key: cord-0973297-3at7hil8
authors: Aleanizy, Fadilah Sfouq; Alqahtani, Fulwah Yahya
title: Saudi Healthcare Facilities Risk Management and Infection Control Preparedness to Overcome the COVID-19 Pandemic
date: 2022-04-28
journal: IJID Regions
DOI: 10.1016/j.ijregi.2022.04.005
sha: cf9db8efdcf9729dd4f768ac144dc98ec4bf3182
doc_id: 973297
cord_uid: 3at7hil8

Objective : The purpose of this study was to evaluate how well prepared Saudi healthcare facilities were to handle the COVID-19 pandemic. Methods : During April-June 2020, a cross-sectional study was conducted employing an online-administered English-language questionnaire given by the Saudi Commission for Health Specialties to Saudi hospitals. The questionnaire evaluates all aspects of risk management, infection control, and preventative programs that should be known and practiced by all healthcare staff (HCW). All healthcare staff in Saudi hospitals designated to accept COVID-19 cases were involved in the study. Results : A total of 161 HCW responded to the survey. The study found that general understanding of hospital risk management plans and infection prevention measures was outstanding (80.4 percent), with no differences in replies by gender, education, or occupation; although, there were some variances in responses by age group and years of experience. Most responses were from hospitals located in Central Province (72.7%) and governmental hospitals (88%), and most provided family services (68%). Furthermore, results showed that the medical professionals received adequate training, which is recognized as baseline for effective risk management and infection control and prevention procedures, policies, and recommendations. Conclusions : Notwithstanding the small differences among the staff, the study found that all healthcare workers in Saudi hospitals had excellent knowledge of risk management plans and pandemic subplans of infection control and prevention policy procedures and principles which has aided Saudi Arabia's health authorities in effectively mitigating COVID-19.

Healthcare facilities play a critical role in national and local responses to crises including communicable disease outbreaks and/or pandemics in all developed and developing countries (Arkoh , Seto et al., 2010 , WHO 2014 , Al-Tawfiq et al., 2016 . The majority of the measures mandatory to prepare for epidemics/pandemics also apply to the management of other crises, such as disasters, or can be altered to do so. Plans for recognition and handling of epidemics/pandemics, update and implementation capacity of these plans, and are required from every hospital (Rebmann 2010) . The plans of Centres for Disease Control and Prevention (CDC) and World health organization (WHO) guidelines can be utilized by hospitals lacking their own response plan in order to begin their planning process and modify their response plans to an epidemic/pandemic (Rebmann 2010) . Of note, Infection prevention and control is a continuous hospital activity in which all healthcare staff and units participate. Access and training for infection control protocols are necessary for all healthcare providers (Gerberding 2006 ). This will decrease the transmission of healthcare-associated infections and subsequently enhancing the safety level of patients, staff and visitors. In addition, this increases the efficiency of hospital responses to an epidemic/pandemic, and to decrease or diminish the risk of the hospital contribution in amplifying the epidemic/pandemic (Gerberding 2006 , Rebmann 2010 . Today, infection with COVID-19 is considered a pandemic.

Internationally, as of 6:30 pm CEST, 19 May 2020, there had been 4,735,622 confirmed cases of COVID-19, including 316,289 deaths, reported to the WHO (Nguyen et al., 2020 , WHO 2020 . From March 2 through 6:30 p.m. CEST on May 19, 2020, there were 59,854 confirmed cases of COVID-19 in Saudi Arabia, including 329 deaths (WHO 2020). In Saudi Arabia, compliance with strict infection prevention control protocols are well established in many healthcare facilities (Ministry of health: Saudi Arabia 2020, Ministry of health: Saudi Arbia 2020). As COVID-19 cases have been reported within Saudi Arabia, the Ministry of Health has intensified observation and infection measures.

