Reporter | Huang Qi
In order to promote "early detection, early intervention and early triage" of severely infected patients with new crowns at the community level, Shanghai launched the expansion of community healthcare services around Dec. 10, 2022, which effectively relieved the pressure on fever outpatient clinics of large hospitals during the peak period of new crowns fever visits.
Since the second round of capacity expansion and capacity increase on December 29, 2022, as of January 2, 2023, Shanghai citywide community health service institutions have added 1,711 oxygen spaces, 2,562 infusion spaces, 238 fever clinics, 665 beds, and 243 cardiac monitors. At the same time, antiviral drugs, finger oxygen meter, oxygen tanks and other supplies prioritized to the community tilt equipped, the community new crown rescue and treatment and prevention of serious illnesses capacity has been continuously improved.
On the last day of the New Year's Day holiday, New People's Weekly visited a community health service center in Minhang District to learn about the current situation of primary health care institutions in triaging patients, and timely detection and referral of critically ill infected patients.
Decrease in fever outpatient visits, increase in general outpatient visits
"Yesterday was the fourth day of fever, and I took ibuprofen to reduce the fever, but I got up yesterday morning and felt dizzy and nauseous, and later vomited. I went to a secondary hospital yesterday and had all kinds of tests done which were fine. Today I got up again a little fever, but not high," the morning of January 2, Chen aunts in Minhang District, Shanghai Hongqiao Community Health Service Center Longbai sub-center fever clinic, to the doctor to describe the symptoms of the past few days.
Dr. Jin Lei, the doctor who saw her, asked her about her underlying condition, learned about the results of the tests she had done at the secondary hospital, and made a comprehensive judgment while diagnosing and comforting her: "It always takes a process to recover from a new crown infection, and it may be a bit repetitive, as your immune system struggles with the virus, so don't be anxious. Your white blood cells are fine and you don't need antibiotics. If you have a fever of 38.5 degrees or more, you can take antipyretics, but be careful not to overdo it."
Auntie Chen has infected both of her elderly family members, "and one is still lying at home". She went to the community hospital this time mainly because she hoped to be prescribed some cough medicine.
Doctors prescribe medication in the interval, Chen aunt exclaimed: "If I had known that the community is so convenient, yesterday there is no need to go to the main hospital, from the morning line to the evening, people strain."
As of 10:30 a.m. on this day, Dr. Jin Lei has seen nearly 40 patients, almost all of whom are fever patients with new crown infections, with the elderly over 60 accounting for 80% of the total. The patient's condition is similar to that of Auntie Chen, with fever, cough, nausea and vomiting, pain and so on, which are common after a new crown infection. Although the number of patients has been roughly half of what it was a week ago, doctors can't stop seeing patients for almost a minute.
The reporter saw in the fever clinic, more than 20 waiting chairs are not full, waiting for basically the elderly, coughing from time to time, but there is no conversation or other sounds, the environment is relatively quiet. Fever clinic opened two clinics, two doctors to receive.
Hongqiao Community Health Center director Zhong Hua introduced, the recent week, Hongqiao Community Hospital fever outpatient clinic visits peak has passed, December 10, 2022 -25, the daily fever outpatient clinic visits reached 400-500 people, recently dropped to about 200 people. However, the demand for general outpatient visits to see patients with coughs and prescriptions for chronic illnesses after a new crown infection has increased, returning to about 1,500 visits per day on a daily basis. Eighty percent of the hospital's health care workers infected with the new crown have returned to work, easing the manpower crunch, and there are enough medicines.
"Last week, many people are concerned about the Pfizer small molecule drug Nematrevir / ritonavir tablets have also been dispensed to our community hospitals, patients come to the clinic after the doctor's assessment of compliance with the indications for the use of medication, the community doctor can prescribe this drug. As of today we have prescribed Pfizer's drug for six patients."
Most of the medical and nursing return to work, open at night and on weekends
The organized fever clinic, in fact, operated less than a month.2022 On December 10, Minhang District deployed the expansion of the fever sentinel point of community hospitals into a fever outpatient clinic, and on the same day, Hongqiao Community Health Service Center initiated the alteration, which was originally 30 to 40 square meters of fever sentinel point, expanded into a The 200-square-meter fever clinic, which has a laboratory, pharmacy, and fee collection office in addition to the clinic. 2 days later, the fever clinic began operation, with at least 3 doctors scheduled to visit the clinic every day.
