How Do Primary Hospitals Enact Early Response to the Relaxation of COVID-19 Prevention and Control Measures? The Experience From Chengdu, China

ABSTRACT

Due to the highly contagious nature of the Omicron variant of SARS-CoV-2 and its subvariants, a high rate of transmission was observed throughout Chengdu, China, within 2 weeks of the relaxation of COVID-19 measures on December 3, 2022, particularly in hospitals. Hospitals experienced different degrees of medical overcrowding during the first 2 weeks, with a high patient volume in the emergency departments and a significant lack of beds in the medical wards, particularly in the respiratory intensive care unit (ICU) and ICU. The authors’ place of employment, Chengdu Jinniu District People’s Hospital, is a tertiary B-level public hospital situated in the Jinniu District in northwest Chengdu. The hospital’s emergency coordination and response efforts emphasized addressing patients’ difficulties in obtaining medical care and hospitalization in the region and keeping the mortality rate of patients with pneumonia to a minimal level. It has been emulated by sister hospitals and was well received by the local populace and municipal government. The hospital made the following significant alterations and modifications to this emergency medical care: (1) immediate establishment of the General ICU (GICU), a temporary unit set up in emergency situations that had most of the functions of but was not as complete as the ICU and had a lower ratio of doctors to nurses; (2) dynamic adjustment of anesthesiologists and respiratory physicians jointly stationed in the GICU; (3) choice of nurses with extensive experience in internal medicine and allocation to the GICU according to a 2:3 ICU bed to nurse ratio; (4) emergency purchase or deployment of pneumonia-related treatment equipment; (5) implementation of the GICU resident rotation system; (6) “twinning” of internal medicine and other departments to add beds; and (7) implementation of uniform hospital bed allocation for inpatients.

Am J Manag Care. 2023;29(6):e159-e161. https://doi.org/10.37765/ajmc.2023.89373

Takeaway Points

Our institution is a tertiary B-level hospital in Chengdu, China. After the relaxation of COVID-19 measures in December 2022, the hospital’s early response emphasized addressing patients’ difficulties in obtaining medical care and hospitalization in the region and keeping the mortality rate of patients with pneumonia at a minimal level. In this letter, we share our COVID-19 experience with readers.

• Considering the change in the number of surgical and medical inpatients, we suggest decreasing the surgical ward to establish the general intensive care unit (GICU) and dynamically adjusting anesthesiologists and respiratory physicians to be jointly stationed in the GICU. Experienced nurses in internal medicine should be selected and allocated to the GICU at a 2:3 ratio of ICU beds to nurses. The GICU resident rotation system should be implemented.
• Pneumonia-related treatment equipment should be urgently purchased or deployed.
• To improve the quality of care, we suggest implementing a “twinning” system between an internal medicine department and another department.
• We suggest the implementation of uniform hospital bed allocation for inpatients.

The COVID-19 pandemic spread quickly across the world and has been deemed a worldwide public health event by the World Health Organization since its outbreak in early 2020. The pandemic has been ongoing for more than 3 years and has caused tremendous damage internationally, with 632 million cumulative confirmed cases and 6.6 million cumulative deaths worldwide as of November 17, 2022.¹ With the increased awareness of COVID-19 and the popularity of vaccination (the number of individuals who have received 1 dose of the COVID-19 vaccine is 5.44 billion as of November 17, 2022, and China has one of the highest vaccination rates globally), the burden of COVID-19 is progressively being relieved and the disease controlled.²