All suspected cases are inspected, mainly at points of entry, and confirmed cases are directly isolated and treated (Al Yousuf et al., 2002 , Barry et al., 2020 Ministry of health: Saudi Arbia 2020). During the yearly hajj pilgrimage, KSA also has gained competence in managing large crowds and disaster preparedness (Alotaibi et al., 2017 , Barry et al., 2020 . To control the spread of COVID19, the Saudi Arabian Ministry of Health is interacting with the public through all possible channels, especially social media, and has created a guide on COVID19 to give Saudi citizens and residents access to the COVID19 facts and precautions in 12 languages (Ministry of health: Saudi Arbia 2020). Measures to involve the public in prevention and control activities and to combat misinformation about the disease have expanded significantly (Alotaibi et al., 2017, Ministry of health: Saudi Arbia 2020). The aim of this study is to assess risk management and infection control readiness in Saudi Arabian healthcare facilities in order to contain the COVID19 pandemic. This study also aims to analyze how well Saudi health facilities are prepared to deal with the COVID19 pandemic.

This is a cross-sectional study that used a survey method, applying a structured online 

Based on a previous review (Al-Hanawi et al., 2019) , the total number of healthcare workers is approximately 350,000, of whom approximately 200 work in infectious disease departments, so a sufficiently representative sample with an error rate of 5% and a confidence level of 95% should have 132 participants. on the sample size calculation website https://select-statistics.co.uk/calculators/sample-size-calculator-population-proportion/.

Questionnaires were distributed to healthcare workers at health centers designated by the Saudi Arabian Ministry of Health to care for patients infected with COVID19. Healthcare providers from hospitals in all provinces of Saudi Arabia were included. A total of 164 responses were collected, of which 161 were analysed and 3 were excluded. The response rate was 80.5 %.

The study included all healthcare workers in Saudi hospitals, regardless of nationality or department.

Uncompleted questionnaires and responses from non-healthcare-oriented workers were excluded.

The Statistical Package for the Social Sciences (SPSS) version 23.0 was used to conduct the statistical analysis (SPSS Inc., Chicago, IL, USA). Chi-square test, Mann-Whitney and Kruskal-Wallis test were used when applicable. Linear regression analysis and Pearson's correlation coefficient (r) were utilized to assess the associations and the correlation, respectively, to find the relationship.

The study sample included 161 subjects, and all their sociodemographic characteristics are shown in Table 1 . The study sample included both males (n = 89) and females (n = 72); a statistically significant difference was found between age groups (p< 0.0001) but not genders, as males and females were included in nearly similar numbers. More than half of the respondents were between 31 to 40 years old (50.3%), followed by 20-30 years old (26.7%) and > 40 years old (23%). Graduates represent the majority of the sample (42.2%) with a master's degree and above (39.8%); professionals with fellowships made up 12.4% of the sample, and approximately half of the respondents were (Doctor of Medicine) MDs (49.7%).

All subgroups contained similar percentages of males and females; however, the distribution of years of experience showed a statistically significant difference (p< 0.0001).

The background characteristics of the healthcare facilities designated to receive COVID-19 cases were analysed, as shown in Table 2 ; nearly all hospitals were government hospitals (90%), and the minority were private (11%), a significant difference with a p value ≤ 0.002.

There were statistically significant (p< 0.0001) differences in the types of care provided by different facilities; most of the hospitals provided family health services, including maternity and paediatric care (67.1%), provided inpatient care (88.2%) and had isolation units (87.6%).

The hospitals that received questionnaires were mainly located in Central Province (72.7%), which was statistically significantly overrepresented (p< 0.0001) compared with other provinces.

For any healthcare facility, to be prepared to face any emergency or risk as a COVID-19 pandemic, an emergency response plan should be constructed with effective mechanisms to be implemented and adjusted based on any risk. Table 3 shows a statistically significant responses (P < 0.0001), with an average of 75% of all respondents agreeing that their hospital has a flexible and well-implemented risk management plan. Such a plan was executed by committee responsible for developing the hospital emergency risk management programme in 68.3% of cases (P < 0.0001), and approximately 66.5% of respondents agreed that their hospital had a well-established command group in the hospital emergency committee (P < 0.0001). One of the most important aspects of the risk management plan during an epidemic emergency is an effective coordination strategy both between departments (75.8% confirmed) and with different hospitals and health authorities (69.6% confirmed that their facility coordinated effectively during the COVID-19 pandemic). Additionally, 67.1% of respondents stated that their facilities coordinated effectively with local infrastructure providers, 72% agreed that the facility managed supplies and infrastructures by implementing infection prevention and control measures during the COVID-19 pandemic, and 67.1% agreed that appropriate resources were available in sufficient quantities, with effective management and usage plans.

