FFA  MO  GUIDE  2020  THE  WAR  WITH  COVID-­‐19  

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Contents  Page  

1.  Before  Your  First  Fever  Shi�    2.  Star�ng  Your  First  Fever  Shi�  3.  Computer  Tips  &  Tricks    4.  Swabbing  Your  First  Pa�ent    5.  FFA  Workflow  for  Special  Popula�ons    6.  So  Where  Are  All  These  Places    

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1.  BEFORE  YOUR  FIRST  FEVER  SHIFT  …  

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Acronyms  and  what  they  are    SASH  =  Swab-­‐and-­‐Send-­‐Home  /  Swab-­‐and-­‐go  

–  General  term  where  pa�ents  are  swabbed  and  discharged.  Offered  in  ED,  polyclinics  and  some  GPs.  

  HO  =  Hospital    SIF  =  SASH  Isola�on  Facility    

–  HO-­‐SIF  =  isola�on  facility  in  hospital  e.g.  CGH  HO-­‐SIF  at  clinics  ABCD    CIF  /  CCF  =  Community  Isola�on/Care  Facility  

–  Well  Covid  posi�ves,  e.g.  Expo,  Downtown  D’Resort    GQF  =  Government  quaran�ne  facility    DIF  =  Dormitory  Isola�on  Facility  

–   Gaze�ed  dormitories  which  can  hold  posi�ve  and  suspect  cases  

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Overview  of  CGH  Fever  Facility  Area  (FFA)  FFA-­‐1  /  FFA-­‐1  EXT   HO-­‐SIF  

Opera�ng  Capacity  –  Operates  all  hours  –  3x  consult  rooms  +  1x  makeshi�  consult  room    –  FFA-­‐1  EXT  about  22  chairs  for  holding  pa�ents  

Equipped  with  XR,  swab  room,  resus  room,  mini-­‐pharmacy    *FFA-­‐2  is  closed  as  of  7  September  2020  

Holding  area  for  pa�ents  who  require  isola�on  while  awai�ng  COVID  swabs  Currently,  following  group  of  pa�ents:  –  Dormitory/non-­‐dorm  foreign  workers  –  People  work/live  at  communal  se�ngs  (Annex  C)  who  

cannot  self-­‐isolate  

Located  at  A&E  Block,  Level  2,  Old  Clinics  A,  B,  C  &  D  Manned  by  doctors  from:  –  CHI  and  Radiology  daily  (Mon  to  Sun)  from  8am  to  5pm  –  A&E  outside  of  these  hours    

 3  Important  Numbers    CGH  Op  Centre  9645-­‐0310  

  COVID  enquiries  à  Check  ID  roster  on  CGH  intranet  

  FFA  Senior  /  Resus  Senior  3  is  your  go-­‐to  best  friend  –  Check  Daily  Roster  at  Triage  before  shi�  starts  –  If  no  designated  FFA  senior,  to  call  R3    –  shi�  change  at  8am,  4pm,  11pm  

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Latest  Workflow  in  FFA  

  The  latest  clinical  pathways  and  “Swab-­‐and-­‐Send-­‐Home”  Workflow  will  be  pasted  on  the  walls  of  the  consult  rooms.  You  should  also  be  receiving  it  in  your  Hmail.    It  describes  what  tests  to  order  and  disposi�on  op�ons.  Do  refer  to  them  regularly  as  you  work  through  a  pa�ent.    

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COVID-­‐19  Daily  Updated  Informa�on  

  Go  to  CGH  Intranet  Homepage  &  click  on  “COVID-­‐19”  at  Right  hand  sidebar    You  will  reach  a  COVID-­‐19  Resource  Page    Click  on  the  respec�ve  links  for  latest  ”MOH  Case  Defini�ons  and  Workflows”  and  “Latest  Documents”    As  there  may  be  new  /  emerging  clusters,  as  a  rou�ne  please  ask  about:    –  occupa�on  and  place  of  work  –  a�endance  at  any  recent  large  scale  events  (e.g.  weddings)  

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COVID-­‐19  Daily  Updated  Informa�on  

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Overcoming  Language  Barrier  

