Coping strategies for batch patient admission in super large temporary hospitals: A case review and effectiveness evaluation

doi:10.21203/rs.3.rs-3251069/v1

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Coping strategies for batch patient admission in super large temporary hospitals: A case review and effectiveness evaluation

https://doi.org/10.21203/rs.3.rs-3251069/v1

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Background: In the beginning of March 2022, coronavirus disease-2019 (COVID-19) rapidly spread in Shanghai. In order to cope with the epidemic, more than 110 fangcang hospitals with over 250000 beds were constructed. Thus, effective batch patient admission strategies suitable to meet the characteristics of fangcang hospital are of essential importance. To summarize the experience of batch patient admission during the operation of three super large square cabin hospitals in Shanghai.

Methods: A case review and effectiveness evaluation based on the batch treatment of patients in three super large Super large temporary hospitals in Shanghai. This case review investigated two methods of batch patient admission in three large Super large temporary hospitals established in Shanghai, China, between March and May 2022, and compared the efficiency and risks of the two methods, as well as summarized the coping strategies for batch patient admission in large square cabin hospitals.

Results: Under the same staffing conditions, the batch patient admission mode of “treatment before triage” was used. The average number of patients admitted per hour, the average number of patients admitted within 72 h in each branch, and the maximum number of patients admitted per hour in each branch were significantly higher compared to the traditional patient admission mode of “triage before admission.” However, the proportion of patients who did not meet the admission criteria in this mode was high, and there was a significant medical risk.

Conclusions: Establish a scientific, standardized, and reasonable batch patient admission strategy to effectively respond to the large number of patients admitted to the shelter hospital.

fangcang hospital

batch patients

management

implementation

COVID-19

The Fangcang hospital refers to a fixed partition type of temporary refitted hospital whose layout includes a certain building, such as a stadium or an exhibition center. The Fangcang hospital is a rapidly constructed, large-scale, and low-cost facility that provides services of isolation, triage, basic medical treatment, condition monitoring, rapid referral, basic life security, and social services. During the coronavirus disease-2019 (COVID-19), it was used as a primary measure for dealing with epidemics and is expected to be used for future epidemics and public health emergencies [1].

On March 11, 2020, World Health Organization (WHO) declared COVID-19 a global pandemic [2]. At the beginning of March 2022, omicron became the main epidemic strain in Shanghai. As a megacity with a population of 22 million, Shanghai faced great challenges in curbing the spread of the epidemic. The Shanghai Municipal Party Committee and the Shanghai Municipal Government immediately began to build a two-level Fangcang hospital in the urban area, mainly for the treatment of new mild coronary disease and asymptomatic infections[3, 4]. The Fangcang hospital built in Shanghai was much larger than the original Fangcang hospital. A single Fangcang hospital can treat up to 49,200 patients, providing a place for the isolation and treatment of new mild coronary disease and asymptomatic infections and exerting a key role in preventing and controlling the epidemic in Shanghai.

Compared to traditional hospitals, the Fangcang hospital is characterized by a short design and construction cycle, simple infrastructure and medical supporting facilities, a large number of open beds and patients, high density, and fast operation turnover. Also, most of the medical and operation support teams were temporarily formed, and some of the patients were with basic diseases, which could easily lead to various doctor-patient conflicts[5]. At the initial stage of the opening of the Fangcang hospital, batch patients arrived at regular intervals. Accordingly, rationing the limited materials and human resources, establishing close team cooperation in the shortest time, completing the admission of batch patients, ensuring the safety of patients, and avoiding medical disputes have become the main operational aims of the Fangcang hospital.

A review of relevant literature revealed that there are relatively complete response processes and plans for the treatment of batches of injured people caused by emergencies; however, the number of injured people is often small. There are few reports on the treatment of extremely large batches of injured patients involving more than 100 people, and they are mostly used for the admission and treatment of trauma patients[6]. n their study, GAN et al. reported on the method of transporting and receiving 421 patients at Huoshen Mountain Hospital in Wuhan, China, for 12 hours a day in 2019[7].

