Arpana R Vidyarthi, MD

Since its inception in the mid-1990s, the hospitalist model of care has enjoyed robust growth in the United States, increasing to around 20,000 providers by the end of its first decade.^1,2 Since then, it has far outstripped early predictions of adoption, currently standing at more than 50,000 hospitalist providers.² Although driven by numerous factors, including system-based management needs, provision of inpatient care for unassigned patients, and demands for improved patient safety and satisfaction, this meteoric growth has been driven largely by cost pressures particular to the US healthcare system.^1,2 Nonetheless, the growing complexity of healthcare systems, substantial fiscal pressures, and increasing healthcare demands from aging populations are worldwide challenges to which countries outside North America also seek solutions. Countries that have initiated hospitalist care have localized adoption, evolving the model to meet their unique fiscal and system-based needs and patients’ expectations.

While there has been keen interest in the hospitalist model in Asia, there has not yet been widespread adoption, despite numerous data demonstrating that this model is associated with lower length of stay (LOS), as well as lower costs and improved patient safety.^3,4 This article explores hospitalist care adoption experiences in Singapore, Taiwan, Korea, and Japan, focusing on stakeholder demand for hospitalist care, respective adoption, outcomes, and associated challenges to date.

Stakeholder Demand for Hospitalist Care

Historically in Singapore, family physicians provided primary care and internal medicine subspecialists provided inpatient care.⁵ Present-day trends, including an aging population, increasing rates of chronic diseases, and multisystem health issues, have stressed the historical model, leading to care fragmentation, long LOS (>9 days), and reduced patient satisfaction.^5,6 Additionally, as 80% of hospital care is government funded, public hospitals are under pressure to reduce healthcare expenditures.⁵

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

To meet patient needs and healthcare system challenges, the hospitalist model has evolved through several iterations in Singapore. The first model, implemented at Singapore General Hospital, utilized family physicians as hospitalists to coordinate inpatient care and integrate care between hospital and community settings.^3,5 This model resulted in shorter LOS and reduced costs for patients cared for by family physician hospitalists.³ Despite these benefits, the family physician hospitalist model did not spread, partly due to biases favoring subspecialist care for hospitalized patients.⁷

The next iteration utilized general internal medicine (GIM) specialists. Traditionally, GIM specialists cared for a small number of low-acuity hospitalized patients. Recognizing the emerging need for holistic inpatient care, the Singapore Ministry of Health supported advances in generalist care, including a financial bonus and a revamped GIM training program. This spawned hospitalist-type models nationwide. At the National University Hospital (NUH), for example, GIM physicians were recruited to care for “specialty” patients in the acute medical unit and increase their ward coverage to include complex multimorbid patients. Additionally, NUH launched the enhanced complex care program, providing integrated inpatient and outpatient care to high-utilizing, complex patients. Overall, the NUH GIM division grew by 70% (faculty) and 60% (trainees) over 5 years. Currently, fueled by government enthusiasm for generalist care, hospitalist-type models are evident at newly minted hospitals across Singapore.

Although physicians act as hospitalists, the term hospitalist is not embraced in Singapore, thus limiting its potential to develop clinical- and system-improvement competencies and establish professional identity. This may be due to the strong UK-based cultural foundations and continued systemic bias favoring subspecialists.⁸

Stakeholder Demand for Hospitalist Care

Under its national health insurance (NHI) system, Taiwan has relatively low copayments for medical services, with acute patients paying 10% of costs for a ≤30-day hospitalization, causing demand for inpatient care to remain strong.^4,9 The NHI system has also led to increased numbers of patients accessing care in emergency departments (EDs), where costs may be as low as US $16 (NT $450), causing long waits for evaluation and transfer to wards.^9,10 There remains an insufficient number of hospital-based physicians to manage this high patient volume, a situation exacerbated by low reimbursements.⁴

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

In order to address rising admissions, inefficient ED management, and physician shortages, a hospitalist care program was first introduced in Taiwan in 2002, followed by the establishment of a hospitalist-run ward in National Taiwan University Hospital in 2009.¹¹ Subsequent studies from Taiwan have found that hospitalist-run wards had lower admission costs, shorter LOS, and more do-not-resuscitate consent, and also had similar in-hospital mortality and readmission rates compared to specialist-run wards.^4,12 Reflecting these successes, the Taiwan Association of Hospital Medicine (TAHM) was established in 2018, and since January 2021, the Ministry of Health and Welfare of Taiwan has mandated hospital medicine programs as an accreditation requirement for all medical centers, with a dual role of educating residents and providing inpatient care.

Despite growing opportunities, Taiwan has seen a modest increase in the number of hospitalists, rising from three in 2009 to around 300 by January 2021. An indistinct professional identity and career path are the main barriers. Given this, TAHM is trying to strengthen hospitalist professionalism by introducing both hard and soft skills, such as utilizing point-of-care ultrasonography and implementing the concepts of Choosing Wisely^® and shared decision-making.

Stakeholder Demand for Hospitalist Care

Korea has experienced a chronic physician shortage, with just 2.4 physicians per 1,000 people (World Bank, 2017), leading to significant physician burnout. Designed to protect trainee well-being, the 2015 Improvement of Training Conditions and Status of Medical Residents Act limited resident work hours while reducing internal medicine and general surgery training periods, further exacerbating physician shortages.¹³ In addition, Korea’s current NHI system—including its’ healthcare insurance reimbursements scheme, established in 1989 when Korea’s per capita gross domestic product was less than US $5,000—provides low reimbursements to healthcare providers.¹⁴ Along with increased attention to patient safety and healthcare-related consumer expectations, the hospitalist system in Korea aims to maintain improvements to residents’ well-being, while increasing hospital revenue and meeting patient demand for improved services.¹⁴

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

Along with the Ministry of Health and Welfare, the Korean Health Insurance Review and Assessment Service launched a hospitalist pilot program in general medicine and surgery in 2016.¹⁵ Services for hospitalist-managed inpatients are charged on a new schedule covered by the NHI system, including facility fees, which are charged per diem, and separate hospitalist fees.¹⁴ New hospital medicine programs are utilized, in part, to recruit new physicians to manage a large volume of inpatients. Previous studies found that these new hospitalist care systems also improved patient safety, quality of care, and overall patient satisfaction, while being associated with shorter LOS and fewer unnecessary intensive care unit admissions.^16,17 After a successful pilot, the revamped reimbursement system for hospitalist care officially started in January 2021.

