Israel’s hospitals received a letter from the Health Ministry last week, whose contents would be almost unimaginable in ordinary times: It warned that according to reference scenarios, within three to four months there will be 15,000 coronavirus patients in Israel in need of hospitalization, with 5,000 on ventilators simultaneously.
“This is a scenario that is hard to comprehend operationally, because it includes all the general care beds in the health care system,” according to the letter, which claims that in the summer the number of seriously ill coronavirus patients is expected to equal the number of hospital beds in Israel. Several days later another letter arrived – with more specific instructions to the hospitals: You must prepare within three weeks to operate the hospitals in such a way that 80 percent of activity will be devoted to treating those with the virus, and only 20 percent to other activity.
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These instructions are arousing a major uproar in the health care system. Already yesterday hospital occupancy dropped to 50 percent the normal rate – an unprecedented situation. The allocation of only 20 percent of beds for all the patients who are not suffering from COVID-19 is equivalent to a death sentence for many patients, warn senior officials in the system. Services such as surgery and treatments for cancer patients, dialysis, neonatal intensive care, heart attacks and strokes, trauma and other life-endangering conditions cannot be compressed into 20 percent of the hospital beds.
“It’s not logical,” said Prof. Ehud Davidson, director general of Clalit Health Services, which operates one third of the general hospital beds in Israel – about 5,000 beds. He estimates that “the minimum that must be left for hospital activity in order to provide a response for acute medical conditions – is about 40 percent of the beds. The allocation of 20 percent is extremely low and is also unfeasible – these people will come to the hospitals in any case, and I have an obligation to treat them.”
The director of Tel Aviv’s Ichilov Hospital, Prof. Ronni Gamzu, also says that “the expectation that there will be 15,000 seriously ill patients at once is an extreme forecast. In every country there is a heavy burden on intensive care, but it doesn’t reach a level of 80 percent of the beds in that country. The best thing is to plan two weeks ahead each time, based on developments, and not to prepare already now for another three months.”
Gamzu believes that “stopping ambulatory activity [which is planned in advance, and is not related to the virus] already on March 22 was premature, because today at Ichilov there are 10 people on ventilators, a similar number at the Sharon, Hadassah and Sheba hospitals, there are 20-25 moderately ill patients in the hospital, and most of the patients don’t belong in the hospitals.” He said “Already now the hospitals are operating at about 50 percent of capacity compared to the usual situation.”
When asked if this number is less than during the doctors’ strike in 2011, Gamzu says: “Far less. This is an unprecedented situation, even if we reduce ambulatory activity, it can’t continue for long. We have to work with a balance between serious restrictions and openness. The moment we go over to such a situation, the greatest challenge will be to ensure that people won’t die for reasons other than the coronavirus.”
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At Sheba Medical Center in Tel Hashomer they are also furious about the order. “This is a demand with a red flag waving above it,” wrote Prof. Arnon Afek, the hospital’s deputy director general, to the Health Ministry. “Such an important decision, which concerns human life, must be made in a joint forum, with experts on ethics, while surveying the situation in the hospital and understanding the significance.”
In a letter sent to the Health Ministry over the weekend by the chairman of the Israel Medical Association, Prof. Zion Hagay, he wrote that “Such a dramatic allocation of beds in favor of coronavirus patients only is likely to doom oncological patients, cardiac patients et al. The meaning of the order is to release hospitalized patients in total contradiction to their medical condition. This is both professionally and ethically unreasonable.” He said that the Health Ministry must find the balance between the need to treat seriously ill COVID-19 patients and the no less crucial need to provide essential medical care for other patients.”
So what can the Health Ministry do differently in order to prepare for a flood of coronavirus patients? The prevailing opinion is that the number of hospital beds must be increased, by setting up field hospitals for coronavirus patients, and to maintain the ability to admit other patients to the hospitals. “If we increase the entire pie and add several hundred more beds, we can accomplish the mission,” says Davidson.
“For that purpose we have to recruit internal medicine specialists who work in the community, and nurses with intensive care training who are also working in the community at present, and we have to train doctors from the surgical professions, such as orthopedists, ENTs, ophthalmologists and urologists, to join the teams that are treating COVID-19 patients,” says Davidson.
The Health Ministry responded: “The subject is constantly being examined, along with increasing the system’s treatment capability for an extreme scenario.”