities in-
them early, this pandemic has reinforced the critical role formed the WHO that this infection was due to a novel
played by Emergency Medicine in public health. coronavirus [7].
We document the measures taken by a busy ED in The first case of the illness in Singapore was in a tour-
Singapore in managing the outbreak; outline the reasons ist from Wuhan who presented to the ED at SGH on 22
for these various measures, their limitations, and details January 2020. On 24 January 2020, the MOH declared
of implementation; and suggest approaches for the long- the Disease Outbreak Response Condition (DORSCON)
term role of Emergency Medicine in the community to be yellow. DORSCON is a colour-coded framework
management of the COVID-19 pandemic and future that shows the current infectious disease situation and
communicable public health emergencies. provides guidelines on what can be done to prevent
In reviewing these measures, we take a step-by-step transmission and reduce the impact of infections. The
approach using the patient’s pathway through the ED as colour codes vary from green (mild) to yellow (severe
a guide. We first describe the background against which and minimal community spread), orange (severe and
the changes in the ED were implemented. Subsequently, contained spread) and red (severe and spreading widely)
we begin with the reception of patients and discuss [8]. The first instance of local transmission was picked
screening procedures, triage, isolation, medical care in up at the same ED on 3 February 2020. On 7 February
resuscitation, critical trolley areas, ambulatory patients, 2020, the MOH upgraded the DORSCON situation to
and the role of observation. Finally, we elaborate on the orange. The first COVID-19 death in Singapore was re-
need for Emergency Medicine to take the lead in ad- corded on 24 March 2020. The first instances of foreign
dressing screening of clusters of these infections and the workers from the dormitories with the infection were on
role of surveillance research. 30 March 2020 when 16 positive cases were identified.
Just prior to that, Singapore had 844 COVID-19 cases,
The environment of whom all were either imported or from local trans-
Singapore is one of the smallest countries in the world. mission. Over the next few weeks, the number of
This tropical island country of 721.5 km2 had a popula- COVID-19-positive cases amongst the foreign workers
tion of 5.70 million people in 2019. Of these, 4.02 mil- in the crowded dormitories surged to more than 700 a
lion are citizens and permanent residents. About 85% of day and became a significant contributor to the national
the residents live in modern high-rise apartments scat- case tally (Fig. 1) On 7 April 2020, the government an-
tered all over the island and the remaining 15% in nounced a state-wide lockdown (referred to as circuit
landed properties [2]. Of the non-resident population, breaker in Singapore) which has since been extended to
the labour force commands approximately 1.41 million 1 June 2020.
persons, of whom around 323,000 are employed princi-
pally in the construction industry, living in crowded dor-
mitories built by employers with financial assistance Patient reception during COVID-19
provided by the government [3]. Ever since the declaration of DORSCON orange, ambu-
Singapore’s healthcare system was ranked sixth in the lance crew and hospital staff have donned personal pro-
World Health Organization’s (WHO) ranking of world tective equipment (PPE) with full-length gown, N95
health systems in 2000 and first by Bloomberg for the masks and goggles when attending to patients (Fig. 2).
most efficient in the world in 2014 [4, 5]. Singapore has All patients picked up are provided with surgical masks.
nine public hospitals with EDs. The 199-year-old When the patient is brought to the ED, reception staff
Singapore General Hospital (SGH) is the oldest public transfer the patient to ED patient trolleys and conduct
healthcare institution in the country. It is also the lar- fever screening initially. The ambulance crew perform
gest, with 1785 beds in total. Its ED was established 72 terminal cleaning of the interior of the ambulance and
years ago and manages approximately 130,000 patients dispose of their gowns and gloves before leaving the ED
annually. The ED has 70 medical staff (25 emergency for the ambulance stations. The fever screening process
physicians and 45 residents) and 200 registered nurses. is described in the next section.
Quah et al. International Journal of Emergency Medicine (2020) 13:32 Page 3 of 11

Fig. 1 Graphic representation of dormitory workers contributing to national tally [9]