According to the plan, the fever clinics at the two sub-centers of Hongqiao Community Health Center can carry a maximum of 1,000 visits a day, and Zhong Hua said the peak reached about 500 visits a day, with the number of patients slightly less than expected. "There may still be some residents who are not too comfortable with community hospitals and prefer to go to big hospitals."
Fever clinics at community hospitals mainly provide basic checkups and symptomatic treatment, with most patients needing only to be prescribed some oral medication. In the case of more serious patients, community doctors will immediately help refer them to higher-level medical institutions.
Since Dec. 19, 2022, all 2,594 fever clinics in various community health service organizations in Shanghai have been opened, playing an important role in easing the pressure on fever clinics in tertiary hospitals.
The opening of the fever clinics at community hospitals in Minhang District came around Dec. 15, 2022, when the city's infections peaked, but it was also the worst time of infection attrition for healthcare workers at community hospitals. "Every day during that time, our scheduling physicians were burnt out. Scheduling required a phone call to confirm: who, who, who, who, who, who, you have a fever too? Can't you work tomorrow?" Shen Aiyue said.
Dr. Jin Lei told reporters that in mid- to late-December colleagues Yang half of the manpower is the most intense when he worked the first day of work to zero, the next day at 8:00 a.m. then on the day shift.
Community hospital service time extended to zero, but also this round of the new crown infection peak in Shanghai, the community hospitals diversion of patients to make new arrangements. 2023 January 1, Shanghai community health service centers, sub-centers full coverage of seven days a week to provide fever diagnosis and treatment services. Minhang District has already launched night fever clinic service as early as December 20, 2022. Minhang District, 14 towns and cities, industrial zones, community health service center headquarters to open night fever "micro emergency", fever clinic service time on weekends extended to 22:00, extended to 0:00 a.m. on weekdays.
Intensive training for grassroots doctors in new crown diagnosis and treatment skills
In fact, more difficult than the expansion of space is the community doctors in the new crown diagnosis and treatment of technical preparation.
Hongqiao Community Health Center Longbai sub-center Shen Aiyue, deputy director of the Shanghai community health care institutions of the original fever sentinel, in the previous anti-epidemic process mainly play a role in the closed-loop referral of febrile patients to the new crown designated hospitals. Due to the previous three years to implement the dynamic zero measures, really in the community fever sentinel point of consultation of the new crown patients are very few, "may meet two or three a week". So fever sentinel sites and fever clinics are completely different in function and doctor responsibilities.
"In the past three years, our community doctors have some theoretical knowledge of new crown diagnosis and treatment, but they do have very little experience in actually facing new crown patients for diagnosis and treatment, so they have to be trained over and over again." Director Zhong Hua told New People's Weekly that since Dec. 8, 2022, community healthcare workers have received at least five trainings on new crown diagnosis and treatment, including one specifically on how to use Pfizer Paxlovid, a new drug.
When are hormonal drugs used? Under what circumstances are antibiotics used? How is the propensity for severe illness that needs to be considered for the use of small-molecule antivirals assessed? These are among the most common and tested technical skills in the diagnosis and management of new crown infections, and they are all within the scope of the training of community doctors.
Shen Aiyue, deputy director of the Hongqiao Health Service Center, said that the number of general outpatient visits increased after Dec. 26, 2022, and that most of them came to see the doctor because of symptoms such as coughing and chest tightness after a new crown infection, and that some of the patients had a combination of other infections after a new crown infection.
In the hospital infusion area reporter saw, infusion chairs are basically full, the wall is decorated with cartoon patterns of children's infusion area, is now also open to adults to use. Shen Aiyue said the hospital has also prepared a large number of oxygen cylinders, as some patients have recently needed oxygen therapy, and the demand for oxygen is likely to increase in the future.
Dr. Shen Jie, who is sitting in the general outpatient clinic, told New People's Weekly that he has been seeing more than 100 patients a day lately, most of whom have a variety of underlying diseases and have just contracted the new crown. Common symptoms include coughing, hoarseness, lack of appetite and mild fever.