The super large square Super large temporary hospitals constructed in Shanghai, included the Expo Exhibition Hall Fangcang Hospital, the New International Expo Center Fangcang Hospital, and the National Convention and Exhibition Center (Shanghai) Fangcang Hospital (see Figure 1 for details), and could accommodate up to 10000 patients per hour. By conducting a case review and in-depth research on the batch patient admission situation of three Super large temporary hospitals, this article discussed the batch patient admission strategy of batch Super large temporary hospitals and summarized the rapid and effective batch admission and valuable experience in safely completing batch patient admissions in a shelter hospital.

Staffing

The establishment of a nursing team ensures the higher effectiveness of the team[8]. According to the requirements of the National Health Emergency Team Management Measures (for Trial Implementation) issued by the National Health Commission[9]and by combining the characteristics of multiple nursing services and high work intensity in the Fangcang hospital, the selection criteria for the shelter nursing personnel are as follows: ① nursing personnel should be staff from medical and health institutions, who usually undertake the daily work of their unit and are responsible for health emergency response tasks in case of emergency; ② are dedicated the health emergency cause, and have team spirit; ③ in good physical and good psychological health, and generally younger than 50 years old; ④ nursing personnel with relevant work experience should be allocated according to the post requirements of the shelter hospital. E.g., pre-examination nurses should have experience in pre-examination emergency. ⑤ Workers who have received health emergency training or participated in health emergency response to emergencies should be given a preference; ⑥ nursing personnel should come from different professional fields, including internal medicine, surgery, pediatrics, emergency treatment, intensive care, and other aspects.

According to the management standard of the Fangcang hospital in China, the nurses are allocated based on the bed-to-nurse ratio of 1:0.2 and the medical care ratio of 1:5[3]. When receiving a batch of patients in a Fangcang hospital, coordination, communication, and joint support from multiple departments are required. Therefore, in addition to medical personnel, the Fangcang hospital also requires management personnel, police, fire protection, cleaning staff, security, and maintenance personnel, i.e., 1 cleaner/100 beds per shift, 2 security guards/100 beds per shift, 1 policeman/100 beds per shift, 1 maintenance personnel/200 pieces, 1 manager/500 beds. All staff should undergo unified and standardized pre-job training; they should be familiar with the job responsibilities, rules and regulations, and emergency response procedures of the shelter hospital and pass the corresponding assessment before starting their shelter hospital work.

Standard for admission and treatment of patients in Fangcang hospital

The Fangcang hospital is mainly responsible for treating asymptomatic COVID-19-infected persons and mild cases with confirmed pathology, who, in principle, can care for themselves. These patients are older than 4 years old and younger than 70 years old, have no basic diseases such as respiratory system and cardio-cerebrovascular system in acute attack period, are free of immunodeficiency disease, and do not require blood purification. Women in pregnancy and perinatal period, patients with late cancer, patients with decompensated cirrhosis, and patients with mental diseases are also not treated in these hospitals. Special populations such as infants, pregnant women, and elderly people with severe underlying diseases, disabilities, and mental illness should be promptly triaged to designated hospitals[10, 11].

Mechanism of patient classification and referral in Fangcang Hospital

During the construction of three super-large Super large temporary hospitals in Shanghai, China, a complete classification and referral system have been established to maximize the medical safety of patients in square cabin hospitals.

According to the classified treatment system, patients are divided into two levels, i.e., emergency and non-emergency. The former refers to patients with an emergency or worsened condition who need to be transferred to the designated hospital for treatment. An emergency transfer mechanism should be established to transfer the patients as soon as possible. The latter refers to patients with chronic complications for whom it is not possible to provide corresponding medical measures in the Fangcang. A transport prediction mechanism should be established to complete the transport of patients in an orderly manner.

The referral mechanism is an efficient linkage referral mechanism established between the “Fangcang hospital and the Emergency Center-designated hospital.” The Fangcang hospital has a special pre-hospital rescue team for transferring patients, which ensures that they are timely transferred to the designated hospital for disease treatment. Thi kind of approach also ensures the life safety of other patients in the Fangcang hospital.