Although Korea had only 250 registered hospitalists by August 2020, this is likely a substantial underestimate, as only hospital medicine teams with more than two hospitalists were allowed formal registration during the pilot period. Wider registration is currently underway for the new official reimbursement system.

Stakeholder Demand for Hospitalist Care

Hospitals in Japan are organized into highly compartmentalized subspecialties. Providing quality inpatient care to senior patients, who account for more than 28% of the population, and managing smooth transitions from hospital to long-term- care facilities remain challenging. In addition, given generous caps on maximum monthly out-of-pocket payments under its NHI system, LOS for Japanese hospitals are as long as 16.1 days.¹⁸ Nonetheless, given rising financial burdens associated with long-term care, hospitals are under government pressure to further shorten LOS and transition patients to local long-term-care facilities after treatment for acute symptoms.

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

To meet these challenges, an increasing number of Japanese hospitals have established departments of general medicine to triage and manage patients with multiple comorbidities and to coordinate patient care across relevant specialties. The Japanese Society of Hospital General Medicine (JSHGM) was established in 2010, and currently has 1,890 members from 896 medical institutions. In 2018, general medicine was recognized by the Japanese Board of Medical Specialties as a formal specialty for certification. Currently, JSHGM is working with the Japan Primary Care Association and other organizations to establish a specialty certification system for hospitalist physicians and raise awareness of hospital medicine. A Japanese study of elderly patients with chronic aspiration pneumonia found that care by hospitalists resulted in shorter LOS and lower costs than specialist care.¹⁹ Recently, hospitalists have played a central role in COVID-19 management, opening fever intake clinics and establishing collaborative guidelines with infectious disease experts and other specialists.

Yet, different from the prototypical hospitalist first defined by Wachter and Goldman, Japanese general medicine hospitalists continue to have substantial outpatient responsibilities, albeit in the hospital setting. Out of 81 university hospitals, 69 now have a department of hospital general medicine, though only 20 have inpatient services.²⁰ In addition, a medical culture in which patients continue to see their surgery attendings long after surgery remains strong. Clear definitions regarding hospitalists’ roles need to be established, while promoting changes toward inpatient care for both patients and subspecialists.

The four Asian countries reviewed here have all established universal access to healthcare, with Taiwan, Korea, and Japan having strong NHI systems and Singapore providing significant healthcare subsidies for those in need. Nonetheless, they also face similar challenges, including the growing complexity of healthcare systems, substantial fiscal pressures, increased healthcare demands caused by aging populations, and increased expectations regarding stakeholder well-being. As such, these countries share common driving forces that are propelling the adoption of hospitalist care models, such as lack of a sufficient physician workforce on inpatient wards; need for extra resources to shorten ED wait times prior to inpatient admission; need for providing quality care to multimorbid senior patients across highly segmented hospital departments and coordinating medical services between hospitals and outpatient care facilities; and government pressure on cutting costs, especially by shortening inpatient LOS. Some common barriers among these Asian countries include unclear definitions of hospitalists’ roles and degree of collaboration with subspecialty departments, and social and systemic biases favoring subspecialty care for inpatients.

The four Asian countries reviewed here have chosen to adopt the hospitalist model as a supplement to already established, specialty-driven inpatient care systems; as such, further comparative outcome studies focusing on cost, care quality, and patient safety and satisfaction are warranted to bolster professional hospitalist roles, further facilitate government/policy-level support for hospital care systems, and promote future training and certification systems appropriate to each country’s unique healthcare system and medical culture. Similarly, evidence-driven educational outreach programs are warranted to facilitate patient understanding of the role of hospitalists in their care.For countries interested in establishing hospital medicine programs, the adoption experiences in Singapore, Taiwan, Korea, and Japan provide valuable insights regarding how to establish hospitalist models to meet country-specific healthcare challenges while successfully functioning in the context of their unique medical-system frameworks.

Since its inception in the mid-1990s, the hospitalist model of care has enjoyed robust growth in the United States, increasing to around 20,000 providers by the end of its first decade.^1,2 Since then, it has far outstripped early predictions of adoption, currently standing at more than 50,000 hospitalist providers.² Although driven by numerous factors, including system-based management needs, provision of inpatient care for unassigned patients, and demands for improved patient safety and satisfaction, this meteoric growth has been driven largely by cost pressures particular to the US healthcare system.^1,2 Nonetheless, the growing complexity of healthcare systems, substantial fiscal pressures, and increasing healthcare demands from aging populations are worldwide challenges to which countries outside North America also seek solutions. Countries that have initiated hospitalist care have localized adoption, evolving the model to meet their unique fiscal and system-based needs and patients’ expectations.

While there has been keen interest in the hospitalist model in Asia, there has not yet been widespread adoption, despite numerous data demonstrating that this model is associated with lower length of stay (LOS), as well as lower costs and improved patient safety.^3,4 This article explores hospitalist care adoption experiences in Singapore, Taiwan, Korea, and Japan, focusing on stakeholder demand for hospitalist care, respective adoption, outcomes, and associated challenges to date.

