Dr Musa Mohd Nordin, Paediatrician
Dr Mafeitzeral Mamat, Anaesthesiologist
Asst Prof Mohammad Farhan Rusli, Public Health Physician
7 July 2021
“My uncle passed away just now at Hospital Ampang whilst waiting for ventilator since morning”
“Please sir come down and join us fight this inside our halls. See our patients on the floor, see our nurses crying for help”
I am sure you have actually witnessed the grim and desperate situation in our Emergency Departments (ED), Intensive Care Units (ICU) and at Pusat Kuarantin dan Rawatan COVID Berisiko Rendah (PKRC) at MAEPS.
Many have written or voiced about the impending upsurge of COVID cases since October 2020 and have sounded like broken records raising the Bendera Merah (red flag), early this year. In January 2021, when the hospital and ICU facilities were overstretched and near breakdown, we wrote to suggest various strategies to protect the hospital services and ensure the cases would not overrun the capacity of our services. [1-6]
The Malaysian Medical Association (MMA) organized a webinar on 1 Feb 2021, to address this specific issue, which featured the Association of Private Hospital Malaysia (APHM), MMA, an infectious diseases (ID) specialist and two of us, one an anesthetist, the other a neonatologist (intensivist of sick newborns). [7 ]
The recommendations from the College of Anesthesiologists, Academy of Medicine Malaysia (COA, AMM), the Malaysian Societies of Anesthesiologists (MSA) and Malaysian Society of Intensive Care (MSIC), dated 17 May 2021 were met with the standard bureaucratic reply. If only the Ministry of Health (MOH) had heeded some if not all of the ideas which were suggested we would not be in the deadly mess we are in today.
As of 5 July 2021, based on official MOH press statements & media reports:
- The usage of COVID ICU bed (including probable cases) is 1224. Prior to COVID the Malaysian Registry of Intensive Care (MRIC) data, inclusive of the university hospitals had approximately 1000 beds. The latest in their planning was 60-70% for COVID cases and 40-30% for non-COVID cases.
- In the Klang Valley Hospitals, the COVID ICU beds including repurposed ICU beds are 85% filled (567/667). This does not include the transit ventilated patients in the ED which may take a while before their transfer to the COVID ICUs or repurposed ICUs.
- As at 7 July 2021, 948 COVID cases are being nursed in ICU with 441 cases on ventilatory support.
- Currently 17 MOH Hospitals in the Klang Valley are treating COVID cases. The dedicated COVID hospitals are Sg Buloh and Ampang. The rest are hybrid hospitals. Hospital KL (HKL) is 70% COVID, in the wards and a full COVID ICU.
The COA, MSA and MSIC recommendations have deliberated extensively on the process of decanting patients from the MOH hospitals to the private hospitals. And the Minister in a media report on 4 July 2021, alluded to the MOH decanting patients to the private hospitals. [8]
We would like to suggest a few unpopular but must do immediate actions:
- Make it mandatory for all the private hospitals to accept non-COVID cases from all the MOH hospitals. Not only must national duty be done, it must also be seen to be done. This must not be under the auspices of the MOH, since their leaders have proven themselves to be failures. Instead, appoint one of the stellar CEOs from the APHM to monitor this exercise and ensure an equitable distribution of all the non-COVID patients to the private hospitals.
- Convert more of the MOH hospitals to be fully designated as COVID hospitals. We have illustrated the process of planning for the surge of critical capacity in the latter part of the article.
- All the Category 3,4 and 5 COVID cases must be sent to these COVID hospitals. Only in this manner we guarantee best quality health care of the sickest COVID patients and protect the safety of all doctors, Health Care Workers (HCW), allied health professionals, supporting staff and the other clients in our healthcare facilities.
