Introduction

The COVID-19 pandemic has wreaked havoc on the hospitals and healthcare systems all over the world. The situation is especially critical in low-income countries and in developing countries where the health and social systems are already weak.

General implications

The COVID-19 pandemic has disrupted routine hospitals globally. A study conducted by COVIDSurg (research network of surgeons and anaesthetists) revealed that globally around 28.4 million procedures were postponed during the peak 12 weeks of the pandemic. It would take an estimated 45 weeks to clear the backlog if countries boost their surgical volume by 20%. In India, around 51,100 cancer surgeries, 5,05,800 non-emergency surgeries, and 27,700 obstetric surgeries could have been delayed during the 3 months before and after the peak of the viral outbreak. This has affected the overall revenues of hospitals around the globe.

How are hospitals affected around the world?

COVID-19 is here to stay, the global health crisis will only worsen till COVID-19 is managed efficiently. Government response to the health crisis has been different around the world.  With the sudden onset of COVID-19, healthcare should be provided to those in need at the lowest cost as economies around the world strive to remain proficient.

Australia has an estimated 682 private and 675 public hospitals but less than 20% of public hospitals have a specialised ICU. Population with the age of 60 is 21.4% of the total. The unexpected nature of the pandemic has resulted in a joint private-public partnership for the crisis with the government committing to pay for half the costs for private hospitals to provide services.

The UK has around 1257 hospitals which include the NHS trust-managed and private hospitals. The percentage of people aged 60 and over increased to 23.8% in 2018. Around 92% of the recorded deaths due to COVID-19 in England have occurred in this age group and hence the UK is in a more vulnerable position. According to the NHS, one-quarter of the population, and two-thirds of people aged 65 or over have two or more long-term co-morbidities. The NHS listed all private hospitals to treat COVID-19 patients. The hospital sector is at severe risk of staff shortage. More than 65,000 retired doctors and nurses in England and Wales have been asked to return to the NHS and anyone in Scotland who has left the medical profession within the last 3 years have been asked to return.  Allied Health Professionals have also been encouraged to return to work. To meet the expected wave of patients, the government has also set up field hospitals in different locations.

Germany has 6 hospital beds per 1000 people and 33.9 intensive care beds per 100,000 people. Germany has 12 nurses and 4.3 doctors per 1000 inhabitants. Hospitals in Germany have been asked to postpone elective surgeries to keep beds free for COVID-19 patients. They have also passed the hospital relief act, where the hospitals will receive a compensation payment of 560 Euros for each patient. This is done to protect the hospitals from financial losses.

The healthcare capacity in the USA is considered as adequate. There are about 3 hospital beds and 3 medical practitioners per 1000 individuals.  People over the age of 60 years account for 17% of the total population.  Healthcare capacity is burdened with the increasing number of cases. The US currently has the highest number of COVID-19 cases in the world. The US has passed 2.1 trillion dollars worth of coronavirus aid to provide significant relief to the US healthcare sector. The US has provided 100 billion dollars worth of grants to hospitals to cover health-care-related expenses and lost revenues.

About 24.2% are aged over 60 years in Canada. Canada has 2.6 medical practitioners and 2.5 hospital beds per 1000 people. This is lower than countries like Germany, the UK and the US. Hospitals are therefore overcrowded and there are limited resources to treat COIVD-19 patients. However, the Canadian government acted quickly and committed more than a billion dollars to expand public health measures. Canada’s relatively low rate of infection currently does not possess a high risk of the healthcare system being overwhelmed but the ever-evolving situation with the virus puts the system at some risk.

In 2019-20 the New Zealand government spent 19.3 billion dollars on health-related items. New Zealand has 2.6 beds and 3.35 medical practitioners per 1000 people. The population aged over 60 years is about 21.3 %. The New Zealand government was swift in taking action against the virus by imposing early lockdowns. This placed New Zealand in a strong position both economically and health-wise. This had enabled them to return to business-as-usual faster than other nations. Due to their stringent lockdown and robust healthcare system, the infection rate was low as compared to other countries and hence their healthcare system is at a low-risk of being overwhelmed.

How are hospitals affected in India?

Hospital revenues have been affected since COVID-19 began picking up pace in India. During the lockdown, all non-emergency procedures and OPDs were shut based on the advisory from the government. According to ICRA, the revenues of the entities in the healthcare sector are about to fall by 15-20% in FY2021. The COVID-19 pandemic has certainly put mid and small-sized hospitals into existential crises.

Difficulties related to healthcare delivery

Patients with chronic conditions like HIV, tuberculosis and those requiring dialysis struggled to access treatment as hospitals shut various departments and due to the travel restrictions imposed during the lockdown. Hospitals lost a huge portion of the revenue during the lockdown. The risk of delayed treatment versus the chances of contracting the infection with compromised immunity is a difficult choice to make. COVID-19 related restrictions have left the patients to decide on the urgency of care that they need.

In India, there is also an issue with the allocation of scarce equipment. Healthcare providers like doctors have to make the ethical call for allocation of equipment. This is deeply distressing and emotionally draining. This not only affects the mental health of the doctors but also affected the mental health of patients and their relatives. Medical emergencies require immediate medical attention and delay could be life-threatening. During the lockdown, many incidences of delay in emergency care were highlighted by the media. Denial of care and consequences were reported as a fallout of stringent lockdowns. Patients faced issues while seeking care for chronic or acute conditions including the closure of public transport, non-availability of care providers (most of them engaged in COVID care), restrictions on movement, etc. COVID-19 and the lockdown have changed the dynamics of the healthcare system.  Many private medical practitioners across various cities have stopped opening the clinics even after the lockdown due to the fear of close contact with coronavirus-infected patients. Many patients were left with no choice but to rush to the hospital. This has led to overcrowding in hospitals defeating the purpose of social distancing. This also puts unnecessary pressure on the already strained hospital staff.