Two batch patient admission methods

During the operation of three super Super large temporary hospitals, there are two types of admission modes, i.e., the "Triage before treatmen" mode and the "Treatment before triage" mode. The specific admission process is shown in Figure 2.

The Expo Exhibition Hall Fangcang hospital and the New International Expo Center Fangcang hospital adopt the "Triage before treatment" mode, i.e., when the patient arrives at the Fangcang hospital, the medical staff carries out a joint triage. The triage team consists of two doctors and two senior nurses, and the ABC method is adopted for preliminary evaluation[12]. Patients who meet the admission standards of the Fangcang hospital are brought into the hospital by the responsible nurse, who completes further admission work. Patients who do not meet the admission criteria are directly sent to the designated hospital by 120.

The National Convention and Exhibition Center (Shanghai) Fangcang Hospital uses the " Treatment before triage " mode, which means that after receiving a large number of patients, all departments (medical, nursing, logistics, and security) immediately make preparations, and the pre-examination personnel waits at the hospital the arrival of an ambulance. Medical personnel organize patients by queuing them up when an ambulance or ambulance bus arrives. First, patients are brought into the Fangcang hospital and assigned beds, after which medical personnel conducts joint triage. The responsible nurse further treats patients who meet the admission criteria of the Fangcang hospital. Patients who do not meet the admission criteria are transferred to the designated hospital by the hospital-responsible person contacting 120 (pre hospital first aid).

Data Collection

Presuming that three super large Super large temporary hospitals had the same human resources and admission standards, case reviews and data analysis were conducted on the methods adopted for batch patient admission in the three super large Super large temporary hospitals established in Shanghai, China, between March and May 2022. The three super large Fangcang uniformly constructed in Shanghai during this time used the Fangcang information system designed and developed by our hospital. The patient filled in all information by scanning the QR code. After receiving the information at the PDA terminal, the nursing staff could submit it after confirming that there was no error. We reviewed and analyzed the relevant data on batch patient admissions in three super large Super large temporary hospitals, including general conditions, daily operation conditions of the three square cabin hospitals, relevant data on the number of patients admitted, and relevant data on patient conditions.

Statistical Methods

SPSS 26.0 was used for the statistical analysis of the data. The measurement data were analyzed using a t-test, and the counting data were analyzed using the chi-square test. P<0.05 indicated a statistically significant difference.

General information

The general conditions of the patients, including gender distribution, age distribution, and marital status, in the three Super large temporary hospitals, were not statistically significant (all P>0.05). See Table 1 for details.

Daily operation

The daily operation of the three Super large temporary hospitals, including the number of patients admitted, discharged, and referred, is shown in Figure 3

Comparison of admission efficiency of two modes

We analyzed the relevant data related to the number of patients admitted to three large square Super large temporary hospitals in batches, including the average number of patients admitted (per cabin per hour), the average number of patients admitted within 72 hours in each branch, and the maximum number of patients admitted per hour in each branch. Moreover, we analyzed the efficiency of the two admission modes. The difference test for the three data groups was P < 0.05, showing that the difference was statistically significant. Furthermore, the treatment efficiency of the "treatment before triage" mode was superior to the "triage before treatment" mode, as shown in Table 2.

Comparison of admission risk between two modes

Based on the analysis of relevant data on the admission of patients in three super large Super large temporary hospitals, including the number of patients aged < 4 years old, the number of patients aged > 70 years old, and the number of patients with complications (Judge according to the admission standards of patients in the Fangcang hospital; at least one complication), the risks of the two admission modes were analyzed. The number of admitted patients older than 70 showed no significant difference between the two modes (P ＞0.05). The number of patients < 4 years old, > 70 years old, and patients with comorbidities admitted under these two modes showed a statistically significant difference (all P ＜0.05). The "treatment before triage" mode included more patients who did not meet the standards. Also, there was a higher medical risk compared to the "triage before treatment" mode, as shown in Table 3.

