Saudi Healthcare Facilities Risk Management and Infection Control Preparedness to Overcome Covid-19 Pandemic

Background: The purpose of this study was to evaluate how well prepared Saudi healthcare facilities to overcome COVID-19 pandemic. Methods: A cross-sectional study was conducted using online-administered English questionnaire that distributed throughout Saudi commission for health specialities at Saudi hospital during the period of April-June 2020. The questionnaire represent a minimum level of knowledge and practices for all components of risk management and infection control and prevention program which should be known and practiced by all healthcare workers. The study population included all healthcare workers in Saudi hospitals designated to deal with COVID-19 cases. Results: The study revealed that the overall knowledge of risk management plan and infection prevention control was found to be comparatively excellent (80.4%), and there were no discrepancies among the participants according to gender, education, occupation, however, some differences and variation according to age group and the years of experience. Most responses were from hospital located in central province (72.7%), governmental hospital (88%), and mostly provide family services (68%). The majority of hospitals have isolation units (88.2%) either under the authority of Ministry of health or not. Also there were enough training for medical staff which is considered as a base for good practice of risk management and infection control and prevention procedures, policies and guidelines. Conclusion: The study concluded that outstanding knowledge of all healthcare workers at Saudi hospitals regarding risk management plan and pandemic sub-plan of infection control and prevention policies procedures and principles, regardless the variations among the staff, however these base knowledge have helped Saudi Arabia health authority to successfully overcome COVID-19. overcome COVID-19 pandemic


Background
In all developed and developing countries the healthcare facilities play a crucial role in national and local responses to emergencies, such as communicable disease epidemics and/or pandemics (1)(2)(3)(4). Most of the actions required to prepare for epidemics/pandemics apply, or can be adapted to, the management of other crises, such as disasters. All hospitals obligated to have plans for their attentiveness and handling epidemics/pandemics, if necessary, to update their epidemic/pandemic response plans and their capacity to implement these plans (5).
Hospitals which do not have response plans can use CDC and WHO guide to make a start in the planning process and in regulating their plans to respond to an epidemic/pandemics (5). Infection prevention and control is an enduring hospital activity undertaken by all healthcare workers and units. All healthcare providers and workers must have access and training on infection control protocols (6). To reduce transmission of healthcare-associated infections and thereby to enhance the safety of all who are present in a hospital, including patients, staff and visitors. To enhance the ability of a hospital to respond to an epidemic/pandemic, and to reduce or eliminate the risk of the hospital itself amplifying the epidemic/pandemic (5,6). Today, the infection with Covid-19 consider pandemic. Globally, as of 6:30pm CEST, 19 May 2020, there have been 4,735,622 con rmed cases of COVID-19, including 316,289 deaths, reported to WHO (7,8). In Saudi Arabia, from Mar 2 to 6:30pm CEST, 19 May 2020, there have been 59,854 con rmed cases of COVID-19 with 329 deaths (8). The Kingdome of Saudi Arabia (KSA) has well established healthcare facility and strict infection prevention control protocol (9,10). As COVID-19 cases reported within Saudi Arabia, the Ministry of Health is intensify observation and infection measures. All suspected cases are inspected, mainly at points of entry, and con rmed cases are directly isolated and treated (9)(10)(11)(12). The Saudi Ministry of health (MOH) has elected 25 hospitals, measure up to 80,000 hospital beds and 8000 intensive care unit (ICU) beds, for the treatment of COVID-19 cases. 2200 beds have been selected for the isolation of suspected cases to be quarantined (9,13). Based on previous experience of KSA with other coronaviruses such as MERS-CoV (14), from June 2012 to 23 February 2016, Saudi Arabia developed speci c guidelines based on WHO guidelines to deal with the virus (9,13). KSA has a unique expertise in managing mass gatherings and emergency preparedness during the annual hajj pilgrimage (11,15). To limit the spread of COVID-19, Saudi Ministry of Health is interreact with the public through all possible channels, exclusively on social media. Also produced guide to COVID-19 to provide Saudi citizens and residents access to COVID-19 facts and precautionary messages in 12 languages (9). Actions to engage the public in prevention and control activities, and to combat false information about the disease, have been signi cantly scaled up (9,15). The aim of this study is to evaluate Saudi healthcare facilities risk management and infection control preparedness to overcome Covid-19 pandemic. The purpose of this study was to analyse how well prepared Saudi healthcare facilities to overcome COVID-19 pandemic