Stakeholder Demand for Hospitalist Care

Historically in Singapore, family physicians provided primary care and internal medicine subspecialists provided inpatient care.⁵ Present-day trends, including an aging population, increasing rates of chronic diseases, and multisystem health issues, have stressed the historical model, leading to care fragmentation, long LOS (>9 days), and reduced patient satisfaction.^5,6 Additionally, as 80% of hospital care is government funded, public hospitals are under pressure to reduce healthcare expenditures.⁵

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

To meet patient needs and healthcare system challenges, the hospitalist model has evolved through several iterations in Singapore. The first model, implemented at Singapore General Hospital, utilized family physicians as hospitalists to coordinate inpatient care and integrate care between hospital and community settings.^3,5 This model resulted in shorter LOS and reduced costs for patients cared for by family physician hospitalists.³ Despite these benefits, the family physician hospitalist model did not spread, partly due to biases favoring subspecialist care for hospitalized patients.⁷

The next iteration utilized general internal medicine (GIM) specialists. Traditionally, GIM specialists cared for a small number of low-acuity hospitalized patients. Recognizing the emerging need for holistic inpatient care, the Singapore Ministry of Health supported advances in generalist care, including a financial bonus and a revamped GIM training program. This spawned hospitalist-type models nationwide. At the National University Hospital (NUH), for example, GIM physicians were recruited to care for “specialty” patients in the acute medical unit and increase their ward coverage to include complex multimorbid patients. Additionally, NUH launched the enhanced complex care program, providing integrated inpatient and outpatient care to high-utilizing, complex patients. Overall, the NUH GIM division grew by 70% (faculty) and 60% (trainees) over 5 years. Currently, fueled by government enthusiasm for generalist care, hospitalist-type models are evident at newly minted hospitals across Singapore.

Although physicians act as hospitalists, the term hospitalist is not embraced in Singapore, thus limiting its potential to develop clinical- and system-improvement competencies and establish professional identity. This may be due to the strong UK-based cultural foundations and continued systemic bias favoring subspecialists.⁸

Stakeholder Demand for Hospitalist Care

Under its national health insurance (NHI) system, Taiwan has relatively low copayments for medical services, with acute patients paying 10% of costs for a ≤30-day hospitalization, causing demand for inpatient care to remain strong.^4,9 The NHI system has also led to increased numbers of patients accessing care in emergency departments (EDs), where costs may be as low as US $16 (NT $450), causing long waits for evaluation and transfer to wards.^9,10 There remains an insufficient number of hospital-based physicians to manage this high patient volume, a situation exacerbated by low reimbursements.⁴

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

In order to address rising admissions, inefficient ED management, and physician shortages, a hospitalist care program was first introduced in Taiwan in 2002, followed by the establishment of a hospitalist-run ward in National Taiwan University Hospital in 2009.¹¹ Subsequent studies from Taiwan have found that hospitalist-run wards had lower admission costs, shorter LOS, and more do-not-resuscitate consent, and also had similar in-hospital mortality and readmission rates compared to specialist-run wards.^4,12 Reflecting these successes, the Taiwan Association of Hospital Medicine (TAHM) was established in 2018, and since January 2021, the Ministry of Health and Welfare of Taiwan has mandated hospital medicine programs as an accreditation requirement for all medical centers, with a dual role of educating residents and providing inpatient care.

Despite growing opportunities, Taiwan has seen a modest increase in the number of hospitalists, rising from three in 2009 to around 300 by January 2021. An indistinct professional identity and career path are the main barriers. Given this, TAHM is trying to strengthen hospitalist professionalism by introducing both hard and soft skills, such as utilizing point-of-care ultrasonography and implementing the concepts of Choosing Wisely^® and shared decision-making.

Stakeholder Demand for Hospitalist Care

Korea has experienced a chronic physician shortage, with just 2.4 physicians per 1,000 people (World Bank, 2017), leading to significant physician burnout. Designed to protect trainee well-being, the 2015 Improvement of Training Conditions and Status of Medical Residents Act limited resident work hours while reducing internal medicine and general surgery training periods, further exacerbating physician shortages.¹³ In addition, Korea’s current NHI system—including its’ healthcare insurance reimbursements scheme, established in 1989 when Korea’s per capita gross domestic product was less than US $5,000—provides low reimbursements to healthcare providers.¹⁴ Along with increased attention to patient safety and healthcare-related consumer expectations, the hospitalist system in Korea aims to maintain improvements to residents’ well-being, while increasing hospital revenue and meeting patient demand for improved services.¹⁴

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

Along with the Ministry of Health and Welfare, the Korean Health Insurance Review and Assessment Service launched a hospitalist pilot program in general medicine and surgery in 2016.¹⁵ Services for hospitalist-managed inpatients are charged on a new schedule covered by the NHI system, including facility fees, which are charged per diem, and separate hospitalist fees.¹⁴ New hospital medicine programs are utilized, in part, to recruit new physicians to manage a large volume of inpatients. Previous studies found that these new hospitalist care systems also improved patient safety, quality of care, and overall patient satisfaction, while being associated with shorter LOS and fewer unnecessary intensive care unit admissions.^16,17 After a successful pilot, the revamped reimbursement system for hospitalist care officially started in January 2021.

Although Korea had only 250 registered hospitalists by August 2020, this is likely a substantial underestimate, as only hospital medicine teams with more than two hospitalists were allowed formal registration during the pilot period. Wider registration is currently underway for the new official reimbursement system.

Stakeholder Demand for Hospitalist Care

Hospitals in Japan are organized into highly compartmentalized subspecialties. Providing quality inpatient care to senior patients, who account for more than 28% of the population, and managing smooth transitions from hospital to long-term- care facilities remain challenging. In addition, given generous caps on maximum monthly out-of-pocket payments under its NHI system, LOS for Japanese hospitals are as long as 16.1 days.¹⁸ Nonetheless, given rising financial burdens associated with long-term care, hospitals are under government pressure to further shorten LOS and transition patients to local long-term-care facilities after treatment for acute symptoms.