Regarding the level of knowledge, practice, capabilities and capacities within the hospital, there was a significant response (P < 0.0001), with agreement from approximately 76% respondents, alongside 81.4% in agreement that the risk management plan included a plan for the hospital to continue to provide general and specialized services while addressing the pandemic emergency. A significant proportion of respondents (74.5%, P < 0.0001) indicated that the risk management plan included a pandemic emergency sub-plan specific to COVID-19, with 72.7% noting that existing sub-plans provided sufficient capacity to cope with the pandemic, 77.6% agreeing that existing sub-plans provided sufficient capacity to cope with the all health demands, and approximately 66% reporting that their hospital risk sub-plan was adapted to COVID-19 and the specific challenges during the COVID-19 pandemic. Hospital personnel awareness related to risk management as needed to deal with a pandemic emergency such as COVID-19 was confirmed by a significant proportion of respondents (approximately 77%, P < 0.0001); 70% reported having training to perform the necessary actions in any emergency, and 73% reported being trained to implement the emergency risk plan during the COVID-19 pandemic; however, only 58.4% replied that their facility sufficiently considered their physical and social concerns related to the burden of covering a pandemic emergency.

The components of the hospital emergency response plan include infection control measures and COVID-19 sub-plans developed based on the hospitals' emergency risk assessments (Table 4) . A total of 74.5% of subjects replied that their hospitals have protocols and measures in place to cope with the COVID-19 pandemic, such as infection prevention control risk plans, and 71.4% of the plans include containment measures to endure the COVID-19 pandemic. Moreover, 66% reported that their risk plan involves a backup plan and local communication plan, and 72% confirmed that the hospital plan included measures to prioritize and adapt work routines and systemic responses during the epidemic of COVID-19.

The prevention and control measures are essential to contain a pandemic infection such as the COVID-19 pandemic must incorporate not only local policies and decisions but also national policies. These national and local policies encompass a variety of strategies, and approximately 80% of respondents in all Saudi hospitals agreed that appropriate measures (all-hazard specific measures) were taken to address the COVID-19 pandemic, with 65% developing incidence action plans with a dedicated command group to report any incidence of COVID-19 cases. In 70-80% of cases, respondents stated that the infection control management plans included all staff members in infection prevention and control protocols in normal and pandemic situations, in addition to training the staff to achieve their roles in implementing the hospital's emergency response in infection prevention and control according to a set of process flow guidelines on standard precautions for infection prevention for COVID-19 and knowledge of basic protective measures against any pandemic.

The association of different variables (age, gender, education, occupation, experience and facility types) with the knowledge level of respondents regarding their facilities' risk management and infection prevention control and how well their facilities are prepared to correlation was found between hospital personnel/infection prevention control and the infection control plans and measures and hospital personnel/risk management, with r = 0.825, P < 0.0001 and r = 0.808, P < 0.0001, respectively ( Table 5 ). In addition, a very good positive relationship was identified between the existence of infection control plans, measures and mechanisms and how well these measures were implemented (r = 0.819, P < 0.0001). 

The swift spread of COVID-19 globally has led to an elevated incidence of infection.

COVID-19 has a higher rate of transmissibility than previous coronaviruses and affects multiple organs. The lack of awareness of hospital infection control and worldwide air travel facilitated rapid global dissemination (Gu and Korteweg 2007) . The WHO declared COVID- (Table 7 ) (Alotaibi et al., 2017 , Barry et al., 2020 . All designated hospitals responded to our survey; hence, other hospitals were sent questionnaires. The study significantly showed that hospitals in Saudi Arabia are at all times in a state of preparedness to contribute fully, competently and successfully in the coordinated health sector response to an emergency, such as an infectious disease outbreak, and particularly the COVID-19 epidemic, with p = 0.0001. Hence, the sum of established risk management mechanisms and procedures comprising strategies required to coordinate the hospital's epidemic risk management efforts, including all-hazards emergency risk assessment and specialized epidemic event risk assessment, prevention, readiness, response, and recovery to overcome the COVID-19 pandemic, was statistically significant (p = 0.0001). In addition, infection control measures and procedures to increasing the ability of a hospital to respond to an epidemic and minimize the transmission of infections were highly significant (p = 0.0001), thereby enhancing the safety of all patients and eliminating the risk of the hospital itself amplifying the COVID-19 epidemic. All risk management-and infection control-related factors showed a significant correlation with age group (p≤ 0.05); in particular, the older age 

This study has some limitations. The first one is that the sample size is too small. Additional limitation is that we employed a web-based survey approach to prevent possible transmission of COVID-19 since the research was conducted during the COVID-19 outbreak; hence, the sample in our survey comprised of volunteer participants who were comfortable utilizing an online system. Therefore, the possibility of selection bias must be considered.