  There  are  print-­‐outs  of  ques�onnaires  in  Bengali,  Tamil,  Hindi,  Sinhali  in  FFA-­‐1  to  help  you  take  history      You  can  access  the  website  by  the  Chowdhury  sisters  on  h�ps://�nyurl.com/covidbengali  to  play  audio  clips  of  ques�ons  you  want  to  ask    Download  a  Google  Translate  app  in  your  handphone  and  enable  microphone  access    

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2.  STARTING  YOUR  FIRST  FEVER  SHIFT  

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Preparing  to  step  in  

  Bring  your  own  issued  N95  and  Goggles      There  are  stethoscopes  and  pens  in  FFA  areas    Gowning  area  at  ICA/observa�on  MO  sta�on  area    Full  PPE  –  surgical  cap,  yellow  gown,  N95,  Goggles,  gloves    Put  your  handphone  in  ziplock  bags  (you  can  get  from  FFA  pharmacist)      There  are  toilets  and  water  dispensers  within  FFA-­‐1  

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Your  Basic  Worksta�on  

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Latest  clinical  workflow  and  MOH  clusters  

Cases  to  review  

Meds  –  tramadol,  maxolon,  steme�l,  buscopan  

Discharge  Advices  

Basic  Opera�on  Workflow    -­‐  Start  New  Case  

  Start  shi�  à  report  to  triage  nurse  in  FA  

  Similar  to  P2  queue,  cases  will  be  given  in  round  robin  –  Find  under  “Comments”    –  Queue  stops  1h  before  your  shi�  

ends    See  the  pa�ent,  order  the  

inves�ga�ons,  send  your  own  bloods  

  Bring  the  pa�ent  folder  to  the  NURSING  COUNTER  for  ac�ons  such  as  XR/ECG/Tx  

  Remind  nurses  to  call  for  XR  services    

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Basic  Opera�on  Workflow  -­‐  Disposi�on    à  Pass  docs  to  Nursing  Counter  (admit/discharge/HO-­‐SIF)  

Admission      Indicate  in  Bed  Admission  remark    

–  “PARI  Ward”  includes:      ARI  or  pneumonia    PSHN/  Dorm  workers  

–  “Fever  and  for  op”    Febrile  pa�ent  +  GS  review  in  ED  for  op  

–  “COVID  Ward  GW/HD”  for  COVID  posi�ve  –  Refer  to  latest  workflow  pasted  on  the  walls  

in  FA  consult  rooms  for  admission  criteria    Order  COVID  swab  when  swabbers  are  around  

i.e.  daily  10am-­‐6pm  

Discharge  checklist    Medica�on  prescrip�ons    Appropriate  Health  Advisories  

1.  ARI  pa�ents  with  no  swab    2.  “Swab  and  Send  Home”  and  HOSIF  

pa�ents      MC    

–  Outpa�ent  MC  (not  HL)  –  Inform  pa�ent  that  they  are  required  

by  law  to  stay  home    –  If  swab:  3  days  –  No  swab  and  ARI:  5  days  

  SOC  /  TCU  if  required  –  Inform  pt  to  go  a�er  swab  results  

known  or  recovery  of  symptoms  –  If  FW:  indicate  “To  see  in  SOC  Clinic  J”  

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PARI  admission   Admit  under  ICU/HD   Internal  Med  or  specific  non-­‐medical  specialty  GW   Specific  Specialty  as  required  otherwise  Internal  Medicine  COVID  +ve  admission   Admit  under  ICU/HD   Internal  Med  or  specific  non-­‐medical  specialty  GW   Specific  Specialty  as  required  otherwise  Infec�ous  disease  

MC  example  

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✅  

✅  

If  digiMC  then  no  need  to  check  this  

3⃣  or  5 ⃣  

Type  here  if  diagnosis  needs  to  appear  in  MC  for  insurance  

✅  ➡  

Discharge Advisory for Patients with Respiratory Diseases Swab-and-Send-Home (SASH)

Dear Sir / Madam,

You have symptoms of upper respiratory tract infection and this is most likely due to a viral illness. Our doctor has examined you on ________________________________ (date), and determined that you do not require admission. We have taken a sputum/throat specimen from you. Starting from the date your MC is issued, you must not leave your home for the duration of your MC, or until you receive a negative COVID-19 swab test result, whichever is sooner. Result notification

