Efforts Against COVID-19 at Keio University Hospital

2020/07/09

In 2020, the year marking the 100th anniversary of our hospital's opening, we faced an unprecedented crisis in the form of the COVID-19 pandemic. As the Director of the Hospital, I would like to express my deepest apologies for the great concern caused to our patients and the Keio Gijuku Shachu due to the nosocomial infections and the cluster infection among junior residents at our hospital. Despite this, I would like to express my heartfelt gratitude for the tremendous support and encouragement we have received from everyone. Although the situation remains unpredictable as of June 15, I would like to report on our progress to date and our future initiatives.

As a medical institution cooperating in infectious disease treatment, our hospital accepted patients with mild symptoms from the cruise ship Diamond Princess on February 13, 2020. On February 17, we established the University Hospital Response Headquarters and began preparations to re-equip an area that had already been closed as a place for fever triage, staffed by a rotation system of multiple clinical departments. In addition, we secured a dedicated COVID-19 area in preparation for the epidemic period, and on February 27, we established a PCR testing system for COVID-19. All emergency admissions for community-acquired pneumonia were placed in private rooms, and border control measures were taken while conducting PCR tests. From March 9, overseas travel by faculty and staff was prohibited, and from March 18, all returnees from overseas, regardless of the region, were prohibited from entering the Shinanomachi Campus for 14 days, maintaining a state of high alert.

Since the opening of the New Hospital Ward Building 1 in May 2018, hospital operations had been smooth thanks to everyone's cooperation. Hospital faculty and staff worked as one to maintain high-capacity, high-turnover operations, and the occupancy rate of general hospital beds reached 97%. In recent months, both inpatient and outpatient operations had recorded record-high figures almost every month. Entering February, the number of outpatients and first-time patients showed a downward trend due to the impact of the spread of COVID-19, but the operating figures continued to increase compared to the previous year. In preparation for the epidemic period, clinical functions were generally maintained while securing beds and manpower in the COVID-19 dedicated area. In this way, we had established a system to continue providing the advanced medical care that our hospital should fulfill as a Special Functioning Hospital while firmly treating COVID-19 patients, but looking back now, this was the calm before the storm.

On the night of March 23, the Center for Infectious Disease and Infection Control received unofficial information from a doctor working as an external physician at another hospital that a serious nosocomial infection of COVID-19 appeared to have occurred at that hospital. An urgent investigation revealed that a patient had transferred from that hospital on March 19 for the purpose of surgery for another disease. An immediate PCR test was conducted, and the result was positive. This patient was completely asymptomatic, and at a time when no hospital in Japan was conducting pre-admission screening PCR tests, it was difficult to detect the infection in advance. Subsequently, PCR tests were conducted on all contacts, including patients in the ward and healthcare workers, and infections were confirmed in four patients, one doctor, two nurses, and one radiological technologist. Furthermore, PCR tests were conducted on all 99 doctors from our hospital who had worked at that hospital as external physicians since February 1, and five were positive, with secondary infection from one of those doctors to two other doctors being confirmed. It was revealed that at a time when we believed we had perfect border control measures and not a single infected person in the hospital, there were patients and doctors who were infected while being completely asymptomatic. The fact of the nosocomial infection was immediately reported to the government and published on our hospital's website.

This nosocomial infection resulting from an unexpected sequence of events drastically changed the situation at our hospital, which had been going smoothly until then. Infected patients and healthcare workers were hospitalized and isolated, and all healthcare workers in the ward who tested negative for PCR were also placed on a 14-day standby. A ward in a different building from the affected ward was hurriedly closed, all of its staff were moved to the affected ward, and the treatment of non-infected patients currently hospitalized in the affected ward was continued by this new team. We suspended the acceptance of new first-time outpatients and emergency outpatients, and decided to continue only the treatments that needed to be continued in the outpatient department and high-urgency surgeries.

When we reported this situation to the Keio University Executive Board, President Haseyama, Vice-President Takeuchi, and other members of the Executive Board instructed us to prioritize the safety of patients and healthcare workers above all else. In addition, President Haseyama gave us warm encouragement, saying, "Keio University will provide maximum support." To this day, we have received support from Keio University and the Federation of Mita-kai, including medical support donations, supplies such as protective equipment, and food for faculty and staff. In the midst of an extremely difficult situation, I once again felt deeply grateful for the Keio University community.