In situations such as the COVID-19 pandemic, it is recommended that health authorities set a unified risk management plan that is distributed and communicated to all healthcare facilities.

A unified risk management plan allows effortless dissemination and follow-up and helps the public and healthcare workers easily follow the same instructions at any healthcare facility.

Guidance on resource allocation, including laboratory testing, and resource management for lab and infection control requirements (acquisitions, tracking, and monitoring) should also be provided (Ministry of health: Saudi Arbia 2020). There are increased demands for surveillance and management of current COVID-19 outbreaks owing to the dread and significant influence on the population's mental health produced by the COVID-19 pandemic.

Previous studies have found effective suggestions facilitating compliance with control measures by both healthcare workers and the public (Lau et al., 2007 , Sim et al., 2010 , Kang et al., 2020 , Sun et al., 2020 , including educational materials and training that should be personalized to all exposed communities. These materials should include information about preventive measures and practical identification of risks in general language and should target not only healthcare workers as well the public (Sun et al., 2020) . Subsequently, the population needs to be educated to communicate to health authorities about any symptoms and not hide them because of embarrassment or fear, as this might further spread the infection (Ministry of health: Saudi Arbia 2020).

The WHO report examines and compares aspects of health systems around the world, providing conceptual insights into the complex factors that explain how health systems perform and offering practical advice on how to assess performance and achieve improvements with available resources. It is reassuring that during such critical times as the COVID-19 pandemic, all Saudi hospitals and healthcare staff and workers showed a relatively high overall prevalence of knowledge and awareness as well as effective communication between all parties throughout the country. This has helped the Saudi health system contain the pandemic with minimal losses.

This research project was supported by Researchers Supporting Project number (RSP-2021/340), King Saud University, Riyadh, Saudi Arabia.

The authors have no conflict of interest 

Healthcare human resource development in Saudi Arabia: emerging challenges and opportunities-a critical review

Middle East respiratory syndrome coronavirus: current situation and travel-associated concerns. Frontiers of medicine

Organization of the Saudi health system

Strengthening health security at the Hajj mass gatherings: characteristics of the infectious diseases surveillance systems operational during the 2015 Hajj

Emergency nurse disaster preparedness during mass gatherings: a cross-sectional survey of emergency nurses' perceptions in hospitals in Mecca, Saudi Arabia

COVID-19 in the Shadows of MERS-CoV in the Kingdom of Saudi Arabia

Pandemic preparedness: pigs, poultry, and people versus plans, products, and practice. The Journal of infectious diseases

Pathology and pathogenesis of severe acute respiratory syndrome. The American journal of pathology

Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study

Perceptions related to human avian influenza and their associations with anticipated psychological and behavioral responses at the onset of outbreak in the Hong Kong Chinese general population

COVID-19 Pandemic: Saudi Arabia's Role at National and International Levels

Ministry of health: Saudi Arabia, C., 2020. Novel Coronavirus (COVID-19)

Ministry of health: Saudi Arbia, M., 2020. COVID-19 Guidelines

Health Indicators for the Year of 1437 H

novel coronavirus disease (COVID-19): paving the road for rapid detection and point-of-care diagnostics

Raising awareness of health care providers about MERSCoV infection in public hospitals in Mecca, Saudi Arabia

Pandemic preparedness: Implementation of infection prevention emergency plans

Core components for infection prevention and control programs: a World Health Organization network report

Psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease

Understanding of COVID-19 based on current evidence

Hospital preparedness for epidemics

Middle East respiratory syndrome coronavirus (MERS-CoV): summary of current situation, literature update and risk assessment, World Health Organization