COVID revolution: How pandemic could change the hospital's role forever

The COVID-19 pandemic re-educated the country of the importance of the hospital within the healthcare system. It also taught hospitals the need to be flexible, forward-thinking and to adopt technology.

From an emphasis on fully staffing facilities, to new technologies and telemedicine changing the way doctors provide care, the post-COVID health system will look different than it did before.

“The importance of the health funds is something we knew all the time, but in the end, the capacity of the entire country to operate depended on the hospitals’ ability to take care of severely sick patients,” Prof. Arnon Afek, deputy director-general of Sheba Medical Center, told the Magazine.

It was a fear that medical centers would get crushed under the pressure of too many severe patients that led Israel’s leaders to repeatedly lock down the country.

Health experts believed that Israel’s underfunded and understaffed hospitals could only manage 800 severe COVID-19 patients before collapsing. Although ultimately there were some 1,200 serious cases, as infection rates rose, lawmakers kept one eye on the economy and the other on the health system.

Part of the Health Ministry’s strategy during the first wave was to require hospitals to cease providing elective and routine patient care in order to free up staff for COVID-19 patients. At the same time, people’s fears of contracting COVID in the hospital led many patients to forego preventative care. According to Wolfson Medical Center director Dr. Anat Engel, “We are now seeing a jump in the number of patients coming to us in all areas.... We see that patients are coming with more complex medical problems and in more severe stages.”

In any future pandemic or other mass casualty event, Engel said, the goal should be to have enough staff to ensure hospitals can maintain routine.

Hospitals were forced to reinvent themselves almost overnight. A paper recently published by Sheba in the peer-reviewed Emergency Medicine Journal shared what it was like to establish a COVID treatment center from a clinical, organizational and logistical standpoint under extreme conditions.

Sheba’s first COVID unit was situated on the periphery of the hospital grounds, about 1,500 meters from the main campus – a decision made by a COVID task force that the hospital quickly established. The task force consisted of representatives from the hospital management, the Center for Disaster Medicine, and the departments of emergency medicine, internal medicine, infectious disease, infection prevention and control, medical informatics, telemedicine, logistics, human resources and public relations.

By placing the complex within the boundaries of the hospital, staff had access to all hospital resources. At the same time, keeping COVID treatment out of the main building helped prevent widespread contamination of staff and other patients.

But using the facility came with its set of challenges.

The report described how the hospital had to develop new operational principles, including methods for patient isolation, preventing contamination and minimizing direct contact between patients and caregivers using personal protection equipment and a multimodal telemedicine system – all in a facility that was previously non-medical.

“Physical construction included cordoning the whole complex from its surroundings, construction of internal walls dividing it into separate zones according to contamination level and needs for personal protective equipment, installing infrastructure for medical gases delivery in patient rooms, wiring for information processing, monitoring and telemedicine and constructing a separate lab, pharmacy and intensive care unit,” the paper details. 

“Devices were constructed for obtaining nasopharyngeal swabs, delivery of food and supplies and waste disposal, all directed at reducing physical patient–caregiver contact.”

All of this was accomplished in two to three days.

AT THE SAME time, it became quickly apparent that the emergency department was going to be the welcoming ground for potential COVID patients, and that staff would have to test and determine the status of all patients before they could enter the campus where they might spread the disease. Sheba adopted a multi-pronged approach, devising what it called a “tented frontal triage area” outside the emergency room where patients could be swabbed for COVID.

The emergency department itself was divided into two colors: blue and red. The blue managed the “normal” patients, and the red became a special “biologic zone” for people with the virus. Within the biologic zone, the department was further color-coded and divided: green for patients who were exposed to COVID but had no symptoms, yellow for ambulatory patients with a confirmed COVID diagnosis, and red for non-ambulatory patients with COVID.

Hadassah University Medical Center’s Prof. Ze’ev Rotstein established a similar center on his campus, treating coronavirus patients in an isolated part of the older Round Building in Ein Kerem. He kept the Mount Scopus campus COVID-free.

Afek said the COVID pandemic drove home the importance of early preparation and the need for leadership to think out of the box.

“One of the key reasons why Israel was so successful in fighting coronavirus is that we are a very flexible country,” he told the Magazine. “What we can do in a very short period is something that other countries cannot.”

