Hospitals become epidemic amplifiers, how to deal with the big test
China News Weekly reporter/Yang Zhijie
Published in the 1073rd issue of "China News Weekly" magazine on December 19, 2022
"On December 11, the city's fever clinics saw 22,000 patients, 16 times that of a week ago." On December 12, Li Ang, deputy director of the Beijing Municipal Health and Health Commission, publicly stated that from December 5 to 11, influenza-like cases were monitored. The data shows that the number of influenza-like cases monitored by hospitals above the second level in the city is 19,000, an increase of 6.2 times compared with the previous week.
The city's 120 emergency calls peaked on December 9, with 31,000 calls in 24 hours, six times the normal rate.
A week ago, there was a long queue outside the fever clinic in the Houhu District of Wuhan Central Hospital.
On December 15, the number of patients in the hospital's fever clinic and emergency department decreased slightly compared with a week ago, but the greater pressure came from the fact that nearly half of the doctors in the hospital's emergency department had been infected, making it difficult to maintain normal schedules.
With the adjustment of domestic epidemic prevention and control policies, the number of infected people in society has increased.
Since December, many places across the country have issued requirements that fever clinics should be opened as often as possible.
At the press conference of the Joint Prevention and Control Mechanism of the State Council on December 14, Jiao Yahui, director of the Department of Medical Administration of the National Health and Medical Commission, said that all medical institutions are required to receive nucleic acid negative and positive patients.
Hospitals are more likely to become "amplifiers" for the spread of the epidemic.
Previously, the country had extremely strict requirements for the prevention and control of nosocomial infection. If a person positive for the new crown is found, it must be reported to the disease control department in a timely manner to determine the close contact in the hospital, and conduct sealing and disinfection within a clear range to block the spread of infection.
Hu Bijie, Director of the Department of Infectious Diseases, Zhongshan Hospital Affiliated to Fudan University and a member of the National Medical Treatment Expert Group for Novel Coronavirus Pneumonia, told China News Weekly that the purpose of domestic epidemic prevention and control has changed. The second is to establish an effective immune barrier among the population.
Under this premise, "(hospital infection standards) must be changed. Before that, we required medical staff to have zero infection, but now it is difficult to achieve, and it cannot be a mandatory requirement. Infection does not mean that the (epidemic prevention and control) work is not done well. , but the risk of epidemic transmission in medical institutions is greater. We hope that medical staff will be infected as little as possible and late infection, so that they can be on top when the peak of the epidemic arrives in the future.
Long queues for fever clinics, medical staff infected
In response to the problem of queuing up for fever clinics, on December 12, the Beijing Municipal Health Commission stated that the number of fever clinics in the city's hospitals has increased from 94 to 303, of which 235 are open 24 hours a day, and 100 of them can treat children with fever .
As of 12:00 on December 14, there were more than 14,000 fever clinics in secondary hospitals across the country, and more than 33,000 fever clinics or fever clinics in grassroots medical and health institutions.
On December 1, the Wuhan Municipal Health Commission also announced a list of 42 general fever clinics.
An emergency doctor at a tertiary hospital in Wuhan, who did not want to be named, told China News Weekly that his department would first divert patients. Patients who developed fever and other symptoms in the past three days went to the fever clinic, and patients without fever symptoms went to the emergency department.
In order to cope with the peak of medical visits, medical staff could take one day off between the two shifts, but now the vacation has been cancelled. "There is no requirement to work overtime, but the work intensity has increased."
On December 7, an internal meeting of the doctor's hospital mentioned that the fever clinic had received 101 patients the day before, and 52 of them had positive nucleic acid results.
The Guangzhou Municipal Health and Health Commission recently made it clear that those who tested positive for the new crown nucleic acid or antigen in the hospital should quickly guide them to wear N95 masks and transfer them to a relatively independent area for isolation and treatment. The area should continue to accept patients.
Among the recently released "New Ten Measures" optimization measures, the latest change is that asymptomatic and mildly positive patients can be isolated at home.
According to the above-mentioned doctor, generally speaking, if positive patients are found in outpatient clinics, they will be sent to designated hospitals or shelters for the treatment of the new crown, but currently designated hospitals in Wuhan are already saturated.
For some patients with mild symptoms, they will notify the community to pick them up.
However, the doctor added that the community is currently too busy. "We generally put on N95 masks for patients, disinfect them well, and suggest that they go home and isolate themselves."
"The scale and capacity of hospitals are limited. If patients flood in, the virus load per unit area will increase, and the risk of infection among medical staff will also increase," said the above-mentioned emergency doctor.