Dr. Shen Jie also found that the patients who came to the clinic are not only physically uncomfortable, many people have anxiety, the reason is to worry about their own condition or worry about their family's condition, and some of them are more bored because they stay at home for a long time. "The treatment we provide generally suggests oral medications and rehydration fluids only if they are necessary. In addition to prescribing medication I have to act as a psychiatrist to relieve the patient, some people have severe insomnia, we can prescribe a little bit of medicine to help sleep."
Real-time tracking of the health status of the "red, yellow and green" population
The elderly is a high-risk group of new crowns of serious illnesses, in order to realize the community level of "early detection, early intervention, early triage," the Shanghai Municipality through the primary health care network and the community village The city's primary care network and neighborhood committees are working together to map the health of the elderly.
Through the assessment, the elderly are marked with three colors, red, yellow and green, according to their health risk level. The red and yellow colors are for those who are at relatively high risk, and are managed on a case-by-case basis, with the community conducting daily health monitoring and providing appropriate guidance and services.
Director Zhong Hua told Xinmin Weekly that family doctors at community hospitals are the health "gatekeepers" for the "red, yellow and green crowd," and that through mapping, they have now set up profiles on the health of the elderly in the community. "If an old man in the onset of chronic diseases, we will classify it as a high-risk situation, if not in the onset of the stabilization period, belonging to the situation of medium-risk, if there is no particularly large underlying disease, it is a low-risk situation. Once the elderly person marked in red develops a new crown infection, our family doctor will give him another assessment to see if he has a tendency to become seriously ill, and prepare a plan for treatment and referral."
This specialized WeChat group on Director Zhong Hua's cell phone has members from the town's sub-committee cadres, village and neighborhood committee cadres, staff from the Committee on Aging, and community doctors. The role of the WeChat group is mainly to inform the community of the focus of the elderly new crown sick condition assessment results, the group will also coordinate to help the need for referral of the elderly in a timely manner to call to the 120 emergency vehicles.
In addition to the elderly living in the community, Hongqiao Town Community Health Center area there are three nursing homes, currently living in nursing homes for the elderly more than 300 people, community doctors have also been mapped.
"In the days before when medicines were tight, we distributed medicines and blood-oxygen testers to the nursing homes, and every day a community doctor made rounds to the nursing homes." Zhong Hua said these measures can detect whether the elderly have a tendency to turn seriously ill in time and can provide them with timely treatment.
Doctors can prescribe Pfizer's new crown drug after assessment
The drug is also being tilted to the grassroots level in order to play the triage role of community health care institutions, with Pfizer's new crown oral drug Paxlovid now in use in some community health service centers in Shanghai and already included in the medical insurance.
Zhong Hua, director of the Hongqiao Community Health Service Center 2022 December 31 prescribed the first box of Paxlovid. she introduced the first box and the second box of Paxlovid, the family took the diagnostic report of the higher hospitals to the community hospital to open, the patient's family, said the big hospitals are tight on medicines, the doctor recommended that they go to the community to prescribe the drug. Already, patients have been prescribed Pfizer Paxlovid after being evaluated by community doctors, and she believes more patients will use the drug as residents learn more about it.
On the morning of January 2, 2023, Dr. Jin Lei prescribed Paxlovid for an elderly patient, "This patient was right at the beginning of her illness with underlying conditions - hypertension, coronary artery disease - and after my assessment I thought she had the potential to develop severe symptoms. Her liver and kidney function were checked to be good and eligible for Paxlovid use. Finally, after a consultation within the hospital, we agreed that this patient could use Paxlovid," Dr. Jin Lei said, adding that because of reimbursement from Medicare, the patient's out-of-pocket payments are minimal and generally reported to be affordable by patients.
Director Zhong Hua said community doctors have mastered the new crown medication after several rounds of training. For example, Pfizer Paxlovid, the requirements of the patient is within five days of the onset of the disease, there is a tendency to severe disease, liver and kidney function is complete, etc., as long as it is in line with the use of the indications of the patient, community hospitals can now meet the demand for medication.