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

To meet these challenges, an increasing number of Japanese hospitals have established departments of general medicine to triage and manage patients with multiple comorbidities and to coordinate patient care across relevant specialties. The Japanese Society of Hospital General Medicine (JSHGM) was established in 2010, and currently has 1,890 members from 896 medical institutions. In 2018, general medicine was recognized by the Japanese Board of Medical Specialties as a formal specialty for certification. Currently, JSHGM is working with the Japan Primary Care Association and other organizations to establish a specialty certification system for hospitalist physicians and raise awareness of hospital medicine. A Japanese study of elderly patients with chronic aspiration pneumonia found that care by hospitalists resulted in shorter LOS and lower costs than specialist care.¹⁹ Recently, hospitalists have played a central role in COVID-19 management, opening fever intake clinics and establishing collaborative guidelines with infectious disease experts and other specialists.

Yet, different from the prototypical hospitalist first defined by Wachter and Goldman, Japanese general medicine hospitalists continue to have substantial outpatient responsibilities, albeit in the hospital setting. Out of 81 university hospitals, 69 now have a department of hospital general medicine, though only 20 have inpatient services.²⁰ In addition, a medical culture in which patients continue to see their surgery attendings long after surgery remains strong. Clear definitions regarding hospitalists’ roles need to be established, while promoting changes toward inpatient care for both patients and subspecialists.

The four Asian countries reviewed here have all established universal access to healthcare, with Taiwan, Korea, and Japan having strong NHI systems and Singapore providing significant healthcare subsidies for those in need. Nonetheless, they also face similar challenges, including the growing complexity of healthcare systems, substantial fiscal pressures, increased healthcare demands caused by aging populations, and increased expectations regarding stakeholder well-being. As such, these countries share common driving forces that are propelling the adoption of hospitalist care models, such as lack of a sufficient physician workforce on inpatient wards; need for extra resources to shorten ED wait times prior to inpatient admission; need for providing quality care to multimorbid senior patients across highly segmented hospital departments and coordinating medical services between hospitals and outpatient care facilities; and government pressure on cutting costs, especially by shortening inpatient LOS. Some common barriers among these Asian countries include unclear definitions of hospitalists’ roles and degree of collaboration with subspecialty departments, and social and systemic biases favoring subspecialty care for inpatients.

The four Asian countries reviewed here have chosen to adopt the hospitalist model as a supplement to already established, specialty-driven inpatient care systems; as such, further comparative outcome studies focusing on cost, care quality, and patient safety and satisfaction are warranted to bolster professional hospitalist roles, further facilitate government/policy-level support for hospital care systems, and promote future training and certification systems appropriate to each country’s unique healthcare system and medical culture. Similarly, evidence-driven educational outreach programs are warranted to facilitate patient understanding of the role of hospitalists in their care.For countries interested in establishing hospital medicine programs, the adoption experiences in Singapore, Taiwan, Korea, and Japan provide valuable insights regarding how to establish hospitalist models to meet country-specific healthcare challenges while successfully functioning in the context of their unique medical-system frameworks.

Since its inception in the mid-1990s, the hospitalist model of care has enjoyed robust growth in the United States, increasing to around 20,000 providers by the end of its first decade.^1,2 Since then, it has far outstripped early predictions of adoption, currently standing at more than 50,000 hospitalist providers.² Although driven by numerous factors, including system-based management needs, provision of inpatient care for unassigned patients, and demands for improved patient safety and satisfaction, this meteoric growth has been driven largely by cost pressures particular to the US healthcare system.^1,2 Nonetheless, the growing complexity of healthcare systems, substantial fiscal pressures, and increasing healthcare demands from aging populations are worldwide challenges to which countries outside North America also seek solutions. Countries that have initiated hospitalist care have localized adoption, evolving the model to meet their unique fiscal and system-based needs and patients’ expectations.

While there has been keen interest in the hospitalist model in Asia, there has not yet been widespread adoption, despite numerous data demonstrating that this model is associated with lower length of stay (LOS), as well as lower costs and improved patient safety.^3,4 This article explores hospitalist care adoption experiences in Singapore, Taiwan, Korea, and Japan, focusing on stakeholder demand for hospitalist care, respective adoption, outcomes, and associated challenges to date.

Stakeholder Demand for Hospitalist Care

Historically in Singapore, family physicians provided primary care and internal medicine subspecialists provided inpatient care.⁵ Present-day trends, including an aging population, increasing rates of chronic diseases, and multisystem health issues, have stressed the historical model, leading to care fragmentation, long LOS (>9 days), and reduced patient satisfaction.^5,6 Additionally, as 80% of hospital care is government funded, public hospitals are under pressure to reduce healthcare expenditures.⁵

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

To meet patient needs and healthcare system challenges, the hospitalist model has evolved through several iterations in Singapore. The first model, implemented at Singapore General Hospital, utilized family physicians as hospitalists to coordinate inpatient care and integrate care between hospital and community settings.^3,5 This model resulted in shorter LOS and reduced costs for patients cared for by family physician hospitalists.³ Despite these benefits, the family physician hospitalist model did not spread, partly due to biases favoring subspecialist care for hospitalized patients.⁷

The next iteration utilized general internal medicine (GIM) specialists. Traditionally, GIM specialists cared for a small number of low-acuity hospitalized patients. Recognizing the emerging need for holistic inpatient care, the Singapore Ministry of Health supported advances in generalist care, including a financial bonus and a revamped GIM training program. This spawned hospitalist-type models nationwide. At the National University Hospital (NUH), for example, GIM physicians were recruited to care for “specialty” patients in the acute medical unit and increase their ward coverage to include complex multimorbid patients. Additionally, NUH launched the enhanced complex care program, providing integrated inpatient and outpatient care to high-utilizing, complex patients. Overall, the NUH GIM division grew by 70% (faculty) and 60% (trainees) over 5 years. Currently, fueled by government enthusiasm for generalist care, hospitalist-type models are evident at newly minted hospitals across Singapore.

