A Shanghai community hospital's new crown-saving curve: the battle will be fought for about a week

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“How many have you seen today?” On January 6, 2023, just after 9 a.m., Zhu Yulong, director of the community health service center in Xiaokunshan Town, Songjiang District, walked into the fever clinic and asked Gu Min, the attending physician who was attending the fever clinic.

“Twenty-six.” Gu Min replied.

On Jan. 7, Gu Min told reporters that from 8 a.m. on the 6th to 8 a.m. on the 7th, he had seen a total of 53 patients. That number, down 78 percent from the peak of 246 on Dec. 22, 2022.

December 22, 2022, was also the peak of fever clinic visits in Shanghai. On this day, the Xiaokunshan Town Community Health Center (“Xiaokunshan”) reached its peak at the same time as the city.

After that, the pressure turned. “My biggest pressure now is one is the demand for hospitalization, and one is the rehydration.” Zhu Yulong said.

After the release of the “New Ten” on Dec. 7, 2022, peak infections and serious illnesses followed in Shanghai. Community health centers, which had never treated new patients before, were suddenly thrust into the front line of treatment, taking on the multiple responsibilities of diverting patients, preventing the crowding of medical resources, and reducing the conversion of serious illnesses and mortality.

The window for the epidemic to reach its peak was short. For a month, community physicians are under stress, hustle and scheduling from all sides, seeing multiples of patients while improving their ability to treat new crowns and prevent serious illnesses.

Reaching the Peak Curve

The first thing to go up was the fever clinic.

Prior to Dec. 7, 2022, the fever clinic in Little Kunshan had only three or five patients a day. starting Dec. 17, patients climbed rapidly. “The growth was small at first, but then it started quickly like a blowout, going from 50 to 100 to 200, doubling.” Zhu Yulong said the fever clinic in Xiaokunshan opened three at the peak from the initial one 7*24-hour clinic.

Gu Min was initially a little nervous, because before mainly in nucleic acid sampling, chasing Yang, encounter nucleic acid positive directly closed loop transfer to the designated hospital, so he did not treat the new crown patients.

Five days after the fever clinic reached its peak, on December 27, the general practice clinic in Xiaokunshan reached its peak, and together with the four health service stations set up under it, the number of visits was about 800 for the whole day, twice as many as before the outbreak.

Then, from December 31, the number of outpatient infusions began to rise, recently exceeding 100 visits per day and still climbing. Substitute refills are also on the rise, with some patients being billed from secondary and tertiary hospitals and coming to the community with their medications to refill their fluids.

At 10:00 on January 6, 2023, outpatient nurse manager Jiang Jingyan is helping out in the infusion area, where there are usually two nurses, but now it takes four nurses to work together. More than 60 patients have come in by this time, mostly elderly people, some with weakness and poor appetite after infection, and some with pneumonia.

The number of infusions in the Xiao Kunshan outpatient clinic continues to rise.

On December 31, 2022, Little Kunshan turned the whole rehabilitation ward on the 5th floor into a community ward and opened 24 beds, which were quickly filled up, mostly with elderly people with mild and underlying illnesses.

Auntie Zhu’s partner is 79 years old, although it turned negative, but still chest tightness and shortness of breath, fever does not subside. “There are too many underlying diseases, he has heart failure level 3, and chronic obstructive pulmonary disease, diabetes, osteoporosis, can’t carry over.” On January 6 Auntie Zhu came to Xiaokunshan to make an appointment for hospitalization, and because of the relative urgency of the situation, admission was prioritized at noon on the 7th. Auntie Zhu said that her old companion has to go to a secondary hospital every year for hospitalization, but now she doesn’t dare to go, it’s too crowded.

From the number of fever clinics and general outpatient clinics, to the successive rise in the number of infusions and hospitalizations, it shows a curve of the epidemic process in Shanghai: the first wave of peak infection has passed, the peak of serious illness is underway, and the pressure of treatment is high.

Patients in the community health centers are mostly mild and calm, but during this time, more emergencies are encountered.