He said that the way Sheba and other hospitals transformed themselves from building intensive care units in parking lots to doubling and tripling ICU beds and staffing within days is “something quite incredible.”

The report highlighted the need for “managerial agility and adaptation,” as well as agility, defined as “the capacity to provide rapid solutions to arising problems through collaboration between medical, organizational and logistical divisions with orchestration by hospital leadership.”

It also stressed the lesson learned of the need for team-building within a hospital.

Perhaps the biggest shift, health experts said, is the move toward telemedicine or remote care, within and outside of the hospital setting.

Sheba quickly realized how telemedicine could maintain patient care while minimizing direct contact between these patients and their caregivers. The hospital established a coronavirus command center that utilized new technologies for remote monitoring and communication with its COVID patients.

Examples of equipment highlighted in the report were a Uniper, a TV box turning the television to an interactive platform enabling video communication, as well as virtual group meetings; an Intouch medical telepresence robot and a two-way walkie-talkie that were placed in the ICU; Earlysense, a wireless bed sensor that continuously monitors heart, respiratory rate and motion while the patient is in bed and includes an artificial intelligence algorithm that can predict deterioration; Tytocare, a device that enables remote physical examination of the heart, lungs, throat and ears, as well as measurement of vital signs such as temperature and heart rate. For easier use of this system, a tablet with the Tytocare app was given to the patients, for simple use, in order to avoid the need to download the designated app to their cellphones; and many more.

Before COVID, Sheba was still in the early stages of developing telemedicine as part of routine care. Now, according to Afek, “telemedicine is here to stay.” So much so, that Sheba recently launched a new program it calls Sheba BEYOND, which is essentially a virtual hospital.

SHEBA BEYOND relies on the expertise of Sheba’s core medical staff, but its entire mission is to use telemedicine to take care of patients beyond the borders of Sheba – even in other countries.

“Our motto is that as one of the world’s top-10 leading hospitals, we have an obligation to take care not just of Israeli or Palestinian patients, but patients all over the world,” Afek said.

Last month, for example, Sheba signed a “breakthrough” agreement to provide treatment to diabetics in Dubai in collaboration with the Al Tadawi Healthcare group. It was the first of its kind signed under the Sheba BEYOND program.

Al Tadawi Medical Center will now be providing its diabetic patients with treatment onsite through visits by top Sheba endocrinologists, as well as by remote monitoring via the Datos Health management application.

Sheba’s website explains the benefits of telemedicine and saving travel and parking time, avoiding exposure to sick patients, and being able to conference with family members or support people who you might need to know about your medical situation.

 

Rotstein told the Magazine that virtual visits with specialists have also become the norm at his hospital.

“We have reduced physical visits to our outpatient clinics,” he maintained, and said that at least 50% of the patients now chose to take advantage of a telemedicine-type visit.

The other lesson that health officials are hoping the country has learned is investment in quality staffing.

“We must not forget the high erosion of the staff and the fatigue caused by the coronavirus,” Engel said. “It is time for the whole system to address the lack of ICU beds... to avoid chronic future consequences.”

During the pandemic, the Finance and Health ministries funded 600 doctors and 1,600 nurses to help provide care through the end of June. It is still unclear if the Finance Ministry will provide the money to continue employing the new staff.

 

“As of today, the Finance Ministry is saying they are not going to fund them anymore,” explained Rotstein. “There is going to be a national fight.”

Health officials argue that the system was starved and understaffed before the pandemic – a core reason for lockdowns and also why they could not maintain routine care.

Israel went into the coronavirus crisis with the highest hospital occupancy rate of any Organization for Economic Cooperation and Development (OECD) member country.

In terms of the number of physicians per capita, Israel is roughly close to the OECD average, but it has 10 times more physicians over the age of 75. Israel has one of the worst nurse-to-population ratios, with five nurses per 1,000 people – significantly lower than the OECD average of 8.8 per 1,000.

“I certainly believe and hope that everyone has recognized the fact that the resilience of the population in Israel depends on a strong health system, stable in terms of resources and budgeted for the challenges of the future,” Engel said. “Regular investment and equitable distribution of resources is critical in the coming years in many areas of medicine, including infection prevention and acute care.

“There is a need for sound and strategic correctness, investment of resources in physical infrastructure and medical equipment, and development of advanced information platforms that are the basis for better decision-making, virtual medicine and efficient management of the health world.”