On December 7, five minutes before the interview, a colleague in his department suddenly developed fever symptoms. After quickly completing the antigen test, he was asked to go home for isolation and observation.
The risk of infection isn't just in the hospital.
With the increase of infected people in the society, some medical staff in many places have tested positive for the new crown in their residences.
Recently, at an online conference on epidemic prevention and control at Huashan Hospital Affiliated to Fudan University, Zhang Wenhong, director of the Department of Infectious Diseases, mentioned that community infection is now more likely. will be very fast.
On December 8, a doctor from a tertiary hospital in Wuhan told China News Weekly that the spread of nosocomial infection was "beyond expectations". 183 tubes came out positive."
As of the same day, almost every department of the hospital where he works has medical staff infected. In some departments, as many as 5 people have been infected. Most of them are mild cases and have been isolated in special wards of the hospital.
The aforementioned emergency doctor said that on December 7, only three or four people in his department were infected. As of December 13, the number had risen to 15, and the doctor himself was not spared.
The above-mentioned emergency doctor mentioned that as the number of positive patients detected increased, critically ill patients admitted to the emergency department also began to stay.
"The entire ward needs to be eliminated, and the nucleic acid of the patient needs to be tested. Except for the emergency department, other departments still conduct mixed nucleic acid tests. Once a positive result is found, all medical staff have to check again. The waiting process takes several hours, which The admission of patients to the hospital is not as smooth as it used to be."
Many interviewed doctors appealed to China News Weekly that the risk of nosocomial infection should be reduced at present, and the most important thing is to advise most patients with mild symptoms of the new crown not to go to the hospital unless necessary.
"We must deal with the new crown infected people in layers. According to the current research, 99% of the infected people are asymptomatic or mild, and these people do not need to go to medical institutions." Hu Bijie told China News Weekly that the most important thing now is I want to tell everyone that 99% of the population should never run out of 0.1% (severe and critically ill patients) of medical resources.
Guo Wei, deputy chief physician of the Department of Infectious Diseases, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, observed that at present, most of the infected patients who visit Tongji Hospital are mild patients with certain symptoms. Temporary fever clinic.
He suggested that patients with a body temperature lower than 38°C, non-sustained high fever, and no severe respiratory symptoms should be isolated at home, and their health should be monitored in a timely manner. If you have high blood pressure, and the blood pressure rises uncontrollably, or the child has lethargy, feeding difficulties, persistent diarrhea, etc., you should go to the hospital immediately."
In addition, the above-mentioned emergency doctor also reminded that the new coronavirus infection does not necessarily manifest as fever symptoms, "it may also manifest as general fatigue, loss of appetite, nausea and vomiting, or sore waist and legs." At this time, everyone should be vigilant and do not go out , pay attention to rest, monitor body temperature.
The Beijing Municipal Health and Health Commission’s analysis of 120 emergency calls on December 9 shows that consultation and repeated calls accounted for about 80% of the calls, and car calls accounted for about 20%. keep rising.
The Beijing Municipal Health and Health Commission appeals to citizens to use the 120 emergency number reasonably and seek medical advice.
Zhengzhou, Chengdu, Shandong Zaozhuang and many other places stated that they should not call 120 if it is not necessary, and set aside emergency hotline channels for critically ill patients.
Medical staff should be infected as little as possible and be infected late
In Hu Bijie's view, with the significant reduction in the pathogenicity of Omicron, "Under the new situation, everyone should be mentally prepared and stop thinking about how many cases of infection have increased, but accept the fact that the new crown virus may No one can hide from it."
On November 26, 2021, after the World Health Organization identified Omicron as a mutant strain that "needs attention", the United Kingdom and the United States ushered in the first wave of infection peaks within one and a half months. The number of infections peaked many months later.
Many experts predict that the peak of domestic infections will occur within the next 1 to 2 months.
In the face of the first wave of large-scale shocks, it is crucial to have enough medical staff.
In January 2022, Omicron swept across the United States, and the number of patients infected with the new crown surged.
Due to infection or leave, nearly 1/4 of American hospitals said there was a serious shortage of medical staff. Some institutions had to reschedule some routine operations, and some places also initiated emergency measures to allow hospitals to employ workers more flexibly to meet community medical needs.
During the fifth wave of the epidemic in Hong Kong this year, the medical staff in public hospitals were in short supply. Gao Basheng, CEO of the Hong Kong Hospital Authority, mentioned in an interview that there were more than 80,000 medical staff in the Hospital Authority, and more than 11,000 people had been infected with the new crown virus. There are also many people who had to leave their posts because their family members were diagnosed as close contacts.