Methods
Study design This is a cross-sectional study used a survey method, applying a structured online English questioner that were distributed to the hospitals designated by Saudi MOH to encompass COVID-19 cases throughout Saudi commission for health specialities during the period of April-June 2020. The questioner involve questions that covers the risk management and infection control preparedness of Saudi healthcare facilities to ful l their role in containing COVID-19 pandemic.

Study population
Based on previous review (16), total number of healthcare workers is about 350,000 of them around 200 are working at infectious disease department so the sample to be su ciently representative with a margin of error of 5% and a con dence level of 95% it should have 132 participants using the following sample size calculation websites (https://select-statistics.co.uk/calculators/sample-size-calculator-populationproportion/). Questioner were distributed to healthcare workers in a healthcare setting that provide care for COVID-19 infected patients designated by Saudi MOH. Healthcare providers from hospitals around all Saudi Arabia provinces' were included. 164 responses were collected of them 161 analysed and 3 of them were excluded.

Inclusion criteria
The study included all healthcare workers in Saudi hospital from different nationalities in all department.

Excluding criteria
Any uncompleted questioner and none healthcare oriented workers were excluded.

Data Analysis
Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 23.0 software (SPSS Inc., Chicago, IL, USA).

Results
The study sample included 161 subjects were all their sociodemographic characteristics shown in (Table 1). The study sample were male (n = 89) and female (n = 72), although, it is found a statistically signi cant difference between age groups p< 0.0001, but not by gender as male and female nearly similar. More than half respondents were between 31-40 years old 50.3%, followed by 26.7% of age group 20-30 years old then >40 years old 23%. The majority of the sample are graduates 42.2 % and with master's degree and above 39.8%, professional with fellowships 12.4% and half respondent were MD doctors 49.7% with similar percent distribution between males and females, however, statistically signi cant difference p< 0.0001 distributed according to their years of experience.
Analysing the background characteristics of the healthcare facility to comprehend COVID-19 cases as shown in (Table 2), nearly all of hospitals were governmental 90 % and minorities were private 11% with signi cant difference with p value ≤ 0.002. It was found statistically signi cance p< 0.0001 responses as most of the hospitals provided family health services including maternity and children 67.1% providing inpatient care 88.2% and having isolation units 87.6%. The distribution of questioned hospitals were mostly located in central Province 72.7% showing statistically signi cance p< 0.0001, differences from other provinces.
Knowledge about risk management preparedness to overcome covid-19 For any healthcare facility to be prepared to face any emergency or risk as COVID-19 pandemic, a hospital should have in emergency response plan with effective mechanisms to be implemented and being adjustable to any risk. Table 3 showed statistical signi cant responses P < 0.0001, with an average of 75% of all respondent agreed that their hospital has exible and well implemented risk management plan. Such a plan executed by committee that responsible for developing the hospital emergency risk management programme 68.3% and P < 0.0001, and around 66.5% of respondents agreed that their hospital have well established command group by the hospital emergency committee with a signi cant value, P < 0.0001. One of the most important aspects of the risk management plan is to have effective coordination strategy of the hospital during an epidemic emergency either between department which observed to be signi cantly matter as 75.8% approved it and 69.6% endorsed that their facility coordinate effectively with different hospitals and health authorities during COVID-19 pandemic. Also 67.1% were compatible the effective coordination of their hospitals with local infrastructure providers, along with 72% manage supplies and infrastructures by implementing infection prevention and control measures during the COVID-19 pandemic and 67.1% agreed on the availability of appropriate resources in su cient quantities, with effective plan of management and usage.
Regarding the level of knowledge, practice, capabilities and capacities within the hospital there was signi cant response with P < 0.0001 from around 76% respondents in agreement alongside 81.4% of the risk management plan include a plan for hospital to provide general and specialized services while dealing with the pandemic emergency. A signi cant value added P < 0.0001 to the risk management plan to include pandemic emergency sub-plan to deal with Covid-19 74.5% and the existing sub-plans with capacity to cope with pandemic 72.7% and have capacity to cope with the all health demands 77.6% and around 66% in agreement to the adaptation of their hospital risk sub-plan to COVID-19, and adaptation to the speci c challenges during COVID-19 pandemic. Planning the hospital personnel relate to the risk management, their awareness to deal with pandemic emergency as COVID-19 a signi cant reply P < 0.0001 of about 77%, as well as 70% consented having training to perform the necessary actions in any emergency and 73% trained to implement the emergency risk plan during COVID-19 pandemic, however, only 58.4% complied that their facility have considered their physical and social matters during covering the burden of pandemic emergency.

