SARS - Reflections on the Public Hospital System

Dr. William Ho
Chief Executive, Hospital Authority

At the time of my writing, the total number of SARS cases in the Hospital Authority (HA) has just dipped for the first time. I hope by the time this issue is published, there will indeed be a sustained decreasing trend.

No doubt, the challenge of SARS to the HA and the public health system in Hong Kong has been unprecedented, even of calamitous proportion. Given the resources that society spends on healthcare, I cannot conceive any decentralized hospital system not already crumbling under such pressure. Thanks to the immense dedication and professionalism of our staff in all the public hospitals, we have been withstanding the almost unmanageable pressure from this crisis so far. The exceptional quality of staff we have is of course the prime and most important success factor. They have paid a big price their health at risk and that of their family members, their social life severely disrupted, their fear and sorrow, and their extreme tiredness from overwork to help the constant flood of new patients, weeks and months on end. Yet they have persevered with great courage. I am deeply indebted and moved by all of them displaying human behavior of the highest order, given their own personal sacrifice and possible risks. The appreciation and gratitude from the community towards hospital staff come streaming in every day. Our private colleagues have not deserted us, and have indeed been greatly supporting us in all possible ways, for which they also should be praised.

There is little doubt that we are fortunate to have this public hospital system. We have seen how separate hospital systems in some places could not communicate effectively, let alone sharing information with common definition on the same platform and updating knowledge on a daily or even twice daily basis.

Yes there are criticisms on the success rate of treatment, on supplies, on statistics, on manpower deployment, and on just about everything. But remember this is a rapidly spreading disease with a lot of unknowns, requiring hospital treatment with lengths of stay almost five times that of the average patient in acute hospitals, and creating huge emotional challenge to staff. Remember the whole world is scrambling for the same sources of supplies, and for some items we even have to compete with others in Hong Kong. Remember that the emotional challenge applies no less to management staff who always take the blame.

There are indeed criticisms on why healthcare workers keep on getting infected. The usual blame is on supplies. Except in the earlier days, observations in the field usually point otherwise. Infection control teams have discovered environmental factors, and many behavior factors. Basically, we have to re-learn the whole game in caring for patients, in extreme busy wards, and with constant vigilance and enforcement. This is not easy! On top of that, there is the extreme difficulty of balancing the interests of patients and that of staff. Although we have repeated emphasized the need to protect staff first, it is easier said than done in the real world. Imagine a confused elderly SARS patient, coughing and sneezing while refusing to wear a mask, at the point of falling from bed. Do you than reflect on your step 1-7 before approaching him? This is just one example of the moral problems our staff face day in and day out. Very atypical presentations in some patients leading to inadequate alertness among staff also presents another big problem, and unfortunately have been accounting for quite a few clusters of staff morbidity.

In this exceptional battle, we did not have the luxury of preparation, something of paramount importance for all battles. This was Pearl Harbour attack magnified many folds, and in a rapidly escalating pattern. We hardly knew anything about the enemy in the beginning, and we still do not know everything. The situation is therefore novel, and extremely dynamic. There are no known rules, and therefore the learning has to be extremely fast, and strategies necessarily contingent and dynamic too.

Hence I mentioned the merit of the system. There are daily computerized updates on hospital situations all over the territory, albeit for a disease difficult to define, especially with the atypical presentations. There are daily updated advice to staff and messages to get across, including lessons learnt from individual hospital units to share among all. There is the need to make timely, bold decisions for opening/closure of services to respond to the uneven and sudden upsurge of patients, such as the Amoy Garden incident, with equally rapid corresponding response from other parts of the system to receive new and transfer patients. The volume pressure is so great everywhere that in fact none has real "spare capacity" to help out without trimming services in other areas, obviously with difficulty. Command and control on a large scale are therefore critical.

With hindsight, we have been lucky in our move towards cluster management of hospitals, which had just been accomplished. At least it is far more efficient and effective to involve, agree, and decide among Head Office and seven Cluster chiefs, and through them down the line, than with forty hospital chiefs together. There has also just been time for different hospitals to have worked together for a while, even consolidating services, to face this crisis where internal mobilization and internal cooperation are of utmost importance.

I do not pretend for one moment that we are satisfied. Indeed we are not, and have been constantly frustrated by the worrying situation. However, given the circumstances and limitations, this is probably what one can realistically hope for in any system. On the other hand, great opportunities have been opened up from such crisis. Experts from different hospitals, and indeed among HA and the two Universities, have come together for a common cause. Wisdom and experiences are pooled. Clinicians from one hospital start seeing patients and sharing expert advice to other hospitals. Whole teams have volunteered to help out others in need. Barriers vanished, bonds made.

In another dimension, variations in clinical and management strengths are also highlighted, magnified by the huge system stress. Some are hardly noticeable in the normal humdrum of the day. Many lessons are learned the hard way. These will no doubt point towards improvement directions and strategies in the re-building phase. The foundation and catalyst for necessary change are laid. Opportunities are opened up for long standing problems hitherto undiscovered, to be solved.

Lastly, when we have been previously frustrated by perceiving the lack of appreciation of our work by the public, I believe this is what they are telling us from the bottom of their hearts. Through solid acts of sustained professional dedication, we have won the respect and reputation that we rightly deserve, that in fact had been there all along in the public's mind. Even in the future, we should not be distracted by the noise out there, which masks the unfathomable gratitude that the community truly feels for our noble deeds.

But right now we need to stay united, together with private sector colleagues and the community, in overcoming this big challenge first. We will continue to make use of the system strengths, and a lot of goodwill and selflessness both inside and outside the HA organization, to fight this battle of the century.

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