I had the rare opportunity of accessing some Ministry of Health (MOH) slides recently. Dated 14 January, 2021, the slides were titled “Integrasi Perkhidmatan Hospital Sektor Awam dan Swasta semasa Pandemik Covid-19”.
I suspect that the data was used to rationalise the MOH decision to mandate private hospitals to manage Covid-19 patients. Upon verification with the president of the Association of Private Hospitals, Malaysia (APHM), I share here the decisions that were made following the meeting with the Deputy Minister of Health, Acting Deputy Director-General (Medical) and their team to address the recent dramatic increase in Covid-19 cases and its impact on government hospitals, namely:
- Private hospitals to manage Covid-19 cases on their own and up to ICU care level.
- Government hospitals will no longer accept Covid-19 referrals from private hospitals.
- Government hospitals may very soon transfer Covid-19 cases to private hospitals.
The 64 per cent occupancy rate of Covid beds is undoubtedly high, but not alarming. But what needs to stated is that the MOH did not mention the breakdown of the patients in the Covid hospitals. I have reliable sources to inform me that in one premier Covid hospital, Category One and Category Two cases occupied 45 per cent and 25 per cent of the Covid beds respectively.
Since October 2020, cademic and military public health experts have been advising the Crisis Preparedness and Response Centre (CPRC) to empty these beds, and allow these Category One and Two cases to be isolated at home in a bid to decongest the hospitals. This expert counsel fell on deaf ears.
Now that the MOH has finally agreed to allow home isolation, this itself would free at least 70 per cent of the Covid beds. It would drop the number of patients in Covid hospitals to 0.3 X 4302 = 1290, which is a Bed Occupancy Rate (BOR) of 19 per cent. Even if they discharged just 50 per cent of the Category One and Two patients, the numbers would be 0.5 X 4302 = 2151, which is a BOR of 32 per cent, which is manageable, and will not overwhelm the services.
This will relieve the burden upon the Covid hospitals, and they would be able to focus their nursing and medical expertise on the sickest Covid-19 patients and deliver optimal care. There will also be less exposure to multitudes of patients during ward rounds and procedures, and this will decrease infection risks from patients.
All these measures will lead to a lessening of isolation and quarantine of our health care workers and less sick leave, allowing them to rest better and decrease the risk of fatigue and burnout. This act will act as a morale booster and mitigate some of the manpower issues in the Covid hospitals.
Looking at the ICU situation, 569 (71 per cent) of the beds are occupied by non-Covid cases. This in my opinion is the next situation that should be remedied. These non-Covid cases should be transferred to non-Covid government and private hospitals.
I would strongly suggest the APHM to consider favourable, competitive fees in managing these cases in their hospital ICUs. This is definitely the better deal than being forced to manage Covid cases. As it is, the private hospitals are down to about 40 per cent BOR, due to public fears of getting anywhere close to a hospital. Imagine the added fear when they learn that we are managing Covid cases in house!
A majority of anesthesiologists, intensivists, pulmonologists and infectious disease physicians in private hospitals are in high-risk categories age wise, and have co-morbidities. These are the vulnerable groups which must be protected from exposure to Covid-19 cases, since persons above 50 years old make up 85 per cent of the national Covid-19 deaths (see diagram).
This is unlike the consultants in government Covid hospitals who are mostly young. They also have a hierarchy of clinical specialists, registrars, MOs and HOs to assist them with the frequent ward rounds and procedures. The consultants in private hospitals are a five in one combination of consultant cum specialist cum registrar cum MO cum HO.
The government must be made to understand that managing sick Covid-19 patients in ICUs constitutes a steep learning curve. Our colleagues in Covid hospitals have virtually mastered the art and science of Covid care in ICUs. Our Case Fatality Rates (CFR) are one of the best in the world at 0.39 per cent.
The government and the MOH, in its haste and insistence to force Covid-19 cases upon the private hospitals, who are only just beginning to learn the ropes of Covid ICU care, and might compromise the outcomes of our sickest Covid cases. I hope they can seriously reconsider their decision.
Our anesthesiologists and intensivists will also be able to manage the non-Covid ventilated cases which make up 40 per cent (636/1583) of the cases in the ICUs. Decongesting the ICU would also allow our colleagues in Covid hospitals to better focus on the 130 (8 per cent) ventilated Covid-19 cases.
