With the United States and many European countries accumulating COVID-19 cases at an alarming rate, medical professionals across the globe are bracing for a deluge of patients. Many authors have already commented on the dangers of healthcare systems being overwhelmed while others have described the risk of doctors and nurses becoming infected, inadvertently facilitating the virus’s spread and crippling healthcare capacity. 

As a professor of cell biology living in Busan, South Korea, I have had the opportunity to observe, firsthand, how Korea’s infectious disease SOP (standard operation procedure) works to protect healthcare professionals. Having received many questions and reports from abroad, both through people I know and the media, I feel some details need sharing. These ideas offer ways for medical personnel to be shielded from viral transmission and unnecessary losses of time and energy, allowing greater focus on the pertinent medical tasks associated with an outbreak.

Not every location handles COVID-19

With COVID-19 treatment demand likely to increase significantly across America and Europe in coming weeks, the fact remains that demand for other medical services will persist in parallel. People will still need to have surgeries, give birth, and receive cancer treatment. To this effect, it is important to consider, in advance, how these two types of demand will be balanced. 

In South Korea, this balance is decided through the first component of the SOP, which gives the Korean Center for Disease Control (KCDC) powers to designate which medical centers will handle COVID-19 testing and treatment. Korea, like any other country, has many clinics and hospitals that lack appropriate facilities (like negative pressure wards) and staff (e.g. respiratory specialists) for COVID-19. 

These sites generally can not offer useful treatment and are often more susceptible to visitor-to-staff virus transmission, potentially threatening their ability to provide normal services such as oral surgeries and colonoscopies. An old student of mine—let’s call her Amanda—works in a small surgery clinic in the United States and said she is “scared to death” every time someone comes in asking about COVID-19 testing because she knows each unnecessary visit increases the chances of transmission to the clinic’s small staff. Having spoken to others in similar situations, I can say Amanda’s anxieties are widely shared. 

In South Korea, the KCDC maintains a curated list of all hospitals and clinics in the country, with detailed information about their capacities to handle infectious disease. Based on this information, only those with adequate facilities and qualified staff are chosen to be designated sites (DSs). A second list of locations with lesser qualifications is also kept, in case the first isn’t enough. 

When the public is properly informed (more on this later), the distinction between DS and non-DS can help reduce the number of infected individuals visiting non-DSs in search of COVID-19 services, reducing contamination risk. Amanda’s clinic, for example, would be more protected as a non-DS, increasing its ability to stay open and provide normal services.

Information support shields non-DSs and medical staff

The distinction between DS and non-DS doesn’t hold much value unless the public is adequately informed about where to go. As I and others have noted, the South Korean government has been very active in making a wide variety of COVID-19 information available online and through real-time text messages. 

The locations of DSs are no exception, with weekly messages reminding people of their nearest facility based on their phone’s geographical location. Telephone hotlines also provide answers to basic coronavirus questions, helping guide people to their nearest DS. Map apps are required to carry this information too, allowing for efficient navigation of symptomatic people to DSs and away from non-DSs.

Unlike in America, where hospital hotlines are often staffed by nurses, potentially diverting useful time and energy away from other duties, COVID-19 hotlines in Korea are staffed by government employees or volunteers trained to answer calls using booklets made by the KCDC. These booklets contain answers to many basic COVID-19 questions, providing a layer of information support to help insulate medical professionals from menial tasks. 

Moreover, dedicated COVID-19 hotlines allow emergency numbers for first responders and other services to remain separated, preventing coronavirus queries from inundating other channels. A friend of mine—let’s call him David—is a triage nurse at a community hospital in the United States. He says COVID-19 calls have increased in number so much that he is afraid other emergencies are being drowned out. Here too, I have found his concerns to be shared by many.

Physical advertising is another requirement. All Korean hospitals and clinics are required to hang banners at each major entrance, clearly identifying whether they are a DS or not. When the location is a non-DS, at least one non-medical employee or volunteer is required to stand outside, giving directions to people looking for a DS. This individual must be dressed in gloves, mask, and long-sleeve gown (I have seen disposable raincoats too) and functions as a buffer between the public and medical staff inside. Both advertising and volunteers help turn away potential COVID-19 patients, reducing contamination risk while, again, freeing time for people like David and Amanda to focus on other things.

Paths diverge and all entries are screened

For both DSs and non-DSs, another important SOP requirement is that medical staff and hospital visitors be separated as much as possible. This means the two groups, where possible, use separate entrances, parking lots, restrooms, and cafeterias. This separation helps reduce visitor-to-staff contact while also preserving exclusive routes for staff that can be better protected from contamination. 

In large hospitals, elevators, stairwells, and corridors are often allotted separately, with volunteers or non-medical staff gatekeeping the flow of people. The Korean SOP requires door handles, elevator buttons, and other common contact surfaces to be sterilized regularly (my local hospital says they do it twice daily), further reducing transmission risk. Two colleagues of mine, one in America and another in France, are currently trying to implement similar procedures in their hospitals.