For patients arriving by transport means other than ensure access control and that all patients and compan-
ambulances, the same group of fully gowned ED recep- ions would only come in from the front of the
tion staff welcome and attend to them in a separate Department.
glass-enclosed fever screening facility at the entrance of
the Department. From this location, the ED staff con- Fever screening
duct the fever screening process. All these patients, as Fever screening was first introduced into the ED 17 years
well as persons accompanying them, will also be pro- ago at the beginning of the SARS (severe acute respira-
vided with a surgical mask each. Only one person will be tory syndrome) outbreak in March 2003. This was in re-
allowed to accompany the patient into the ED. Add- sponse to the challenge of segregating high-risk patients
itional accompanying persons will be advised to wait in from other patients early on in their patient journey and
the cafeteria at the neighbouring hospital block. placing them in appropriate areas with airborne and
The ED has two entrances, one at the front of the droplet precautions addressed. This served to prevent
Department and one at the rear. At the onset of the spread to other patients and was also a reminder to at-
DORSCON yellow period, the rear entrance was closed tending healthcare staff that appropriate PPE should be
with a staff-card accessed door. This was to better donned before such patient contact. Since then, all

Fig. 2 Staff in full personal protective equipment when attending to patients

Quah et al. International Journal of Emergency Medicine (2020) 13:32 Page 4 of 11

patients coming to the ED undergo fever screening The fever screening form is updated regularly depend-
before they are triaged or formally registered at the ing on the current international epidemiological situ-
Department. ation as updated by the MOH through circulars issued
During fever screening, a trained staff member will to all hospitals and medical alerts to all medical practi-
ask the patient to provide demographic and contact tioners in the state.
particulars, symptomology and travel and contact his-
tory. The contact particulars of the accompanying The ED’s fever (isolation) areas
person(s) are also recorded. The temperature of the In 2003, Singapore was one of 21 countries around the
patient will be checked. These details will be docu- world affected by the SARS crisis [10]. Because SARS
mented in a fever screening form (Fig. 3). If the pa- was thought to be an extremely infectious illness, an iso-
tient is deemed to have failed the screening (possibly lation area was carved out of the ambulatory section of
likely to have a communicable infectious disease), he the Department on the day the SARS outbreak was de-
will be shunted immediately to the fever (isolation) clared in Singapore. This area was made a negative pres-
area. Accompanying persons will not be allowed in sure area with its own ventilation and airflow system.
the isolation area. Fresh air was introduced into this area, unlike conventional

Fig. 3 Fever screening form

Quah et al. International Journal of Emergency Medicine (2020) 13:32 Page 5 of 11

air-conditioned systems which use re-circulated indoor air local transmission, the number of patients presenting at the
for an efficient cooling process. All effluent air from each of ED fitting the high-risk criteria at fever screening quickly
the rooms in the fever section would be diverted to the outer overwhelmed these areas. To meet this challenge, the hos-
atmosphere through ducts in the roof equipped with HEPA pital cancelled elective procedures and transferred the man-
(high-efficiency particulate air) filters and after they had been agement of the adjacent 40-bedded Ambulatory Surgery
ultraviolet radiated. The section has 11 beds, its own triage Centre, to the ED (Fig. 4). This area was also provided with
room, X-ray suite, toilets, registration counter and protected isolation facilities. Therefore, at the start of ramped-up oper-
access to the Department’s own pharmacy. This section had ations, the ED had a total of 51 isolation beds.
been used frequently during the SARS outbreak and during In the first 2 weeks of the outbreak situation, the isola-
subsequent international outbreak situations such as the tion areas received up to 110 patients daily. All staff work-
H1N1 (2009), MERS CoV (from 2012 onwards) and the ing in these areas are clothed in full PPE, including N95
Ebola crisis (from 2014 onwards). In addition, four of the re- masks, splash-proof goggles, disposable water-resistant
suscitation bays in the ED’s resuscitation zone had been also isolation gowns with knitted cuffs, shoe covers, gloves and
equipped with negative pressure facilities. By early February head covers when attending to suspect COVID-19 pa-
2020, owing to increasing numbers of COVID-19 cases from tients. Isolation gowns and gloves have to be changed in

Fig. 4 Ambulatory surgery centre as an expansion of ED fever area

Quah et al. International Journal of Emergency Medicine (2020) 13:32 Page 6 of 11

