Jikeikai Med J 2022 ; 69 : 35-41

The effect of the COVID-19 outbreak on intensive carein northern Saitama, JapanKen Nakamura1, Kouan Orii2, Taichi Kondo2, Mitsutaka Nakao2,
Makoto Wakatabe2, and Takashi Kunihara1
1

Department of Cardiovascular Surgery, The Jikei University School of Medicine
Department of Cardiac Surgery, Saitama Prefectural Cardiovascular and Respiratory Center

2

ABSTRACT
Background : The 2020 COVID-19 pandemic had various effects on local healthcare. The aim of
this study was to assess the extent to which local healthcare and healthcare workers were affected by
the COVID-19 pandemic.
Methods : In this observational study we examined and compared intensive care units (ICUs)
before (2019) and during (2020) the COVID-19 pandemic to assess its effects. Emergency patient
data were obtained from the Saitama Prefecture Emergency Medical Information System. The effectof COVID-19 on emergency care responses was compared with the admission and refusal of patientsin 2019 and 2020. We also examined the number of patients who were admitted to ICUs and required
surgery. The effect on ICUs was examined with the number of Nurses’ incident reports and severity
percentages calculated from the integrated team medical care and safety system. We also compared
the overtime hours of physicians on the basis of employment records.
Results : In 2019, 2,136 emergency requests were made to admit patients, and 1,811 patients(85%) were admitted. In contrast, in 2020, 2,371 emergency requests were made, and 1,822 patients(76%) were admitted, representing a decrease to 76% (p = 0.931). The percentage of patients forwhom admission was refused was significantly greater in 2020 (506 patients, 21.3%) than in 2019 (303patients, 14.1% ; p = 0.0004). In 2020, the number of neurosurgical, cardiac, and vascular operations
increased and, over time, the number of operations increased for all surgical units. The number of incidents reported in ICUs increased significantly from 396 in 2019 to 510 in 2020 (p = 0.001).
Conclusion : Although intensive care management was restricted, the numbers of patients andphysician overtime hours were greater during the COVID-19 pandemic than before, and the resulting
environment led to an increase in the number of incidents. The ICU environments must be proactively improved to prepare for more severe situations in the future.
(Jikeikai Med J 2022 ; 69 : 35-41)
Key words : COVID-19, intensive care, incident report, emergency patients, overtime work

Introduction
The number of patients with new coronavirus infections has increased, leading to a prominent reduction in thenumber of hospital admissions for stroke, myocardial infarction, heart failure, or chronic obstructive pulmonary disease1.
Throughout Japan, this reduction of admissions has

Received January 14, 2022 / Accepted December 9, 2022
中村賢，織井 恒安，近藤 太一，中尾 充貴，若田部 誠，國原孝Mailing address : Ken Nakamura, Department of Cardiovascular Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi,
Minato-ku, Tokyo 105-8462, Japan
E-mail : cardiacsurgken@gmail.com, kenkentakota@yahoo.co.jp35

36

K. NAKAMURA, et al.

been referred to as the “healthcare shortage,” but to what

Vol. 69, No. 3

amined at the incident level.

extent it is currently being addressed is unknown and statistical data on the effects of the virus in local areas is not

Material and Methods

currently available. We undertook this research because theacceptance of emergency patients was no longer decided on

Study Design

the basis of the department’s capacity as it had been before

This study was approved by the Institutional Review

the COVID 19 pandemic. Against this background, we in-

Board of the Saitama Cardiovascular and Respiratory Cen-

vestigated the effect of COVID-19 on the intensive andter (No. 2021013) as an observational study. Written in-emergency care of patients in departments of surgery

formed consent to use the data for academic publication(mainly cardiac surgery, vascular surgery, neurosurgery, andpurposes was obtained from surgically treated patients, andrespiratory surgery) in 2020. In the Saitama Cardiovascular

opt-out information was provided on the hospital website

and Respiratory Center, we have dedicated personnel and a

and posted in the hospital.