Knowledge about infection prevention control preparedness to overcome covid-19
Component of the hospital emergency response plan include infection control and measures and also include COVID-19 sub plan developed based on the hospital's hazards emergency risk assessment (Table 4) General Knowledge about facility preparedness to overcome COVID-19 Regarding the association of different variables (age, gender, education, occupation, experience and facility types) with the knowledge level of respondents towards their facilities risk management and infection prevention control and how well their facilities prepared to overcome COVID-19 pandemic represented in (Table 5). A very good positive relation (correlation) was found between Hospital personnel/Infection prevention control and each of Infection control plans and measures and Hospital personnel/ Risk management since r = 0.825, P < 0.0001 and r = 0.808, P < 0.0001 respectively. In addition, very good positive relationship between infection control plans and measures and mechanisms and how well implemented r = 0.819, P < 0.0001. Also, a good positive relation between Hospital personnel/Infection prevention control and well implementations of all measures since r = 0.738, P < 0.0001. Good positive correlation observed between infection control plans and measures with both Pandemic as Covid-19 Sub-plan and hospital personnel/risk management as r = 0.782 and r = 0.757, P < 0.0001 respectively. Good positive correlation showed between hospital personnel/risk management and mechanism and implementation and pandemic as COVID-19 r = 0.792 and r = 0.731, P < 0.0001 respectively. Similar correlation between mechanism and implementation of pandemic as COVID-19 r = 0.741, P < 0.0001. Also, a moderate positive relation (correlation) between Hospital personnel/Infection prevention control and each of pandemic as Covid-19 Sub-plan and Hospital effective coordination were found since r = 0.678, P < 0.0001 and r = 0.623, P < 0.0001 respectively. However, a weak positive relation (correlation) between Hospital personnel/Infection prevention control and availability of resources, with effective plan was found since r = 0.416, P < 0.0001.
Finally, the multi-line analysis ( Table 6) shows that Hospital Emergency Response Plan have signi cant correlation mechanisms and implementations p ≤ 0.014 and with hospital emergency response COVID-19 pandemic sub-plan p ≤ 0.039. However, slight signi cant correlation concerning the effective coordination p ≤ 0.037, yet, no signi cant correlation with the knowledge and involvement of the hospital personnel in the risk management plan p ≤ 0.055, as well as the availability of resources, with effective plan p ≤ 0.071. In case of Infection control plans there is strong correlation with the application and implementation of the infection measures p ≤ 0.016 and the knowledge, involvement and training of all hospital personnel p ≤ 0.022 of all infection prevention and control procedures to overcome COVID-19 pandemic.