between patients. Every bed there has its own alcohol rub improvised cubicle partitions, electrical re-wiring for com-
bottles and other common user items that would be re- puter network access, support for electrical devices, space for
quired for patient care. placement of medical equipment and supplies and facilities
for command room, restrooms, pantry and rest areas (Fig. 5).
The forward/flu screening area The hospital had trained staff of the ED and other clinical
The surge in the number of fever patients being referred to and non-clinical departments to manage the FSA and had
the EDs for screening raised concern that the isolation areas conducted full-scale, real-time exercises to practice the pro-
would be overwhelmed. The hospital activated a forward cedures there in the 2 months before the circuit breaker was
fever screening area (also dubbed flu screening area) to declared. Once activated on 20 March 2020, the FSA man-
screen ambulant patients being referred to the hospital either aged up to about 80 patients daily.
by primary care clinics or coming on their own accord. The
need for such an area had been anticipated soon after news Management of resuscitation, critical care trolley
of the outbreak in China had broken. The hospital had pre- and ambulatory areas
pared its multi-storey car park located in the campus, about On a normal day, the ED is manned by three shifts of
800 m away from the ED, to be converted to an FSA for am- doctors and nurses over a 24-h period. Owing to the in-
bulant patients. This FSA could cater to about 73 ambulatory crease in the number of patients coming to the ED, the
patients at a time. For this purpose, it was fitted with diversion of ambulances from the main hospital that was

Fig. 5 Exterior facade and interior layout of patient care area in the forward screening area
Quah et al. International Journal of Emergency Medicine (2020) 13:32 Page 7 of 11

housing the majority of COVID-19 patients and the resuscitation. Resuscitation equipment and monitors
opening up of more areas being manned by the ED, were made available in these areas.
shortage of ED manpower became a real concern. The Provision was made for the occasional patient sched-
hospital provided additional Residents to help in the uled for discharge from the ED but with a need to get a
staffing of the ED. This was made possible because elect- naso-oropharyngeal swab done. All such patients were
ive surgical procedures in the hospital were curtailed also provided with 5 days of medical leave and a stay-
leading to the availability of staff for needed critical home order for that period. This order was backed up
areas. At the ED, staff moved to a 12-h shift system to legally by the state.
maximize the numbers available per shift. In addition, To minimize the risk of ED staff cross-contaminating
the Department divided the staff into five separate the community after work, personal scrubs were no lon-
teams, with each team assigned covering multiple areas ger allowed. Hospital-issued scrubs were organised by
during each 12-h shift. The longer shift hours allowed the hospital’s linen department twice daily in large trol-
better coverage of the various areas of need. The inter- leys. After their clinical shift, all staff would proceed to
vals between each 12-h shift allowed each team to ad- the restrooms for a shower, leave their used hospital-
equately recuperate from a long busy shift and ready to issued scrubs in allocated bins, change into their civilian
work non-stop for their next clinical session. During this clothes and straight out to the car park or the public
period, there was a need to ensure that the ED remained transportation systems without moving into the clinical
operational in the event any ED staff contracted areas again. After use, the scrubs are sent to the linen
COVID-19. The team-based system ensures that if one department for disinfection and washing.
member of a team were to turn positive for the virus, it
will be more likely that only members of that team may The role of the emergency observation ward
be affected and would need to be taken out of action. In normal times, the 40-bedded emergency observation
The other teams would be likely to remain clean. This ward would be managing patients on protocolized care of
would minimize threats to the integrity of ED staffing. between 8 to 23 h. Some would be on shorter observation
Vacation leave was also cancelled for all grades of staff stay while waiting for investigations results. Others may
across the hierarchy of the hospital. be waiting for an inpatient bed. When DORSCON orange
When performing aerosol-generating procedures for was declared, there was concern with distancing require-
any patient, the minimal requirement was an N95 mask ments and a need to keep available beds in the observation
with goggles or powered air-purifying respirator (PAPR). ward for patients awaiting a bed and especially for those
All hospital staff had undergone prior N95 mask fitting requiring short-term observation. Therefore, prolonged
in the weeks following the first indication of the out- observation protocols were suspended and arrangements
break in China. Those who needed to use the PAPR had made with multiple clinical departments to conduct re-
to attend a refresher recertification course on its use. views of patients undergoing shorter sub-4-h observation,
The non-fever areas of the ED are split into 3 separate at their specialist outpatient clinics. This released quite a
areas—the resuscitation room for severely ill patients number of observation beds.
(priority 1), the critical care trolley area for moderately With increasing involvement of dormitory workers in
ill patients (priority 2) and the ambulatory area for pa- the infection, there was an expectation that a large num-
tients with mild conditions (priority 3). ber of such persons may be brought to the ED and re-
All patients brought to the six-bedded resuscitation quiring inpatient admission. This would require a larger
room were regarded as potentially infected with number of isolation beds and even resuscitation beds
COVID-19 because of likely difficulty in obtaining a within the ED. For this contingency, approximately half
clear contact history from them. When the history sug- the observation beds have been also assigned for priority
gested possible contact, the patient would usually be 2 use and the logistics requirements also put in place.
managed in one of the four resuscitation bays that were This flexibility in use of the emergency observation ward
isolation-type. X-rays for these patients were done in the has been utilized in previous mass casualty situations
bays which were fitted with ceiling-mounted X-ray such as during a chlorine gas accident and a mass or-
tubes. The exterior of the equipment was cleaned soon ganophosphate poisoning incident.
after each use so that the X-ray tubes would be available
for the next patient. The radiology department also re- Disposition of patients
ported on the X-rays within 1 h of the images being At the beginning of the outbreak, there were differences
taken. Blood, throat and nasal samples were all handled in the risk stratification methods used by Emergency
with strict infection-control precautions by the staff. In Physicians and Infectious Diseases Specialists. This could
the event of a large number of severely ill patients, speci- potentially affect patient disposition in the hospital. To
fied bays in the priority 2 area were used for mitigate this issue, the ED teamed up with the ID
Quah et al. International Journal of Emergency Medicine (2020) 13:32 Page 8 of 11