-

department for treating patients who have COVID-19, andLocated in the northern part of Saitama Prefecture in

our emergency medical care system gives priority to admit-

Japan, our hospital can provide emergency medical care toting these patients. The admission to the emergency sys-

approximately 600,000 people, including those in the sur-tem of patients who do not have COVID 19 depends on therounding area. Apart from our hospital, there are 3 coreoccupancy of beds for patients who have COVID-19.

hospitals in the surrounding area that are smaller. We are-

The respiratory disease intensive care unit (RCU)

the only hospital in northern Saitama that provides emer-

plays an important role in treating patients who have severe

gency care and surgery in the fields of cardiovascular and

COVID-19 infections, and patients requiring intensive care

respiratory medicine. For this reason, our hospital attracts

after an operation are most often treated in the intensive

many patients who have been infected with COVID-19.

care unit (ICU). The RCU nurses are chiefly responsible for

The total number of beds in our hospital is 343, with-the care of patients who have COVID 19 but are supported

12 ICU beds and 10 RCU beds. Patients who have COV-

by ICU nurses during labor shortages.

ID-19 are most often treated by the respiratory medicine

Beds in the RCU have not always been fully occupied
by patients with COVID-19 as a result of the ongoing emer-

department, but when staffing is insufficient, other departments provide back-up.

gency declarations from the government throughout 2020.

In this study, we examined the effect of COVID-19 on

The number of nurses needed has varied according to CO-

the intensive care system by comparing 2019 (before the

VID 19 infection rates and the status of ICU support nurses

pandemic) with 2020 (during the pandemic). In the field of

has also fluctuated.

emergency medicine, we compared the effect of COVID-19-

The number of ICU beds depends on the number ofon emergency responses in terms of the number of re-nurses supporting the RCU and currently fluctuates from 4

quests for emergency patient admissions, the actual num-to 10 beds. Because the number of beds available for inten-

ber of admissions, and the admission refusal rate in 2019

sive care fluctuates during COVID 19, the effect of bed

and 2020. We also examined the number of operations per-control on the prognosis of patients is significant, and theformed by surgical departments and the number of patients-

emergency system for patients without COVID 19 is inevi-

requiring ICU admission. In addition, we compared thetably limited, which contributes to a tightening of regional

number of overtime hours of physicians engaged in inten-

medical care.

sive care from each department.

-

Due to the COIVD-19 pandemic the stress on nurses

The effect on intensive care, including that provided in

is extremely high, and the workload of ICU nurses has in-

the ICU, under the support system of nurses was examinedcreased and affected their usual way of providing care. A

in terms of the total number of incident reports and the se-study by Fernández Castillo et al assessing the effect onverity percentage calculated from the integrated team med-

nurses states found a high-quality training system is need-ical care and safety computer system (Safe Master®, Safe

ed because of the lack of humanistic nursing care2. The ef-

Master Inc., Fukuoka, Japan). The incident levels followed

fect on nurses during the COVID-19 pandemic was also ex-

the categories developed by Safe Master® (Table 1).

-

September, 2022

37

Intensive care during COVID-19
Table 1.

Incident levels*

Incident
Level

Description

0
0.01

Even if it had been implemented, the impact upon patients would have been small

0.02

If implemented, the impact upon patients would be considered moderate (requiring treatment).

0.03

If implemented, the effects on the bod y would be significant (potentially life-threatening).

1

Conducted, but no real harm to patient s (some effects t cannot be ruled out)

2

No treatment or therapy was given (the need for increased patient observation, minor changes in vital signs, and safety checks
arose).

3a

Required simple procedures and treatments (disinfecting, compressing, suturing skin, administering pain-killers, etc.)

3bRequired intensive treatment or therapy (e.g., severe change in vital signs, placement on a ventilator surgery, extended hospitalstay, outpatient admission, fracture)

4aPermanent disability and sequelae, with no significant functional impairment or cosmetic problems

4b

Death (excluding death due to the natural course of the primary disease)5

Effect on the patient cannot be determined

Results

Data Collection
Emergency patient data were managed by the Saitama

The total number of emergency patients, actual admis-

Prefecture Emergency Medical Information System. The

sions, and refusals of admission in 2019 and 2020 are shown®

incident level data were calculated with Safe Master . The

in Table 2. In 2019 and 2020, a total of 452 patients withnumber of operations was collected from hospital surgicallaboratory-confirmed COVID-19 were admitted to our hos-records, and the number of overtime hours was collectedpital.

from staff employment records.