Although physicians act as hospitalists, the term hospitalist is not embraced in Singapore, thus limiting its potential to develop clinical- and system-improvement competencies and establish professional identity. This may be due to the strong UK-based cultural foundations and continued systemic bias favoring subspecialists.⁸

Stakeholder Demand for Hospitalist Care

Under its national health insurance (NHI) system, Taiwan has relatively low copayments for medical services, with acute patients paying 10% of costs for a ≤30-day hospitalization, causing demand for inpatient care to remain strong.^4,9 The NHI system has also led to increased numbers of patients accessing care in emergency departments (EDs), where costs may be as low as US $16 (NT $450), causing long waits for evaluation and transfer to wards.^9,10 There remains an insufficient number of hospital-based physicians to manage this high patient volume, a situation exacerbated by low reimbursements.⁴

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

In order to address rising admissions, inefficient ED management, and physician shortages, a hospitalist care program was first introduced in Taiwan in 2002, followed by the establishment of a hospitalist-run ward in National Taiwan University Hospital in 2009.¹¹ Subsequent studies from Taiwan have found that hospitalist-run wards had lower admission costs, shorter LOS, and more do-not-resuscitate consent, and also had similar in-hospital mortality and readmission rates compared to specialist-run wards.^4,12 Reflecting these successes, the Taiwan Association of Hospital Medicine (TAHM) was established in 2018, and since January 2021, the Ministry of Health and Welfare of Taiwan has mandated hospital medicine programs as an accreditation requirement for all medical centers, with a dual role of educating residents and providing inpatient care.

Despite growing opportunities, Taiwan has seen a modest increase in the number of hospitalists, rising from three in 2009 to around 300 by January 2021. An indistinct professional identity and career path are the main barriers. Given this, TAHM is trying to strengthen hospitalist professionalism by introducing both hard and soft skills, such as utilizing point-of-care ultrasonography and implementing the concepts of Choosing Wisely^® and shared decision-making.

Stakeholder Demand for Hospitalist Care

Korea has experienced a chronic physician shortage, with just 2.4 physicians per 1,000 people (World Bank, 2017), leading to significant physician burnout. Designed to protect trainee well-being, the 2015 Improvement of Training Conditions and Status of Medical Residents Act limited resident work hours while reducing internal medicine and general surgery training periods, further exacerbating physician shortages.¹³ In addition, Korea’s current NHI system—including its’ healthcare insurance reimbursements scheme, established in 1989 when Korea’s per capita gross domestic product was less than US $5,000—provides low reimbursements to healthcare providers.¹⁴ Along with increased attention to patient safety and healthcare-related consumer expectations, the hospitalist system in Korea aims to maintain improvements to residents’ well-being, while increasing hospital revenue and meeting patient demand for improved services.¹⁴

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

Along with the Ministry of Health and Welfare, the Korean Health Insurance Review and Assessment Service launched a hospitalist pilot program in general medicine and surgery in 2016.¹⁵ Services for hospitalist-managed inpatients are charged on a new schedule covered by the NHI system, including facility fees, which are charged per diem, and separate hospitalist fees.¹⁴ New hospital medicine programs are utilized, in part, to recruit new physicians to manage a large volume of inpatients. Previous studies found that these new hospitalist care systems also improved patient safety, quality of care, and overall patient satisfaction, while being associated with shorter LOS and fewer unnecessary intensive care unit admissions.^16,17 After a successful pilot, the revamped reimbursement system for hospitalist care officially started in January 2021.

Although Korea had only 250 registered hospitalists by August 2020, this is likely a substantial underestimate, as only hospital medicine teams with more than two hospitalists were allowed formal registration during the pilot period. Wider registration is currently underway for the new official reimbursement system.

Stakeholder Demand for Hospitalist Care

Hospitals in Japan are organized into highly compartmentalized subspecialties. Providing quality inpatient care to senior patients, who account for more than 28% of the population, and managing smooth transitions from hospital to long-term- care facilities remain challenging. In addition, given generous caps on maximum monthly out-of-pocket payments under its NHI system, LOS for Japanese hospitals are as long as 16.1 days.¹⁸ Nonetheless, given rising financial burdens associated with long-term care, hospitals are under government pressure to further shorten LOS and transition patients to local long-term-care facilities after treatment for acute symptoms.

Adoption of Hospitalist Care, Outcomes, and Challenges Faced

To meet these challenges, an increasing number of Japanese hospitals have established departments of general medicine to triage and manage patients with multiple comorbidities and to coordinate patient care across relevant specialties. The Japanese Society of Hospital General Medicine (JSHGM) was established in 2010, and currently has 1,890 members from 896 medical institutions. In 2018, general medicine was recognized by the Japanese Board of Medical Specialties as a formal specialty for certification. Currently, JSHGM is working with the Japan Primary Care Association and other organizations to establish a specialty certification system for hospitalist physicians and raise awareness of hospital medicine. A Japanese study of elderly patients with chronic aspiration pneumonia found that care by hospitalists resulted in shorter LOS and lower costs than specialist care.¹⁹ Recently, hospitalists have played a central role in COVID-19 management, opening fever intake clinics and establishing collaborative guidelines with infectious disease experts and other specialists.

Yet, different from the prototypical hospitalist first defined by Wachter and Goldman, Japanese general medicine hospitalists continue to have substantial outpatient responsibilities, albeit in the hospital setting. Out of 81 university hospitals, 69 now have a department of hospital general medicine, though only 20 have inpatient services.²⁰ In addition, a medical culture in which patients continue to see their surgery attendings long after surgery remains strong. Clear definitions regarding hospitalists’ roles need to be established, while promoting changes toward inpatient care for both patients and subspecialists.