Zhang Wenhong mentioned at the above-mentioned online conference on epidemic prevention and control work that the peak of the epidemic in Shanghai may come within a month. Simultaneous infection to avoid a run on medical resources.
Many clinicians interviewed said that they are psychologically prepared to be infected, and may even be infected two or three times in the future, but they still hope that "the number of infections will increase slowly."
The above-mentioned emergency doctor gave an example, "For example, there are 200 medical staff in the emergency department, and one or two people are infected a day. The people who were infected in the early stage recover and come back to the top, which will not affect the normal work. But if within a day, the medical staff are infected at the same time. With 10 to 20 people, the emergency department will definitely not be able to bear it.”
Timely identification of infected persons is an important means to prevent large-scale infection of medical staff.
In Germany, personnel in key places such as hospitals and nursing homes must conduct antigen self-tests twice a week. In addition, medical staff in the oncology department are required to test nucleic acid once a day.
In Hong Kong, all hospital employees must also undergo antigen tests every day, and employees working in higher-risk wards must undergo nucleic acid tests twice a week.
On December 8, the joint prevention and control mechanism of the State Council held a press conference, mentioning that the occupational exposure risk of medical staff should be minimized, and management should be strengthened in areas with relatively high occupational exposure risks such as fever clinics, emergency departments, and wards.
On December 3, when conducting special infection prevention and control training for Shanghai medical staff, Hu Bijie mentioned that medical staff engaged in emergency department, fever clinic, ICU, tumor radiotherapy and chemotherapy, diagnosis and treatment of geriatric diseases, etc., it is best to do nucleic acid once a day detection, or supplemented with antigen detection.
"China News Weekly" learned that in recent days, many tertiary hospitals in Wuhan have adjusted the requirements for nucleic acid testing of medical staff.
Guo Wei introduced that at present, Tongji Hospital no longer requires doctors to perform nucleic acid testing every day. For high-infection risk departments such as the Department of Infectious Diseases, Respiratory Medicine, and Emergency, medical staff are required to perform nucleic acid testing three times a week, and other departments once a week. Medical staff do antigen tests every day, and take pictures of the results and upload them.
The hospital where the above-mentioned emergency doctor works also recommends that medical staff try their best to work from home to the hospital at "two points and one line", and go to work normally with a negative nucleic acid test certificate. If they are infected, they must accurately identify close contacts.
In Hu Bijie’s view, if the number of infections among medical staff in a medical institution rises too rapidly in the short term, nosocomial infection prevention and control needs to be adjusted dynamically. The speed has slowed down, which tests the daily management capabilities of each hospital.
He mentioned that at present, medical institutions cannot close wards, outpatient clinics, and emergency departments at will. Nucleic acid Ct values can be used to accurately judge and isolate close contacts, precise prevention and control, and even avoid unnecessary "non-combat attrition" of medical staff.
The nucleic acid Ct value can evaluate the viral load of an infected person. The smaller the number, the higher the viral load.
For example, an infected person with a Ct value of 40 is basically not contagious, and the circle of close contacts can be very small.
An infected person with a Ct value of 20 is extremely contagious.
Therefore, when the laboratory department of a hospital reports positive infections, its Ct value should be used as an important reference for prevention and control measures.
The aforementioned emergency doctor mentioned in an interview with "China News Weekly" on December 13 that according to the regulations issued by his hospital on December 8, medical staff who tested positive for antigens can stay at home after reporting to their departments. Quarantine for 5 days. Before returning to work, if the antigen self-test is negative for two consecutive days, you can return to work.
However, due to the shortage of emergency staff this week, the hospital changed its requirements, and the positive infection patients should be isolated at home for 3 to 5 days, and return to work as soon as possible if they are asymptomatic.
It is reported that several infected doctors in the emergency department of the hospital have returned to their posts.
At the end of December 2021, in the face of the infection of medical staff, the US Centers for Disease Control and Prevention urgently changed the isolation recommendation, shortening the isolation time of asymptomatic medical staff from 7 days to 5 days. If the shortage of hospital staff is serious, the isolation time will be further extended It is also an international practice to shorten and relax the isolation requirements.
In addition, California has also made non-mandatory requirements, and hospitals can make every effort to introduce staff support through external personnel agencies and other means.
The criteria for medical personnel to be judged as close contacts are also changing.