department and drew up disposition protocols for pos- 6. Low-risk patients are placed in well-ventilated
sible infectious disease patients. These protocols were wards with beds, at least 2 m apart.
based on the latest national epidemiological risk and pa-
tient assessments and served to standardize management The risk stratification process is regularly updated and
of possible infectious disease patients based on their refined as more information about the disease becomes
probability of having COVID-19. They also better ensure available. The updated protocols are put up daily in all
that all doctors follow the case definitions for the dis- the care areas of the Department for doctors to refer to
ease, including the criteria for diagnosis. when in doubt.
The principles of disposition are as follows:
Emergency department organisation and
1. The ED doctor decides if COVID-19 swabbing is leadership during the outbreak
required based on the latest disposition protocols. Ensuring that patients coming to the ED undergo a rela-
2. Patients who are well enough for discharge are tively seamless and hassle-free process requires clear or-
given stay-home and self-quarantine orders, which ganisation and leadership. This is especially important
are enforced until swab results are made available. during an unpredictable crisis situation, like the
3. If hospital admission is necessary, patients are risk COVID-19 pandemic. For SGH ED, leadership was re-
stratified (low, medium or high) based on their organised at the beginning of operations to allow for this
history, radiological and blood investigations. (Fig. 6). The need to split the ED into multiple teams
4. High-risk patients are isolated in single-bedded and serve multiple areas required a good command and
rooms. control system. Operational command and control was
5. Medium-risk patients are placed in well-ventilated established with the Department Chair as the ED
common wards, with beds more than 3 m apart Commander, directly commanding the five clinical
and separated with partitions. operational teams and the FSA team. Each of these

Fig. 6 SGH emergency department leadership and operational organisation for COVID-19 outbreak. Each clinical team leader is in charge of a
team of doctors, in a team-based 12-h roster format. For each shift, each team will allocate doctors to see patients in resuscitation room (P1),
trolley area (P2), ambulatory area (P3), observation room (Obs) and fever (isolation) area
Quah et al. International Journal of Emergency Medicine (2020) 13:32 Page 9 of 11

teams was led by a Senior Emergency Physician. Within Operations

each operational team, members were assigned to the The constantly evolving COVID-19 situation, clinical
various patient care areas within the Department. These and operational protocols and arrangements required
were the fighting troops meeting the patients presenting frequent review and amendments. The operations team
to the Department head-on and managing them within would work out the needed changes and discuss with
the framework of the operational guidelines and proto- relevant members of the ED via telephone, email, What-
cols provided by the Department. sApp™, TigerConnect™ or ZOOM™ videoconferencing.
Supporting the ED Commander was a staff team cov- After final discussion with the ED Chair, the operations
ering five areas, each team led by other senior Emer- team will produce instructions and revised protocol
gency Physicians. Assistance was also provided by an charts to be disseminated to the teams. In addition, the
executive secretariat led by the Department’s administra- operations team would monitor the clinical load at each
tive manager. The five areas covered were as follows: of the areas being covered by the ED. Feedback was
regularly received during the various shifts of work to
 Manpower adjust operational plans and address needs. The opera-
 Operations tions team would also work closely with the logistics
 Logistics team to ensure that resources needed by the clinical
 Communications and information management teams were requisitioned early and sent to the required
 Clinical liaison areas in timely fashion.