"Treatment before triage" mode can effectively improve the treatment rate of batch patients

The "triage before treatment" mode strictly classifies patients according to the admission standards of the Fangcang hospital. This mode takes a long time to triage, which may result in transfer vehicle congestion, long waiting times for patients, and small admission numbers per hour. This approach is not suitable for large-scale Super large temporary hospitals and admission of batch patients. The "treatment before triage" mode features short triage time, fast turnover of transfer vehicles, short patient waiting times, and a large number of admissions per hour. This approach can be used to rapidly place patients waiting to be admitted, thus effectively improving the efficiency of batch treatment of patients in the Fangcang hospital. The batch patients usually arrive in the Fangcang in the early stage of the opening of the square cabin hospital, especially within the first 72 hours after the opening of the cabin. With the same manpower ratio, each branch hospital can effectively respond to the admission of batch patients and improve the admission speed by using the "admission first and then triage" mode.

There are high medical risks in the mode of "treatment before triage"

Compared to the "triage before treatment" model, the proportion of patients who did not meet the standard of the "treatment before triage" model was significantly higher. Although patients with mild and asymptomatic symptoms are treated at Fangcang Hospital, there is still a risk of changes in the patient's condition. When using the "treatment before triage" mode to treat mass patients, it may not be possible to timely and accurately screen out patients who do not meet the treatment standards of Fangcang Hospital, which may lead to significant medical risk.

The "treatment before triage" mode requires nurses in the Fangcang hospital to have higher clinical work ability. The patients admitted to Fangcang hospital may have various basic diseases and complications, and the professionals working in these institutions should come from various nursing specialty fields such as internal medicine, surgery, pediatrics, gynecology, and emergency treatment. Nurses should be able to quickly and accurately identify changes in the condition and potential risks to timely conduct patient condition assessment and implement a hierarchical referral to ensure rapid and accurate admission of batch patients, thus ensuring the patients' safety.

Selecting the optimal admission mode based on the actual operation

Following a review and data analysis of batch patient admission methods in three large Super large temporary hospitals, we found that the two methods had particular advantages and disadvantages. During the admission process of batch patients, the optimal admission mode could be selected based on the actual admission situation.

When the number of patients is small and the arrival time is scattered, the "Triage before admission" mode can be selected. This admission mode can be used to identify patients who do not meet the admission standards of the Fangcang hospital as soon as possible and transfer them to a designated hospital for further treatment as soon as possible, reducing current medical risks.

When a batch of patients arrive at the Fangcang hospital at the same time period, the mode of "Treatment before triage " can be selected, as such an approach allows patients to be placed in the Fangcang hospital for rest as soon as possible and medical personnel to be at the patient's bedside and jointly complete the work of patient pre-examination, triage, and condition collection, identify patients who do not meet the admission standards of the Fangcang hospital, and implement referral. This can effectively shorten the waiting time of patients, improve the admission efficiency of batch patients, and avoid the occurrence of adverse events such as changes in the condition of patients due to excessive waiting time.

Study limitations

The present study analyzed only asymptomatic COVID-19-infected patients and those with mild illnesses. These patients have good mobility and self-care ability, so this is not fully applicable to treating batch patients with trauma, disaster, and other mobility difficulties.

Implications for nursing management

The Fangcang hospital is a powerful means of responding to public health emergencies that can effectively provide treatment for many patients to improve their success rate of treatment and reduce the social burden. The batch treatment of patients in super large Fangcang hospital is different from the traditional treatment of patients in batches. By analyzing and summarizing the experience of batch treatment of patients in three super large square hospitals, a scientific and reasonable strategy for batch treatment of patients in square hospital can effectively ensure the orderly operation of Super large temporary hospitals and provide a reference method, has been established. Furthermore, the reported findings can be used as a reference and copied for dealing with large-scale patient admission in case of future emergencies.

The two mass patient admission methods have their respective advantages and disadvantages, which could be combined to establish a scientific, standardized, and reasonable management strategy suitable for the batch patient admission of square cabin hospitals, thereby effectively responding to the admission of large quantities of patients in square cabin hospitals.

