Keywords
COVID-19 - epidemic investigation - visiting - chaperoning - hospital - hospital information
systems - public health - monitoring and surveillance
Background and Significance
Background and Significance
The novel infectious disease named by the World Health Organization (WHO) as coronavirus
disease 2019 (COVID-19) is caused by a novel β coronavirus called severe acute respiratory
syndrome (SARS) coronavirus,[1]
[2] which first appeared in Wuhan, China in December 2019. On March 11, 2020, WHO officially
declared the COVID-19 a pandemic.[3] As of January 4, 2021, over 85 million laboratory-confirmed cases, including 1,847,030
deaths, were reported from more than 191 countries, territories, or areas.[4] As our country is located near China, it also faced various challenges from COVID-19.
However, our country had fewer cases as of March 2020 than the other countries near
China, such as Korea and Japan. The SARS epidemic in 2003 might be one of the possible
reasons for our country's relatively low number of cases as the outbreak was an important
lesson for our country.[5] Our country's Centers for Disease Control (CDC) took extensive precautions to control
the outbreak.[6] One of the many precautionary efforts was a change of visiting policies at almost
all levels of health care facilities. The CDC recommended that hospitals limit the
duration per visiting slot to a maximum of 1 hour, with only two visitors per patient
at a one-time period, and to avoid unnecessary inpatient visits.[7] Other countries implemented similar stipulations during the COVID-19 pandemic.[8] After the COVID-19 pandemic, medical institutions promptly initiated various epidemic
preventive measures for implementing patient admission and treatment, managing chaperones
and visitors, and the correct use of personal protective equipment.[9]
[10] Most hospitals also conducted other common infection control measures for visitors
and chaperones, such as travel, occupation, contact, and clustering (TOCC) history
taking, body temperature monitoring, hand sanitizing, and identity checks.[10]
[11]
[12]
Visiting and chaperoning patients is one of the most frequent needs of relatives caring
for a hospitalized loved one. Several studies have indicated a significant relationship
between the level of satisfaction with social support from relatives with a patient
suffering from a life-limiting disease and the degree of life meaningfulness in a
patient.[13]
[14] Studies have highlighted that visits can also lower the anxiety levels in patients
and their families and foster communication among them.[15] Although visiting and caregiving by family members is a culturally active standard
in our country's health care system, active family care increases the risks of disease
transmission through frequent contacts with patients and hand-touch areas.[16]
[17]
[18]
Hospitals established the Health Information System (HIS) to rally resources from
organizations in response to this unprecedented event. Through a shared sense of purpose
and nimble response to clinical and operational requests, the information technology
services team played an integral role in responding to this public health emergency.[19]
Objectives
The study objectives were to develop a Hospital Visiting/Chaperoning Monitor System
and to implement the system during the COVID-19 pandemic. The newly developed Hospital
Visiting/Chaperoning Monitor System allowed medical staff to access the information
instantly on the overseas travel history of patients, visitors, and chaperones. As
the system was connected to a centralized countrywide system, conducting epidemic
investigations, following the infection path, identifying and isolating all contacts,
and blocking virus spread could be easily performed.
Methods
This project involved 2,099 beds (main hospital: 1,078 and branch hospital: 1,021)
in 57 ward units of the academic medical center. The Hospital Visiting/Chaperoning
Monitor System was connected to the Virtual Private Network (VPN) of the National
Health Insurance (NHI) system and the HIS. The developed monitoring system consists
of the Microsoft Visual Studio as the main development tool. This tool has an excellent
performance, optimized memory usage, and high-security ORACLE 9i to build a safe and
fast information system for database system development ([Fig. 1]).
Fig. 1 The monitoring system scheme.
The system was built and started on March 20, 2020 so that when people enter the hospital
or ward to visit or chaperone patients, their basic information will be read by using
their NHI smart card or National identification (ID) card. Then, by logging in to
the VPN database to obtain NHI cloud TOCC data (such as travel history, travel location,
and so on), the information can be registered in the HIS Visiting/Chaperoning Monitor
System.
The government established the NHI system in our country to provide comprehensive
medical services for all our country's residents.[20] To address the threat from COVID-19, as of January 13, 2020, our country's health
authorities combined each citizen's travel history into the NHI database. This allows
the health care personnel to access each user's travel history (other countries globally)
for the past 14 days by entering their NHI smart card numbers or inserting their ID
cards. Health care staff can obtain comprehensive medical information and services
by inserting their NHI smart cards into the HIS. Based on our experience, this newly
developed Hospital Visiting/Chaperoning Monitor System utilizes an interdepartmental
teamwork model for combining the processes of nursing, infection control, and information
technology, and it is connected to the NHI and HIS.
Our hospital, an academic medical center, has a main hospital and a branch hospital.