- Make all the PKRCs especially the largest in MAEPS to undertake what they were originally designed to do, which is to nurse the Category 1 & 2 COVID cases who are for various reasons unable to be quarantined at home
From the earlier notes, it therefore makes perfect sense that HKL should be designated as the next COVID hospital. They have enough medical gas terminal units including oxygen gas outlets, electrical points and the other paraphernalia to create more than 200 repurposed COVID ICU beds. Hospital Tunku Ampuan Rahimah (Klang) would be the next hospital with this capability and capacity.
To do this the 4S,namey Space, Staff, Stuff and Standard must be put in place. This demands an urgent sit-down and brainstorming among the intensivists, anesthesiologists and Infectious Disease physicians to finalize the plans. In fact, it should have been done when the planning for COVID Category 1-3 was done with the COVID Assessment Centres (CAC) and PKRCs. We simply fail to understand why the MOH and its host of experts did not prepare for this worst-case scenario!
Our gut feeling is that, the clinicians had planned for all of these eventualities but was not acted upon the by top echelons, both medical and administrative in the MOH. This is reflected in today’s rant from a clinician to the Chief Commander of the MOH:
“If help is promised, it must be provided within either 24,48 or 72 hours. Deployment of manpower should be easily in place within 24 and 48 hours. It should have been yesterday”
The bottle-neck is obviously due to the 100% utilization of COVID ICU beds and though the measures would now be ad-hoc, we would still need to marshal some form of “order in the disorder”. We would have to operate like in the 1995 American space movie “Apollo 13”. Flight Dynamics Officer, Jerry Bosstick, wrote in an email:
“One of their (script writers) questions was “Weren’t there times when everybody (people in Mission Control), or at least a few people just panicked?” My answer was “No, when bad things happened, we just calmly laid out all the options, and failure was not one of them.”
A powerful message from the “Apollo 13” epic movie: FAILURE IS NOT AN OPTION!
If we can do this plan successfully in the Klang Valley, it can act as the template for the states to replicate to increase the critical care capacity in the other MOH hospitals.
There are 2 excellent references for the MOH to plan for their surge in their critical capacity.
The first, Surging Critical Care Capacity for COVID-19: Key now and in the future, dwells on the features of an effective response which demands coordination, anticipation and solidarity. All of which seems to be sorely lacking in the present response due to a failed political and health leadership and governance [9,10]
Whilst the other, Managing ICU surge during the COVID-19 crisis: Rapid Guidelines focuses specifically on key questions about how to manage ICU surge during COVID-19. [11]
As to space and stuff, the MOH needs to prepare for this expeditiously.
Staff and standard needs to be rapidly retrained towards a pandemic-centric style of care. [12]
HKL and HTAR ward staff are fairly experienced to high intensity critically ill patients and they would fit aptly into the retraining plan for this COVID crisis.
Italy, the US and the UK doctors and HCW did all of these in 2020. Why can’t we?
References:
- https://www.malaysiakini.com/columns/546082 Make use of all tools available, not just lockdowns.
- https://drmusanordin.com/2020/11/02/the-science-and-politics-of-the-covid-19-pandemic-the-malaysian-experience/
- https://drmusanordin.com/2021/01/18/the-litmus-test-of-public-private-partnership-in-pandemic-management/
- https://drmusanordin.com/2021/01/24/covid-19-management-if-it-aint-broke-dont-fix-it/
- https://drmusanordin.com/2021/01/30/malaysia-in-covid-19-crisis/
- https://drmusanordin.com/2021/01/30/comment-covid-19-its-all-doom-and-gloom-unless/
- https://t.co/P4KZqfmaXK?amp=1
- https://www.astroawani.com/berita-malaysia/penyumberluaran-pesakit-bukan-covid19-ke-hospital-swasta-diperluas-dr-adham-306590
- https://www.sciencedirect.com/science/article/pii/S2590061720300739
- https://drmusanordin.com/2021/05/14/a-plan-to-exit-the-covid-19-pandemic/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276667/
- https://www.sccm.org/Blog/March-2020/United-States-Resource-Availability-for-COVID-19