A doctor from a tertiary hospital in Guangzhou recently revealed that starting from December 5, positive medical staff in the hospital will no longer be counted as nosocomial infection, and medical staff who receive positive patients will no longer be counted as close contacts.
On December 7, the above-mentioned emergency doctor’s internal meeting at the hospital mentioned that all outpatient medical staff are required to wear isolation gowns, N95 masks, face screens, gloves, hats, etc. , no isolation is required.”
After reporting to the Hospital Infection Office and completing regional disinfection, the medical staff can continue to work after replacing a full set of protective equipment, and do a good job of health monitoring every day.
Zhang Wenhong emphasized that the most important protection measures for medical staff are masks. He suggested that medical staff minimize gatherings and wear N95 masks when necessary.
In addition, in the past epidemic prevention and control, many front-line medical staff had to wear protective clothing, N95 masks and face screens at the same time.
In Hu Bijie's view, this has increased the labor intensity of medical staff too much. "If you don't do anything, you will feel very tired just sitting there. I hope that this time, we can improve scientifically while protecting the medical staff." For example, Said that it is possible to explore whether it is possible not to wear protective clothing.
Xu Shuchang, an expert consultant to the Hong Kong Special Administrative Region government and a chair professor of respiratory system at the Chinese University of Hong Kong, told China News Weekly that in Hong Kong's practice of preventing infection among medical staff, in addition to requiring them to wear N95 masks, they also include all vaccinations against the new crown vaccine.
According to reports, in February this year, the Hong Kong Hospital Authority stated that the vaccination rate of medical practitioners in the Hospital Authority exceeded 98%, and another 1% of doctors were not suitable for vaccination.
In July of this year, the World Health Organization updated the global new crown vaccination strategy, raising the target vaccination rate of medical workers and the highest risk groups to 100%, saying that vaccines can effectively prevent severe illness, hospitalization and death.
Hu Bijie also mentioned in the training of medical staff in Shanghai that in addition to vaccinating all staff, doctors in key positions should also monitor their antibody levels. If the antibody level is not enough, supplementary vaccination should be considered.
How are positive patients treated?
Among the optimization measures proposed in the "New Ten Articles", they all clearly focus on a focus of epidemic prevention and how to protect vulnerable groups.
Many countries and regions, such as Singapore, have requested that visits to hospital wards be banned when facing multiple rounds of epidemic peaks.
In Guo Wei's view, "Most of the patients who are currently hospitalized have underlying diseases and low immunity, and cluster infections must not occur." He introduced that setting up buffer wards is a solution.
At present, Tongji Hospital will treat all patients who are going to be hospitalized in the buffer ward after checking the nucleic acid certificate. Transfer to general ward.
"The patients we found positive for the new crown before were all tested in the buffer ward to ensure the greatest degree of safety."
On December 7, Guo Yanhong, director of the Medical Emergency Department of the National Health and Medical Commission, emphasized that all medical institutions have been required to set up buffer areas in emergency rooms, operating rooms, and hemodialysis areas, including wards and wards, to be separated from other areas. The diagnosis and treatment areas are relatively separated. If patients with underlying diseases are infected with the new coronavirus, they will be treated in the buffer area.
But Guo Wei mentioned that not all hospitals have such conditions.
A medical staff at a county-level public hospital in western Henan told China News Weekly that currently, the hospital has set up eight isolation wards in addition to the inpatient department, including internal medicine, surgery, oncology, pediatrics, and other departments according to regulations. There are only a few beds in the ward, and only three or four medical staff are equipped in the eight wards.
In addition, nucleic acid testing is no longer performed in the entire county, and the inpatient department implements a rotation system for medical staff. "The backup force lives at home every day and is easily infected."
Guo Wei also emphasized that nosocomial infection prevention and control is facing a "dilemma", that is, how to balance strengthening the nosocomial infection prevention of the new crown and promoting the treatment of patients.
He explained that without buffer wards, it will be difficult to find positive patients on the front line, and the risk of infection among patients and medical staff will increase.
But on the other hand, if the hospital strictly manages buffer wards, it will also reduce the efficiency of admission and treatment. "Buffer wards have special requirements, and the occupancy rate of medical resources is higher."
The "Notice" also mentioned that relatively independent areas such as hospital areas, buildings, wards or wards should be arranged to treat nucleic acid positive patients, and the medical staff should be relatively fixed, and no visits should be strictly enforced for inpatients.
Guo Wei introduced that Wuhan Tongji Hospital has separated a branch hospital to treat COVID-19 positive patients.
In addition, the United States, Singapore, Hong Kong and other places faced the difficulty of finding a bed in the intensive care unit at the peak of Omicron infection.