An even more serious situation occurred. On March 31, the Health Management Center reported that several junior residents had developed fevers, and one of them was found to be PCR positive that evening. Despite requests from the national government and the Tokyo Metropolitan Government to refrain from large group dinners, and our hospital's own request for faculty and staff to refrain from such gatherings, it was discovered that some junior residents had gone ahead with an unofficial dinner party on March 26, resulting in a cluster infection among the residents. It is truly regrettable that this dinner party was held despite the School of Medicine and the hospital having decided and announced the cancellation of the annual junior residency completion ceremony and social gathering more than a month in advance. I deeply feel that we had not thoroughly implemented even the minimum ethical education for junior residents as members of society. Many residents were scheduled to take up posts at new locations from the following day, April 1. We made the decision to return to the ironclad rule of putting all potentially at-risk groups on standby. All 99 junior residents at our hospital were ordered to stay on standby for 14 days even if their initial PCR was negative, and furthermore, all off-campus work for faculty and staff (including taking up new posts and external work) was temporarily suspended.

Ultimately, as a result of conducting contact response investigations on all close contacts of the residents, it was confirmed that there was no spread of infection from this cluster to healthcare workers other than the residents or to patients. On April 6, when the PCR test results for everyone, including contacts, were known, we published this fact on our website and informed patients who were hospitalized or visiting the outpatient department of the situation in writing and apologized. The only saving grace was that we were able to prevent the spread of infection from the resident group to patients or other medical facilities.

While preventing the spread of infection within the hospital, we prepared our medical system for the approaching explosion of infections in the Tokyo metropolitan area. We reorganized the personnel of each clinical department into multiple teams as much as possible, and teams other than those necessary to maintain clinical functions were placed on standby, adopting a system of working in shifts for a certain period. In addition, a system in which Special Functioning Hospitals and university hospitals share the acceptance of severely ill patients was started under the guidance of the Tokyo Metropolitan Government. To prepare a system for actively accepting severe and moderate cases at our hospital, we closed multiple wards in stages for the purpose of securing manpower and space.

Since the occurrence of the nosocomial infection, we had published information on our website each time and reported detailed data to the government every day, but we felt it was important to continue accurately communicating the situation to all faculty, staff, and related hospitals. In addition, we decided to distribute video messages from the Director of the Hospital to all faculty and staff as needed. I felt that sharing the situation created solidarity and a relationship of trust with the faculty and staff.

From the last week of March, community-acquired infections expanded rapidly, and many severe and moderate patients were transported to our hospital. While sharing information, we formed a COVID-19 lifesaving team consisting of multiple clinical departments to strive to save the lives of severe patients and prevent moderate patients from becoming severe. Professor Koichi Fukunaga of the Department of Pulmonary Medicine, who is an Assistant to the Hospital Director, became the team leader. Severe cases were handled by the Department of Emergency Medicine led by Professor Junichi Sasaki, the anesthesiology and intensive care team led by Professor Hiroshi Morisaki, internal medicine, and surgery. Moderate cases were handled by an internal medicine team centered on pulmonary medicine and the department in charge of treating the underlying disease. For mild cases, a team was formed by gathering doctors from many other clinical departments to provide treatment. Vice-President Tsutomu Takeuchi also joined the treatment himself as an expert in immunity and inflammation.

Mental care for COVID-19 patients, their families, and healthcare workers working on the front lines is also an important issue. A "Mental Care Team" that performs multifaceted stress management was launched, centered on Professor Masaru Mimura of the Department of Neuropsychiatry. In addition, the "Keio Donner Project," in which basic researchers multifacetedly promote COVID-19 research for clinical application, was launched, centered on Dean of the School of Medicine Masayuki Amagai and Director of the Clinical and Translational Research Center Hideyuki Saya. This is a general term for cross-sectional research projects by elite units of the basic and clinical departments, named after the nickname (Donner: thunder) of Dr. Shibasaburo Kitasato, the first Director of the Hospital and Dean of the School of Medicine. To safely and quickly conduct numerous observational studies, specific clinical research, and clinical trials related to COVID-19, the COVID-19 Clinical Trial and Clinical Research Task Force was launched, centered on the Clinical and Translational Research Center, and began providing support. In addition, the Keio COVID-19 Registry, which integrates multiple studies, was also launched and is expected to serve as a database that will generate many research results in the future.

