The patient pathway of COVID-19: 4 key challenges to overcome in Wuhan
From a patient’s perspective, in Wuhan, the center of the coronavirus outbreak, what are the hurdles in the patient pathway and how are they handled at this moment? As of March 2nd, the number of confirmed COVID-19  cases in China reached 80175, with 2915 deaths , of which 2227 were in Wuhan, the capital city of Hubei province. The mortality rate in Hubei was 10 times higher than the rest of the world, as the overloaded local healthcare system is challenged by the fast-growing infected population. At Alcimed, we identified four major hurdles along the patient pathway.
Illustration of the patient pathway for COVID-19 in Wuhan
Source: Health Commission of Hubei Province, illustrated by Alcimed
1. Long waiting list for the initial coronavirus examination in hospitals
The Challenge: The classic symptoms of COVID-19 include coughing, fever and breathing difficulties, yet the incubation period can be 14 days long. The fear spreads together with the virus. The citizens are obligated to report their symptomatic cases to the community center. The community center will screen the reported cases and give priority to the elderly and severe cases. As the hospitals are already full, the direct contact to the hospital will usually be denied or redirected to the community center. Initially, as the number of reported cases was rising continuously, waiting times for a reply from the community center increased steadily. As a consequence, people started to ask for help online via social media while fearing transmission of COVID-19 to their family.
Latest Solution: To ensure that patients, who suspect they may be suffering from COVID-19, can obtain guidance more efficiently, the Chinese government set up several hotlines and emails directly to higher-level officials and emergency response teams. The communist party members from the government and from state owned companies were ordered to share the burden of local community centers, receiving phone calls and coordinating with hospitals, arranging transportation, disinfecting public areas, and delivering living essentials to the elderly living on their own. However, those measures stay rather on an emotional level for the potential patients. The actual improvement appeared after the enormous installation of novel medical infrastructure such as “Fangcang” emergency hospitals and the arrival of healthcare professionals from other Chinese provinces.
2. Extremely reduced transportion to the hospitals for COVID-19 suspected patients
The Challenge: Since January 23rd, Wuhan shut down all public transportation. Three days later, the use of private car was forbidden with only a few exceptions. Thus, most citizens do not have any means of transportation available. Each community center has only about four cars to transport the potential patients to the hospitals for the first diagnosis, while an average of 3000 new suspected cases is reported each day in the city. Therefore, many patients suffering from fever and respiratory symptoms have to walk or bike to the hospitals. In a large city such as Wuhan, the closest hospital may be far and are not capableof taking new patients.
Latest Solution: More than 2000 volunteers organize the transportation of potential patients via social media and several ride-hiring platforms like Gaode, Didi, T3, Caocao, DFGO and taxi companies provide free services to help people in need. A second priority is to help healthcare professionals to commute between the hospital and their home. Ambulances usually take several patients in one trip, while some minivans have been modified to allow the transportation of stretchers. Through these measures, the very critical transport situation for potential patients could be managed.
3. Suspected patients having to go home for self-isolation while waiting for treatment in an inpatient clinic, due to insufficient healthcare resources
The Challenge: The highly infectious nature of COVID-19 requires effective quarantine to avoid virus transmission. However, the already burdened healthcare system in Wuhan does not have the resources to facilitate the quarantine. While the emergency measures are still in the process of being increased, waiting at home and self-monitoring the progression of symptoms is the only option for potential patients. This carries the potential risk that mild symptoms progress to severe and the possibility of transmitting the virus to their relatives is a high burden. For some severe cases, waiting times of up to 9.84 days – between showing first symptoms and being admitted to a hospital – have been reported, which is much higher than the Chinese average of 4.95 days .
1. Additional infrastructure: Officials accelerated the construction of two new specialized hospitals with about 2000 beds. With the other 46 existing hospitals, there are now 21722 beds for severe patients. “Fangcang” emergency hospitals are providing 20,567 beds for patients exhibiting mild symptoms but also acquired hotels and school dorms for probable cases.
2. Mobilization of additional healthcare professionals: Until February 12th, 29 Chinese provinces sent a total of 189 medical teams, or a total of more than 20,000 healthcare professionals, to Hubei.
3. Protective consumables: The local Red Cross Association was heavily criticized for its inefficiency and lack of transparency in managing donations of protective consumables such as face masks. So logistic professionals were assigned by the government to manage the storage of donations. Meanwhile, the consumables manufacturers re-started the production at full capacity.
4. Slow pathogen diagnosis (PCR testing) due to the heightened demand, and high rate of false-negative PCR results
The Challenge: PCR testing takes about 3 to 5 days, from patient’s registration to result delivery, yet only 30% – 50% of coronavirus carriers showed a positive result. There are three main reasons for a false negative result from the PCR testing:
– Unstable nature of the RNA virus
– Errors in collecting the sample
– The quality of the kit not being high enough
Prior to February 12th, there is a probability that COVID-19 patients who did not have a PCR positive result could have been wrongly classified as a “probable case” and consequently may not have received inpatient treatment, therefore missing the best timing to initiate medical care.
Latest Solution: China identified the pathogen and shared the genetic sequence immediately with the world through the WHO. The race to find a pharmaceutical solution started by then. Over the past few days, the development of the improved PCR testing kit has accelerated.
The pathway for COVID-19 patients in Wuhan focuses limited resources to the patients in most critical condition, while keeping patients showing only mild symptoms on hold. Delayed treatment has caused many casualties, but is there a better way in this situation? The remaining infected population dropped dramatically from 50633 to 30543 in the last 3 weeks in Hubei. Wuhan government started a blanket search for missed cases and non-reported symptomatic cases, which eased people’s fear of unknown and removed the hidden risks. During the course of February 2020, the messages on social media platforms asking for help has been replaced by online grocery shopping exchanges, with a much lighter heart. To quote a Chinese expression: when winter is here, spring will not be too far. Alcimed GmbH will continue to follow the COVID-19 respiratory disease progression and treatment development.
About the author
Anran, Consultant, Alcimed Healthcare Cologne Office
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