Discussion
Since the swiftly spread of COVID-19 globally, and the elevated incidence of people infected. COVID-19 has a higher rate of transmissibility properties than previous coronaviruses and alters multiple organs. The lack of awareness in hospital infection control and worldwide air travel facilitated rapid global dissemination (17). As WHO internationally declares COVID-19 as a pandemic (8), and advice for adapting certain protective measures to control the disease's outbreak (18), almost all countries adhere and pertain all these measures. However, the variation depends when and how they applied them. Starting by applying quarantine and closing all public activities, were telecommuting, virtual learning, and halting all airlines internationally are the leading measures (13). In Saudi Arabia, since the start of the COVID-19 pandemic, the Ministry of Health operates a Command and Control Centre for COVID-19, and started applying careful monitoring of the current situation (9, 10, 14), particularly in the absence of any prophylactic vaccines or curative treatment globally (8, 13). All protective safety measures started as early as the pandemic announced and healthcare rights were equal to all Saudi population (Saudis citizens and expatriates ) in spite of a very low number of reported COVID-19 cases in the country compared to the world. Daily updates through Saudi CDC and Wegaya, to ensure educating and updating healthcare providers and public about the disease (9, 10). Uni ed management procedures and protocols for all healthcare facilities were mandated and tracked (9). The purpose of this study was to measure the level of preparedness of Saudi healthcare facilities to overcome COVID-19 pandemic and the level of knowledge of healthcare workers of the preparedness plan, although different public health policies were implemented in the last months, and the mandatory nature of these protective measures. Previous reports of Saudi healthcare facilities adherence to protective measures display that the level of information and education are related to a positive attitude toward infectious preventive practices (19). Of the 470 total hospital in Kingdome of Saudi Arabia (20), 25 designated hospital (20 Primary and 5 secondary) to endorse COVID-19 cases (Table 7) (11,15). All designated hospitals have responded to our survey and hence other hospital were even questionnaire. The study signi cantly showed that hospital in Saudi Arabia are at all times in a state of preparedness to participate entirely, competently and successfully in the coordinated health-sector response to an emergency, such as infectious disease and particularly COVID-19 epidemic with p = 0.0001. Hence, a sum of statistical signi cant established risk management mechanisms and procedures comprising strategies needed for overall coordination of the hospital's epidemic risk management activities, p = 0.0001, such as; all-hazards emergency risk assessment and speci c epidemic event risk assessment, prevention, preparedness, response and recovery to overcome COVID-19 pandemic. In addition, strong signi cance p = 0.0001 shown in regards to Infection control measures and procedures to enhance the ability of a hospital to respond to an epidemic and reduce transmission of infections and thereby to enhance the safety of all and eliminate the risk of the hospital itself amplifying the COVID-19 epidemic. All risk management and infection control related factors showed signi cance level of correlation with age groups p≤ 0.05, in particular older age group ≥ 31 years old showed more understanding and awareness about their hospital's risk management plan and infection control measures along all related aspect of how well prepared to conquer COVID-19 pandemic, but not by gender as male and female approximately comparable. Also the level of education either holding diploma or above master degrees did not have

Conclusion
WHO report examines and compares aspects of health systems around the world and provides conceptual insights into the complex factors that explain how health systems perform, and offers practical advice on how to assess performance and achieve improvements with available resources. It is assuring that during such critical time as COVID-19 pandemic all Saudi hospital and healthcare staff and workers showed an overall relatively high signi cance of knowledge and awareness as well as effective communication between all parties throughout the country.
This have helped the Saudi health system to contain the pandemic with minimum forfeiture.

Study limitation
This study has some restraints. First, it is related to the sample size. The other limitation is due to the fact that the study was only focused on the outbreak of COVID-19, we used a web-based survey method to avoid possible transmission, causing the sampling of our study to be voluntary and conducted by an online system. Given this circumstance, the possibility of selection bias must be considered.

Recommendations
It is recommended in situation like COVID-19 pandemic for health authority to set a uni ed risk management plan distributed and communicated for all healthcare facilities. Uni ed risk management plan will allow effortless circulation and follow-up and easy application for public and healthcare workers to follow same instruction at any healthcare facilities. Provide guidance for rational use of resources including laboratory testing and manage resources for lab and infection control requirements (acquisitions, tracking and monitoring) (9). Due to frightening attitudes and considerable impact on population's mental health towards COVID-19 pandemic and new demands for surveillance and control of current COVID-19 outbreaks. Some previous studies identi ed appropriate suggestions to facilitate compliance with control measures by the population either healthcare workers or public (22-25), including; educational and training involvement should be personalised to all exposed communities either public or healthcare workers, and including teaching preventive measures and practical identi cation of risks in generalized language that include not only healthcare workers but also the public (23). Subsequently, the population needs to be educated to communicate to health authority about any symptoms and not hide it because of embarrassment or fear as this might furtherly spread the infection (9). 184, in addition to personal agreement from all respondents were required before they ll the online-questionnaires.

Consent for publication
Not applicable

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request

Competing interests
The authors declare no con ict of interest.