The four Asian countries reviewed here have all established universal access to healthcare, with Taiwan, Korea, and Japan having strong NHI systems and Singapore providing significant healthcare subsidies for those in need. Nonetheless, they also face similar challenges, including the growing complexity of healthcare systems, substantial fiscal pressures, increased healthcare demands caused by aging populations, and increased expectations regarding stakeholder well-being. As such, these countries share common driving forces that are propelling the adoption of hospitalist care models, such as lack of a sufficient physician workforce on inpatient wards; need for extra resources to shorten ED wait times prior to inpatient admission; need for providing quality care to multimorbid senior patients across highly segmented hospital departments and coordinating medical services between hospitals and outpatient care facilities; and government pressure on cutting costs, especially by shortening inpatient LOS. Some common barriers among these Asian countries include unclear definitions of hospitalists’ roles and degree of collaboration with subspecialty departments, and social and systemic biases favoring subspecialty care for inpatients.

The four Asian countries reviewed here have chosen to adopt the hospitalist model as a supplement to already established, specialty-driven inpatient care systems; as such, further comparative outcome studies focusing on cost, care quality, and patient safety and satisfaction are warranted to bolster professional hospitalist roles, further facilitate government/policy-level support for hospital care systems, and promote future training and certification systems appropriate to each country’s unique healthcare system and medical culture. Similarly, evidence-driven educational outreach programs are warranted to facilitate patient understanding of the role of hospitalists in their care.For countries interested in establishing hospital medicine programs, the adoption experiences in Singapore, Taiwan, Korea, and Japan provide valuable insights regarding how to establish hospitalist models to meet country-specific healthcare challenges while successfully functioning in the context of their unique medical-system frameworks.

One of the worst public health threats of our generation, coronavirus disease 2019 (COVID-19), first emerged in Wuhan, China, in December 2019 and quickly spread to Singapore, Hong Kong, and Taiwan. These three countries have been praised for their control of the pandemic,^1,2 while the number of cases worldwide, including those in the United States, has soared. Political alignment, centralized and integrated healthcare systems, small size, effective technology deployment, widespread testing combined with contact tracing and isolation, and personal protective equipment (PPE) availability underscore their successes.^1,3-5 Although these factors differ starkly from those currently employed in the United States, a better understanding their experience may positively influence the myriad US responses. We describe some salient features of Singapore’s infection preparedness, provide examples of how these features guided the National University Hospital (NUH) Singapore COVID-19 response, and illustrate how one facet of the NUH response was translated to develop a new care model at the University of California, San Francisco (UCSF).

Singapore, a small island country (278 square miles) city-state in Southeast Asia has a population of 5.8 million people. Most Singaporeans receive their inpatient care in the public hospitals that are organized and resourced through the Singapore Ministry of Health (MOH). In 2003, severe acute respiratory syndrome (SARS) infected 238 people and killed 33 over 3 months in Singapore, which led to a significant economic downturn. Singapore’s initial SARS experience unveiled limitations in infrastructure, staff preparedness, virus control methodology, and centralized crisis systems. Lessons gleaned from the SARS experience laid the foundation for Singapore’s subsequent disaster preparedness.⁶

Post-SARS, the MOH created structures and systems to prepare Singapore for future epidemics. All public hospitals expanded isolation capacity by constructing new units or repurposing existing ones and creating colocated Emergency Department (ED) isolation facilities. Additionally, the MOH commissioned the National Centre for Infectious Diseases, a 330-bed high-level isolation hospital.⁷ They also mandated hospital systems to regularly practice mass casualty and infectious (including respiratory) crisis responses through externally evaluated simulation.⁸ These are orchestrated down to the smallest detail and involve staff at all levels. For example, healthcare workers (HCW) being “deployed” outside of their specialty, housekeepers practicing novel hazardous waste disposal, and security guards managing crowds interact throughout the exercise.

The testing and viral spread control challenges during SARS spawned hospital-system epidemiology capacity building. Infectious diseases reporting guidelines were refined, and communication channels enhanced to include cross-hospital information sharing and direct lines of communication for epidemiology groups to and from the MOH. Enhanced contact tracing methodologies were adopted and practiced regularly. In addition, material stockpiles, supplies, and supply chains were recalibrated.

The Singapore government also adopted the Disease Outbreak Response System Condition (DORSCON) system,⁹ a color-coded framework for pandemic response that guides activation of crisis interventions broadly (such as temperature screening at airports and restrictions to travel and internal movements), as well as within the healthcare setting.

In addition to prompting these notable preparedness efforts, SARS had a palpable impact on Singaporeans’ collective psychology both within and outside of the hospital system. The very close-knit medical community lost colleagues during the crisis, and the larger community deeply felt the health and economic costs of this crisis.¹⁰ The resulting “respect” or “healthy fear” for infectious crises continues to the present day.

The NUH is a 1,200-bed public tertiary care academic health center in Singapore. Before the first COVID-19 case was diagnosed in Singapore, NUH joined forces with its broader health system, university resources (schools of medicine and public health), and international partners to refine the existing structures and systems in response to this new infectious threat.

One of these structures included the existing NUH ED negative-pressure “fever facility.” In the ED triage, patients are routinely screened for infectious diseases such as H1N1, MERS-CoV, and measles. In early January, these screening criteria were evolved to adapt to COVID-19. High-risk patients bypass common waiting areas and are sent directly to the fever facility for management. From there, patients requiring admission are sent to one of the inpatient isolation wards, each with over 21 negative-pressure isolation rooms. To expand isolation capacity, lower-priority patients were relocated, and the existing negative- and neutral-pressure rooms were converted into COVID-19 pandemic wards.

The pandemic wards are staffed by nurses with previous isolation experience and Internal Medicine and Subspecialty Medicine physicians and trainees working closely with Infectious Diseases experts. Pandemic Ward teams are sequestered from other clinical and administrative teams, wear hospital-­laundered scrubs, and use PPE-conserving practices. These strategies, implemented at the outset, are based on international guidelines contextualized to local needs and include extended use (up to 6 hours) of N95 respirators for the pandemic wards, and surgical masks in all other clinical areas. Notably, there have been no documented transmissions to HCW or patients at NUH. The workforce was maximized by limiting nonurgent clinical, administrative, research, and teaching activities.