“Some patients are sent to the community first because their vital signs are already weak and their sanity is not too clear, and their families are worried about the danger while waiting for 120. We will send them to the resuscitation room urgently through the green channel to rescue them, while calling 120 to transfer them.” Chen Caixia, director of the Xiao Kunshan Health Management Center, who is also a family doctor, said that this type of case used to be just a handful a month, but there have been four or five cases in the last two weeks.

On December 7, 2022, the joint prevention and control mechanism of the State Council issued the “work plan to do a good job in grading and treating new crown pneumonia with medical association”, requiring the construction of a grading and treatment service network for patients with symptoms related to new crown pneumonia. Focus on family doctor contracted services to guide patients to primary care.

Under the goal of “primary care, two-way referral and up-and-down linkage”, community health service centers become the “bottom of the network” and family doctors become the closest “gatekeepers” to people at risk. “The family doctor becomes the closest gatekeeper to the people at risk.

Two rounds of capacity expansion and capacity enhancement

In response to the demand for peak infections and serious illnesses, Shanghai has launched two rounds of capacity expansion and expansion of community health service centers.

The first round, around December 10, 2022, centered on fever clinic expansion to avoid fever clinic crowding. 2,594 fever clinics were opened on December 19 in all types of community health service institutions (centers, sub-centers, service stations, and village health offices) in Shanghai. In addition to expanding the fever clinic to three at peak times, the four health service stations in Xiaokunshan were also extended from opening five days a week to seven days a week from December 23.

Gu Min saw more than 100 patients a day at the most, making her work much more intense. When the four doctors in the fever clinic became infected one after another, Chen Caixia and other family doctors were scheduled to come on duty.

On December 29, 2022, Shanghai launched the second round of capacity expansion, the core of which was to realize the “forward shift” of the critical care gate and prevent the crowding of critical care resources.

At this time, Shanghai’s fever outpatient clinics reached a peak of one week, the rapid growth of emergency care in secondary and tertiary hospitals, the increase in serious illnesses, and the pressure on bed turnover increased dramatically, requiring the treatment of light and medium-sized patients to be left in the community.

Therefore, this round of expansion, the community should increase the number of treatment beds, infusion beds, oxygen suction beds, and facilities and equipment such as simple ventilators, cardiac monitors, blood oxygen analyzers, and finger pulse oxygen meters.

Xiao Kunshan has 14 new infusion cards to 56, 3 more oxygen absorption areas to 9, and 4 nebulization areas. After opening 24 community beds, the next step is ready to expand to 40, “The first step is to expand 9 first, which is already ready.” Zhu Yulong said.

However, the magnitude of the expansion and capacity increase also depends on the physical space of the community health service center.

According to the China Health Statistics Yearbook 2022, in 2021 Shanghai’s 335 community health service centers, 38.8% (130) have no beds and 12.5% (42) have 100 or more beds. 824 community health service stations, all without beds.

After the outbreak of the new crown epidemic in 2020, Shanghai implemented a new round of functional construction standards for community health service institutions in September of that year, which greatly improved the configuration standards for area settings, facilities and equipment to enhance the capacity of primary health services and response to major epidemics and public health and safety events.

According to the new standards, new community health service centers set up beds according to the standard of 1 to 1.5 / 1,000 population, with at least 100 beds. Set up a fever clinic in the community at least 2 additional isolation detention beds. Community health service center floor space standards are not less than 80 square meters per 1,000 people, it is recommended to reach 100 square meters per 1,000 people.

Xiaokunshan is one of the 42 community health service centers with more than 100 beds, with a total floor area of 15,675.8 square meters, serving a resident population of 54,000 in the town, which is obviously far more than the standard.

Chen Caixia has classmates working at the community health service center in the city, and recently we often discuss the handling of patients and conditions together, and her classmates ask her for advice on how to manage the beds. “They don’t have any hospital beds, and they are going to add more this time. But we already have more than 100 beds, so we have experience and are within our capacity to deal with the current peak.”

Catching patients

In addition to hardware expansion, the bigger challenge is whether community health centers and family doctors can catch patients.

