key: cord-0918931-lscqtmjq
authors: Kamada, Keisuke; Konno, Satoshi; Kaneko, Takeshi; Fukunaga, Koichi; Hasegawa, Yoshinori; Yokoyama, Akihito
title: The effect of the outbreak of COVID-19 on respiratory physicians and healthcare in Japan: Serial nationwide surveys by the Japanese Respiratory Society
date: 2021-07-31
journal: Respir Investig
DOI: 10.1016/j.resinv.2021.07.001
sha: d35228774d8ac98d4c1dc9a192daac4f971a0aa0
doc_id: 918931
cord_uid: lscqtmjq

BACKGROUND: The impact of the outbreak of COVID-19 on the work of respiratory physicians in Japan has not yet been evaluated. The study investigates the impact of the outbreak on respiratory physicians’ work over time and identifies problems to be addressed in the future. METHODS: We conducted a web-based survey of respiratory physicians in 848 institutions. The survey comprised 32 questions and four sections: Survey 1 (April 20, 2020), Survey 2 (May 27, 2020), Survey 3 (August 31, 2020), and Survey 4 (December 4, 2020). RESULTS: The mean survey response rate was 24.9%, and 502 facilities (59.2%) participated in at least one survey. The proportion of facilities that could perform PCR tests for diagnosis and more than 20 tests per day gradually increased. The percentage capable of managing extracorporeal membrane oxygenation (ECMO) or more than five ventilators did not increase over time. The proportion that reported work overload of 150% or more, stress associated with lack of personal protective equipment (PPE), and harassment or stigma in the surrounding community did not sufficiently improve. CONCLUSION: While there was an improvement in expanding the examination system and medical cooperation in the community, there was no indication of enhancement of the critical care management system. The overwork of respiratory physicians, lack of PPE, and harassment and stigma related to COVID-19 did not sufficiently improve and need to be addressed urgently.

one survey. The proportion of facilities that could perform PCR tests for diagnosis and more 48 than 20 tests per day gradually increased. The percentage capable of managing 49 extracorporeal membrane oxygenation (ECMO) or more than five ventilators did not increase 50 over time. The proportion that reported work overload of 150% or more, stress associated 51 with lack of personal protective equipment (PPE), and harassment or stigma in the 52 surrounding community did not sufficiently improve. 53

Since the recognition of the first case of severe acute respiratory syndrome coronavirus-2 66 (SARS-CoV-2, COVID-19) infection in Japan in January 2020, the infection has spread 67 throughout the country, and many healthcare institutions and their staff have been exposed 68 to a variety of stresses for long durationsa situation that they have never experienced 69

previously. The shortage of intensive care beds due to the increase in the number of critically 70 ill patients and medical cooperation across hospital departments and facilities have become 71 major topics of discussion. In addition, it has become clear that COVID-19 has a significant 72 impact on healthcare workers' mental health that cannot be ignored, such as prevention and However, to date, we have not been able to clarify the following: 1) what role respiratory 78 physicians play in COVID-19 care, 2) how COVID-19 care has affected the work system of 79 each institution and the work content of respiratory physicians (e.g., increase or decrease in 80 total workload, restrictions on regular care, etc.), and 3) what issues respiratory physicians 81 face with COVID-19 care. In addition, respiratory physicians' stress in relation to COVID-19 82 practice was unclear, 4) whether discrimination and stigma related to COVID-19 occurred 83 around respiratory physicians, and 5) what kind of therapeutic agents were selected in actual 84 clinical practice. The Japanese Respiratory Society, therefore, conducted a nationwide 85 questionnaire survey four times to clarify the aforementioned areas, share the situation and 86 problems encountered nationwide, and provide data for proposing improvements to the 87 medical environment in the future. 88 89

We conducted a questionnaire survey of 848 accredited, affiliated, and specified regionally 91 affiliated facilities under the previous Japanese Respiratory Society medical specialty board. 92

The survey was conducted four times between April 2020 and December 2020 (Survey 1: 93

April 20, 2020, Survey 2: May 27, 2020, survey 3: August 31, 2020, Survey 4: December 4, 94 2020). The status of COVID-19 prevalence in Japan at the time of each survey is illustrated 95 in Figure 1 . We prepared 32 questions to assess the situation related to COVID-19 treatment 96 and obtained responses using a web questionnaire (Table 1) Of the 502 medical institutions that responded, 71.9% were hospitals with more than 300 110 beds. The proportions of medical institutions designated for infectious diseases and those 111 providing outpatient care for returnee contacts generally remained unchanged (Figure 2A) . 112