If you are a Singaporean/Permanent Resident, you can get the test results via the Health Hub app or https://www.healthhub.sg with your SingPass within 48 to 72 hours. We strongly advise that you make your way home directly from the hospital’s Emergency Department and self-isolate as you await the results of the test. Legal requirement to stay home during MC period

The doctor has issued a medical certificate (MC) for you to recover at home. In view of the ongoing COVID-19 situation, you are required by law to stay home for the duration of MC issued for this episode of illness unless you receive notification of a negative COVID-19 swab test result. Persons who do not comply will be liable to a fine of up to $10,000, or imprisonment up to six months, or both, under the Infectious Diseases Act. You should only leave your home to seek medical attention. If you need to go for any outpatient medical appointments prior to the confirmation of your swab test result, please inform the medical staff that you were recently screened for COVID-19. While awaiting the results of the swab test, it is very important that the following precautions be observed to protect others from being exposed to possible COVID-19 infection.

To travel home from the hospital’s Emergency Department after your consultation and evaluation: Please avoid taking public transport; Take your own private transport or a taxi / private hire car.

If you are being driven, please wear a mask and sit alone in the back seat. The windows of the car should be wound down and the air-conditioning switched

off. Please scan the SafeEntry QR codes and obtain taxi / private hire car receipt for

the journey, for contact tracing purposes in the event of a positive swab test.

Health  Advisory  -­‐  SASH  or  HOSIF  pa�ents  

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  Only  the  posi�ve  pa�ents  will  get  informed.      Pa�ents  to  access  HealthHub  SG  mobile  

app  with  SingPass  for  their  own  results.  

Health  Advisory    -­‐  ARI  pa�ent  with  no  swab  

(<13yo)  

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Where  to  find  advisory  (Other  languages  available)  

FFA-­‐1  Layout  (Not  to  scale)  

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WAITING  AREA  1  

STAFF/

PATIEN

T  EN

TRAN

CE      

CONSULT  ROOMS  1  &  2  

WAITING  AREA  2  

 

XRAY  

NURSING  COUNTER  

ISO  /  RESUS  ROOM  

EXIT  TO  FFA-­‐1  EXT  

993  AMB  ENTRANCE  

TRIAGE  /  PSA  

PHARMACY  

CONSULT  ROOM  3  

Pneuma�c  tube  =  Where  to  send  bloods  Racks  to  place  swabs  

Make-­‐shi�  CONSULT  ROOM  4  

FFA-­‐1  EXT  Layout  (Not  to  scale)  

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NURSING  COUNTER  CONSULT  STATION  

ENTRAN

CE/EXIT  

WAITING  AREA  

To  F

FA-­‐1

 

3.  COMPUTER  TIPS  &  TRICKS  

A)  Ordering  COVID  swab  B)  Ordering  CXR  for  faster  repor�ng  C)  Requirement  to  update  CDLENS  D)  Acronym  expansion  E)  Previous  COVID  serology/PCR  posi�ve  (coun�ng  day  of  illness)  F)  Pre-­‐consult  ques�onnaires  

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A)  Ordering  COVID  Swab  Search  “COVID”  and  fill  the  fields:    Priority**    

–  “STAT”  for  HO-­‐SIF  (swab  &  hold)  and  use  RED  biohazard  bag  

–  “Rou�ne”  for  the  rest  (swab  &  send  home)  and  use  TRANSPARENT  biohazard  bag  

  Indica�ons  –  select  appropriate  clinical  indica�ons  

  Specimen  site  –  select  “Nose  &  Throat  Swab”  

27/9/20   22  **Please  make  sure  you  do  this  for  faster  processing  of  HO-­‐SIF  pa�ents.  

B)  Ordering  CXR  

  Under  Special  Instruc�ons,  indicate      “COVID-­‐FA”    

  If  you  do  this,  your  CXR  gets  reported  faster    

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C)  Requirement  to  update  CDLENS  

  “Apps”  >  “ID  No�fica�on”  >  “New  Submission”    When?  