In 2019, the total number of emergency patient requests was 2,136, and the total number of patients admitted

Statistical Analysis

was 1,811 (85%) (Table 2). In contrast, in 2020, the total

All data were analyzed with the software program IBM

number of emergency patient requests was 2,371, and the

SPSS Statistics for Windows (version 26.0 ; IBM Corp., Ar-

number of patients admitted was 1822 (76%), which was amonk, NY, USA). Continuous variables are presented as

decrease (p = 0.924). As a result of the inclusion of themeans. The normality of all variables was assessed with thefloating number of emergency calls, such as cancellations,Shapiro-Wilk test. A nonpaired t-test, the χ² test, or Fish-call failures, and requests for instructions, in the actual

er’s exact test was used to compare 2019 and 2020. Statisti-

number of emergency patients admitted, the number of pa-

cal significance was defined as a probability value of p < .05.

tients for whom admission was refused was significantly
higher in 2020 (506 patients, 21.3%) than in 2019 (303 pa-

Table 2.
Response

Emergency patient responses in 2019 and 2020
2019

Monthly average

2020
Total

Monthly average

Total

P

Emergency request*

178

2,136

197

2,371

0.067

Admission

150

1,811 (85%)

151

1,822 (76%)

0.924

Admission refusal

25  303 (14.1%)

42  506 (21.3%)≤ 0.01*Emergency requests were not equal as the actual acceptances and refusal because of the floating number of emergency requests, such as cancellations and call failures.

38

K. NAKAMURA, et al.

tients, 14.1% ; p ≤ 0.01).

Vol. 69, No. 3

higher, which require intense treatment, increased from 3

In 2020, the number of operations by the departmentsof neurosurgery, cardiac surgery, and vascular surgery wasin 2019 to 7 in 2020, but the difference was not significant(Table 3).

greater than that in 2019 (Fig. 1). The average number ofovertime hours per physician was also increased for those

Discussion

in the departments of neurosurgery, cardiac surgery, vascular surgery, cardiology, respiratory surgery, and gastrointes-

In 2020, hospitals throughout Japan began to give pri-tinal surgery (Fig. 2). The number of Nurses’ incident re-ority in their emergency systems to patients who had COV-

ports registered in Safe Master® and the severity of the

ID-19 infections, and the emergency responses for otherincidents are shown in Table 3. The number of incidents re-patients became a problem in every region. Our hospital,

ported in the ICU in 2019 was 396 and had increased signif-

located in the northern part of Saitama Prefecture, was no

icantly in 2020 to 510 (p ≤ 0.01) (Table 3).

exception, and gave priority to patients with COVID-19.

The average monthly number of incidents of level 0

Our hospital is one of the few hospitals in the region thatwas significantly higher in 2020 than in 2019 (p ≤ 0.01) (Ta-admits patients with COVID-19 and patients with other se-ble 3). Number
However, the numberof incidents of levelorvere conditions.
Because theinnorthernpartandof Saitama
Preof operations
per3bsurgicaldepartment
2019
2020
number
450

2019

400

2020

350
300
250
200
150
100
50
0

Average hours of overtime work by physicians per surgical department
Fig. 1. Number of operations per surgical department in 2019 and 2020.
in 2019 and 2020.
neurosurgery

cardiac surgery

vascular surgery

respiratory surgery gastrointestinal surgery

Fig. 1.

180
160

2019

2020

140
120
100
80
60
40
20
0

neurosurgery

cardiac surgery vascular surgery

cardiology

respiratory
surgery

respiratory
gastrointestinal
internal medicine
surgery

Fig. 2. Average hours of overtime work by physicians per surgical department in 2019 and 2020.
Fig.2.

September, 2022

39

Intensive care during COVID-19
Table 3.
Incident
Level

Number of incident reports in 2019 and 2020

2019
Monthly average

2020
Total

Monthly average

Total

P

0

4.3

52

10.3

124

≤ 0.01

1

16.7

201

18.8

226

0.05

2

8.1

98

8.8

106

0.15

3a

3.5

42

3.9

47

0.48
0.37

3b

0.25

  3

0.58

  7

4a

0

  0

0

  0

4b

0

  0

0

  0

5

0

  0

0

  0

Total

33

396

42

510

≤ 0.01fecture is a depopulated area with few hospitals, the needshowed surprising results compared with the situation be-

for local medical care is higher than in urban areas. De-fore the COVID-19 pandemic in 20195. The number of inci-

creases have been reported in the United States in thedents reported in our ICUs and RCUs was significantly

number of emergency admissions to Veterans Affairs hospi-

greater in 2020 than in 2019. We believe a reason for this1tals for patients without COVID 19 infections and theincrease was the inadequate management system for criti-

number of cardiac catheterizations performed3. However,cally ill general patients. The intensive care for patientssuch decreases do not apply to our hospital because it is inwith COVID-19 must be special, and medical personnel

a rural area.