According to statistics from the Hong Kong Hospital Authority, in February this year, the inpatient rate of medical inpatient beds in Hong Kong public hospitals exceeded 95%, and the average occupancy rate of pediatric inpatient beds exceeded 72%. The number of beds in Wells Hospital, United Hospital and other hospitals were all full .
Hu Bijie mentioned that the current hospital is adopting various measures to reduce the severity of high-risk groups, including early identification of signs of severe disease and increasing antiviral drugs, but "if there is a peak in two weeks, it may not be enough. Therefore, it is necessary to upgrade and expand the critical care capacity now."
On December 9, Jiao Yahui, director of the Department of Medical Affairs of the National Health Commission, mentioned that there are currently 138,100 intensive care beds across the country, including 106,500 intensive care beds in tertiary medical institutions.
The number of intensive care beds is close to 10 per 100,000 people. In the next step, the intensive care department should increase the number of beds and strengthen medical staff.
The official requirement is that the comprehensive ICU of tertiary hospitals should reach 4% of the total number of beds, and then transform the convertible ICU beds according to the ratio of 4% of the total number of beds. If necessary, it can be quickly changed within 24 hours.
However, according to an infection doctor in a tertiary hospital in Anhui, this indicator is difficult to achieve in reality, "it is equivalent to doubling the number of ICUs suddenly, and it is difficult to produce hardware such as ventilators in a short period of time. In addition, in a short period of time , It is also difficult for medical staff to learn the operation of various equipment in the ICU."
On December 7, the State Council's Joint Prevention and Control Mechanism issued the "Work Plan for Hierarchical Diagnosis and Treatment of New Coronary Pneumonia Using Medical Alliances as a Carrier" mentioned that the use of resources such as family doctors, community health service centers or township health centers, and medical alliances , allowing patients with fever and other new coronary pneumonia to be first diagnosed at the grassroots level, and referred in an orderly manner, and at the same time ensuring that high-risk infected persons receive timely assistance, which may reduce the rate of severe illness and mortality to the greatest extent.
A staff member of the Chaoming Street Community Health Service Center in Hangzhou City told China News Weekly that around December 10, the community hospital had just established a fever clinic, which could provide needed medicines for people infected with the new crown in the community. Municipal hospitals such as the Municipal Red Cross Hospital have a mature referral mechanism.
However, the staff member mentioned that the greatest pressure lies in the shortage of manpower. The community hospital has more than 100 medical staff, but it has to serve nearly 100,000 community residents, and it is also responsible for strengthening the vaccination of the elderly. It will face greater pressure in the future.
Some experts are also worried that in China, people's medical habits have always been to go to tertiary hospitals for serious and minor illnesses, and only a few people go to community hospitals, which may affect the implementation of the plan.
At the press conference of the joint prevention and control mechanism of the State Council on December 15, the National Health and Medical Commission stated that it may be difficult to train manpower in the short term. In the short term, the secondary and tertiary hospitals need to be subsidized to support the grassroots. They can also recruit for the past five years. Retired staff members will be enriched in grassroots medical and health institutions.
In addition, the National Health and Medical Commission also stated that taking prefectures and cities as units and according to the population size of the city, upgrade and transform the shelter hospital into a sub-designated hospital, that is, to make the original shelter hospital have certain therapeutic functions, and according to its bed capacity 10% Ratio to transform monitoring beds.
The above-mentioned doctor from a tertiary hospital in Anhui believes that this may alleviate the future pressure on the ICU to a certain extent.
"Among them, if an infected person with severe respiratory disease is admitted to the ICU, other severe patients do not necessarily need to occupy ICU resources, and can be treated by installing new ventilators in other wards."
"If it is not handled well, there may be a medical run, so that critically ill patients cannot be admitted to the hospital." Guo Wei said, "We still have to try our best to 'soft landing', so as not to cause a surge in the number of infections in the short term." In his view, every medical The role that institutions can play is limited. I hope to conduct more publicity and education in the whole society so that everyone can strengthen protection at this stage.
On December 8, at the annual meeting of the Chinese Medical Association Respiratory Diseases, Wang Chen, vice president of the Chinese Academy of Engineering and president of the Chinese Academy of Medical Sciences and Peking Union Medical College, said that the epidemic prevention and control policy is changing. In this way, the peak of the epidemic can be controlled, so that medical resources can be used in an orderly, appropriate, and scientific manner, so as to better promote economic and social development while maximizing protection good patient health.
"China News Weekly" Issue 47, 2022
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