The litmus test of public-private partnership in pandemic management — Dr Musa Mohd Nordin

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JANUARY 17 — I had the rare opportunity of accessing MOH’s data recently. I had to first verify that it was genuine. One of the slides was similar to what Dato’ Dr Suresh presented at our joint webinar recently. And a senior colleague vouched that it was the same set of slides that were presented to the CEOs of three major private hospital groups. It was forwarded to me on multiple occasions, so I trust it is not an OSA document.

Dated 14 Jan 2021, it was 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 APHM, I share here the decisions that was made following the meeting with the Deputy Minister of Health, Acting Deputy DG (Medical) and team to address the recent dramatic increases in Covid-19 cases and its impact on MOH hospitals, namely:

1. Private hospitals to manage Covid-19 cases on their own and up to ICU care level.

2. MOH hospitals will no longer accept Covid-19 referrals from private hospitals.

3. MOH hospitals may very soon transfer Covid-19 cases to private hospitals.

The 64% 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, the Category 1 and Category 2 cases occupied 45% and 25% of the Covid beds respectively.

Academic and military public health experts had advised the CPRC, since October 2020 to empty these beds, and allow these Category 1 and 2 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% of the Covid beds. It would drop the numbers of patients in Covid hospitals to 0.3 X 4302 = 1290 which is a BOR of 19%. Even if they discharged just 50% of the Category 1&2 patients, the numbers would be 0.5 X 4302 = 2151 which is a BOR of 32%, which is manageable and not overwhelming the services.

This would relieve a lot of burden upon the HCW in the Covid hospitals and they would be able to focus their nursing and medical expertise on the sickest Covid-19 patients and deliver optimal outcomes.

Besides, there would be less exposure to multitudes of patients during ward rounds, procedures etc and this would decrease the infection risk from patients to our HCW.

All these measures would lead to less isolation and quarantine of our HCW, less sick leave, unburdens them, allows them to rest better and decrease the risk of fatigue and burn out. They have virtually been on-call for the past 10-11 months. This act would be a morale booster to them, which is presently at its lowest ebb. In some way, this helps to mitigate some of the manpower issues in the Covid hospitals.

Looking at the ICU situation, 287 (36%) of the beds are occupied by Non-Covid cases. This in my opinion is the next situation that is immediately remediable. These Non-Covid cases should be decanted to Non-Covid government and private hospitals.

I would strongly suggest the APHM to consider favourable, rock bottom 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% BOR due to the pandemic consequent upon the public fear of getting anywhere close to a hospital facility. Imagine the added fear when they learn that we are managing Covid cases in-house!

Besides, a majority of the anaesthesiologists, intensivists, pulmonologists, and ID physicians in private hospitals are in the high risk categories, age wise and have co-morbidities. As Dr Suresh emphasised in the webinar, these are the vulnerable groups which must be protected from exposure to Covid cases! Persons above 50 years old make up 85% of the national Covid deaths.

This is unlike the consultants in government Covid hospitals who are mostly Gen-Y, and they have a hierarchy of clinical specialists, registrars, MOs and Hos to assist them with the frequent ward rounds and procedures. The consultant in private hospitals are a 5 in 1 combination of Consultant cum Specialist cum Registrar cum MO cum HO.

The government, which is now very scalpel happy to invoke the Emergency Ordinances, must be made to understand that managing the sick Covid-19 patients in the ICU is a steep learning curve. Our colleagues in the Covid hospitals have virtually mastered the art and science of Covid care in the ICUs. Our Case Fatality Rates (CFR) are one of the best in the world at 0.39%.

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, maybe compromising the outcomes of our sickest Covid cases. I hope they would seriously reconsider their decision.

Our anaesthesiologists and intensivists would aslo be able to manage the Non-Covid ventilated cases which make up 40% (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%) ventilated Covid-19 cases.

I would 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 co-horting them is a real challenge.

I think we now need to look at the granular data to elicit where is the exact problem. This next dataset might be useful.

The BOR of the Covid and Non-Covid cases are 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% BOR with all Covid cases. There is a real need to either ramp 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 3-5 cases.

Apparently, UMMC has currently 8 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 ICU 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% and 21 % 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 3-5 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, pragmatic, QUALITY CARE and SAFETY FIRST 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:

1. The QUALITY of care of our sickest Covid patients will be compromised

2. The SAFETY of in-house non-Covid patients and HCW will be affected

3. Nosocomial infections are a real risk, with transmission to non-Covid patients, which might inevitably lead to ward closures.

4. HCW despite their attention to isolation protocols, risk being infected, like as happened in our premier HSB and others, and require to be isolated and quarantined further depleting a residual workforce.

5. 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).

6. With due respect, in comparison to the likes of Dr Suresh and Prof Adeeba and their teams in HSB and UMMC, the consultants in private hospitals are really novices in the care of Covid ICU cases.

7. 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.

8. The role of private nurses in the care of Covid ICU cases is another major challenge that needs to be addressed.

9. If we flood the Hybrid hospitals and private hospitals with Covid patients, we threaten the wider population who as it is are very fearful of going anywhere close to hospitals. This would negatively impact the management of other Non-Covid illnesses e.g. NCDs, cancers and immunisation uptake. A grim reminder is the following comparison:

Deaths from Covid-19 (17 Mar-2 Dec 2020) = 402

Deaths from IHD (Jan-Dec 2019) = 16325 (50 deaths/day)

I think the government and the MOH needs to 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 recognising 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 healthcare 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 and does not necessarily represent the views of Malay Mail.

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