In February, COVID-19 testing was initiated internally and deployed widely. NUH, at the time of this writing, has performed more than 6,000 swabs with up to 200 tests run per day (with 80 confirmed cases). Testing at this scale has allowed NUH to ensure: (a) prompt isolation of patients, even those with mild symptoms, (b) deisolation of those testing negative thus conserving PPE and isolation facilities, (c) a better understanding of the epidemiology and the wide range of clinical manifestations of COVID-19, and (d) early comprehensive contact tracing including mildly symptomatic patients.

The MOH plays a central role in coordinating COVID-19 activities and supports individual hospital systems such as NUH. Some of their crisis leadership strategies include daily text messages distributed countrywide, two-way communication channels that ensure feedback loops with hospital executives, epidemiology specialists, and operational workgroups, and engendering interhospital collaboration.¹¹

In the United States, the Joint Commission provides structures, tools, and processes for hospital systems to prepare for disasters.¹² Many hospital systems have experience with natural disasters which, similar to Singapore’s planning, ensures structures and systems are in place during a crisis. Although these are transferable to multiple types of disasters, the US healthcare system’s direct experience with infectious crises is limited. A fairly distinctive facet—and an asset of US healthcare—is the role of hospitalists.

Hospitalists care for the majority of medical inpatients across the United States,¹³ and as such, they currently, and will increasingly, play a major role in the US COVID-19 response. This is the case at the UCSF Helen Diller Medical Center at Parnassus Heights (UCSFMC), a 600-bed academic medical center. To learn from other’s early experiences with COVID-19, UCSF Health System leadership connected with many outside health systems including NUH. As one of its multiple pandemic responses, they engaged the UCSFMC Division of Hospital Medicine (DHM), a division that includes 117 hospitalists, to work with hospital and health system leadership and launch a respiratory isolation unit (RIU) modeled after the NUH pandemic ward. The aim of the RIU is to group inpatients with either confirmed or suspected COVID-19 patients who do not require critical care.

An interdisciplinary work group comprising hospitalists, infectious disease specialists, emergency department clinicians, nursing, rehabilitation experts, hospital epidemiology and infection-prevention leaders, safety specialists, and systems engineers was assembled to repurpose an existing medical unit and establish new care models for the RIU. This workgroup created clinical guidelines and workflows, and RIU leaders actively solicit feedback from the staff to advance these standards.

Hospitalists and nurses who volunteered to work on the UCSF attending-staffed RIU received extensive training, including online and widely available in-person PPE training delivered by infection-prevention experts. The RIU hospitalists engage with hospitalists nationwide through ongoing conference calls to share best practices and clinical cases. Patients are admitted by hospitalists to the RIU via the emergency department or directly from ambulatory sites. All RIU providers and staff are screened daily for symptoms prior to starting their shifts, wear hospital-laundered scrubs on the unit, and remain on the unit for the duration of their shift. Hospitalists and nurses communicate regularly to cluster their patient visits and interventions while specialists provide virtual consults (as deemed safe and appropriate) to optimize PPE conservation and decrease overall exposure. The Health System establishes and revises PPE protocols based on CDC guidelines, best available evidence, and supply chain realities. These guidelines are evolving and currently include surgical mask, gown, gloves, and eye protection for all patient interactions with suspected or confirmed COVID-19 and respirator use during aerosol-generating procedures. Research studies (eg, clinical trials and evaluations), informatics efforts (eg, patient flow dashboards), and healthcare technology innovations (eg, tablets for telehealth and video visits) are continually integrated into the RIU infrastructure. Robust attention to the well-being of everyone working on the unit includes chaplain visits, daily debriefs, meal delivery, and palliative care service support, which enrich the unit experience and instill a culture of unity.

The structures and systems born out of the 2003 SARS experience and the “test, trace, and isolate” strategy were arguably key drivers to flatten Singapore’s epidemic curve early in the pandemic.³ Even with these in place, Singapore is now experiencing a second wave with a significantly higher caseload.¹⁴ In response, the government instituted strict social distancing measures on April 3, closing schools and most workplaces. This suggests that the COVID-19 pandemic may fluctuate over time and that varying types and levels of interventions will be required to maintain long-term control. The NUH team describes experiencing cognitive overload given the ever-changing nature and volume of information and fatigue due to the effort required and duration of this crisis. New programs addressing these challenges are being developed and rapidly deployed.

Despite early testing limitations and newly minted systems, San Francisco is cautiously optimistic about its epidemic curve. Since the March 17, 2020, “shelter in place” order, COVID-19 hospitalizations have remained manageable and constant.¹⁵ This has afforded healthcare systems including UCSF critical time to evolve its clinical operations (eg, the RIU) and to leverage its academic culture coordinating its bench research, global health, epidemiology, clinical research, informatics, and clinical enterprise scholars and experts to advance COVID-19 science and inform pandemic solutions. Although the UCSF frontline teams are challenged by the stresses of being in the throes of the pandemic amidst a rapidly changing landscape (including changes in PPE and testing recommendations specifically), they are working together to build team resilience for what may come.

The world is facing a pandemic of tremendous proportions, and the United States is in the midst of a wave the height of which is yet to be seen. As Fisher and colleagues wrote in 2011, “Our response to infectious disease outbreaks is born out of past experience.”⁴ Singapore and NUH’s structures and systems that were put into place demonstrate this—they are timely, have been effective thus far, and will be tested in this next wave. “However, no two outbreaks are the same,” the authors wrote, “so an understanding of the infectious agent as well as the environment confronting it is fundamental to the response.”⁴ In the United States, hospitalists are a key asset in our environment to confront this virus. The UCSF experience exemplifies that, by combining new ideas from another system with on-the-ground expertise while working hand-in-hand with the hospital and health system, hospitalists can be a critical facet of the pandemic response. Hospitalists’ intrinsic abilities to collaborate, learn, and innovate will enable them to not only meet this challenge now but also to transform practices and capacities to respond to crises into the future.