The dynamic zero COVID-19 strategy that China had been adhering to and that had produced positive outcomes had effectively stopped the epidemic’s progress in China and saved a significant number of lives. After the Omicron variant entered China in 2022, as of December 6, 2022, there had been a total of almost 250,000 confirmed cases nationwide, with almost 1.7 million infections and a fatality rate (deaths / confirmed cases) of 0.24%. (Infections are defined as patients who have COVID-19 and have positive nucleic acid amplification tests with no pneumonia manifestation seen on CT of the lungs; confirmed cases are defined as patients who have COVID-19 and have positive nucleic acid amplification tests with abnormal imaging examinations.) That value of 0.24%, which includes previous data, has recently approached 0.1%.³ According to some studies, Omicron is mutating and becoming more transmissible but far less pathogenic than the original COVID-19 virus.⁴ China has gradually loosened restrictions on COVID-19 prevention and control measures since December 3, 2022, in particular on the management requirements for the frequency of nucleic acid amplification (eg, polymerase chain reaction) tests and asymptomatic infections with positive nucleic acid amplification tests. The Comprehensive Group of Joint Prevention and Control Mechanism for Novel Coronavirus Infection by the State Council of China released the General Plan for the Implementation of the Downgrade of COVID-19 to a category B disease (from the top-level category A) on December 26. The phrase “novel coronavirus pneumonia,” which had been used in China to refer to COVID-19, has now been changed to “novel coronavirus infection,” and starting on January 8, 2023, novel coronavirus infection has been treated as a category B disease.

However, due to the highly contagious nature of Omicron and its subvariants, a high rate of transmission was observed throughout Chengdu within 2 weeks of the relaxation of COVID-19 measures, particularly in hospitals. The majority of infected patients displayed varying degrees of fever, muscle pain, cough, and sore throat. Additionally, it was discovered that patients 70 years and older and those with comorbidities such as diabetes, cardiovascular disease, chronic kidney disease, and tumors had a higher risk of becoming seriously ill. A life-threatening combination of hypoxemia and pneumonia struck down some of these patients. Hospitals experienced different degrees of medical overcrowding during the first 2 weeks, with a high patient volume in the emergency departments (EDs) and a significant lack of beds in the medical wards, particularly in the respiratory intensive care unit (ICU) and ICU. This led to certain delays and challenges when treating patients with COVID-19.

The authors’ place of employment, Chengdu Jinniu District People’s Hospital (also known as Sichuan Provincial People’s Hospital Jinniu Hospital), is a public hospital situated in the Jinniu District in northwest Chengdu. Chinese hospitals are classified by the level of medical technology and the number of beds, with the highest level being tertiary A-level, followed by tertiary B-level, secondary A-level, secondary B-level, and primary; this hospital is classified as a tertiary B-level hospital. It provides health care for more than 500,000 residents within a 35-acre campus with a building area of 110,000 square meters and 500 actual open beds. After the relaxation of COVID-19 measures, the hospital experienced a similar increase in sudden visits and hospitalization of patients. Through the hospital’s emergency coordination and response efforts, the hospital quickly opened up 800 inpatient beds in total within a week without increasing the number of medical or nursing staff; more than 80% of the beds were for patients with COVID-19, greatly easing patients’ difficulties in obtaining medical care and hospitalization in the region and keeping the mortality rate of patients with pneumonia at a minimal level. It has been emulated by sister hospitals and has been well received by the local populace and municipal government. The hospital made the following significant alterations and modifications to this emergency medical care:

1. Establishing the General ICU (GICU) right away: Observing a large decline in the number of surgical patients and an increase in the number of medical patients, we first combined cardiothoracic surgery with general surgery by decreasing the number of beds in the surgical ward. Freeing up 1 floor to establish a 40-bed GICU effectively relieved the pressure on the respiratory ICU and the ICU. The GICU was a temporary unit set up in emergency situations that had most of the functions of but was not as complete as the ICU and had a lower ratio of doctors to nurses.
2. Dynamic adjustment of scheduling for anesthesiologists and respiratory physicians jointly stationed in the GICU: Both types of physicians had extensive knowledge of ventilator use, which significantly alleviated the staffing shortfall.
3. Choosing nurses with extensive experience in internal medicine and allocating them to the GICU in a 2:3 ratio of ICU beds to nurses: Priority was given to choosing nurses with extensive internal medicine knowledge to work in the GICU, whereas some operating room nurses were assigned to help meet the nursing needs of the GICU.
4. Emergency purchase or deployment of pneumonia-related treatment equipment: With the support of the Jinniu District Government and the Health Bureau, 30 electrocardiogram monitors, 15 noninvasive ventilators, and 6 invasive ventilators were quickly purchased, deployed, and centrally placed in the GICU, increasing the ability to treat patients experiencing combined respiratory failure who were in acute or critical condition.
5. Implementation of the GICU resident rotation system: In the case of a hospitalwide shortage of physicians, attending physicians were anesthesiologists and respiratory physicians, and resident physicians were rotated by surgical resident physicians every half month to alleviate the shortage of physicians and provide short-term and rapid training in pneumonia-related treatment capabilities.
6. The “twinning” of internal medicine and other departments to add beds: As the number of inpatients with pneumonia kept rising within approximately 1 month of the relaxation of COVID-19 measures, the hospital gradually opened oncology, more surgical, and even pediatric inpatient beds to treat patients with pneumonia in the internal medicine department. To improve the quality of care, the hospital also implemented a twinning system between the internal medicine department and another department. In this system, physicians with the title of attending or higher from the internal medicine department conducted room inspections and provided guidance, whereas physicians from the other department carried out medical orders and monitored the conditions of the patients.
7. Implementation of uniform hospital bed allocation for inpatients: For patients with respiratory failure, priority admission to the ICU, GICU, or respiratory ICU was guaranteed in order to appropriately determine their conditions and indications for hospitalization, and each patient was assigned to the appropriate unit. The hospital established an inpatient communication team, and each department was required to report the number of patients eligible for admission that day every morning. The ED had to evaluate each patient with pneumonia, and then the communication team and the ED decided together which unit each patient should be admitted to. As a result, there was a notable reduction in the number of hospital days required, as well as in patient mortality and critical condition following admission, and a notable increase in the success rate of patient treatment.

As of mid-January, the majority of the hospitalized patients had been discharged, and the number of patients with SARS-CoV-2 infection in Chengdu has greatly decreased. The number of patients in the ED has decreased significantly. Due to the primary hospitals’ emergency measures, Chengdu’s health care system has gradually returned to normal provision of services. Because COVID-19 is still not completely under control, we recommend that each primary hospital set up an emergency response system, examine the capability of setting up a GICU on a temporary emergency basis, pay attention to the training and use of anesthesiologists, and enhance duration and intensity of nurse rotation training in the internal medicine department to deal with the challenges ofany future epidemic we may face.

Author Affiliations: Department of Nephrology, Affiliated Hospital of Southwest Medical University, Clinical Medical College of Southwest Medical University (YK, WY), Luzhou, Sichuan, China; Department of Nephrology (YK, JM, SX, FD), President’s Office (BL, PL), Department of Nursing Administration (YF), and Department of Anesthesiology (RW), Chengdu Jinniu District People’s Hospital, Sichuan Provincial People’s Hospital Jinniu Hospital, Chengdu, Sichuan, China; Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology (YK, WY, WZ, SM, FD), Chengdu, Sichuan, China.

Source of Funding: This work was supported by Sichuan Medical Research Project Program (S20014&S21002), Sichuan Medical Association (Hengrui) Scientific Research Fund (2021HR16), Chengdu Medical Research Project Program (2020208&2022533), and Chengdu Jinniu District Medical Association Research Project (JNQN20-21).

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (YK, JM, WY); acquisition of data (YK, WZ, SM); analysis and interpretation of data (YK, JM, WY, WZ, SM, FD); drafting of the manuscript (YK, JM); critical revision of the manuscript for important intellectual content (YK, JM, WY, WZ, SM, SX); statistical analysis (YK, JM, PL, WY, WZ, SM); provision of patients or study materials (JM, BL, PL, YF, SX, RW); obtaining funding (BL, YF, SX, FD, RW); administrative, technical, or logistic support (BL, PL, YF, SX, FD, RW); and supervision (BL, PL, YF, FD, RW).

Address Correspondence to: Fei Deng, MM, Department of Nephrology, Chengdu Jinniu District People’s Hospital, Sichuan Provincial People’s Hospital Jinniu Hospital, Chengdu, Sichuan, 610036, China. Email: dengfei@med.uestc.edu.cn.

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