must take all possible precautions ; hence, the use of ICUs-

Even when COVID-19 infections were widespread infor critically ill patients who did not have COVID-19 had to2020, the total number of emergency patient requests in-

be restricted because of a labor shortage. The level ofcreased for an unknown reason and confirmed that commu-

events was low in the majority of cases, however, indicating

nity based emergency medical care needed to be devel-that a minimum level of control could be maintained even in

oped. At the same time, our hospital, being a regional

the context of a high acceptance rate of patients who have

COVID 19 hospital, refused emergency admission for a

COVID-19 infections.

--higher percentage of patients than in 2019. A similar situa-

In contrast, the present study found that the number oftion led to an increase in out of hospital cardiac arrests insurgical operations for general critical care patients in-

Italy4. Moreover, for unknown reasons, the number of pa-

creased during the COVID-19 pandemic, reflecting the hightients in our hospital undergoing operations in surgical de-demand for critical care management and overtime by phy-partments, the main source of patients admitted to ICUs,

sicians. The increase in the number of overtime work hours

increased in 2020. Of note is that the present study foundof physicians might have been influenced by the overload ofthat COVID 19 had no effect on the number of operations

work due to the COVID-19 pandemic, which was not part

performed in 2020, compared with that in 2019. In the fu-of the normal system of care.

-

-

-

ture, we must ensure that services for emergency patients

Our results show that the environment in our region isare promptly available regardless of the situation of the pan-challenging, and that physicians, nurses, and other medical

demic.

staff work at the limit of their abilities. Nevertheless, ef-

The present study found that overtime work became

forts to treat emergencies, including COVID-19 infections,more common for physicians of the departments of neuro-

cannot be discontinued, and comprehensive national mea-

surgery, cardiac surgery, and vascular surgery, which oftensures are needed to prevent the collapse of community

refer patients to ICUs. This high amount of overtime work

healthcare.

was thought to be partly due to the increased number of

The Japanese Ministry of Health, Labour and Welfare

meetings and responses related to patients infected withaims to reform how physicians work and has established a

COVID-19. A study of the effect of this situation in the ICU

special level of overtime, which will come into effect in40

K. NAKAMURA, et al.

Vol. 69, No. 3

April 2024, to manage the problem of the uneven distribu-

important intellectual content. T.K. and M.N. provided ad-tion of physicians in rural areas. Nevertheless, this problem

ministrative support. K.N. and K.O. provided the study ma-

will not be solved unless the COVID-19 pandemic im-terials and access to the patients. K.N. collected and assem-

proves6. In addition to addressing working hours, also im-

bled the data. K.N. and T.K. analyzed the data andportant is to ensure that special infection prevention mea-

interpreted the results. All authors helped in the manu-

sures are implemented for healthcare workers exposed toscript writing and approved the version to be published.

7

COVID 19, especially those involved in intensive care .

Ethical statement : The authors are accountable for all

Phua et al. insisted that hospital administrators, govern-

aspects of the work in ensuring that questions related toments, and policy makers must work with ICU practitioners

the accuracy or integrity of any part of the work were ap-

to prepare for the substantial increase in critical care bed

propriately investigated and resolved. This study conformed

capacity and must protect healthcare workers from nosoco-

to the provisions of the Declaration of Helsinki and all its

mial transmission, physical exhaustion, and mental healthamendments. This study was approved by the Institutional

issues8.

Review Board of the Saitama Cardiovascular and Respirato--

A challenge for the future is to improve the medicalry Center (No. 2021013). Written informed consent was ob-

system and reduce the total number of incidents, even intained from the patients for use of the data for academic

situations where COVID 19 infections are widespread.

publication purposes if the patient needed an operation.

-

Reporting checklist statement : We present the folLimitations

lowing article/case in accordance with the STROBE

The northern part of Saitama Prefecture is a depopulated medical area, and this study is limited in its generaliz-(Strengthening the Reporting of Observational Studies in
Epidemiology) reporting checklist.

ability to the entire area because the data was collected at asingle institution. Furthermore, incident reports could not

Authors have no conflicts of interest.

be assessed with the person time method, which might not-provide an accurate comparison. In addition, we compared

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Conclusion
We investigated the current situation of intensive care2.

3.

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4.

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cidents. The environment of ICUs must be improved toprepare for more severe situations in the future.

6.

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