Logistics
Secretariat The need for logistical items special to disease outbreak
The administrative manager coordinated the work of the situations is often not well appreciated in healthcare in-
secretaries, executive and administrative assistants to en- stitutions until the eleventh hour. Previous experience
sure that all operational charts and workflow informa- with the SARS outbreak 17 years ago, H1N1, MERS and
tion were updated and logistics arrangements executed. Ebola situations helped in the logistics planning this
The secretariat set up the areas for key meetings held in time around. Immense preparations were made for those
the ED with precautions taken for social distancing and events, and the team was well-aware of the need to an-
use of appropriate PPE during such meetings. Desig- ticipate requirements and plan for these early. Once the
nated areas were set up for meals provided to the staff. situation is evolving, logistical arrangements may not al-
Sourcing for PPE and appropriate disposal arrangements ways be executed smoothly. The team, therefore, lis-
were made by them. tened to feedback from the clinical teams and ensured
that any hitches in supplies were rectified promptly. Lo-
gistical needs were not only in the areas of medical
Manpower equipment and pharmaceuticals, but also for internal lo-
As mentioned earlier, separate operational teams were gistics, such as appropriate PPE, meals and even special
set up from the manpower available within the Depart- meals for staff. These have helped to keep morale high
ment. Critical manpower shortfalls were identified early during the disease outbreak period.
and liaison established so that requirements for medical,
nursing and patient care assistant staff were addressed Communications and information management
from within the hospital without having to be sourced During any disaster, communication is extremely im-
from the general community. The manpower team en- portant to ensure that units are apprised as to what is
sures that rostering arrangements are worked out and all happening, able to effectively transmit relevant messages
staff promptly informed of any changes. Their require- and advise those in need. Lack of communication or
ments for the various forms of PPE were determined, misinformation can have dire consequences on patient
and this information passed on to the secretariat. Staff care, staff safety and morale. The ED has been using
with special needs had arrangements specially arranged multiple modes of communication to enable the depart-
for them by the team. The manpower team also ad- mental leadership to communicate with the staff. These
dressed the often-forgotten area of staff welfare and include email, creation of WhatsApp™ groups, TigerCon-
wellness. A peer counselling team was set up within the nect™, Workplace by Facebook™, daily routine instruc-
Department to address issues pertaining to stress man- tions and departmental bulletins, in addition to face-to-
agement during the conduct of departmental operations. face briefings albeit with PPE. Every shift begins with a
Peer support leaders have also been appointed in every short clinical team meeting, after which information is
clinical team to facilitate the conduct of debrief sessions shared with the team members. Owing to the tremen-
at individual and team level, whenever necessary. dous amount of information that needs to be exchanged
Quah et al. International Journal of Emergency Medicine (2020) 13:32 Page 10 of 11