–  For  posi�ve  cases  that  you  swab  and  send  home  (SASH)  

–  Suggest  doing  when  acknowledge  results  on  SCM  (usually  on  next  shi�)  

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NO  need  to  no�fy  suspect  covid  cases  any  more  NO  need  to  no�fy  pa�ents  you  admi�ed  to  ward  if  they  turn  posi�ve  (ward  will  do  that)  NO  need  to  no�fy  if  the  pa�ent  was  diagnosed  with  COVID  by  someone  else  (CIF,  dorm  swabs  etc)  

D)  Acronym  Expansion  Saves  Time!  

  Preferences  >  Acronym  Expansion      Consider  one  for:  URTI  /  

Fever  /  Covid  Risk  Factors    Other  �me-­‐saving  

templates  such  as:  history  /  PE  /  return  advice  /  MC  documenta�on  

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E)  Previous  COVID  PCR/serology  posi�ve  Coun�ng  the  days:    Use  calculator  desktop  app   Where  to  Admit  

  <  28days:    –  Admit  COVID  Ward  under  ID  –  If  in  doubt,  call  ID  physician  to  discuss  

  29-­‐90  days:    –  If  pneumonia  or  suspected  re-­‐infec�on  

with  COVID  à  discuss  with  PARI  doctor  for  PARI  admission.    

–  Do  not  need  to  swab  in  ED  –  If  not  any  of  above:  to  admit  to  GW  

  >90  days:    –  Treat  as  per  pre-­‐covid  norms  (as  

if  pa�ent  never  had  COVID)  

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Covid  Results  Interpreta�on  

Individual/  Pooled  

Swab  +  Sero  

PCR  +,  Sero  +  

Day  15  of  illness  

CCF/Hospital  �ll  

Day  21  

Clean  (dorm)  Block  

PCR  +,  Sero  -­‐  

Day  1  of  illness  

CCF/Hospital  

PCR  -­‐,  Sero  -­‐  

COVID  naïve  

PCR  -­‐,  Sero  +  

Recovered  MW  

Clean  (dorm)  Block  

CCF:  Community  Care  Facility,  e.g.  Expo  

Likely  swab  and  HOSIF  

S�ll  always  check  with  senior  /  CGH  OC  

F.  Pre-­‐Consult  Ques�onnaires  

  Helps  to  reduce  �me  taken  to  obtain  travel  and  contact  history  from  pa�ents      What  happens  

– Pa�ent  registers  in  ED  – Pa�ent  receives  SMS  to  fill  up  this  form    – Doctor  can  autopopulate  the  PCQ  into  provider  note  – Helps  to  save  �me  to  type  note  and  ask  the  ques�ons  

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Select  Presen�ng  Illness  

Click  here  to  load  pa�ent’s  PCQ  

If  available,  pa�ent’s  answer  to  your  ques�onnaire  will  be  loaded  

here  

Click  here  to  copy  the  PCQ  to  your  clerking  

You  may  further  update/amend  the  ques�onnaire  and  integrate  it  

to  your  history  taking  

4.  SWABBING  YOUR  FIRST  PATIENT  

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If  there  are  swabbers  …  Who  are  they?    Allied  health  colleagues  to  

help  our  turn-­‐around  �me      When?      Daily,  10am-­‐6pm  

When  the  swabbers  are  not  around,  you  have  to  do  your  own  swabs  for  FFA  discharges  only  (no  need  to  swab  admissions)  

For  FFA  PARI  admissions    Order  CPOE,  put  “PARI”  in  comments,  print  out  label,  put  in  transparent  biohazard  bag    

1.  Print  admission  documents  2.  Pass  file  to  swabbers  /  nurse  counters  

(This  is  to  help  PARI  ward  turn-­‐around  �me)    For  FFA  discharges    1.  Order  COVID  swab  2.  Collect  specimen  to  print  s�ckers    3.  Place  s�cker  in  biohazard  bag  

–  RED:  HO-­‐SIF  (swab  &  hold)  –  Transparent:  the  rest  (swab  &  send  home)  

4.  Print  rest  of  discharge  materials  5.  Pass  to  swabbers  /  nurse  counters  27/9/20   35  

Your  Swab  Kit  Swab-­‐and-­‐Send  Home    Discharge  Advice  

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Discharge Advisory for Patients with Respiratory Diseases

Swab-and-Send-Home (SASH)

Dear Sir / Madam,

You have symptoms of upper respiratory tract infection and this is most likely due to a viral illness. Our doctor has examined you on ________________________________ (date), and determined that you do not require admission. We have taken a sputum/throat specimen from you. Starting from the date your MC is issued, you must not leave your home for the duration

of your MC, or until you receive a negative COVID-19 swab test result, whichever is

sooner.

