New crown positive critical care patients reached the peak of 128,000 experts: the most difficult is the ICU medical care can not increase short-term

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At a press conference on January 14 on the State Council’s joint prevention and control mechanism, Jiao Yahui, director general of the medical department of the National Health Commission, introduced that the number of fever outpatient consultations nationwide peaked at 2.867 million on December 23, 2022, after which it was a continuous decline, falling back to 477,000 on January 12, an 83.3% decrease from the peak number. The number of emergency room visits nationwide peaked at 1.526 million on Jan. 2, 2023, after which it continued to decline.

Jiao Yahui also said that the number of hospitalized newly crowned infected patients now shows a continuous downward trend, according to surveillance data. The peak of 1.625 million inpatient NICs was reached on January 5, after which it continuously declined, falling back to 1.27 million on January 12, and the proportion of inpatient NICs showed a continuous downward trend.

The surveillance data showed that 2 weeks after the fever outpatient clinic reached its peak, the number of inpatient neo-coronary-positive severe patients also reached its peak, and then showed a slow decreasing trend. On January 5, 2023, the number of new coronary-positive patients in the hospital reached a peak of 128,000, after which the number fluctuated continuously and dropped to 105,000 by January 12, and the utilization rate of critical care beds was 75.3%, so the number of critical care beds could meet the need for treatment.

On the morning of January 12, Wang Renyuan, director of the Zhejiang Provincial Health Commission, said after the opening of the first meeting of the provincial People’s Congress that the number of outpatient visits for fever in Zhejiang has fallen back significantly, 120 emergency and urgent care is now in a gradual decline, and the overall epidemic in the province has passed the peak of infection and is expected to drop to a lower epidemic level at the end of January. However, hospitalizations and serious and critical illnesses are still at their peak plateau, with about 90 percent of the population over 60 years old. He said, “The province’s medical resources are generally in balance and can basically meet the current demand for medical treatment for the prevention and control of the epidemic, but it is still at the most critical stage, and the task of treating serious and critical illnesses is still very difficult.”

On the evening of January 8, China News Weekly interviewed Cai Hongliu, director of the Department of Critical Care Medicine at the First Hospital of Zhejiang University School of Medicine. He is an expert of the medical treatment team of the joint prevention and control mechanism of the State Council, and has participated in the fight against the epidemic in Shijiazhuang, Hebei in 2021, Changchun, Jilin in 2022, Shanghai and Sanya, Hainan. For the past three weeks, the intensity of Cai Hongliu’s work has been steadily increasing as the director of the Integrated ICU. Just on the Sunday of the interview, his day was packed with discussions on cases during the day and training on the 10th edition of the treatment plan at night. It was not until 10:30 p.m. that he finished his day’s work and talked to the reporter about Zhejiang’s preparation before the arrival of the critical care peak, why ICU renovation takes time, how to train a critical care team that can go to war in a short period of time, and what are the major misunderstandings in the treatment of new crowns. He said frankly: “After the launch of the ‘Article 20’ measures, I speculated that the rise in the number of infections in China might take three months to go the way of other countries in three years, and it actually took us less than 20 days.” Here is Cai Hongliu’s account.

Zhejiang has been gradually entering the peak of serious illness since mid-December 2022 and is still at a plateau, with no clear inflection point in sight. At the First Hospital of Zhejiang University School of Medicine, where I work, the greatest stress was in the early days when the number of infections began to surge, and the large number of medical and nursing collapses and peak infections partially overlapped into one. At that time, staffing was so tight that doctors in one of our hospitals even rented a house next to the unit and used it as a group dormitory. When the doctors and nurses who were sick lived there, they went to lie down for three or four hours after working for seven or eight hours, and then returned to the hospital to continue the battle.

In the past three weeks, the work intensity of our intensive care doctors and nurses has been continuously increasing, and the proportion of patients admitted to the intensive care unit who are senior in age and have aggravated their original base after contracting a new crown is increasing, and the hospitalization period is also lengthening. At the same time, the number of ICU beds we are responsible for has increased exponentially. For example, the intensive care medicine department where I work originally had 184 beds, and then four new wards were opened, adding more than 100 beds. And the total number of ICU beds in the whole hospital was more than 250 before, but now the number of ready ICU beds has increased to nearly 600.

The National Health Care Commission has continuously emphasized since early December last year that comprehensive ICU in tertiary hospitals should reach 4% of the total number of hospital beds, and each specialized ICU should also be converted into convertible beds according to the ratio of 4% of the total number of beds, that is, to ensure that comprehensive ICU and convertible ICU can reach 8% of the total number of hospital beds in total, and the conversion must be completed by the end of December last year. According to the previous requirements, the number of ICU beds in hospitals above the second level is 2% to 8%, that is, 8% is already the ceiling.

Normally, the renovation of ICU beds usually takes at least a few months, but now there is less than a month.

Why does it take time to renovate an ICU? It is not as simple as adding a bed, for example, the ventilator, not just move it over, it is immediately behind the gas equipment belt, the renovation of ICU on the ward oxygen, air, negative pressure suction interface, power outlets, etc. also have very strict requirements, we require an air switch for a bed. ICU are life monitoring, support equipment, once the problem, may be life-threatening in an instant. So the renovation of the ICU must pursue speed while ensuring quality.

