Healthcare Workforce Response to The Coronavirus Disease Outbreak in Daegu, Korea: A Multi-Center, Cross-Sectional Survey

In 2020, countries worldwide were unprepared when the coronavirus disease 2019 (COVID-19) pandemic struck them; a massive outbreak of COVID-19 within a short period led to the collapse of healthcare systems [1, 2]. To prevent similar future collapses, various policies and measures have been enacted by countries to maintain and enhance the competencies of healthcare workers (HCWs), who are regarded as essential to effective anti-COVID-19 policy efforts [3]. During the pandemic, a “shortage of available HCWs” has been reported as the most common reason for disruptions in healthcare services [4, 5]. HCWs play a pivotal role in the COVID-19 response; however, a rapid spike of COVID-19 patients within a short period of time creates a serious staff shortage [6]. Ensuring proper staffing is critical for managing infected patients, preventing secondary transmission to other patients and staff, and controlling the rapid spread throughout the community [7].

Because of inconsistent reporting, the exact number of COVID-19 cases and deaths among healthcare providers is unknown; however, the International Council of Nurses (ICN) reported that 572,578 HCWs from 32 countries contracted severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as of August 2020, accounting for 10.0% of all cases [8]. Similarly, the World Health Organization (WHO) reported that 14.0% of COVID-19 patients in Europe and America were HCWs [9]. The ICN estimated that at least two million HCWs worldwide had contracted the infection based on these data. The WHO estimated that more than 30,000 HCWs had died of COVID-19 in February 2021 [10]. Many HCWs were exposed to COVID-19 early in the pandemic. In China, 3,300 HCWs were infected and at least 22 had died of COVID-19 by March and February 2020, respectively. In Italy, 20.0% of HCWs were infected, and some of them died [11]. The infection spread among HCWs was attributed to inappropriate use of personal protection equipment (PPE), prolonged exposure to COVID-19 from many patients, shortage of PPE, lack of knowledge about infection prevention, low test sensitivity, and patients lying about epidemiological associations [12]. Moreover, HCWs may have an increased risk of COVID-19 owing to their close contact with highly infectious patients and exposure to undiagnosed or subclinical infectious cases [13].

Following the first case of COVID-19 in Daegu, Korea, on February 18, 2020, a massive outbreak occurred for the first time outside China; as healthcare facilities in Daegu were unprepared, they were overwhelmed by the need for a COVID-19 response, which prompted health authorities enforced several innovative measures, including drive-through screening centers, designation of COVID-19 hospitals, implementation of community treatment centers, restructuring of the healthcare system, mandatory universal face-mask policy, and rapid large-scale testing [14]. Through these measures, the epidemic was controlled without serious infections of HCWs [15, 16, 17, 18]. Many HCWs in Daegu committed to participating in the COVID-19 response during this period; however, the number of those involved in the COVID-19 response and the characteristics of those who developed COVID-19 in Daegu have not been investigated. Therefore, this study analyzed the scale and characteristics of healthcare staff needed to respond effectively to a COVID-19 outbreak, and the clinical and epidemiological features of HCWs who developed COVID-19 infection in six major teaching hospitals in Daegu that had experienced the outbreak with insufficient preparation. The ultimate goals of this study were to determine how to manage a healthcare workforce for pandemic response and to present foundational data on infection control among HCWs.

During this study, the cumulative number of COVID-19 in Daegu was 6,852 [19]. Most of them were asymptomatic to mild cases and were isolated in community treatment centers that compensated for hospital bed shortages [20, 21]. Only 8.9% (n = 611) of them (n = 6,852) were hospitalized in participating hospitals, and they were only 1.3% of the entire hospitalized patients (n = 48,807). However, 6.0% (n = 303) of the total hospital beds (n = 5,056) were occupied by COVID-19 patients, and 23.7% (n = 3,471) of the total HCWs (n = 14,651) worked in response to COVID-19. Therefore, all hospitals that participated in this study should have rapidly created dedicated hospital beds for COVID-19 inpatients by using portable negative pressure machines [22]. The COVID-19 pandemic requires many more beds and staffing per patient than would normally be necessary; thus, COVID-19 patient care is burdensome for healthcare facilities [23]. The number of HCWs required increases as the severity of COVID-19 increases [23]. Once an HCW contracts the virus, many people within the facility are identified as contacts, some of whom are quarantined, ultimately disrupting routine hospital operations [24]. Consequently, this situation adds to the burden on healthcare facilities, particularly imposing substantial burdens on healthcare resources. Therefore, beyond the Korean National Health Insurance Service reimbursement level, a new type of reward system needed to prepare hospitals for emerging outbreak of infectious diseases. In response to COVID-19 pandemic, some rewards for dedicated hospital beds for COVID-19 patients and infection control allowances for HCWs have been provided temporarily. Establishing a comprehensive workforce plan for future pandemics at the hospital, local, and national levels are also necessary.

