Cognizant that we are only as strong as our weakest link, we rapidly disseminated information to all staff at the start of the outbreak. This was facilitated by meetings and e-mails and also using smartphones with new capabilities not available in 2003. These capabilities included approved group instant messaging applications and workplace social media. Before the first publications about COVID-19 emerged in Western medical literature, our residents found, translated, and disseminated a Chinese-language presentation by medical personnel from a hospital in Wuhan detailing the clinical features and radiologic findings of COVID-19.

One challenge is to ensure that every staff member is included when information is shared. Our hospital radiologic services have more than doubled in size since 2003, and some groups were inadvertently overlooked in the initial rapid dissemination of information (e.g., research assistants, elective students, and part-time staff). There is also a need to quickly address false rumors so that personnel have the correct information to work safely.

Because of our SARS experience, staff are already primed for various levels of infection prevention and control. Most are fitted for N95 masks, and only a few need refitting. Everyone also undergoes annual infection prevention and control education, so there is familiarity with using PPE (Fig. 1). However, familiarity with theory does not necessarily translate into competence in practice; hence, refresher courses and videos are provided to bring everyone up to speed.

During the SARS outbreak, a shift system was used to prevent cross infection between teams working at different times or locations. This allowed radiology services to continue uninterrupted in the event any group had to be quarantined. The extent of any quarantine then depended on how closely group members interacted and whether they were wearing PPE.

Our current subspecialty radiology team setup facilitates radiologist cohorts. Because of our growth in size since 2003, the plan was updated to include new sites comprising a mix of subspecialty radiologic expertise. Resident rotations between teams have been temporarily halted until the risk of transmission within health care settings becomes clearer. The use of electronic medical records, radiology information systems (RIS), and PACS allows remote provision of services. The updated cohort plan is also applied to all other staff members including radiographers, nurses, and other health care support staff. We are also activating back-up teleradiology plans to allow radiologists who may be quarantined to report from home.

In addition to addressing radiology work, radiology leadership must address the emotional response of staff. SARS veterans are mostly calm and measured, though some have posttraumatic stress. For newer or younger staff members, responses range from indifference to concern to near panic. We deliberately share our SARS stories with newer staff. For those who worry about PPE effectiveness, it is reassuring to hear a SARS veteran say, “I know PPE works because I treated SARS cases while wearing PPE, and that is why I am still alive today.” Special attention is paid to staff with specific concerns (e.g., those with young children or who are pregnant). The radiology leadership mantra is not only “wear PPE and clean your hands” but also “look out for each other.” Beyond informal ground-level staff support initiatives, official staff welfare groups in our department and hospital are ramping up efforts to actively manage increased staff stress levels during this time.

At the start of the outbreak, basic PPE like surgical masks was made available in multiple department locations. As the outbreak progressed, the global supply chain for selected PPE was progressively strained. Mask distribution is now centralized at fewer points to ensure PPE stock can be sustained for an extended period.

Learning from the SARS experience, our radiology infrastructure was modified to cater to infection prevention and control. We now have negative air pressure rooms for radiography, ultrasound, CT, and MRI to cater to high-risk or isolation cases. Patients from different groups (e.g., inpatient, outpatient, emergency, febrile, and nonfebrile) are segregated by place or time with minimal crossover. Protocols detail which elevators and routes to take to radiology services during an outbreak.

Access control to our department has been tightened. All entrances are now only accessible with a staff card. New screening stations have been set up at entrances to screen patients, accompanying persons, and other visitors (e.g., research assistants, vendors, or technicians) (Fig. 2). Screening is done on the basis of hospital advisories and includes assessment for fever, travel and contact history, and symptoms. Department access is tracked, and screening before entry and visit records are kept to facilitate contact tracing. Nonessential clinical meetings are postponed to reduce staff traveling through our department. Wherever possible, virtual or telephone consultations are used instead.

Our department has decentralized reporting rooms at six locations across the campus. Before the outbreak, each radiology reporting room was occupied by one subspecialty team. In the current epidemic, we now configure mixed subspecialty teams to work from each reporting room. These mixed teams are separated physically to minimize cross infection.

Because portable imaging capability was in high demand during the SARS outbreak, our department procured several additional portable imaging units in its aftermath. Despite that, the need for dedicated portable imaging units for the isolation wards, emergency department, staff clinic, and selected outpatient sites rapidly drained our existing portable radiography resources. We preemptively rented extra portable radiography units so that they could be rapidly deployed into operations. During the SARS epidemic, in addition to portable radiography and ultrasound, one other Singapore hospital reconfigured a hospital ward for portable CT [12]. At the time of writing, our hospital is in the process of setting up a large separate fever screening area with portable radiography capability.

As the outbreak progressed, we quickly reviewed processes and policies across our service and different professional domains. Prior SARS policies were useful templates for updated processes in the COVID-19 outbreak. These included policies for enhanced screening of cases and visitors, managing isolation or high-risk cases, expansion of portable imaging capability, using powered air-purifying respirators, resuscitation protocols, temperature monitoring, and contact tracing.

One new area needing review was the use of off-site imaging facilities. These off-site facilities include scanners in other public hospitals, medical centers, and privately owned facilities. We ensured that all these external sites use effective screening procedures.

Imaging isolation or high-risk cases exposes more health care personnel to the risk of cross infection; therefore, the value of requested imaging for such patients is discussed between the referring physician and radiologist. This helps ascertain that the study is indicated and can answer the clinical question. Wherever possible, portable imaging is performed to reduce transport of infectious patients. When portable imaging is performed, efforts are made to minimize staff exposure time. Studies are tailored to answer a specific clinical question, rather than as general screening. Portable ultrasound teams are composed of a sonographer and a radiologist so that the procedure can be expedited and focused on the clinical issue.

After the SARS outbreak in 2003, our interventional radiology (IR) facilities were segregated to cater to inpatient and outpatient procedures in separate physical locations. In the current epidemic, all procedure requests are vetted for indication, urgency, and infection risk so that nonurgent procedures can be postponed and cases with high infection risk identified. It is important to reduce nonur-gent workload because heightened infection control measures lengthen procedure time and require increased staffing.

To minimize movement of high-risk infective patients, portable ultrasound-guided procedures are performed at the bedside when possible. If patient transfer is unavoidable, we use preplanned routes straight into a procedure suite designated for infectious patients with thorough cleaning of equipment and the procedure room after use. Our IR clinics and electronic medical records allow procedure triage and appropriate case scheduling.

For IR practices covering multiple hospitals, segregation of IR staff members for different sites minimizes risk of cross transmission. The separation of staff into independent teams also prevents disabling of the entire team should quarantine be required.

During the SARS epidemic, chest radiographs were crucial in early diagnosis because there was no confirmatory test available initially. For COVID-19, the genetic profile was rapidly shared, allowing a confirmatory test to be created. However, chest imaging is still valuable in identifying suspected or confirmed COVID-19 cases. To facilitate rapid reporting of chest radiographs, radiographers flag such cases into new dedicated RIS work lists. This also allows tracking of workload so that staff can be redeployed to areas with surge in demand. The possibility of using chest CT to stratify risk in patients with minimal or no changes on chest radiography is also being considered.

Daily routine instructions (issued by the hospital outbreak control task force) are disseminated to staff through all available communication channels. This was critical at the start of the COVID-19 outbreak because the situation evolved rapidly, with new workflows implemented each time. New hospital policies to ensure sustainability of health care services (e.g., freezing of leave, postponement of meetings) also had to be disseminated and explained. To mitigate information overload, summaries are made to highlight changes relevant to radiology services. Senior leadership also regularly record video messages to encourage staff through this demanding period.