There used to be a lot of people dancing and singing in the square cabin in Shanghai, so why are there more people with symptoms now?

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The last day of 2022, a Saturday, was still spent by Chen Erzhen at work, checking in, meeting and treating patients until zero hour on New Year’s Day 2023.

As vice president of Ruijin Hospital affiliated with Shanghai Jiaotong University School of Medicine and a member of the Shanghai New Crown Rescue Expert Group, the epidemic-fighting veteran’s attention is divided into two parts. On one side is the hospital, facing the dramatic increase in patients, integrating resources and optimizing processes to continuously reduce patient waiting time and improve treatment efficiency; on the other side is the grassroots, guiding community medical institutions to improve treatment, intervene early and effectively, and standardize treatment by stratification and classification. Both sides have the same goal: prevent serious illness! Reduce death!

How to optimize the process? How can the process be optimized? How to stop serious illnesses at the grassroots level?

What is the most important support for medical care?

Reporter: I’m curious, have you ever been infected? During the Battle of Shanghai, you participated in the construction of seven cabins, we also interviewed you to preside over the medical treatment of the cabin, found that the infected people have square dancing, singing, the proportion of asymptomatic infected people is quite high, and now we all feel that the proportion of symptoms is significantly higher, why?

Chen Erzhen: The new coronavirus is universally susceptible to humans, and the clinical manifestations of the infection vary from person to person. I have been infected, the symptoms are very mild, fever to 38.5 degrees, half a day to get better, no headache, muscle pain, may be related to my full vaccination, but also may encounter the virus load is low.

Now, it does seem to be not quite the same as during the Great Shanghai Defense War. At that time, more than 600,000 infected people in Shanghai were screened out by full nucleic acid testing, of which those isolated in the square cabin, many were asymptomatic. Now the spread of the epidemic in Shanghai is so wide that it may have reached 70% of the population, more than 20 to 30 times what it was then. In absolute numbers, one must feel that there are more people with symptoms.

The proportion of asymptomatic infected people in this wave needs to be further studied and judged by data statistics.

Reporter: What is the current emergency situation at Ruijin Hospital? What is the percentage of newly crowned patients? Are there many patients with serious and critical illnesses? How to optimize the treatment process within the hospital?

Chen Erzhen: These days, the hospital’s emergency services have doubled, with the usual daily average of about 800 people now reaching 1,600. However, the fever clinic has dropped from more than 600 to more than 100 daily. We have opened a special outpatient clinic for new crowns, and we also have about 400 visits per day.

Eighty percent of the 1,600 emergency visits are related to new coronary; 45% to 50% of the vulnerable population over 65 years of age and about 50% of those with pneumonia manifestations. There are more than 100 ambulance arrivals per day. Serious and critical care patients account for about 10% of the daily visits, the vast majority with underlying conditions, or elderly.

The hospital has expanded its emergency room capacity from four to eight, and has deployed medical staff from other departments to reinforce them, especially in the emergency resuscitation room. We vacated the entire infected pulmonary building to treat patients with new crowns, including three types of wards: intensive care units, subacute wards and general wards. Currently, we are admitting about 80 patients per day, with a high of about 100. The classified ward setting has a good triage effect, reducing the detention of emergency patients and allowing better treatment for critically and critically ill patients.

We set up special screening shifts to identify patients at risk of serious illness in a timely manner. For severe and critical illnesses, we follow the 9th edition of the treatment plan and make every effort to save the patients, from general symptomatic treatment to oxygen therapy, antiviral therapy, appropriate hormones, monitoring of organ function, and prone position ventilation when available.

Despite the dramatic increase in the volume of services, the rescue and treatment work is still being carried out smoothly, safely and in an orderly manner.

Reporter: In a previous interview, you said that the peak of critical illness has slowly emerged, how should medical institutions make adjustments to cope with this change?

Chen Erzhen: The most critical thing for medical institutions to do is to improve efficiency as the number of critically ill patients increases.

The first thing is to simplify the process. In the past, patients had to be pre-screened, then registered, then go to the consultation room, then the doctor will prescribe tests, then the results will be reviewed in the consultation room, and then prescribed medication after the review, and then prescribed medication and then treated, and there are several queues.

Now, we have established a screening process for suspected patients in the emergency room. During the pre-screening, patients are prescribed all the tests as soon as they register, including the mandatory tests related to the new crown, such as electrocardiogram, chest CT, routine blood, liver and kidney function, and cardiac protein, so that we can promptly identify whether the patient has underlying disease, pneumonia, or heart damage. We classify the results into those with and without underlying disease, and stratify the results by age: less than 50, 50 to 59, 60 to 69, 70 to 79, and 80 years old and above.

These processes have greatly improved our efficiency. Before the optimization, patients had to wait for 3 to 4 hours to be treated when there were 1,200 emergency room visits in a single day; after the optimization, even if the number of emergency room visits rises to 1,600 in a single day, the treatment can be completed in one or two hours.

Reporter: Shanghai community health centers also welcome a large number of new patients.

Chen Erzhen: Shanghai has done a lot of work on this, hoping to give full play to the function of the three-tier treatment system, so that most of the mild and common type of patients can be treated in the community, and more than 2,000 community medical institutions have opened fever clinics to provide medical services for patients with initial screening.

Community medical institutions also provide guidance on home treatment for mild cases according to the tiered classification management; antiviral treatment is given to general type patients, and patients at risk or critically ill are promptly referred to higher level hospitals.