The COVID stigma

In India, app-based technologies were used to track hotspots and understand the spread of COVID-19. The lack of good data protection systems made the patients’ data vulnerable. Breaches in confidentiality if patients’ health data can exacerbate the degree of stigma within the communities.

Healthcare workers are discriminated against for working in hospitals and COVID care centres. Due to the collective fear and anxiety regarding the spread of infection patients suffering from COVID-19 were discriminated. There were several reports of healthcare workers being harassed by their landlords or neighbours for working in hospitals. Keeping this in mind the government of India noticed the challenge of fear and stigmatisation and began promoting positive messages and gratitude towards health and sanitation workers through caller tunes and social media.

Why few countries performed better than others?

Many countries have flattened the COVID infection curve and a very few countries have almost eliminated COVID. This has allowed the precarious work of resuming economic activity. Different countries have used varying strategies to beat COVID.

Sweden emerged with a model of sustain and support. The Swedish approach involved largely voluntary restrictions for the vulnerable population while keeping much of the economy open. They aim to build herd immunity among the young and healthy. This approach had attracted speculation from all over the world. The number of deaths was much higher as compared to other Nordic countries. However, the number of cases in Sweden has not completely overwhelmed their healthcare system as seen in Italy. Survey data suggests that most Swedes support the approach of the government.

The crush and contain strategy was successfully implemented by countries like South Korea, Taiwan, New Zealand etc. COVID-19 arrived in South Korea and the US in Jan 2020. Mid-March, the disease continued to surge in the US but South Korea had already flattened its curve owing to the crush and contain strategy. This strategy is built in response to past epidemics. Governments in Taiwan and South Korea rapidly imposed restrictions and deployed comprehensive virus-monitoring systems that included mass testing, contact tracing, etc. South Korea and Taiwan kept the number of cases below the limit by acting early. New Zealand initiated early countrywide lockdowns, along with rapid virus-monitoring systems. This type of strategy could be beneficial for small countries. It poses considerable challenges and harms international trade,  tourism, etc. which are important economic drivers for many of these governments for eg: tourism accounts for 10% of New Zealand’s economy.  Public health officials made innovative use of digital technology to aid contact tracing, which worked well in Hong Kong, Vietnam, China and Taiwan. The hard lessons learned from previous outbreaks readied Asian countries to act swiftly during COVID-19.

Hospitals could cope with COVID-19

The situation won’t be as simple as things began to normalise. The benefit, however, would be that as the restrictions are eased, non-emergency surgeries will pick up. These types of surgeries are more profitable to the hospitals. However, the footfalls are expected to stay low due to the fear of infection amongst the public.

Health care systems can ensure that essential services are not disturbed during the pandemic.

Using teleconsultation

Teleconsultation could be a life-saving technology. This technology makes it easier to access healthcare and in many cases, on-demand healthcare is also available. Teleconsultation can minimise the exposure risks for both healthcare professionals and patients especially during the time of the pandemic. In India and around the world there are various guidelines available to implement telemedicine and teleconsultation. Teleconsultation can help in ‘forward triage’, which means the patients can be sorted before they arrive in the emergency department.

Efficient and clear communication

Undesirable outcomes and unnecessary fear could spread during pandemics via misinformation. Central and state governments must ensure that all the information that reaches to the public is clear. Regulatory authorities must also ensure that awareness of the disease is created effectively. Hospitals should ensure to check the mental health of healthcare professionals to avoid burnout.

Improving readiness of healthcare facilities

Hospitals should consider physical/infrastructural changes to cater COVID and non-COVID patients, eg: if the hospital is utilised completely for COVID, the hospital could consider temporarily shifting the OPD elsewhere provided they have enough staff.

Anticipate staff fatigue

A shortage of supplies and staff getting infected with COVID-19 will put pressure on the staff and ultimately lead to burnout. This should be avoided at all costs. Fatigue can cause the staff to become less focused, which leads to breaches in hospital protocol. The hospital management must maintain adequate stock of PPE and other medications. They should also track the vacancy rate of the staff and try their best to fill the vacancies.

Providing medicines at doorstep

Various companies around the world and some companies in India have started delivering medication to the patients at their homes. The MoHFW has issued a notification on 26 March 2020, specifying guidelines for such deliveries, including prescription validity of 30 days. Healthcare companies and even hospitals can utilise this opportunity to ensure that their patient receives proper remote care.

Conclusion

The impact of COVID-19 on hospitals is visible. COVID-19 has disrupted the operations of almost all hospitals around the world. Reconfiguration of care in hospitals in response to COVID-19 has led to many patients suffering from the non-COVID-19 condition to delay their treatment. Governments should take steps to mitigate the major burden on such patients. As hospitals around the world try to cope, they need to be mindful about the ethical dilemmas that may occur during patient care. Hospitals should also come up with strategies and adopt technology to allow them to survive and sustain this COVID storm.

Reference
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Published On: November 24th, 2020 / Categories: Articles /