Result notification

If you are a Singaporean/Permanent Resident, you can get the test results via the Health Hub app or https://www.healthhub.sg with your SingPass within 48 to 72 hours. We

strongly advise that you make your way home directly from the hospital’s Emergency Department and self-isolate as you await the results of the test.

Legal requirement to stay home during MC period

The doctor has issued a medical certificate (MC) for you to recover at home. In view of the ongoing COVID-19 situation, you are required by law to stay home for the duration

of MC issued for this episode of illness unless you receive notification of a negative

COVID-19 swab test result. Persons who do not comply will be liable to a fine of up to $10,000, or imprisonment up to six months, or both, under the Infectious Diseases Act. You should only leave your home to seek medical attention. If you need to go for any outpatient medical appointments prior to the confirmation of your swab test result, please inform the medical staff that you were recently screened for COVID-19. While awaiting the results of the swab test, it is very important that the following

precautions be observed to protect others from being exposed to possible COVID-

19 infection.

To travel home from the hospital’s Emergency Department after your consultation and evaluation: Please avoid taking public transport; Take your own private transport or a taxi / private hire car.

If you are being driven, please wear a mask and sit alone in the back seat. The windows of the car should be wound down and the air-conditioning switched

off. Please scan the SafeEntry QR codes and obtain taxi / private hire car receipt for

the journey, for contact tracing purposes in the event of a positive swab test.

Your  Swab  Room  Survival  Tips  for  MO      Print  CPOE  Label  and  bring  to  room    Ask  pa�ent  to  check  name  and  IC  on  

label      Paste  label  on  swab  bo�le  then  start  to  

swab    Double  gloves  and  stand  to  the  right  side  

(not  in  front)  of  pa�ent    Then  explain  what  you  are  going  to  do    

Survival  Tips  for  Pa�ent    Look  up  to  opposite  ceiling  (45-­‐70  degree  

head  �lt)    Throat  swab  –  say  “Aahhh”  to  minimise  

gag    Nose  swab  –  most  painful,  breathe  

through  mouth  during  swab  

27/9/20  

Official  Swab  Instruc�on  

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Official  Swab  Instruc�on  

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Single  RED  biohazard  bag  for  Dormitory  Foreign  Workers    Single  TRANSPARENT  biohazard  bag  for  other  popula�on  

5.  FFA  WORKFLOW  FOR  SPECIAL  POPULATIONS  

A.  PUIO/PUQ/SHN    B.  HO-­‐SIF  (swab-­‐and-­‐hold)  Pa�ents  C.  Cat  A  and  B  and  NH    

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A.  PUIO/PUQ/SHN  -­‐  Summary  

  Will  usually  be  wrist-­‐tagged  but  remember  to  confirm!      All  tagged  cases    =  mandatory  COVID  swab    =  inform  CGH  Ops  center  prior  to  discharge      Place  discharge  documents  in  nursing  tray  and  will  be  duly  reminded    

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A.  Transport  for  discharged  PUIO/PUQ/SHN  

PUIO/PUQ    Pa�ent’s  documents  will  have  

an  extra  label  that  states  “PUQ”.  Pa�ent  will  wear  a  coloured  wrist  tag.    

  Inform  CGH  Ops  Centre  on  pa�ent  discharge  

  Cannot  go  home  via  personal  /  public  transport    

PSHN  (more  details  in  next  slide)    From  Hotel:  Ask  pa�ent  or  

look  for  hotel  memo.  If  present,  call  CGH  Ops  center  on  discharge    

  From  Home:  Pa�ent  to  call  People’s  Associa�on  (Tel:  63448222)  to  request  for  assistance  in  transporta�on  advice  /arrangements  

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Note:  PUIO,  PUQ,  PSHN  etc.  cannot  AOR    àà  face  a  problem  =  call  CGH  Ops  Center  