At every entrance into a Korean hospital or clinic, teams of volunteers screen entries for COVID-19 symptoms, using handheld thermometers to check temperatures. Most large hospitals supplement the handhelds with thermal detection tunnels, like the ones used in airports. People with respiratory symptoms or high temperatures are immediately separated from the rest and taken to an isolated area for COVID-19 testing. For most DSs, these areas are usually tents in a parking lot equipped with air pumps for negative pressure. 

In these isolated quarters, tests are administered by medical or military staff dressed in full protective gear. Having testing separate, again, functions as a buffer to protect medical personnel inside the hospital. Drive-through test centers help protect medical staff further by channeling potentially infected individuals away from hospitals entirely. David lamented the fact that the few tests his hospital has administered were all conducted by nurses in normal examination rooms in the absence of negative pressure, significantly increasing the risk of transmission. 

In Korea, non-essential hospital visitors who exhibit symptoms, once tested, are sent home immediately until their test results are reported, usually a wait of three to twelve hours. The interiors of isolation tents are sterilized regularly to protect future visitors. Staff entrances are also manned by symptom checkers with thermometers, who have the authority to submit any personnel for testing if a cough or fever is detected.

Questionnaires help screening, even retroactively

After passing the thermometers, visitors without masks are either turned away or given one. Once through the entrance, each visitor is required to write their name and contact information on a questionnaire and give answers about recent travel and illness. 

Questionnaires are again administered by volunteers and the travel and illness information is used to help screen for isolation and testing. Been abroad recently? Off to the tent you go. It is only after the questionnaire is filled out that people can take a pump of hand sanitizer and finally go about their business inside the facility.

Contact information collected on questionnaires is kept for up to two weeks to alert people retroactively about on-site infections. If, for example, I visited a hospital at 10:00AM and an infected individual was later identified as having been there at 11:00AM, I, along with anyone else there at a similar time, would receive a text message about the incident, warning me about the potential need to be tested. 

Most Korean medical centers record, on computers, the times patients check in at different departments, like when receiving an injection or undergoing a test. This provides a loose trail of travel points to help inform the hospital about which staff might need testing or monitoring due to their proximity with infected individuals. David told me his hospital has the capacity to do this but, so far, has not. I imagine this is a common situation for many hospitals, an important option to explore.

Personal protection is a must

Another critical aspect of the Korean SOP is personal protection. Explicit national guidelines are given for the types of protective gear worn by different personnel. Nurses staffing information desks, for example, are required to wear an N95-grade protective mask, gloves, and a long-sleeve gown. Staff handling COVID-19 testing, on the other hand, are required to wear gloves, full protective gear, and a face shield. 

These guidelines specifically cover every type of personnel imaginable: x-ray nurses, respiratory nurses, biohazard waste handlers, and even sterilization teams. Yes, Korean DSs have dedicated sterilization teams that regularly clean emergency vehicles, respiratory patient wards, and isolation quarters. Even ventilation cleaners are given explicit guidelines. 

Although I have observed some instances of hospitals and clinics running out of gloves or masks, occasionally forcing personnel to fall short of the requirements, the overall level of compliance has been extraordinary. With the Korean government actively supporting and coordinating activities while providing clear and consistent guidelines, the local doctors and nurses I have spoken to all say confusion and hesitation has been virtually non-existent. Many credit this to annual infectious disease training all personnel are required to take.

When I mentioned this training to David, he just sighed heavily, telling me many of the nurses in his hospital either don’t wear masks or don’t know how to use them. He described a pair staffing an information desk who would put their masks on only when a visitor came but then take them off as soon as the visitor left. He said many of his colleagues don’t yet seem to fully grasp the importance and reasoning behind personal protection, making him worry an in-facility outbreak is inevitable.

Manufacturers do their share

The Korean SOP, understandably, creates high demand for protective gear (especially masks) and sterilization chemicals (alcohol and bleach). The domestic manufacturing of masks and their distribution nationally by day of the week have been well-documented. Receiving less attention, however, are the Korean wine and beer manufacturers who have shifted their activities to produce tons of alcohol for medical use. This cooperation from the manufacturing sector is an integral part of the Korean SOP, something other countries will likely need to emulate if outbreaks persist into the summer.

In closing, I do acknowledge some elements of the Korean SOP might be difficult to implement in certain contexts. Many components I describe, for example, connect to or rely on testing, which remains a primary deficiency across the United States and Europe. Here too, the manufacturing sector has a critical role to play. 

Even without testing, however, I think it is immensely important to share information about the procedures Korea has used to help protect its healthcare staff. As the pandemic continues, these professionals will be risking their lives on the front lines to save us. All should be done to shield them from unnecessary risk. I have been volunteering to help, have you?

Justin Fendos is a professor at Dongseo University in South Korea.

Image: Reuters