During the COVID-19 pandemic, we set up common rules and processes for visitors and
chaperones during the COVID-19 pandemic. When patients or people accessed the hospital,
they were asked to insert their NHI smart cards into the system to obtain information
of their travel history by VPN of NIH, profession, contact history, and cluster information
(TOCC history), they were asked to perform correct hand disinfection with ethyl alcohol,
and their body temperature was obtained by using infrared thermometers. If an individual
had a high temperature (>38°C), he/she was transferred to a fever screening station
for further diagnosis, treatment, and decision-making on where to admit them (individual
ward or general ward). Finally, we used the Hospital Visiting/Chaperoning Monitor
System to identify hospital check-ins for visitors and chaperones, including whether
this check-in was completed with ID cards or NHI smart cards. When the individuals
were identified as normal by the system, they could access the ward ([Fig. 2]).
Fig. 2 Process of visiting and chaperoning during the COVID-19 pandemic.
If the individuals requesting access to the hospital still need to enter the hospital
wards, they must visit the wards during opening hours. Our country's CDC also suggested
time restrictions on hospital visits. Our hospital visiting and chaperoning policies
followed the CDC guidelines.[21] Visits were prohibited when the epidemic was at its peak. Thereafter, from the previous
once-a-day visits, the visiting time has now become twice a day, and the number of
visitors allowed is restricted to two at a time.
In the Hospital Visiting/Chaperoning Monitor System, personal data are obtained from
the HIS. First, the system will automatically pull up the ward being checked, and
the hospital staff just will choose the bed number. Then, the staff will choose whether
the individual is visiting or chaperoning. Chaperones include family members, caregivers,
or foreign helpers. Subsequently, the health care staff will check the travel history
records by the VPN of the NIH. If the system is able to read the VPN information,
it would automatically pull up results on the system, and performing another survey
is not necessary. Finally, if the result in the monitoring system is normal (the system
displays the “O” symbol), the individual will be able to access the ward to visit
or chaperone a patient. Otherwise, if an individual traveled to any country in the
last 14 days and has a positive contact history, the system will display the “ × ”
symbol, and he/she should not be allowed to visit or chaperone a patient and will
be denied access to the ward ([Fig. 3]). If the visitor had already been logged into the system, the previous information
will show automatically during the next visit. The system is able to determine whether
the number of visitors meets the hospital policies, whether the VPN travel history
complies with the regulations, and whether the relationship between the patient and
visitor is correct before an individual enters the ward. Additionally, if some individuals
have not brought their NHI smart cards or ID card, the staff could key in their resident
ID card numbers or passport number of non-Taiwanese persons to reveal their travel
histories. We also considered that since all data are stored in the database during
the COVID-19 outbreak, we can easily retrieve data to carry out contact tracing and
to monitor exposed patients, which are key control measures.
Fig. 3 The newly developed hospital visiting/chaperoning monitor system.
It is worth mentioning that, to shorten the time for manual identification, the medical
and technology services team of this hospital developed a new system of “app for appointment
visits and chaperones,” which was launched in December 2020. The new system allows
visitors or chaperones to make appointments online, and only those who visit enter
the patient information; visitor or chaperone's information; risk assessment form
and symptom, travel, occupation, contact, cluster (STOCC) survey form; and health
statement directly into the online appointment system or “app for appointment visits
and chaperones.” Symptom refers to the survey for fever of unknown cause, respiratory
symptoms, unknown diarrhea, and loss of smell and taste. The system will also be connected
to the VPN of the NHI system to check their travel and contact history. At that time,
when people go to the hospital to visit, as long as you show your QR Code to verify
your identity at the hospital, you can quickly pass without using an NHI smart card
or ID card to enter the Visiting/Chaperoning Monitor System ([Fig. 4]).
Fig. 4 The system of app for appointment visits and chaperones.
Results
Our country's CDC initially regulated visiting and chaperoning in hospitals and then
standardized the access measures. Our hospital complies with this regulation. Access
control was started on March 9, 2020.
On March 20, 2020, the Visiting/Chaperoning Monitor System was officially used to
monitor the entry of chaperones and visitors of patients in the ward. The hospital
units include general, outpatient, emergency, and intensive care wards.
The number of visitors is restricted to two at a time. When patients or people accessed
the ward every time, they were asked to insert their NHI smart cards or ID card to
access the system.
From March 20 to May 30, 2020, 67,692 visitors and chaperones were monitored. Specifically,
the number of visitors was 31,259 (main hospital: 15,492; branch hospital: 15,767), while the number of chaperones was
36,433 (main hospital: 22,620; branch hospital: 13,813; [Table 1]). A total of 89 people failed the initial checking and went to the hospital's outdoor
clinic for medical treatment. There were approximately 420 people who were denied
entry to visit or chaperone. Three people who were identified and traced using this
system tested positive for COVID-19.