The proportion of facilities that could perform PCR testing in the hospital and facilities that 113 could perform more than 20 tests per day clearly increased over time ( Figure 2B ). The 114

proportion for ventilator management and extracorporeal membrane oxygenation (ECMO) 115 management did not change significantly during Surveys 1−4 ( Figure 2C ). The percentage 116 of facilities capable of managing five or more ventilators decreased from 42.1% in Survey 1 117 to 31.9% in Survey 4. The percentage of facilities that reported regional cooperation in 118 COVID-19 care showed a gradual upward trend over time, while those that reported 119 cooperation from other departments in the hospital remained unchanged at about 80% from 120 Survey 3 ( Figure 2D ). 121 122

The proportion of facilities with experience in treating confirmed COVID-19 cases increased 124 from 65.7% in Survey 1 to 90.1% in Survey 4. The proportion where more than 76% of 125 confirmed COVID-19 cases were treated by respiratory physicians increased until Survey 3, 126 but then decreased to 41.7% in survey 4 ( Figure 3A ). Figure 3B illustrates the severity of 127 COVID-19 confirmed cases managed by respiratory physicians at each facility. In all the 128 surveys, 70-80% of facilities were in charge of mild, moderate I (no oxygen therapy required), 129 and moderate II cases (requiring oxygen therapy), and 30-40% were in charge of severe 130 cases (requiring intensive care). 131

The proportion of facilities that reduced the routine respiratory medicine services decreased 132 significantly in Survey 3 but increased slightly in Survey 4 ( Figure 3C ). Postponement of 133 scheduled bronchoscopy and hospitalization were the most common routine medical 134 services reduced throughout Surveys 1−4 ( Figure 3C ). These decreased significantly after 135 Survey 2, while postponement of chemotherapy did not ( Figure 3C ). When evaluating the 136 change in workload, we found that 20.6% of the facilities in Survey 4 showed a serious 137

increase of 150% or more in the workload, which was the worst value in all the surveys 138 ( Figure 3D ). 139 Figure 4B ). In addition, in Surveys 2−3, these 150 discriminations were more likely to occur outside the hospital, but in Survey 4, it was more 151 likely to occur inside the hospital ( Figure 4B) . 152

Questionnaires on treatment were performed in Surveys 2−4. For mild and moderate I cases 155 symptomatic treatment alone was the most common, followed by favipiravir and ciclesonide 156 inhalation ( Figure 5A ). Systemic steroids were administered in most facilities after Survey 2 157

for moderate II cases. The proportion of facilities using remdesivir and heparin increased 

As shown in Figure 2C , the capacity of the facilities for ventilator and ECMO management 173 remained almost the same across all surveys. It is impossible to draw a definite conclusion 174 because those who responded to the questionnaire differed from survey to survey, and 175 comparisons could not be made between the same facilities. However, it is likely that the 176 capacity of intensive care requiring ventilator and ECMO has not increased through this 177 pandemic (the number of operable ECMO was not surveyed in Surveys 3−4 due to an error 178 in questionnaire preparation). Although public opinion is calling for an increase in medical 179 treatment capacity, a high level of expertise in the field of intensive care is required, especially 180 for the treatment of severe cases. It is impossible to train medical staff with such skills 181 overnight, and the issue should be discussed on the premise that the capacity for treating 182 critically ill patients will not increase easily in the future. Increasing the number of medical 183 experts trained in infectious disease and intensive care with a long-term perspective may be 184 one solution. However, the need for such experts changes drastically depending on the 185 disease prevalence, thereby complicating the problem. On the other hand, there was a clear 186 improvement in the PCR testing system over time. Figure 2B shows that more laboratories 187 can now perform PCR tests at their facilities, and the number of tests available per day has 188

increased. The ability to perform tests without delay is extremely important for the 189 management of suspected cases. Although not evaluated in this survey, it is expected that 190 many facilities have started to perform SARS-CoV-2 diagnostic tests other than PCR, such 191 as loop-mediated isothermal amplification (LAMP) and antigen tests. It is believed that the 192 overall testing system is improving. 193 194

The workload of respiratory medicine has increased due to the COVID-19 pandemic. As may not be able to refuse medical treatment even if there is a shortage of PPE. Support from 226 society is, therefore, essential as one-sided devotion of the healthcare workers alone will 227

probably lead to failure [9, 10]. The lack of PPE has already been shown to have a negative 228 impact on the mental health of healthcare workers [5] . Therefore, it is hoped that more 229 detailed data will be collected on where and what type of PPE is in short supply and that the 230 supply is improved. There are two possible solutions to the PPE shortage problem. One is to 231 support the PPE manufacturing supply chain more actively with the national budget. The 232 other is to establish a system that can quickly estimate the specific types of PPE in short 233 supply at each medical institution and distribute them more effectively. A total of six months 234 have passed since Survey 4, and although there is no precise data, the availability of PPE 235 seems to be improving nationwide. However, it is necessary to steadily promote these 236 measures due to the possibility of further demand for PPE in the future. predictions about the future, but it is unlikely that the problem will be solved in the short term. 269