and to ensure that staff stay updated on the latest infor- not a single member of the staff of the SGH ED has come
mation and able to easily communicate with all levels of down with the illness during this period. The various mea-
the Department, the ED has applied the discipline of en- sures undertaken by the staff have helped to ensure good
suring better security of patient information during this staff morale and strict adherence to safety procedures. We
outbreak period. All staff have been advised that no clin- share the lessons we have learnt during the outbreak with
ical or treatment information on patients can be shared others who manage EDs around the world and look for-
via WhatsApp and that only secure applications are to ward to seeing the establishment of an international shar-
be utilized for such. ing and communication network with EDs worldwide. We
Of course, the ED Commander also attends daily meet- all need to learn from each other.
ings with the hospital’s Emergency Preparedness Task
Abbreviations
Force and represents the ED in all dealings with senior COVID-19: Coronavirus disease 2019; WHO: World Health Organization;
management and with the MOH, whenever, necessary. SGH: Singapore General Hospital; ED: Emergency department;
DORSCON: Disease Outbreak Response System Condition; PPE: Personal
protective equipment; FSA: Forward screening area
Clinical liaison
Liaising with the other clinical departments in the hos- Authors’ contributions
pital by the ED leadership has become the norm for Li Juan Joy Quah—study design, manuscript writing. Boon Kiat Kenneth
Tan—editing. Tzay-Ping Fua—editing. Choon Peng Jeremy Wee—editing.
many years in the hospital. During the COVID-19 out- Chin Siah Lim—editing. Gayathri Nadarajan—literature review. Nur Diana
break, such liaison has been very helpful in drawing up Zakaria—figures. Shi-En Joanna Chan—editing. Paul Weng Wan—figures. Lin
departmental infectious disease management protocols, Tess Teo—editing. Ying Ying Chua—editing. Evelyn Wong—editing. Ana-
ntharaman Venkataraman—study design, manuscript writing, editing. All au-
patient disposition protocols, arrangements for subse- thors read and approved the final manuscript.
quent early follow-up of patients being discharged from
the ED, and in adjustments of current arrangements the Funding
Not applicable
department has with the other 36 clinical departments
in the hospital for various aspects of patient care. These Availability of data and materials
have helped to better ensure that the ED’s management Data sharing is not applicable to this article as no datasets were generated
or analysed during the current study. All data quoted in this paper are in the
of suspect and confirmed COVID-19 patients stays in public domain.
line with the hospital’s and with the state’s overall man-
agement framework. On-line clinical decision rules Ethics approval and consent to participate
Not applicable
based on these algorithms have also been developed,
based on the clinical algorithms created, via Microsoft© Consent for publication
Forms accessible with QR codes. These have helped to Not applicable
decrease the cognitive workload and increased confi- Competing interests
dence of doctors in management of the variety of poten- The authors declare that they have no competing interests
tially infected patients presenting to the ED during this
Author details
period. 1
Department of Emergency Medicine, Singapore General Hospital, 1 Outram
Road, Singapore 169608, Singapore. 2Department of Infectious Diseases,
Contribution to the community during the Singapore General Hospital, 1 Outram Road, Singapore 169608, Singapore.
outbreak Received: 15 May 2020 Accepted: 8 June 2020
In addition to all of the above, and in response to calls
from the hospital and from the MOH, the ED has taken
References
the lead and mobilized a small team to go in full PPE into 1. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/
some of the foreign worker dormitories in the country to question-and-answers-hub/q-a-detail/q-a-coronaviruses#:~:text=symptoms
screen persons staying there, conduct nasopharyngeal last accessed 9 May 2020.
2. Government of Singapore. Department of Statistics, Singapore. Population &
swabs and speed up the process of early identification of Population Structure (September 2019). https://www.singstat.gov.sg).
COVID-19 cases, whether symptomatic or otherwise. The Accessed: 6 May 2020.
team has screened a few thousand such persons. This has 3. Government of Singapore. Department of Statistics, Singapore. Labour,
Employment, Wages and Productivity (April 2020). https://www.singstat.gov.
contributed to speedier identification, isolation, safe dis- sg Accessed: 6 May 2020.
tancing and treatment of symptomatic cases. 4. Ajay Tandon CJM, Jeremy A Lauer, David B Evans, World Health
Organization. Measuring overall health system performance for 191
countries. Year 2000. https://www.who.int/healthinfo/paper30.pdf Accessed:
Conclusion 6 May 2020.
The situation continues to evolve. With the large num- 5. Bloomberg. Where do you get the most for your health care dollar? 18
bers of undifferentiated patients managed by the ED, we September 2014. https://www.bloomberg.com/graphics/infographics/most-
efficient-health-care-around-the-world.html Accessed: 6 May 2020.
have identified, as of 8 May 2020, 820 patients with the 6. Government of Singapore. Ministry of Health, Singapore. Precautionary
COVID-19 infection [9]. Since the start of the outbreak, measures in response to severe pneumonia cases in Wuhan, China. (January
Quah et al. International Journal of Emergency Medicine (2020) 13:32 Page 11 of 11

2020) https://www.moh.gov.sg/news-highlights/details/precautionary-
measures-in-response-to-severe-pneumonia-cases-in-wuhan-china Accessed:
6 May 2020.
7. World Health Organization. Novel Coronavirus (2019-nCoV) situation report -
1. 21 January 2020. https://www.who.int/docs/default-source/coronaviruse/
situation-reports/20200121-sitrep-1-2019-ncov.pdf Accessed: 6 May 2020.
8. Government of Singapore. What do the Different DORSCON levels mean?
(February 2020) https://www.gov.sg/article/what-do-the-different-dorscon-
levels-mean Accessed: 6 May 2020.
9. Government of Singapore. Ministry of Health, Singapore. COVID-19 Situation
Report (8 May 2020) https://covidsitrep.moh.gov.sg/ Accessed: 9 May 2020.
10. World Health Organization. Summary of probable SARS cases with onset of
illness from 1 November 2002 to 31 July 2003. 31 December 2003 https://
www.who.int/csr/sars/country/table2004_04_21/en/ Accessed: 6 May 2020.

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