“When secondary and tertiary hospitals are running at overload, we need to join the battle, but whether we can do it is another matter. If residents have discounted trust in you, or if you can’t give enough to them, you can’t actually do this.” Chen Caixia said.

There are 16 family doctors in Xiaokunshan, evenly divided among four family medicine teams in Dagang, Yukun, Plain and Xiangkun, with 23,000 residents under contract, accounting for 43% of the town’s resident population.

Chen Caixia has a total of 1,852 contracted residents, and the mapping found that there are 96 red cards (high risk) and 56 yellow cards (medium risk). The key populations in Xiaokunshan Township totaled 8,679 people, including 1,720 red cards and 1,667 yellow cards.

On December 23, 2022, Chen Caixia received a notice that Shanghai had established a “green channel” mechanism for family doctors to call 120, entering the family doctor’s phone number into the 120 emergency dispatch system and giving priority to patients referred to 120 by the family doctor. “When the green channel was not opened, we called 120 with the same effect as the family, but after it was opened, it was quite fast, and we transferred the patient in about 20 minutes at the earliest.” Chen Caixia said.

On Dec. 29, Songjiang District announced the cell phone numbers of family doctors, so residents can find them at any time.

At the same time, the frequency of follow-up visits by family doctors has been increased. On top of follow-up visits by WeChat and phone, Chen Caixia has to assess some residents in need at home and, depending on the situation, either arrange for hospitalization in the community or refill fluids at the community outpatient clinic. “The more serious ones call 120 directly and are referred to higher level hospitals.”

There are two main channels for referrals in Xiaokunshan: first, when family doctors encounter patients who need to be referred during follow-up visits or outpatient clinics, they call 120 directly and are prioritized through the green channel; second, they are connected to the medical department of the counterpart regional medical center, Songjiang District Central Hospital, through the medical department.

Over the past month, the Dagang family medicine team, of which Chen Caixia is the team leader, has referred more than 10 people upward in the outpatient clinics, mostly referring to low pulse oxygen, aggravation of underlying diseases, and unknown diagnosis requiring further refinement of tests in higher-level hospitals.

Blood oxygen saturation and CT imaging are the main tools to help Gu Min determine the patient’s risk status and achieve triage. Once the in-hospital CT detects pneumonia, or the patient has low oxygen saturation, the patient is referred directly upward.

There are not many community health service centers with CT, currently there are only 27 in the city of Shanghai. Recently, many community hospitals have also raised the hope that they can add CT and other equipment to improve the diagnostic capabilities of doctors. This CT in Xiaokunshan was added in June 2020, when Shanghai added 32 exclusive CTs to the city’s fever clinics. “We are the first community in the city. The usage rate was not very high in the first period because there were few patients, but the value of the CT came through during this time, with 30 to 50 visits a day.” Zhu Yulong said.

CT images and others are the main means to help Gu Min determine the risk status of patients and achieve triage.

So far, the upward transfer has been smooth. Zhao Wenbiao, vice president of Songjiang District Central Hospital, said the hospital has had no 120 pressures or bed pressures.

Being able to dispense drugs is a grip that enhances the attractiveness of community hospitals.

“The pre-fever clinic is mainly dispensing drugs.” Gu Min said. Therefore, one of the keys to achieving primary care is to sink drugs such as antipyretic, cough and expectorant into the community. “Our drugs are first guaranteed for fever clinics, and there have been strains during this time, but they have not been broken. When it’s tight, we split the change and prescribe a 3-day supply to patients.” Zhu Yulong said.

Around New Year’s Day, small molecule drugs under also began to sink and tilt to the community. “Paxlovid we stocked 100 boxes, and now use more than 20 boxes, if the shortage of re-application, can be urgently deployed from other hospitals, the drug is coordinated by the district health committee district-wide.” Zhu Yulong said.

Little Kunshan stockpiled 100 boxes of Paxlovid, and now uses more than 20 boxes.

Having been a family doctor for 10 years, Chen Caixia feels that the function of family doctors has recently become more comprehensive and residents feel that family doctors really make a difference. Currently, her Red and Yellow Card patients are overall stable. “2 senior residents passed away, and the others are currently free of serious illnesses, most of which are dispensed and treated in our community.”