Although this survey was comprehensive, there may be a need for a more specialized survey 270 focused on the mental health of respiratory physicians. Our survey had several limitations. 271

First, the response rate to the questionnaire, especially for Survey 4 was low. The facilities 272 with increased workload due to COVID-19 could have responded more actively. Conversely, 273 due to the outbreak of COVID-19, they may have had difficulty finding time to respond. 274

Furthermore, only one representative of each facility could answer the questionnaire. The 275

representativeness of the data must, therefore, be interpreted with caution. Second, some 276 facilities did not participate in all the surveys; therefore, it is important to note that the data 277 do not show changes over time for the same facilities. Finally, more than 70% of the facilities 278 that responded to the survey had 301 or more beds, which may not reflect the situation of 279 smaller hospitals. 280 281

Despite these limitations, our report is the first survey to identify the problems (increased 283 workload, lack of PPE, harassment, and stigma) encountered by respiratory physicians in 284

Japan regarding COVID-19 management. Our study also presents the COVID-19 influence 285 trend in medical institutions during the first year of the pandemic in Japan. It may be useful 286

in predicting the problems that may arise in the future when emerging infectious diseases 287 follow SARS-CoV2. Table 1 . The questionnaire. 334

Major problems in clinical practice include a lack of PPE, harassment, and stigma (Figure 4)

Surprisingly, about 30% of medical institutions were still stressed about PPE shortages in 224

How many beds does your medical facility have? Q2. How many full-time respiratory physicians are employed at your medical facility? Q3. How many total full-time doctors are employed in your medical facility? Q4. Is your medical facility designated for infectious diseases? Q5. Does your medical facility provide outpatient care for returnees/contactees? Q6. Could your medical facility manage ECMO? Q7. How many ECMO units are available in your medical facility? Q8. Could your medical facility manage ventilator? Q9. How many ventilators are available in your medical facility? Q10. Did your medical facility perform SARS-CoV-2 PCR tests? Q11. How many SARS-CoV-2 PCR tests were performed per day in your medical facility?

How well does your medical facility obtain cooperation from other departments for the management of COVID-19 patients? Q14. How well does your medical facility have a regional collaboration for the management of COVID-19 patients? Q15. How many suspected COVID-19 patients are seen per week in the outpatient and emergency care at your medical facility? Q16. Does your medical facility have a specific department that manages suspected COVID-19 patients? Q17. What department is responsible for managing suspected COVID-19 patients in your medical facility? Q18

What is the percentage of patients with moderate disease (requiring oxygen) from the total number of confirmed COVID-19 pa Q20. What is the percentage of severe disease (requiring ventilator management) from the total number of confirmed COVID-19 pa Q21. In your medical facility, what percentage of patients with confirmed COVID-19 are treated by respiratory physicians? Q22. What severity of COVID-19 patients are managed by respiratory physicians?

COVID-19) of respiratory physicians when compared to the same period in pre Q24. Has your medical facility reduced its usual respiratory practice operations due to the COVID-19 pandemic? (Multiple answer Q25. At your medical facility, have staff or patients been subjected to harassment (stigma) in connection with COVID-19 clinical ca Q26. What kind of harassment (stigma) has occurred in your medical facility? Q27. Are there any plans to change the system of medical care at your medical facility due to COVID-19 ?

How does the role of the respiratory physician change (or has changed) when the medical system is changed in your medical Q29. Which of the following items do you find most stressful when you care for COVID-19 patients at your hospital? (Multiple ans Q30. What treatment is provided for mild COVID-19 at your facility?

What treatment is provided for moderate II (requiring oxygen therapy) COVID-19 at your facility? (Multiple answers are accep Q32. What treatment is provided for severe COVID-19 (requiring intensive care) at your facility?

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Manuscript Title: The effect of outbreak of coronavirus disease 2019 on respiratory physicians and healthcare in Japan:Serial nationwide surveys by the Japanese Respiratory Society All authors are required to disclose any COI within 3 calendar years preceding the current year, prior to the submission of any manuscript in the subject matter of which any company, entity, or organization has an interest.

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