That SARS, or Severe Acute Respiratory Syndrome, has debilitated Asia, its people, economies, and way of life is not exactly news.
Morale in Singapore, if our less-than-packed malls, airport and general wariness towards any audible cough were anything to go by, hit rock bottom. There was a break in the clouds more recently, with the countdown to a SARS-free status on the horizon, that is, if Singapore goes without any new cases for 20 days.
But if there is a point to mark the end of the initial scare, it must be the announcement that Tan Tock Seng Hospital (TTSH), the designated SARS facility in Singapore, has successfully contained the spread of the virus. However, the story of how its staff – half of whom were deployed to care for SARS patients – had first to contend with personal crises and infections is nothing less than the stuff of medical thrillers.
Managing crises, however, is something that Dr. Lim Suet Wun M.B.A. ’90, M.P.H. ’90, CEO of TTSH, has had to do on a daily basis these past few months. The CEO heads a million-dollar-a-day healthcare organization. He’s also the deputy group CEO of the National Healthcare Group. Now, he’s had to manage the expectations of patients, relatives, nurses and doctors in an outbreak of killer flu – an unenviable job with the limelight focused on him. But what qualifies Lim as a prime candidate for dealing with days when life hands him lemons is that he’s had his fair share of them. Early in his career, problems with his eyesight had kept him from performing surgery, and ruled out “half of medicine” for him. In the mid-1980s, when his wife, Christina W.L. Soh Ph.D. ’91, had to go abroad for her studies, Lim, then still in National Service had had to map out his career. During the three years that she would be in the U.S. completing her degree, he seized his own opportunities where he could.
The Ministry of Health had started administrative trainee programs to encourage younger doctors to go into administration, whereas it had previously limited those positions to senior practitioners in the clinical hierarch who would then become medical directors in hospitals.
He went to see the newly appointed Permanent Secretary Dr. Kwa Soon Yee (“he was very nurturing and very forthcoming,” says Lim), who enlisted him as an administrative trainee. Lim was subsequently rotated to National University Hospital, which sponsored his studies abroad, and in time, he became interested in the practice of medicine, “not so much in the usual sense, but in the more economic and operational aspects.
Running a hospital, he points out, isn’t fundamentally different from running any other business in terms of keeping the organization on track. Nonetheless, he adds, the nature of health care deviates from normal corporate culture in the “balance is probably more complex.”
SARS, nonetheless, unleashed the worst of both the economic and emotional aspects of his industry all at once, and not without its own impact on him. “I was looking at the stats and they were quite frightening,” he recounts. “Within a period of seven days, the cases rose from as many to 40-plus cases. The first few days were very much a quick succession of problems coming in, which needed to be solved based on the little information. For example, at that point in time, nobody knew whether it was a virus. That was speculation. Could have been a bacteria … we didn’t think so. Could have been some form of micro plasma or any other form of fungal infection or something … nobody knew. So there was a presumption that is was a virus. There was a lot of guess or informed guess.”
Now, as the hospital braces itself for a long-term battle, Lim, 43, gives us an insight into his world.
When did you realize that you had a major crisis on your hands?
Lim: The index case was admitted on March 1. Our doctors were very sharp and isolated her on March 6. We were exposed to her for six days. The WHO [World Health Organization] warning regarding atypical pneumonia came out on March 12. By March 14 and 15, our doctors were seeing secondary infections … our own staff, whom had taken care of the index case, were starting to become infected. On March 14, the day of our [staff] dinner and dance, the head of infectious disease and two other senior doctors in the department, together with the chair of the medical board, the director of nursing and the chief operating officer said, ‘We have to see you very urgently.’ They suspected that there was an atypical pneumonia, and that two of our staff had already come down with it.
What were some key steps you took to contain the virus?
We made the decision then to isolate anyone who came into contact with the index patient and start the contact tracing in regard to who else had taken care of this patient and start monitoring them, and that we had to watch this closely. We decided to commission our operations center, where we would meet regularly to follow up. Based on the information we were getting from a lot of key professionals, we were quickly able to make decisions and address the challenges as they came along.
For example, there was a lot of discussion based on the few cases that had already come up, what we had seen in terms of their epidemiology: who had been infected and what kind of exposures they had. At that point in time, it was very much best guess. We made the best guess that yes, it was probably not airborne. It was probably droplet, although there was no confirmation. The date set we were working with was actually very small, rapidly growing, but very small. Based on that presumption, we said we do need to isolate the patients.
What happened then?
Straight away, we started to mobilize. One of the key things was rooms – isolation rooms. We started to mobilize. When we looked at the wards, we weren’t comfortable as there was a lot of mixture of air between the rooms and the nurses station. So the support services staff suggested we switch off the air-conditioning from the rooms, put a suction on the window, switch the air-conditioning on full blast at the nurses station so that we created a flow of air through the ward and we get more exchange, so that if it was airborne, we have a least given them protection.
What knowledge did TTSH have to its advantage?
Because the hospital has always had strong infectious disease knowledge, we were able to quickly mobilize in terms of what was the right equipment. We started using masks very early. We started using gloves and gowns for those staff taking care of SARS patients. To this day, it remains the standard, and protected us from the very beginning. These were very good and very accurate guesses. We had quickly put up what we now called the Protect Scheme – in other words protect the staff from getting infection, protect the patients from passing on the infection by isolating them. That was our first level of defense.
