As the outbreak of covid-19 developed in Wuhan and the number of people infected grew, health authorities realised that failure of home isolation was fuelling the epidemic: over half of the patients had one or more family members infected and up to 80% of the clusters were household ones. With hospital beds barely coping with the number of severe cases, the concept of “Fangcang” field hospitals was conceived. Field hospitals are not a new invention. It is a commonly employed measure during wars—the main ceremonial hall of the university where we work was converted during the peak of WWI for wounded soldiers returning from frontlines. Its introduction at the initial epicentre of the covid-19 pandemic to care for mild and moderate patients represents a timely and ingenious adaptation that has contributed to the control of the massive outbreak in Wuhan. 

In a recent paper in The Lancet, Chen et al. described the Fangcang hospitals in Wuhan. Their key features are “rapid construction, massive scale, and low cost.” In total, sixteen hospitals were set up in a three-week period, with a total of 13000 beds. Over a month or so from 6 February, they provided care to approximately 12000 patients with mild or moderate diseases. The last patient was discharged on 10 March 10, when operation of these hospitals was suspended.

In the UK, seven Nightingale Hospitals have been set up or commissioned, with three in London, Birmingham, and Manchester already in operation. Like Fangcang hospitals, they are based on repurposed convention centres. The planned functions of these hospitals are however different, with emphasis on supporting existing acute hospitals through providing additional bed based care, with varying levels of dependency and acuity. In the UK, is there a role for Fangcang hospitals?

Let’s look at the functions performed by these hospitals in Wuhan. They include: effective isolation to prevent household transmissions, triage of patients into different levels of severity, provision of basic medical care, close monitoring and prompt referral when patients’ conditions deteriorate, and basic living and social engagement.

Nightingale hospitals share little in common with Fangcang hospitals, even though they provide additional capacity for bed based care. Firstly, Nightingale hospitals do not prevent household transmission of covid-19. When patients with a clinical diagnosis of covid-19 are sent home from initial assessment in an emergency department or from a community covid hub, Nightingale hospitals are not included as a potential discharge location to prevent onward transmission within a patient’s household. Secondly, Nightingale hospitals do not perform face to face triage functions, leaving existing NHS physical assessment centres at risk of being overwhelmed during a surge in presentations. 

There is a marked variation in the level of acuity of patients that are treated in different Nightingale hospitals. The East London Nightingale has capacity to deliver mechanical ventilation which requires not only a stock of ventilators, but also a dedicated oxygen supply, a trained multidisciplinary team and sufficient drugs and drug infusion equipment for sedation. This risks removing staff from existing intensive care and acute medicine rotas and reducing stocks of essential items in intensive care units.

The Birmingham Nightingale, located at the National Exhibition Centre, will not have the capacity to deliver care that is escalated beyond general medical ward level. The aim of this particular Nightingale is not to provide additional intensive care beds, but instead to allow acute hospitals to maximise re-purposing of their existing infrastructure to increase their own intensive care capacity. The provision of step down care at this Nightingale will allow for greater availability of the general medical bed base within existing hospitals which will increase capacity to admit and monitor patients for whom intensive care is considered to be beneficial.

Nightingale hospitals are also not designed to deliver the basic living and social engagement of Fangcang hospitals. For the many older patients with frailty who are at significantly elevated risk for delirium with covid-19, the early instigation of rehabilitation and social contact is important in recovery. [1] There will be a significant requirement for rehabilitation amongst older and frail patients who recover from covid-19 which will overwhelm existing rehabilitation capacity.

Currently, Nightingale hospitals are significantly underutilised and remain largely empty. If social distancing measures have indeed reduced the risk of an unmanageable peak in presentations, then the net care capacity of the Nightingale Hospital space and staffing should be re-purposed to include components of the Fangcang Hospitals.

One prime candidate for consideration is the use of some of the Nightingale hospitals for isolating patients who would be identified by extensive case finding after substantially increased testing.  We do not have access to accurate figures, but anecdotal evidence suggests that household transmission is an important issue during lockdown as the risk of transmissions outside households is substantially reduced by social distancing.

In Wuhan this was considered a major problem that fuelled the epidemic after strict lockdown began. In fact, the primary motivation of Fangcang hospitals was probably to effectively isolate these patients to halt household transmissions. In the UK this could be a voluntary option and some patients who envisage difficulties in isolating themselves without infecting their loved ones may take up the offer. In multi-occupancy households with limited space, home isolation is particularly challenging if one or more of the members is infected. This approach may therefore help to reduce the socioeconomic disparities in the consequences of this pandemic. In the US similar schemes are being used in Florida and North Carolina, though patients are housed in settings such as unused hotel rooms.

As the epidemic evolves, Nightingale hospitals could provide resilience across the care system for future waves of infections after the reversal of “lockdown” measures. In addition to providing an alternative to home isolation, functions such as assessment and triage, supporting rehabilitation and end of life care can be considered. As most acute hospital trusts have rapidly provided additional acute care capacity through agile internal reconfigurations in the last few weeks, it would be important to look at how the existing Nightingale hospitals can be put to best use to help alleviating the health and social burdens from Covid-19.

Dan Lasserson is Professor of Ambulatory Care at the Institute of Applied Health Research, University of Birmingham. 

KK Cheng is Professor of Public Health and Primary Care and Director at the Institute of Applied Health Research, University of Birmingham. 

Competing interests: None declared

References:

1] LaHue S, James TC, Newman JC, Esmaili AM, Ormseth CH, Ely EW. Am Geriatr Soc, 2020 Apr 11  doi: 10.1111/jgs.16480