The Impact of the COVID-19 Pandemic on Dermatology in Singapore: the Experience at the National Skin Centre

Prof. Tan Suat Hoon, Director NSC, Vice-President 25th WCD Dr. Benson Yeo, Chair of COVID-19 Task Force, NSC

Introduction

The novel coronavirus pneumonia outbreak which emerged in Wuhan as the epicentre in December 2019, reached the shores of Singapore with its first infected case on 23 January 2020. Singapore was well prepared for this, having experienced the SARs outbreak in 2003. A new hospital to manage disease outbreaks, the National Centre for Infectious Diseases was opened just months earlier in September 2019. The Ministry of Health swung into action co-ordinating and centralising operations of the national healthcare system – from increasing the capacity of ICU and hospital beds and equipment, to galvanizing manpower for pandemic operations and securing supplies of personal protection equipment and test kits. A multi-ministry taskforce directed a whole-of-government response to the novel coronavirus outbreak.

While the National Skin Centre (NSC) is not directly involved in the care of COVID-19 patients, the impact of the pandemic on the specialty was deeply felt. Infection control processes had to be put in place to continue our service provision safely. We scaled back business-as-usual operations in order to conserve manpower to support frontline operations in other acute hospitals and community care facilities. The latter were set up to manage milder patients outside of hospitals, leaving hospitals to care for the more severely ill patients. To this end, NSC deployed staff members (40% of its medical staff and 30% of its nursing staff) to support COVID-19 operations elsewhere. Many staff from all the other NSC departments (allied health, ancillary and administrative) also volunteered and were deployed where needed.

Here we describe NSC’s multi-pronged measures in response to the COVID-19 pandemic and how we changed our clinic operations. These were in implemented in phases, in line with heightened epidemic risk status from Dorscon Yellow to Dorscon Orange* in February 2020, to the Circuit Breaker(our term for lockdown) when significant community outbreak in migrant worker population was recorded in April 2020. With sustained effective outbreak control and few new cases in the community, this has been followed by phased resumption of healthcare services in tandem with phased reopening of the economy from early June 2020.

The key impact on dermatology services and operations are summarized here:

Team and Physical Zonal Segregation Singapore raised the risk status to the second highest of Dorscon Orange on 7 February 2020 when there was clear evidence of local community spread. We implemented a split-team working arrangement as part of our business continuity plan. The team segregation cut across all clinical

*Footnote: Singapore’s Disease Outbreak Response System Condition’ (DORSCON) is a colour-coded framework which provides general guidelines on what needs to be done to prevent and reduce the impact of infections.

departments and operations. Back office staff in administrative roles had work-from-home (WFH)

arrangements to relieve public transport system and reduce virus transmission through

commuting to work.

NSC itself was demarcated with clear zonal segregation into high risk and clean areas. Two teams (A and B) were rostered to work in different offices, wings and floors. Team and zonal segregation extended to social interaction at breaks and meal times.

Essential and Non-Essential Services

The country entered lockdown, termed Circuit Breaker, on 7 April 2020. To conserve hospital resources and manpower for surge demands, Ministry of Health directed healthcare institutions to reduce workloads such as non-essential service (e.g. aesthetic services) and elective procedures. The reasons for this were two-fold: firstly, to ensure most people stayed home except when needing essential clinical services and secondly, to ensure have a reserve of healthcare manpower to be activated to support COVID-19 operations.

In NSC, all referrals were triaged for medical acuity, listing or deferring of appointments was based on medical needs. Dermatological conditions such as skin cancers, immunobullous diseases, severe psoriasis, acute STI and eczema flares were prioritized for continuity of care. Non-essential services including stable chronic skin conditions and aesthetic consults were deferred. Non-urgent dermatological treatment or tests such as targeted phototherapy, patch testing, skin prick testing, drug provocation and contact immunotherapy for alopecia areata were similarly deferred. Cryotherapy was scaled down in frequency as we faced a shortage of nursing manpower.

Teledermatology

COVID-19 greatly accelerated the adoption of teledermatology for patient consultations. Patients were hesitant to visit hospitals and it was advisable keep vulnerable patients e.g. elderly and those on immunosuppressive treatment safe at home to reduce infection risk during clinic visits.

There were four major considerations in our ramp up of teledermatology:

• The standard of medical care should be similar for physical consults and e-consults which includes video and telephonic consultation, and which may be supplemented by photoimaging if necessary. We derived a list of inclusion and exclusion criteria on patient suitability for teledermatology and the mode of e-consultation. For example, only stable patients known to our doctors could be seen via teledermatology.
• Doctors were required to be certified in telemedicine before providing teledermatology and this was facilitated by the roll out of the Ministry of Health’s Telemedicine online course.
• Cybersecurity standard was ensured using a updated version of videoconferencing on Zoom licensed for clinical care.
• Provision of home deliveries for drugs and engaging vendors who could meet the requirements for cold chain deliveries of biologic drugs.

Safety Measures

Many safety measures were introduced in the centre to ensure a safe environment for patients and staff. They were focused on 3 main areas:

Personal protective equipment (PPE) and safe distancing

• Staff had to wear a face mask at all times while at work. Surgical masks were provided for patient-facing staff, while full PPE was required for staff attending to patients in the high risk screening area.
• Staff lounges had to be reconfigured to ensure sufficient spacing between seats and break times were staggered to prevent crowding in areas when staff congregate.
• The role of every staff member was reviewed, and those who could WFH were provided the resources to do so (e.g. laptops and VPN access).

Contact tracing

• All staff and visitors entering and leaving NSC had to use a digital check-in and check-out system via a national electronic system called SafeEntry, to facilitate contact tracing

Health monitoring

• All staff had to report their temperatures twice daily. This was facilitated by the electronic staff health surveillance system, which allowed online reporting by staff and review by administrators.
• Those who were sick were reminded to get a PCR test and to stay away from work for several days.

Education and Training Activities

COVID-19 also changed the way we teach and learn. All activities requiring face-to-face interactions were replaced by virtual lectures, Zoom meetings, e-learning or self-study. In-house CME activities were conducted through videoconferencing or shared through Microsoft Teams with interactive platform, or other e-learning platform. Lectures for medical students were converted to online lectures. All overseas travel whether for conferences or personal were cancelled from February and staff turned to attending virtual conferences e.g. the AAD VMX in June 2020.

Concluding Remarks

The country has embarked on a phased re-opening after exiting from the Circuit Breaker on 2 June 2020. For NSC, the task at hand is tiered service resumption with safe management in place. Overcrowded clinics will be a thing of the past, harnessing teledermatology and home deliveries of medications will be used for more patients, and enhanced social responsibility and personal hygiene practices will need to be a feature of the ‘new normal’. The COVID-19 pandemic has also given many of us the opportunity to provide medical and humanitarian services where they are most needed, above and beyond our training as healthcare professionals in dermatology.