Then, at the next level, we found that yes, some of our staff had been exposed. Because there was no test, there was no way to discern which staff had or had not been exposed. Again, we had a good team of people who were familiar with epidemiology; based on the data, we concluded that you were only infectious after your symptoms come on, and that the most consistent symptom was the temperature. That’s why again, within a day, we mobilize. We bought cheap mercury thermometers. We issued them to everyone and mandated everyone to check their temperatures. So, if any of our staff came down, we could isolate them. That was the second part, after detecting – we could detect who had come down and who needed to be isolated amongst our staff. Unlike other hospitals, we never stood down our teams into groups and tried to isolate the teams. Our whole principle was we don’t know who has been exposed, too much of the hospital had been exposed, and therefore it is a better strategy to detect as quickly as possible.
Did you ever feel that perhaps you might be fighting a losing battle against SARS?
I suppose prior to March 22 we were struggling principally because of a lot of logistics problems, from trying to take care of SARS patients and still running the rest of the hospital services, so that being declared the SARS hospital was helpful to us in many ways in that it allowed us to mobilize all our resources to focus on SARS rather than trying to do two things at one time. We closed our emergency department. We declared our hospital full and turned away the emergency ambulances to the other hospitals. This we had done for some time even before March 22. We did that on purpose, to restrict the load within the hospital, otherwise we would have too many balls to juggle.
Was the hospital’s crisis management plan adequate in dealing with such a crisis?
Yes and no. There were certain things we had put in place. We had an operations center, that’s a no-brainer. The ops center was well quipped, centrally located, a good command post fitted out with video cameras linked back to that place so we could monitor things. We were all ready and had planned what our structure was like in terms of quick command and control. But in terms of being fully prepared for something like SARS, no. Everyone tells me that this is something that is unique. There is no vaccine right now to prevent staff from being infected.
What were the most difficult decision you had to make?
When to go home (laughs). Not a matter of difficulty. Again, when I look back, what was extremely important and helpful was having extremely good counsel from so many professional staff who were very clear and competent on what was happening or what the various parameters were.
How many staff members were infected with SARS at TTSH?
Approximately 56 of our staff were infected with SARS. [TTSH has a 3,600-strong workforce.] [The] majority were nurses. The majority of them were infected in the first and second week. Although we had already put in these infection control measures, I think that was the most difficult period for the staff. They were very good. They asked a lot of questions – very pointed questions. We tried to give them the best information possible. But in the end, on their part, it was an act of faith and an act of courage.
How did you encourage staff who considered quitting?
All the more amazing, during that time, we did an early survey during the third week, two staff had left and said the reason was SARS. The rest of the staff questioned, I am sure they were definitely questioning. But they had great strength of character. They said OK, based on this, the job needs to be done.
How do you keep morale up among staff?
Information, making sure that we give them support by physically being there as well as trying to assess any real concerns they have. Also, making sure that little things would be addressed as well. Every time we changed some of our policies or came up with new requirements, the staff would be the first to know. I think that it is good we got ourselves to a level where the staff don’t read the news from the papers. They can actually rely on the updates to get the news before it goes to the press. I think that is important because it gives them a sense of being in the know and, therefore, being in control. I think the information is important in terms of keeping the morale up because a lot of staff have [given feedback] to me that the updates were key to them. They needed to know what the rest of the organization was doing, [the information] was good to keep everyone together.
Because, unfortunately, for SARS, the load is very uneven. There is not a big role for a surgeon. It affects the lungs: you need ICU physicians, respiratory medicine physicians, infectious disease physicians. There is not much surgery can do. So, it’s been important for those people who could be otherwise very anxious because they were already feeling anxious as they had no direct role to play, they were down there cheering and they couldn’t see the game.
What is required of a leader in a major crisis?
Good subordinates, good troops. It was fortunate that all my colleagues are extremely professional, very capable. When it came to certain issues about things that need to be done, it was never ‘Oh, no, you do this, I am not going to do this.’ It was everybody rushing up to do what they needed to do.
What sort of research or findings does TTSH intend to publish about its SARS experience?
Reporting on fundamental things like epidemiology, what is the mortality rate amongst the various age groups, things like this. How to clinically diagnose and project, how to clinically treat, and how to interact with the other technologies such as diagnostic kits or vaccines that have not come on line yet. We are collaborating with other Singapore and international efforts to develop the various test kits, test techniques. Our Genome Institute in Singapore has developed a test kit, the samples for the test have essentially come from the patients so we can match to the various test kits. Over time, there will be more collaborations regarding whatever vaccines there are available. But frankly, I don’t see a vaccine coming out within less than a year.
TTSH has had a long-held tradition of doctors with the best bedside manner. How has this come into play when consoling patients and families with SARS? I think it has been important and critical. Some of the fundamental characters of the organization have put us in good stead during this period of crisis. That is one. The other is that the doctors, the nurses are very altruistic, very giving, very caring.
What advice do you have for someone who is coping with the isolating effects of SARS?
Look to a positive future.
Both Lim and Roolvink are members of the UCLA Association of Singapore.