About  PSHN    They  may  come  to  you  if  

unwell,  from:  –  border  entry  (with  ICA  memo)  –  from  SHN  Designated  Facility  

e.g.  hotel  (with  SDF/ICA  memo)  

–  own  residence  (by  993)  –  exit  swab  facili�es  

  Disposi�on  –  If  admi�ng,  please  admit  to  

PARI.  –  If  discharging,  call  CGHOC  to  

determine  swab  need  and  transport  

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  Info  required  by  CGHOC  usually  in  this  memo  (all  PSHN  should  have  something  like  this  from  ICA)  

  Generally  pa�ents  can  be  on  7  or  14  day  SHN  or  swab  on  arrival  (deemed  SHN  �ll  arrival  swab  out)  depending  on  country  of  origin.  

  May  be  asked  to  swab  them.  If  in  doubt,  just  ask  CGHOC.  

B.  HO-­‐SIF  (swab-­‐and-­‐hold)  Pa�ents  

  Some  of  our  dormitory  foreign  workers  may  not  have  isola�on  facili�es  at  where  they  stay.  Hence,  we  need  to  swab  and  hold  them  �ll  results  are  out.    They  will  be  held  in  CGH  Fever  Holding  Area  (HO-­‐SIF)  under  A&E  care  or  designated  external  SASH  Isola�on  Facili�es  (SIF).    HO-­‐SIF  can  also  cater  to  non-­‐dormitory  FW  and  people  at  communal  se�ng  (e.g.  CGH  staff)  who  cannot  self-­‐isolate  at  home.  

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B.  HO-­‐SIF  (swab-­‐and-­‐hold)  Pa�ents  

  Ideally,  we  want  to  speed  up  the  processing  of  HO-­‐SIF  pa�ents.  

   This  affects  our:  

1.  CPOE  COVID  Swab  Order  (STAT  Order)  2.  Swab  specimen  management  (Red  Biohazard  Bag)  3.  Disposi�on  on  EMD  Provider  Notes  

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B.  DISPOSITION  (HO-­‐SIF)  

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Please  prescribe  Meds,  MC  and  TCU  as  per  discharged  pa�ents.  

C.  Cat  A/B  and  NH  residents  Pa�ent  Groups   Fit  for  discharge?   Swab  where     Hold  where    

Cat  A    =  prisoners  and  SAF  DB  detainees    

Yes    (Rule  out  pneumonia)  *For  CAT  A  non-­‐prisoners  (i.e.  NOT  in  jumpsuits):  check  if  able  to  isolate  in  police-­‐lock  up,  otherwise  to  admit    

Send  back  prison  service/DB  with  memo  to  swab  and  isolate.    

Not  applicable    

No      

Admit.     PARI  holding  

Cat  B   Yes     Obs  extension  or  FA   FFA  1  ext  or  BID  room  if  needed.  

No   Admit.  Swab  in  ED  FA  during  swabbing  hours  

PARI  holding  or  FA  

Nursing  Home   Yes  *Confirm  with  NH  if  able  to  isolate  un�l  result  is  out,  otherwise  to  admit  

Obs  extension  or  FA   PARI  holding  or  FA  

No   Admit.  Swab  in  ED  FA  during  swabbing  hours  

PARI  holding  

27/9/20   47  Cat  B  and  Nursing  Home  swabs  need  to  ordered  as  URGENT  i.e.  STAT  and  RED  bag  

6.  SO  WHERE  ARE  ALL  THESE  PLACES?  

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HO-­‐SIF  

  Level  2,  Li�  Lobby  A,  Above  main  A&E  

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FFA  Loca�ons  (Front  door)    

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FFA  Loca�ons  (Back  door)  

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FFA  Loca�ons  (Back  door)  

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Swab  area  

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Acknowledgements  

  Nursing  Department  for  working  with  us  hand-­‐in-­‐hand  in  se�ng  up  our  FFAs    FFA  MO  Guide  Contribu�ng  Authors  

– Dr  Ho  Shu  Fang,  Dr  Janice  Soo  

  Overseeing  EPs  – Dr  Jimmy  Goh,  Dr  Kelvin  Kuan,  Dr  Ang  Shiang-­‐Hu,  Dr  

Thng  Shin  Ying  

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