In addition, Chen Caixia believes that, unlike downtown, residents here are more accustomed to visiting community health centers and have greater adherence to their family doctors. The city center, on the other hand, is more easily accessible to secondary and tertiary hospitals, so residents’ demand for community health centers is not as strong. “This, in turn, has exercised us and improved our capabilities.”

Medication challenges

As the peak of serious illnesses arrives and the need to treat people at risk increases, another challenge comes for community doctors.

The “2022 Edition of Shanghai Novel Coronavirus Infection Diagnosis and Treatment Standards and Graded Treatment Process” (hereinafter referred to as the “Shanghai Grassroots Program”) released on January 4 proposes that clinical recognition of the importance of early standardized treatment, especially seizing the early rescue time period after infection in vulnerable groups and giving antiviral and anti-inflammatory treatment, will significantly reduce the rate of severe illness and death from novel coronavirus infection.

It is also proposed that light or common type of cases should be treated at home or in the nearest local area, and the standardized treatment should be provided by the medical force of community health service centers.

The shift in treatment requires community doctors to be able to identify people at risk and intervene early to prevent minor cases from turning into serious ones.

A few days before the release of the Shanghai Primary Care Program, on December 26, 2022, Chen Caixia received online training on community medical treatment from Professor Zhang Wenhong, when the golden 72-hour, four-step approach to treatment had been proposed. This four-step approach was further clarified in the Shanghai Primary Care Program as a four-step simple treatment approach – general symptomatic treatment, oxygen therapy and respiratory support, oral small molecule antiviral drugs, and glucocorticoid application.

Azulfidine and Paxlovid arrived in Xiaokunshan on December 29 and December 31, 2022, respectively. Thus, the task of screening risk groups and giving timely standardized treatment was given to community doctors, and their treatment plans began to be adjusted.

Gu Min said there would be some stress because she had not used these drugs before. Because there are contraindications, Chen Caixia also said that in the early days when there was no training for small molecule drugs, she actually had no bottom in her heart.

Once the small molecule drugs arrived, the training also came. “There is centralized training, there is also sent materials to learn by themselves.” Chen Caixia said, after the training to understand how to do a good assessment, such as to understand whether the patient is within 5 days of the onset, he is now taking the drug there is no contraindication to the drug, his liver and kidney function is good. “I feel more grounded in my heart.”

Out of prudential requirements, Chen Caixia said that after the clinician prescribes the medication, there is a director to review the prescription, and the pharmacy will issue the medication only after the two double signatures. There are also residents who want to prepare medication but do not meet the indications, Chen Caixia will refuse after explaining.

The current tension of medicine has been eased.

Gu Min has also been prescribed small molecule drugs several times, but he still has concerns about the use of hormones and has not used them yet. “When I encounter one that I can’t decide on, I will look for the medical department and senior chief physician to discuss it.”

Chen Caixia usually used hormones in the treatment of chronic obstructive pulmonary, but felt it was a challenge because she didn’t use anticoagulants much. During the training, she paid special attention to how anticoagulants are used.

Zhao Wenbiao is also the head of the Songjiang district-level medical treatment expert group, and he has to visit the community health service centers in the corresponding district every week. His cell phone and WeChat are also pushed to the community doctors, so they can communicate the treatment plan online at any time. “We take community doctors on rounds together to help implement the Shanghai Primary Care Program to avoid unreasonable use of antibiotics and to achieve standardized treatment.”

During the rounds, Zhao Wenbiao always finds some problems, such as the community health service center’s oxygen saturation equipment to increase, community doctors find the use of small molecule drugs a bit tricky, prone ventilation is not familiar with the follow-up training to follow up in a timely manner.

Chen Caixia said that the four-step simple treatment method in the “Shanghai Primary Care Program”, as well as the various types of training and expert rounds currently available, give very clear rules and regulations, so community doctors are relatively easy to get started.