Among them, the most critical is to establish an early identification and warning system, and to improve the screening ability of primary health care workers. Shanghai’s New Crown Medical Treatment Expert Group, including myself and Prof. Wenhong Zhang, is conducting a series of basic knowledge and skills training in primary care institutions so that primary health care workers can master how to identify whether patients have high-risk factors and how to provide early standardized treatment.

The Shanghai government attaches great importance to building capacity for treatment at the community level, and antiviral drugs have been widely distributed to the community for first-time use. The earlier the drug is used, the more effective it will be; if it takes more than 5 days, its effectiveness will be reduced.

Community doctors can classify patients for timely diagnosis and timely and effective intervention. In addition to antiviral drugs, some community health centers can also provide symptomatic treatment, including the use of oxygen therapy and hormones, which can effectively stop the progression of some high-risk patients to serious illness, reduce the pressure on secondary and tertiary hospitals, and, more importantly, implement the goal of “preventing serious illness and reducing death.

On April 6, 2022, Chen Erzhen was interviewed by reporters in the “four-leaf clover” square cabin.

Reporter: Many doctors from different departments are on the front line of new crown treatment, how to improve the ability of “cross-border” health care workers to treat new crowns?

Chen Erzhen: At present, the volume of medical services has increased dramatically, and the number of related professional medical care is obviously lacking, coupled with the fact that many medical personnel are also infected and need to rest, it is necessary to mobilize more medical personnel to participate in treatment. After three years of fighting the epidemic, medical personnel have some knowledge of the new crown. In medical school, internal medicine is the foundation, including pneumonia diagnosis and treatment, which everyone has learned.

To treat the new crown, it is mainly the respiratory department, emergency department, critical care medicine department, and infection department, which are more specialized departments, that lead the team of other departments to support.

We have developed a training program for medical staff of other departments, mainly focusing on the standardized procedures for the treatment of neo-crown infections, and medical staff of non-specialized departments can basically master them, and there is also a group of experts to guide them, so they can be competent in the treatment of general type patients.

The four specialties of emergency medicine, critical care, respiratory medicine and infection are still required to lead the treatment of patients with severe and critical illnesses. We take classification treatment, support team is responsible for general type of patient treatment, we strengthen the quality control, treatment process, multidisciplinary team of experts, regular inspection, timely detection of patients who may be transferred to serious illness, and transferred to the more specialized departments or wards treatment, to avoid observation is not in place, treatment is not in place, and efforts to reduce the risk of serious illness or even death.

Reporter: Previously, there were more infections among doctors and nurses, how is the situation of medical and nursing returning to work in Ruijin Hospital now? What is the most urgent need of medical and nursing staff?

Chen Erzhen: In mid-December, many medical staff infections, many people have high fever, generalized pain, progressed to pneumonia also, affecting our fighting ability. But the vocation of the medical staff is to treat the sick and save lives, basically, as soon as the fever subsided, they returned to work on the front line. At the most difficult time, more than half of the staff were not on duty, but now only a quarter of them have not returned to duty due to infection, and the return rate has increased significantly. But the manpower is still tight, all medical staff are “day and night, 5+2”, working 12 hours a day.

This is what we should do as medical professionals. We also need the understanding of society. The volume of medical services is increasing, and every doctor and nurse is working overtime, so we may not have the right service sometimes. As long as we are united, we will be able to win.

Reporter: Many people go to the hospital for CT when they have chest tightness and shortness of breath, is it necessary? What condition is recommended to go to the hospital? Cured patients go home, do they still need to wear a mask? What should the “Yang”, less symptomatic elderly pay attention to?

Erzhen Chen: CT is indeed the key imaging tool to determine whether there is pneumonia. According to the four types of typing, there are no pneumonia manifestations in the mild type, pneumonia manifestations in the common type, and indications for the severe and critical type. The vast majority of patients, especially young adults, have a very, very low chance of developing pneumonia, and CT is generally not necessary unless there are significant symptoms of pneumonia.

High-risk patients must be screened with CT, such as older patients over 65 years of age, who have a higher percentage of positive CT (showing the presence of pneumonia). The doctor will determine whether you need CT or not. some people do not have a fever, they have a cough, they have chest tightness, but they do not have shortness of breath, their blood count is good, their lymphocytes are not dropping, and their oxygen saturation is good, so there is no need to do CT. blindly flocking to hospitals and crowding medical resources will affect those who really need treatment.

There is no need to wear a mask at home for “Yang Kang” people. However, it is still necessary to wear them in crowded places. I have read an overseas study where the secondary infection rate was 2% to 3% in a sample of over 800,000 people. This may be related to the interval between two infections and the immune function of the infected person, for your health, please adhere to the “three sets” “five also”.

Elderly people who are infected but not too symptomatic should pay special attention. The clinical features of the infection are different from those of young people, as the mobility and reaction ability of the elderly are decreasing. It is possible that pneumonia has occurred but only drowsiness, slow reaction, and limited mobility. It is especially important to pay attention to elderly people living alone. Oximeters can be monitored, but they are not foolproof. Also observe if the elderly are unresponsive and confused, if the skin mucosa has changed, and if the lips and nails are a little purple in color. If accompanied by persistent fever, cough and chest pain, the risk is even greater, and it is necessary to go to the hospital and see if there is inflammation in the lungs through CT, etc.