How a diverse 'strike team' delivered an effective VSM technology system in record time

The rapid rise of hundreds and thousands of COVID-19 cases amongst Singapore's foreign worker population required an equally rapid response. Central to the response was the consideration that the sheer number of cases could easily overwhelm the local hospital system.


Responding to the crisis, Singapore set up Community Care Facilities (CCFs) to cater to patients who are COVID-19 positive but at low risk of developing respiratory complications. Such patients are isolated and safely cared for in this facility until they are tested negative for COVID-19. 
 

At risk patients in CCFs require regular vital signs monitoring (VSM), and the growing demand on local healthcare staff plus the need for the patients to be isolated made CCFs an ideal site for use of remote telehealth technology – an area where the Future Primary Care programme at MOHT has both experience and expertise in. 


VSM allows patients to self-measure vital signs and automatically transmit their vital sign data to a central dashboard, monitored by healthcare staff from Woodlands Health Campus.
The four vital signs measured are temperature, heart rate, blood pressure and oxygen saturation. Patients are required to measure their vital signs three times a day to pick up early signs of serious medical problems. When a reading is out of range, it is immediately flagged up in the system in red font on the dashboard which is monitored by a healthcare staff. For example, a patient’s oxygen saturation is normally between 96 to 100%. Readings of 95% and below are flagged up in the dashboard so that healthcare staff can detect oxygen desaturation early.

 

MOHT's Professor Gerald Koh (Clinical Director, FPC) was appointed to drive the VSM effort at the Singapore Expo, the nation’s second CCF. Singapore Expo was not purpose built for isolation of infected patients using tele-VSM. Prof Koh, who holds a concurrent appointment at the Telehealth Core at the National University Health System (NUHS), was thus a natural choice to lead a 'strike team' in partnership with Integrated Health Information Systems (IHiS) to help with the deployment of the system. 
 

The work was not without its challenges however, ranging from procurement of tablets and VSM devices to charging and installing VSM app into hundreds of tablets a day.
 

Luckily Prof Koh could count on the help of colleagues such as Mr Gerard Chew from IHiS who scoured the island for more than 500 Apple iPad tablets, and MOHT colleague Ms Ng Ling Ling (Senior Consultant, FPC, MOHT), who fast-tracked the funding paper and approvals for the required equipment.
 

Another issue lay with how to instruct patients to use the machines as the majority of the tele-VSM patients at Expo were foreign workers who spoke Bengali as their first language, with varying literacy levels and tech adoption capabilities. 
 

The team quickly activated tech design experts from the NUHS Telehealth Core to create picture-based intuitive user manuals in paper and video format, and a team of volunteer translators who translated whatever minimally-needed text for the user manuals into Singapore’s four major languages, plus Bengali. 

 

With rapid improvement cycles called "sprints" everyday, the team improved the user manuals in tandem with daily improvements to the VSM system.
 

Other situations called for quick and improvised solutions. In the early phase of operations with low patient levels, the team was able to issue one monitoring kit to each patient. However, as patient numbers rapidly increased and more halls were activated, the team had to devise new solutions. The team converted monitoring kits to 'VSM Kiosks' where patient could visit and take their vitals. As patient numbers ramped up even higher, the team created mobile kiosks on wheels, which could be moved to different locations as needed.

Above: The evolution of the VSM setups in the
Singapore Expo CCF

Said Prof Koh, "There was a learning curve for everyone. When CCF started, VSM compliance was only around 20%. But by the end of second week of operations, almost all patients in the halls have learnt to measure all four vital signs (temperature, HR, BP and oxygen saturation) and enter their readings into their iPad on their own."


There are clear benefits to using remote monitoring technology. Patients are self-empowered to monitor their own vital signs anytime they feel unwell even though they are only required to measure their vital signs three times a day. In addition, fewer healthcare staff are needed to take the vital signs for the hundreds of patients in the hall. Self-VSM also minimises unnecessary "close-physical-proximity time" between HCW and infected patient.
 

There were heartwarming moments too, said Prof Koh, who shared about how the healthcare staff in the halls identified patients who quickly learned to measure vital signs and got them to teach their peers to do it. Through this peer-to-peer training process, the patients who were admitted in the halls earlier taught the newly admitted patients to self-measure, building a pipeline of compassionate teachers and patient ambassadors.

Selected news coverage:

Channel 8 Online - Expo CCF adopts remote monitoring to save manpower and improve efficiency

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