Professor Takanori Kanai, Professor Koichi Fukunaga, and others have launched a nationwide host genome analysis study focusing on the fact that there are few severe or fatal cases among Japanese people, which is also attracting social attention. The epidemiological survey team led by Professor Toru Takebayashi provided professional advice on the nosocomial infection control activities of the Center for Infectious Disease and Infection Control, and the virus gene analysis team of Professor Haruhiko Siomi of Molecular Biology and Professor Kenjiro Kosaki of Clinical Genetics started research to scientifically support this and has achieved interesting results. Verification of new serodiagnostic methods by Professor Naoki Hasegawa of the Center for Infectious Disease and Infection Control and Professor Mitsuru Murata of the Department of Clinical Laboratory Medicine, development of plasma therapy by Professor Ryuji Tanosaki of the Center for Transfusion Medicine and Cell Therapy, and clinical trials and clinical research of various drugs were started at a rapid pace. Truly, under an "All-Keio" system, the Kitasato spirit of "basic and clinical sciences as one family" is demonstrating great power in the greatest crisis encountered in the 100th year of the hospital's opening. It is truly reassuring and something to be grateful for.

From April 6, we began screening PCR tests for all patients scheduled for admission to our hospital for diseases other than COVID-19, ahead of hospitals nationwide. In the third week of April, 5 out of 67 completely asymptomatic pre-admission patients tested positive, which caused a great social response. Since entering May, there have been no positive cases among 570 people, and the screening PCR test positivity rate for April and May was 0.85% (7 out of 828). This figure almost matches the infection rate in the Tokyo metropolitan area inferred from current antibody test data. It can be inferred from this figure that mid-April was indeed the peak of the spread of infection in Tokyo.

The transferred patient who was the origin of the nosocomial infection at our hospital was completely asymptomatic at the time of transfer, and the nosocomial infection occurred during the few days until the onset of symptoms. There are also research reports that the period from two days before the onset to immediately after the onset is the most infectious. If procedures that generate aerosols, such as laparoscopic surgery or endoscopy, are performed on a completely asymptomatic infected person, there is a significant risk of infection, and at the same time, the possibility that serious symptoms may appear in the patient themselves cannot be denied. We believe that pre-admission screening PCR testing is a necessary test in the current Tokyo metropolitan area to protect patients and healthcare workers.

Through thorough contact investigation, standby, and PCR testing, we were able to report the convergence of the nosocomial infection on our hospital's website on April 21. Even now, all faculty and staff with even slight symptoms undergo PCR testing, and faculty and staff are permitted to return to work after confirming the disappearance of symptoms and a negative PCR result. PCR tests were also conducted on healthcare workers who treat patients in immunosuppressed states, such as those at the Cancer Center, Immunotherapy Center, Apheresis and Dialysis Center, and Organ Transplant Center, and all were confirmed negative once. As healthcare workers also lead social lives as general citizens, it is difficult to zero out the risk of infection in the community. We have established a system to prevent the spread of infection within the hospital through standard precautions, thorough hand hygiene, daily temperature checks, and PCR testing for those who are unwell.

Having established such a system, we decided to restore clinical functions in stages from May 7.

Upon the recovery of hospital functions, I believe it will be difficult to regain the same daily life as before with the same system and methods. It is difficult in terms of infection control to safely treat as many as 3,500 to 4,000 outpatients a day. In the future, as an AI Hospital model hospital, it is necessary to explore medical care that "interacts with patients in a new way," including high-quality telemedicine, by making full use of various sensing technologies and sophisticated imaging and communication technologies. In addition, in order to fight the eternal enemy of infectious diseases, the nature of preventive medicine and public health based on new concepts is also being questioned. Those of us who have studied at Keio University bear the mission of being "leaders" who create the next society in a rapidly changing era. It goes without saying that "education" and "research," which have been forced to be kept to a "minimum" under the state of emergency, will be the driving force for the future.

Since the occurrence of the nosocomial infection at the end of March, a very harsh time has passed, but the reason we have been able to move forward nonetheless is thanks to the dedicated efforts of the healthcare workers on the front lines who continue to provide treatment under great tension, all the faculty and staff who support them, the members of the Juku Shachu who provide great support both materially and spiritually, and the support of many patients and supporters. Considering the hardships faced by Dr. Shibasaburo Kitasato, who would later become the first Dean of the School of Medicine and Director of the Hospital, when he confronted the plague that broke out in Hong Kong at the end of the 19th century, we must be grateful for the various scientific technologies and the support of everyone. Taking this difficult experience as a lesson, we will work with all our heart and soul toward reconstruction as a world-leading medical institution. We look forward to your continued support and guidance.