Table 1
Number of visitors and chaperones from March 20 to May 30 in 2020
|
Visitor
|
Chaperone
|
|
Main hospital
|
15,492
|
22,620
|
|
Branch hospital
|
15,767
|
13,813
|
|
Total
|
31,259
|
36,433
|
All the data on visitors and chaperones can be accessed from the nursing information
system. When an epidemic investigation is needed, the chaperoning and visiting data
of all patients within a specified time could be exported from the system to Excel
for data sorting ([Fig. 5]).
Fig. 5 Exported visiting and chaperoning data.
Discussion
Our hospital visiting and chaperoning monitoring system that was developed during
the COVID-19 pandemic has the following advantages: in case of a confirmed COVID-19
case, regardless of whether it is a visitor or a chaperone, an epidemic investigation
can be performed through the system to identify all contacts. Furthermore, when there
are policy changes, such as the number of visitors, the system can be easily adjusted
by the information staff.
The system plan that uses nationwide data sources is adopted for visitors and chaperones
by the information technology team. In addition, to prevent people from hiding their
travel histories, the government has made it possible for medical staff to access
the travel records of people through their NHI cards, and their basic information
will be linked to the HIS personnel without additional manual input. It can more accurately
screen hospital visitors and chaperones. The previous studies also indicated that
the information technology services team is a cornerstone of organizational response,
as they coordinate operational and clinical activities; they must also rapidly rearrange
infrastructure, policies, and priorities to remain responsive to the COVID-19 outbreak.[19]
We also developed the mobile applications “app for appointment visits and chaperones,”
which allows making appointments directly online. It is more convenient for visitors
and chaperones, and the staff can save time on history taking and recording information.
The studies have demonstrated that with encouragement from clinical professionals,
patients can have a positive experience using mobile health applications.[22] Finally, the system uses the existing equipment of the hospital and connects the
system to the original hospital system; thus, there is no extra cost involved.
The protocols for the COVID-19 epidemic are still very strict. With the establishment
of the system, individuals entering the ward can be accurately identified. When there
is a confirmed case, an epidemic investigation can be conducted through the system
to identify all contacts. These results can help health policymakers to optimize hospital
visiting policies and may lower the risk of hospital cluster outbreaks when novel
infectious diseases occur.
We think that the framework of the system can be a reference for other countries.
The entry and exit information of countries can be used to control infection in hospitals
in the face of an impending crisis.
This study also had some limitations. First, the visiting policies might change at
any time due to the progression of an infectious disease. We could only take a snapshot
of visiting policies at the hospital during a particular time. For that reason, the
results of our study may not correlate with those of another study at a different
time. Second, we only set up a Hospital Visiting/Chaperoning Monitor System and did
not investigate the opinions of patients, visitors, and staff members toward the change
of visiting policies; these data would be valuable to gain an extensive understanding
of the influence of visiting policy changes on patients, visitors, and the multidisciplinary
team. Further investigations are then required to benefit patients, visitors, and
health care providers.
Conclusion
During the fight against COVID-19, the Hospital Visiting/Chaperoning Monitor System
was able to identify potential cases, while public health staff identified their contacts.
It is important that medical staff immediately access a patient's travel history and
conduct epidemic investigations to prevent the spread of an infectious disease. However,
the impact of the current visiting and chaperoning policy changes on health care teams
as well as on patients and their families requires further investigation.
Clinical Relevance Statement
Clinical Relevance Statement
The spread of emerging infectious diseases may continue to occur in the future. The
accurate and timely surveillance of our newly developed Hospital Visiting/Chaperoning
Monitor System provides essential intelligence for hospital operations during the
COVID-19 pandemic. This monitoring system can provide hospitals with information on
an individual's travel history in high-risk areas, which is useful in performing disease
monitoring and contact tracing, playing a key important role. The international pandemic
situation is still severe. During this very challenging time, hospitals still need
to cooperate with national policies to implement source controls, such as establishing
hospital visiting and chaperoning policies, strict STOCC history and body temperature
taking for hospital visitors, and using face masks, to provide a safe environment
for patients and hospital staff during this COVID-19 pandemic.
Multiple Choice Questions
Multiple Choice Questions
-
Which of the following sources of information is used to create the Hospital Visiting/Chaperoning
Monitor System?
-
Emergency Room Information System
-
NHI system and HIS
-
Community Health Information System
-
Reports in the CDC system
Correct Answer: The correct answer is option b. The monitoring system was connected to the VPN of
the NHI system and HIS.
-
Which of the items below is not the main function of the Hospital Visiting/Chaperoning
Monitor System?
-
Determine people's travel history in high-risk areas
-
Perform disease monitoring and contact tracing
-
Monitor an individual's body temperature
-
Determine the number of individuals visiting and chaperoning
Correct Answer: The correct answer is option c. Monitoring the body temperature is the main function
of the Hospital Visiting/Chaperoning Monitor System.