Redeployment of HCWs is one of the recommendations for augmenting staff capacity with internal hospital resources [25]. In this study, about half of the entire doctor population was involved in COVID-19 response regardless of their specialty. Patients with COVID-19 at the COVID-19 ICU, GW, and ER were mainly treated by attending physicians specializing in infectious diseases, pulmonology, critical care, emergency medicine, and internal medicine residents. Additionally, doctors in other departments were mainly collecting samples at screening centers [23]. The deployment of a flexible physician workforce was required to create surge capacity for COVID-19 care and ensure and sustain routine hospital care [26]. Registered nurses, the largest component of the hospital workforce, played a critical role in caring for patients during the pandemic [27]. Furthermore, they were primarily involved in the COVID1-19 response in this study. There was a study which analyzed personnel recruitment ads and found that nurses were the most frequently recruited; frontline HCWs were in greater demand than managers or other decision-making positions [28]. Apart from the physicians and nurses, 697 HCWs (20.0%) were involved in the COVID-19 response, including radiographers, laboratory technicians, nurse aides, cleaning staff, transport staff, and hospital administration staff. Middle managers alternately played the leading role in entrance control. Some HCWs were dispatched to a COVID-19 designated hospital in Daegu [18].

As of March 24, 2020 — a month after the massive outbreak in Daegu — a total of 121 HCWs had been infected with COVID-19 in the entire area (14 doctors, 56 nurses, 51 nurse aides), accounting for 1.8% of all 6,620 COVID-19 patients in the area [15]. This infection rated was low, considering that HCWs account for 10% of all COVID-19 cases worldwide [15, 29]. Nevertheless, the incidence of COVID-19 infection per 1,000 HCWs in the Daegu area was 4.42, which was higher than the incidence (2.72) of COVID-19 per 1,000 HCWs in the general population. In this study, the incidence was 3.48 per 1,000 HCWs, which is lower than the incidence among the entire HCW population in Daegu but higher than that pf the general population [15]. These results may be attributable to this study involving one general and five tertiary hospital that have the highest infection-control capacity in Daegu. In terms of infection route, two-thirds of the cases were acquired in the community, presumably because the massive outbreak in Daegu was mainly linked to a specific religion [30]. Infected HCWs can infect their coworkers, patients, or caregivers; therefore, contact tracing and mandatory quarantine of close contacts are essential. Among the 1,018 identified contacts, 333 HCWs with close contact were quarantined. Fortunately, only one of them developed an infection. However, more epidemiological personnel are required to manage many contacts. Routine hospital operations would have been hindered if many staff members had been quarantined. In Australia, at least 536 HCWs were infected in the first six months of the outbreak, which accounted for 6.0% of all confirmed cases. This rate was 2.7-fold higher than that among the general population [31]. During the 21 COVID-19 waves, 131 HCWs were infected, and 1,656 were quarantined. One of these waves led to the closure of one hospital, and 1,200 people were quarantined from this hospital alone [31]. In this study, nurses, primarily women, were the predominant group among HCWs who developed COVID-19. As the infections were linked to a specific religious group, the mean age was young (35.4 ± 12.9); consequently, all patients recovered.

This study highlights the importance of HCWs in ensuring routine healthcare system operation during the COVID-19 pandemic. The results revealed the risk of workforce shortages and inadequate skills, and the importance of protecting healthcare personnel. The COVID-19 pandemic has highlighted the significance of assessing, protecting, and caring for the healthcare workforce and the need to make strategic investments in healthcare personnel to secure an adequate number of competent and motivated HCWs [32]. The costs for mobilizing more healthcare personnel and adequately supporting them for the COVID-19 response not only support the healthcare system in engaging in immediate response but also act as an investment for cultivating competencies in the healthcare personnel who will lay the foundation of global health security in the future [33].

This study has some limitations. First, the study enumerated all personnel involved in COVID-19 care, as opposed to using a standardized value: therefore, it is difficult to quantify the actual required staff size. However, this can be considered the size of healthcare staff who had been at risk of COVID-19 infection due to direct patient exposure in the early days of the COVID-19 pandemic. Second, only teaching hospitals in Daegu were surveyed; hence, the survey did not explore all the healthcare facilities in the region. However, this sample involved the six largest teaching hospitals in Daegu that played pivotal roles in the COVID-19 response by promptly converting their wards and ICUs for COVID-19 care. Despite these limitations, this study sheds significant light on the detailed size and characteristics of HCWs involved in the COVID-19 response in extensive healthcare facilities in Daegu during an outbreak that struck an unprepared city.

In conclusion, the surge in COVID-19 patients required much more human resources than the typical situation in all participating hospitals. Therefore, it is necessary to establish a comprehensive workforce plan for future pandemics at the hospital, local, and national levels, and a new reward standard for hospitals that goes beyond the current reimbursement level of the Korean National Health Insurance Service. Despite the large number of healthcare personnel committed to COVID-19 care, COVID-19 infection among healthcare personnel was low in six major teaching hospitals that treated severe COVID-19 patients in the Daegu region due to the strict infection control measures. Keeping HCWs safe from COVID-19 is crucial for maintaining the healthcare workforce during a sudden massive outbreak. Because community-acquired infections are two times higher than hospital-acquired infections, healthcare personnel must strictly adhere to routine infection-control measures, monitor their symptoms, and promptly seek testing as necessary. Through detailed research on the working hours and intensity of HCWs responding COVID-19, further studies are needed to determine the standard of required HCWs.

Supplementary Table 1

Departments of healthcare workers by occupation