Critical care medical experts: Patients with severe COVID-19 should be screened in advance and intervened as soon as possible

Making every effort to treat severe patients and reduce the mortality rate is one of the most urgent and severe tasks in epidemic prevention at present.

According to the Shanghai Municipal Health Commission, as of 24:00 on April 26, 244 cases of severe patients and 27 critically ill patients were treated in designated medical institutions. On the 26th, there were 48 new local deaths, with an average age of 80.85 years old, and all of them suffered from serious multi-organ underlying diseases, including cerebral hemorrhage, coronary heart disease, severe cardiac insufficiency, severe hypertension, uremia, and advanced pancreatic malignancy.

"In this round of the epidemic, the situation of severely ill COVID-19 patients is more complicated." Li Yingchuan, a critical care medical expert, member of the Critical Care Physician Branch of the Chinese Medical Doctor Association and vice president of shanghai Tenth People's Hospital, said in an interview with the first financial reporter that on the one hand, there are more elderly patients, who have underlying diseases, including tumors, chronic renal insufficiency, heart disease (having done bypass surgery, valve replacement, etc.) and chronic bronchitis, etc., and the vaccination rate of the elderly is often not high; on the other hand, the CT progression of the lungs is very fast in patients who develop critical illness. In addition, almost all critically ill patients ventilate in the prone position as much as possible for much longer than ever.

At the beginning of April, Li Yingchuan led the team of Shanghai Tenth People's Hospital to take over some of the square cabin hospitals of the New International Expo Center, and then came to the Shanghai Public Health Clinical Center (the earliest designated hospital for the treatment of new crown in Shanghai) on the 7th, responsible for the admission and treatment of the most serious and large number of severe covid-19 patients; the A3 building he was responsible for had a total of about 70 beds, and the patients were referred from the designated hospitals.

Li Yingchuan said that the key to reducing the rate of severe illness and mortality is to identify and intervene in advance, and it is the focus to accelerate the speed of early diagnosis and early transfer of patients and improve comprehensive nursing capabilities.

First, it is to identify and intervene in advance. Li Yingchuan said that in the major cabin hospitals, for the elderly with underlying diseases (especially those who have not been vaccinated), it is necessary to strengthen daily attention and testing, in addition to providing daily life protection in the past, it is also necessary to regularly do some physical assessments for them, such as oxygen saturation testing, which can add some similar removable devices; if there is a risk of progression to severe illness under the assessment, it is necessary to refer them to the municipal designated hospital in time.

Taking the Fang Cabin Hospital of the New International Expo Center as an example, from the total of about 94,000 patients admitted, 22.2% have underlying diseases such as hypertension, diabetes, and coronary heart disease, that is, about 20,000 people with risk factors (with potential risk of severe disease).

Chen Erzhen, head of the medical treatment team of the Shanghai centralized isolation point and commander-in-chief of the cabin, told reporters that early intervention is to strengthen daily disease observation, timely discover abnormal indicators and potential risks, establish an early warning mechanism, and improve the screening rate.

"For some patients who progress rapidly, it is recommended to adjust the frequency of chest CT examination appropriately, and cooperate with laboratory tests (such as lymphocyte counts, inflammatory response indicators, etc.) to assess the patient's condition, rather than simply based on oxygen saturation indicators, whether chest tightness, etc., which will lag behind the elderly."

Secondly, it is necessary to speed up the speed of early diagnosis and early transfer of patients in the square cabin and district-level designated hospitals; and to make a good connection with the existing district-level and municipal-level designated hospitals.

"The basic setting of most cabin hospitals is still asymptomatic and mild patients, and then equipped with some emergency emergency units, so it may not be widely deployed detection functions." Li Yingchuan said that the purpose of hierarchical management of patients, in addition to distinguishing a type of asymptomatic and mild patients, is that sub-severe patients (may develop into severe diseases), severe and critically ill patients can be handed over to designated hospitals at the district and municipal levels for better treatment.

Some experts suggest that the above-mentioned early intervention also includes careful screening at the beginning of the transshipment. For example, new crown positive patients with high risk factors can be isolated at the beginning of community transfer through a hierarchical zoning management mechanism and isolated in a fixed place with more front-ended gates and more complete medical facilities. Li Yingchuan said that at present, an expert group has been set up at the municipal level to help the district-level designated hospitals identify cases that may develop into severe diseases in advance.

Third, how to make seriously ill patients recover and discharge as soon as possible through integrated nursing, so as to make room for other patients.

Li Yingchuan told reporters that for example, some seriously ill elderly people, although their new crown is negative, but because his underlying disease has been hit once, the situation is still relatively serious, but also have to be treated in the hospital, therefore, he also needs to occupy the beds and medical resources of the designated hospital, and the relevant resources may face a shortage.

"In addition to early intervention, screening and targeted treatment, comprehensive nursing is also an important link, and it is necessary to participate and intervene earlier, which will also improve with the help of medical care in many places." Li Yingchuan said.

In March this year, the National Health Commission issued the "Norms for the Care of Severe and Critically Ill Patients with COVID-19" (hereinafter referred to as the "Norms"), which mentioned in the "ICU Nursing Manpower Allocation and Scheduling Principles" that "the bed care ratio is 1:6, and each shift is scheduled for 4 hours; nurses should have a professional background in the ICU, have strong business ability and high professional quality".

A nursing industry professional also told reporters that in addition to the prescribed testing and nursing matters related to artificial airway, prone ventilation, extracorporeal membrane oxygenation (ECMO), sedation and analgesia, the nursing work of critically ill patients under this round of epidemic should also include continuous kidney replacement therapy, enteral nutrition, pressure ulcer protection, humanistic care, etc.

Li Yingchuan said that it is necessary to strengthen the professional training of nursing personnel in district-level designated hospitals, and some nursing personnel such as geriatrics and general medicine can also join one after another. "After the patient gradually recovers and the nucleic acid test is negative, it is also necessary to make timely referrals, so that the medical resources can be fully utilized."