I strongly urge the MOH to stop the hybrid hospital initiative. It is best to designate hospitals as Covid or Non-Covid hospitals. If you allow Covid patients “everywhere”, not only will you be compromising quality care but also safety, since nosocomial transmissions is a real complication between patients, patients to HCW and HCW to HCW, since single or isolation rooms are scarce and cohorting them is a real challenge.
We now need to look at the granular data to identify where is the exact problem. This next dataset might be useful.
The BOR of the Covid and non-Covid cases is expressed as a percentage of the total ICU beds available in the Covid hospitals. Immediately, it can be seen that Selangor is in a critical situation with 92 per cent BOR with all Covid cases. There is a real need to either ramp up the number of ICU beds in HSB or create another Covid hospital. The latter can be created from either a government or private hospital. In my opinion, it should be a dedicated Covid hospital managing Category Three to Five cases.
Apparently, UMMC has currently eight Covid ICU beds which they can ramp up to 14. HKL has 18 ICU Covid beds which they might be able to increase if their non-Covid ICU patients are decanted to a nearby private hospital. I am unaware of the situation in HUKM.
The high BOR of ICUs in Melaka and Perak can be readily solved by shifting the majority non-Covid ICU cases to private hospitals. Their Covid ICU BOR is low at 25 per cent and 21 per cent respectively.
I totally agree that private hospitals have only played a minor role in our Covid response over the past 10-11 months of the pandemic. Therefore, expecting the private hospitals to now manage Category Three to Five cases literally overnight is unrealistic and in my opinion very dangerous.
Freeing the ICU beds in the government Covid hospitals, and creating more Covid ICU beds would seem to be the more sensible and pragmatic modus operandi.
Allowing Covid cases to house “everywhere” in Hybrid and Private hospitals is a very dangerous exercise. It brings upon itself and creates its own set of problems and complications. I would reiterate that:
- The quality of care of our sickest Covid patients will be compromised.
- The safety of in-house non-Covid patients and HCW will be affected.
- Nosocomial infections are a real risk, with transmission to non-Covid patients, which might inevitably lead to ward closures.
- Health care workers, despite their attention to isolation protocols, risk being infected, as what has happened in our premier HSB and others, and requiring to be isolated and quarantined will further deplete a residual workforce.
- Our consultants in private hospitals are best prepared to manage non-Covid ICU patients, both ventilated or non-ventilated. Hand to them your patients. They will do this ungrudgingly as part of their national duty. Cost of care is really a secondary issue which can be worked out amicably with the APHM and the Association of Specialists in Private Medical Practice (ASPMP).
- In comparison to theteams in HSB and UMMC, the consultants in private hospitals are still novices in the care of Covid ICU cases.
- I personally would not entertain the idea of my loved ones being managed in a private hospital that is only beginning to learn the intricacies of Covid ICU care.
- The role of private nurses in the care of Covid ICU cases is another major challenge that needs to be addressed.
- If we flood the hybrid hospitals and private hospitals with Covid patients, we will threaten the wider population who will be very fearful of going anywhere bear hospitals. This would negatively impact the management of other non-Covid illnesses e.g. NCDs, cancers and immunisation uptakes. A grim reminder is the following comparison:
- Deaths from Covid-19 (17 March – 2, December 2020) = 402
- Deaths from IHD (January – December 2019) = 16325 (50 deaths/day)
The government and the MOH must engage with the APHM and the ASPMP in a civil manner. The decorum of engagement should exclude wielding the Emergency Ordinance and the RM5 million fine over their heads.
The overriding question is how best we serve the nation with our respective talents and expertise and recognise each other’s limitations and inexperiences.
The best brains of public health physicians, ID specialists, wide based representations from APHM, ASPMP, the medical (MMA), nursing (MNA and MNU) and other allied health professionals must be consulted in order to arrived at the best consensus and solutions.
Careful analysis of the present data and forecasting of future implications on our overall health care services is very crucial. Decisions and solutions should be driven by evidence, experience, good sense and wisdom, not coercion and punitive threats.
This would be another invaluable exercise in Public Private Partnership (PPP) that would contribute to the legacy of best practices in pandemic management and our future preparedness.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.