The Zhejiang Provincial Health Care Commission recently organized critical care medical and nursing experts to conduct critical care rounds for 22 medical units in 11 prefecture-level cities across the province. I found during the just-concluded rounds that because hospitals are scrambling to renovate ICUs, the current supply of critical care medical equipment is tighter, with some county hospitals in a tight balance of ventilators, high-flow oxygen therapy equipment, and CRRT machines (hemofiltration machines).

Hardware renovation, equipment acquisition is not the biggest challenge, the most difficult thing is that there is no way to increase ICU medical care in the short term. It takes at least three years of training to train a qualified ICU doctor, because ICU admissions are all patients with heavy and fast-changing conditions, and therefore rely on a lot of monitoring and treatment equipment, such as monitors, ventilators, CRRT machines, ECMO (extracorporeal membrane lung oxygenation machine), etc. Therefore, we in the industry describe critical care doctors as “special forces Therefore, we in the industry describe critical care nurses as “special forces”, who have to face a large number of critically ill and complex patients every day, and also use various “weapons”, which requires a high level of competence.

In fact, the previous three years, the country really participated in the new crown treatment, especially critical care is not too many medical personnel, this time after the epidemic prevention policy adjustment, is the first time almost all medical care are really into the new crown treatment of the real mode of combat, this battle must be fought, and must win. In this situation, one of the most realistic options is to adopt a mixed group work mode.

For example, there is an anesthesiologist working with us, he is characterized by strong operational ability, because the anesthesia machine and ventilator are very close, relatively professional in tracheal intubation, deep vein penetration, and even circulatory respiratory resuscitation, but relatively inexperienced in how to fight infection, nutritional support, etc., so then find the infection doctor to join in. In other words, with limited resources, the strengths of the other doctors who come to support the mixed team must be brought into full play to form a most efficient combination. In our hospital, a mixed team is basically composed of a critical care physician, an anesthesiologist, plus an internist and surgeon.

And, after this combination is set, try not to change, now the newly expanded ICU ward, many ventilator brands even I “old critical care” have never seen, we all need and equipment to break in, medical and nursing each other also need to break in, we took two weeks to really break in, if we wait for the battlefield and then break in is too late.

Therefore, mixing cannot be done on paper. Before the peak of critical care, we have to let these doctors who come to support us to work in the ICU early, and work for 1~2 weeks first, and then optimize and adjust in between. This is also the most important part of emergency training for non-critical care doctors: it must be in the form of a team, in the form of a real battle.

Zhejiang is more adequate in the training of the critical care team, the provincial health care commission issued a document in early December last year requiring that all cities report a specific list of medical and nursing staff involved in training, and that each hospital should be equipped with one doctor and 2.5 to 3 nurses for one ICU bed, with an additional 20% to 30% of staff as backup on top of that. On December 8 last year, all cities in the province sent a skeleton team of doctors, nurses and respiratory therapists to Hangzhou for five days of intensive training, with the most experienced doctors, nurses and respiratory therapists from our hospitals in the treatment of new coronary intensive care to teach and introduce their experience.

However, although Zhejiang has made various plans including ICU renovation and staff training, the number of infections rose faster than we estimated after the “New Article 10”. After the introduction of the “Article 20” measures, I speculated that the rise in the number of infections in China would take three months to complete the three years of other countries, but it actually took us less than 20 days.

Medical staff care for a patient in the respiratory intensive care unit of Huzhou Central Hospital in Huzhou, Zhejiang province, on the evening of Jan. 11, 2023.

The ICU’s mission is to hold the last line of defense. Back in 2020 we summarized our experience in fighting the epidemic, and the most important thing is to move the gate forward, which is still applicable today. The key to moving the gate forward is to identify high-risk groups as early as possible. The 10th edition of the treatment plan mentions heavy/critical high-risk groups, and there are six points that every community doctor must memorize so that no high-risk patient can be missed. One of the changes in the 10th edition compared to the 9th edition is that the age threshold for high-risk groups has been raised from 60 to 65 years old, with special emphasis on those who have not been fully vaccinated. This “critical minority” of vulnerable people must be given priority attention.

Community doctors should tell high-risk people what to look out for, who to contact first if they develop several conditions, and direct them to the community instead of running to a tertiary hospital when they can’t take it anymore, so they can build trust in the community hospital. The training for the initial treatment of new crown can actually take a few hours to complete, and community doctors are fully capable of dealing with it. If they feel they can’t solve it, they must immediately refer to the next level, so there must be an efficient referral process, so that the limited medical resources of large hospitals can be used to save heavy, critical type patients, which is the lowest cost and the best treatment.

There are two main lines of treatment for new coronavirus, one is to provide early antiviral treatment, and the second is to treat various underlying diseases and complications caused by new coronavirus infection. There are two other points to pay extra attention to: first, we should pay attention to prone position rescue treatment, should be lying down, to mention it and antiviral treatment to the same important status; second, must not blindly use antibacterial drugs, especially the combination of broad-spectrum antibacterial drugs. A few doctors have overused antibacterial drugs, which is a major misunderstanding. If the possibility of co-infection is considered, doctors should actively look for evidence that blind use of antibacterial drugs is harmful, and it is important to strictly grasp the indications for antibacterial drug use and rational use of antibacterial drugs.