Tertiary hospital pressure relief

The Songjiang District Central Hospital, 13 kilometers away from Xiaokunshan, is responsible for the admission of more than 50% of the region’s critically ill patients. In the past 10 days or so, the hospital’s emergency visits have been around 1,000 cases a day, with about 80 serious cases and 80 to 100 cases sent by 120.

“Emergency medicine is still at a high plateau and is expected to continue for another week or so.” Zhao Wenbiao said that the recent pressure is in the ICU, and it is expected that it may slowly go down in 1 to 2 weeks, and the plateau period should be controlled now.

The peak in emergency care at Songjiang District Central Hospital occurred on Dec. 23, 2022, followed by the peak in critical care. However, there has been a positive change in the last few days: the number of critically ill and elderly patients is decreasing, and the number of patients on ventilators is also decreasing. “From the 4th onwards, there was a marked improvement, and the pressure on the ICU was significantly reduced, with even a dozen empty beds in the 55 ICU beds throughout the hospital on the 5th, and nine ventilators were temporarily unused.”

In the past week, Zhao Wenbiao said, there has been a significant decrease in mortality and an increase in the success rate of resuscitation.

According to Zhao Wenbiao, the graded treatment has worked, with early detection, early intervention and early triage in the community, allowing patients to be treated effectively in the golden 72 hours and fewer turning into serious illnesses.

At the same time, with the expansion of wards and beds in community hospitals around New Year’s Day, there were 40 to 50 patients stranded in the hospital’s emergency ward every day, but now there are no more than 20.

The strengthening of classified and graded care has also given the Songjiang District Central Hospital room to accelerate bed turnover. The hospital has 700 beds with a daily utilization rate of 90% to 95%. Currently, some patients whose conditions have been stabilized after 5-7 days of treatment but have not yet reached the discharge criteria can be transferred down to secondary hospitals or community health service centers to continue consolidation treatment for underlying diseases after assessment.

On December 26, 2022, 83-year-old Ruan went to Songjiang District Central Hospital in Xiaokunshan Township and was diagnosed with “type 2 diabetes, peripheral neuropathy, lung infection, respiratory failure, atrial fibrillation, and heart failure”. After treatment, Ruan’s condition gradually stabilized. On January 4, the medical department of the central hospital started the graded treatment procedure, and the old man was transferred to the ward of Xiao Kunshan in the afternoon of the same day.

Zhao Wenbiao told reporters that the hospital beds, experts, patients, drugs, oxygen cylinders, ventilators, etc. are currently coordinated across the district. Songjiang District has established a district-level daily dispatch mechanism to coordinate and solve all the work.

The district-wide coordination and closer referral mechanism has brought a new opportunity for graded treatment and primary care. “Keeping patients in the community is graded diagnosis and treatment. Otherwise, tertiary hospitals have long been paralyzed, after all, the equipment and beds are limited.” Zhao Wenbiao said.

On Jan. 10, Zhao Wenbiao told reporters that he just visited the community health service center yesterday, and the implementation of the treatment plan by community doctors has been very standardized, plus the drugs and tests are more abundant, and patients are willing to come to the community because they can get homogeneous treatment.

After the new crown epidemic is under control, Zhao Yuanbiao believes that this tighter upward and downward transfer mechanism can be expanded more toward chronic disease management, realizing the integration of chronic obstructive pulmonary disease, diabetes, respiratory disease, and public health downward. “Once the community, homeopaths and residents understand this model, the downward transfer will also flow smoothly. It will also relieve pressure on district hospitals and support other doctors in hospital emergency care who can return to their specialties so that they can play to their expertise.”

For community health centers, Zhao Wenbiao said the pressure will ease a few days earlier than for tertiary hospitals. “The battle in the community should be about a week away, after which the volume of infusions hospitalizations can stabilize on the downside.”

After that, Zhao Wenbiao said, the focus of community health centers, again, will shift from new crown salvage to rehabilitation. “The patient is continuously followed for 1 to 3 months, focusing on the rehabilitation of the heart and lungs and other functions, and the general practitioner should play a good rehabilitation guidance, Chinese medicine rehabilitation and other functions.”