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\begin{document}

\title{Converting a standard internal medicine ward into an isolation unit
during the COVID-19 outbreak}



\author[1]{iftach sagy}%
\author[2]{Elli Rosenberg}%
\author[1]{Leonid Barski}%
\affil[1]{Soroka Hospital}%
\affil[2]{Affiliation not available}%


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  \date{June 16, 2024}


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\textbf{}

The COVID-19 pandemic has substantial implications on almost every
aspect of life. Its ongoing influence on health care, as well as other
financial, social, psychological, educational and emotional aspects are
yet to be fully recognized. Although the COVID-19 outbreak emerged in
China at the end of December 2019, the first patient arrived in Israel
on February 21\textsuperscript{st}. This nearly two month gap enabled
the Israeli health system to implement preparations at a both national
and institutional level. Every hospital established an isolated internal
medicine ward, which was assigned to treat only COVID-19 patients. Since
there was no previous experience or recommended published guidelines, on
a national level the Ministry of Health instructed each hospital to
convert at least one standard internal medicine ward into a specialized
isolated COVID 19 unit, usually within a few days. Although several
series of protocols to treat critical COVID-19 patients in ICUs have
been proposed, similar recommendations for treatment in internal
medicine wards are scarce (1,2). Hence, we would like to summarize our
experience in the organizational aspects of managing COVID-19 patients
in an isolated internal medicine ward of a tertiary medical center.

\textbf{Minimal exposure} . The major concept of working in the
isolation ward is minimal exposure to the pathogen. The medical and
nursing staff are essential resources and it is crucial to minimize
their risk of SARS-COV-2 infection. The staff are also instructed to
minimize social contacts outside of working hours to avoid infection
risk outside of the hospital. The ward's staff is divided into two
separate ''capsules'', each capsule with consistent personnel (nursing
and medical staff) that work at separate shifts without physical
interaction between the shifts. In this manner, if one member is
accidently infected, only one capsule is isolated instead of the entire
staff.

Minimal exposure concept is facilitate in the following methods:

\begin{enumerate}
\tightlist
\item
  Medical staff enter the ward the least as possible -- usually once for
  morning rounds and later only for new admissions or for deteriorating
  patients.
\item
  Every entrance to the ward is carried out only with the minimal staff
  needed (e.g. two physicians and two nurses). Communication with the
  remaining team situated outside of the isolation unit is continuous.
\item
  Every entrance is planned ahead and equipment (e.g. PCR swabs, fluids)
  are prepared a priori.
\item
  We conduct minimal procedures and only on an as-need bases.
\item
  We use point-of-care ultrasound for lung and heart physical
  examination instead of stethoscope use(3)
\end{enumerate}

\textbf{Situation room.} We facilitate a situation room (SR) manned 24/7
by a physician or nurse. Patients' vital signs and medical follow-up are
transmitted from the isolated ward to the SR. The are multiple
communication channels for facilitating transmission of medical data to
and from the SR. In addition, the SR is connected to other units inside
and outside of the hospital who used as needed.

\textbf{Telemedicine.} Telemedicine devices allow the staff to monitor
patients with little SARS COV 2 exposure(4). The ward is interconnected
with cameras which broadcast to the SR, allowing continued monitoring of
the patients. In a addition, mobile sensors are attached to the
patients, which wirelessly transmit vital signs, via wifi, to the SR. A
remote control mobile robot with a screen, microphone and camera, can be
remotely moved around the isolated ward, allowing constant communication
with the patients.

\textbf{Patients examination.} Due to the use of personal protective
equipment (PPE) the routine physical examination of COVID 19 patients is
limited. Instead, we recommend focusing on appreciating the general
condition of the patients, his/her speech flow, mobility level and in
mild to moderate cases on POCUS of the lungs.

\textbf{Inter-disciplinary approach.} The significance of
inter-disciplinary cooperation cannot be more emphasized. During rounds
physicians assist nursing staff in their routine tasks: e.g. measuring
vital signs, feeding patients and replacing bed ridden patient's diaper.
We also are aided by social workers with routine talks with patients and
family members for daily updates and for psychological support (5). In
addition, a physiotherapist is involved to perform respiratory and
ambulatory physiotherapy as needed.

\textbf{Research.} We initiated several small-scale studies in our ward.
Data of the admitted COVID 19 patients are collected to evaluate
possible association with demographical and clinical characteristics. We
also evaluate several compounds with minimal adverse evets, which were
recently reported to have possible positive effect on disease
progression, such as hydroxychloroquine, Zinc, vitamin C and
N-acetyl-cysteine(6,7).

In conclusion, treating COVID-19 patients create unique clinical and
institutional challenges. These challenges can be managed with minimal
exposure to the medical staff, but without losing the therapeutic
Continuum. Notwithstanding, the basic concept of internal medicine
remain the same: maximal treatment with minimal risk for the patients
(Primum non nocere), but also to the treating team. More studies are
needed to investigate the functioning of the isolated COVID-19 wards in
larger scales, and the preparedness of health systems to this pandemic
at national levels.

All authors declare no conflict of interest

(1) Xie J, Tong Z, Guan X, Du B, Qiu H, Slutsky AS. Critical care crisis
and some recommendations during the COVID-19 epidemic in China.
Intensive Care Med 2020:1-4.

(2) Wang H, Wang S, Yu K. COVID-19 infection epidemic: the medical
management strategies in Heilongjiang Province, China. Crit Care 2020
Mar 18;24(1):107-020-2832-8.

(3) Peng QY, Wang XT, Zhang LN, Chinese Critical Care Ultrasound Study
Group (CCUSG). Findings of lung ultrasonography of novel corona virus
pneumonia during the 2019-2020 epidemic. Intensive Care Med 2020 Mar 12.

(4) Wendelboe AM, Amanda Miller J, Drevets D, Salinas L, Miller E,
Jackson D, et al. Tabletop exercise to prepare institutions of higher
education for an outbreak of COVID-19. Journal of Emergency Management
2020;18(2):1-20.

(5) Lima CKT, de Medeiros Carvalho, Poliana Moreira, Lima, Igor de
Ara\selectlanguage{ngerman}újo Silva, de Oliveira Nunes, José Victor Alexandre, Saraiva JS, de
Souza RI, et al. The Emotional Impact Of Coronavirus 2019-Ncov (New
Coronavirus Disease). Psychiatry Res 2020:112915.

(6) Matthay MA, Aldrich JM, Gotts JE. Treatment for severe acute
respiratory distress syndrome from COVID-19. Lancet Respir Med 2020 Mar
20.

(7) Razzaque M. COVID-19 Pandemic: Can Maintaining Optimal Zinc Balance
Enhance Host Resistance? 2020.

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