COVID-19, coronavirus disease-2019

WHO, World Health Organization

Ethics approval and consent to participate

- According to the requirements of Document [310] issued by the Shanghai novel coronavirus Epidemic Prevention and Control Leading Group Office in 2022, the research of this project further strengthens the management of patient admission in large temporary hospitals. Confirm that all methods are implemented in accordance with relevant guidelines and regulations.

- Confirm that all experimental protocols were approved by a named institutional and/or licensing committee.
- Informed consent was obtained from all subjects and/or their legal guardian(s).

- The ethical institution that approved this study is the Ethics Committee of Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine

Consent for publication

Not applicable

Availability of data and materials

All data generated or analysed during this study are included in this article

Competing interests

The authors declare that they have no competing interests

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

Authors' contributions

Chen Huang and Feng Jing conceived and supervised the study; and also designed experiments; Hanbing Shang and Yibo Zhang performed experiments; Ying Chen and Zhitao Yang analysed data; Chen Huang Feng Jing and Yufang Bi wrote the manuscript; Erzhen Chen and Yufang Bi made manuscript revisions. All authors reviewed the results and approved the final version of the manuscript.

Acknowledgments

Not applicable

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Table 1. Comparison of general conditions of patients in three Super large temporary hospitals

Variable		General information of patients admitted to each Super large temporary hospital [n (%)]
Variable		Expo Exhibition Hall	New International Expo Center	National Convention and Exhibition Center (Shanghai)		P
Gender					0.192	0.908
	Male	13881 (59.90)	27306 (56.98)	103596 (59.38)
	Female	9294 (40.10)	20614 (43.02)	70870 (40.62)
Age (years)					2.220	0.898
	0–17	1081 (4.66)	3395 (7.08)	7959 (4.56)
	18–44	11213 (48.38)	21731 (45.35)	90320 (51.77)
	45–59	8559 (36.93)	15886 (33.15)	53600 (30.72)
	≥60	2322 (10.02)	6908 (14.42)	22587 (12.95)
Marriage					1.222	0.996
	Unmarried	8076 (34.85)	18215 (38.01)	64912 (37.21)
	Married	14454 (62.37)	28240 (58.93)	103583 (59.37)
	Divorce	479 (2.07)	1010 (2.11)	4259 (2.44)
	Widowhood	101 (0.44)	305 (0.64)	1150 (0.66)
	Other	65 (0.28)	150 (0.31)	562 (0.32)

Table 2. Comparison of admission efficiency of two modes

Admission mode	Hospital name	Set the number of branches (PCs)	Number of beds in each branch (PCs)	The average number of patients admitted (per cabin per hour)	The average number of patients admitted in each branch hospital within 72 h (cases)	Maximum number of patients admitted to each branch hospital per hour (cases)
Triage before treatment	Expo exhibition hall	4	1875	231	2334.67±790.28	275
Triage before treatment	New International Expo Center	10	1500	275	1433.89±121.43	276
Treatment before triage	National Convention and Exhibition Center (Shanghai)	14	3514	984	3039.36±314.72	843
	t/χ2			171.896	-7.816	77.084
	P			0.001	0.001	0.001

Table 3. Comparison of admission risk between two modes

Admission mode triage before treatment	Hospital name Expo Exhibition Hall New International Expo Center	Open beds (PCs)	Number of patients admitted	Condition of admitted patients [n (%)]
Admission mode triage before treatment		Open beds (PCs)	Number of patients admitted	<4-years-old	>70-years-old	Complication*
Triage before treatment	National Convention and Exhibition Center (Shanghai)	7 500	23 175	46 (0.23)	98 (0.50)	690 (3.50)
Triage before treatment	Hospital name	15 000	47 920	390 (0.96)	956 (2.35)	1 466 (3.60)
Treatment before triage	Expo exhibition hall	49 200	174 466	359 (0.25)	2 597 (1.81)	1 8141 (12.63)
	χ2			259.915	0.012	3613.969
	P			0.001	0.911	0.001

* Evaluated according to the admission standards of patients in the super large temporary hospital. At least one complication

No competing interests reported.

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Coping strategies for batch patient admission in super large temporary hospitals: A case review and effectiveness evaluation

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