Acknowledgment

Bradley Sharpe, MD, Division Chief, Division of Hospital Medicine, University of California, San Francisco, California, for his input on conception and critical review of this manuscript.

One of the worst public health threats of our generation, coronavirus disease 2019 (COVID-19), first emerged in Wuhan, China, in December 2019 and quickly spread to Singapore, Hong Kong, and Taiwan. These three countries have been praised for their control of the pandemic,^1,2 while the number of cases worldwide, including those in the United States, has soared. Political alignment, centralized and integrated healthcare systems, small size, effective technology deployment, widespread testing combined with contact tracing and isolation, and personal protective equipment (PPE) availability underscore their successes.^1,3-5 Although these factors differ starkly from those currently employed in the United States, a better understanding their experience may positively influence the myriad US responses. We describe some salient features of Singapore’s infection preparedness, provide examples of how these features guided the National University Hospital (NUH) Singapore COVID-19 response, and illustrate how one facet of the NUH response was translated to develop a new care model at the University of California, San Francisco (UCSF).

Singapore, a small island country (278 square miles) city-state in Southeast Asia has a population of 5.8 million people. Most Singaporeans receive their inpatient care in the public hospitals that are organized and resourced through the Singapore Ministry of Health (MOH). In 2003, severe acute respiratory syndrome (SARS) infected 238 people and killed 33 over 3 months in Singapore, which led to a significant economic downturn. Singapore’s initial SARS experience unveiled limitations in infrastructure, staff preparedness, virus control methodology, and centralized crisis systems. Lessons gleaned from the SARS experience laid the foundation for Singapore’s subsequent disaster preparedness.⁶

Post-SARS, the MOH created structures and systems to prepare Singapore for future epidemics. All public hospitals expanded isolation capacity by constructing new units or repurposing existing ones and creating colocated Emergency Department (ED) isolation facilities. Additionally, the MOH commissioned the National Centre for Infectious Diseases, a 330-bed high-level isolation hospital.⁷ They also mandated hospital systems to regularly practice mass casualty and infectious (including respiratory) crisis responses through externally evaluated simulation.⁸ These are orchestrated down to the smallest detail and involve staff at all levels. For example, healthcare workers (HCW) being “deployed” outside of their specialty, housekeepers practicing novel hazardous waste disposal, and security guards managing crowds interact throughout the exercise.

The testing and viral spread control challenges during SARS spawned hospital-system epidemiology capacity building. Infectious diseases reporting guidelines were refined, and communication channels enhanced to include cross-hospital information sharing and direct lines of communication for epidemiology groups to and from the MOH. Enhanced contact tracing methodologies were adopted and practiced regularly. In addition, material stockpiles, supplies, and supply chains were recalibrated.

The Singapore government also adopted the Disease Outbreak Response System Condition (DORSCON) system,⁹ a color-coded framework for pandemic response that guides activation of crisis interventions broadly (such as temperature screening at airports and restrictions to travel and internal movements), as well as within the healthcare setting.

In addition to prompting these notable preparedness efforts, SARS had a palpable impact on Singaporeans’ collective psychology both within and outside of the hospital system. The very close-knit medical community lost colleagues during the crisis, and the larger community deeply felt the health and economic costs of this crisis.¹⁰ The resulting “respect” or “healthy fear” for infectious crises continues to the present day.

The NUH is a 1,200-bed public tertiary care academic health center in Singapore. Before the first COVID-19 case was diagnosed in Singapore, NUH joined forces with its broader health system, university resources (schools of medicine and public health), and international partners to refine the existing structures and systems in response to this new infectious threat.

One of these structures included the existing NUH ED negative-pressure “fever facility.” In the ED triage, patients are routinely screened for infectious diseases such as H1N1, MERS-CoV, and measles. In early January, these screening criteria were evolved to adapt to COVID-19. High-risk patients bypass common waiting areas and are sent directly to the fever facility for management. From there, patients requiring admission are sent to one of the inpatient isolation wards, each with over 21 negative-pressure isolation rooms. To expand isolation capacity, lower-priority patients were relocated, and the existing negative- and neutral-pressure rooms were converted into COVID-19 pandemic wards.

The pandemic wards are staffed by nurses with previous isolation experience and Internal Medicine and Subspecialty Medicine physicians and trainees working closely with Infectious Diseases experts. Pandemic Ward teams are sequestered from other clinical and administrative teams, wear hospital-­laundered scrubs, and use PPE-conserving practices. These strategies, implemented at the outset, are based on international guidelines contextualized to local needs and include extended use (up to 6 hours) of N95 respirators for the pandemic wards, and surgical masks in all other clinical areas. Notably, there have been no documented transmissions to HCW or patients at NUH. The workforce was maximized by limiting nonurgent clinical, administrative, research, and teaching activities.

In February, COVID-19 testing was initiated internally and deployed widely. NUH, at the time of this writing, has performed more than 6,000 swabs with up to 200 tests run per day (with 80 confirmed cases). Testing at this scale has allowed NUH to ensure: (a) prompt isolation of patients, even those with mild symptoms, (b) deisolation of those testing negative thus conserving PPE and isolation facilities, (c) a better understanding of the epidemiology and the wide range of clinical manifestations of COVID-19, and (d) early comprehensive contact tracing including mildly symptomatic patients.

The MOH plays a central role in coordinating COVID-19 activities and supports individual hospital systems such as NUH. Some of their crisis leadership strategies include daily text messages distributed countrywide, two-way communication channels that ensure feedback loops with hospital executives, epidemiology specialists, and operational workgroups, and engendering interhospital collaboration.¹¹

In the United States, the Joint Commission provides structures, tools, and processes for hospital systems to prepare for disasters.¹² Many hospital systems have experience with natural disasters which, similar to Singapore’s planning, ensures structures and systems are in place during a crisis. Although these are transferable to multiple types of disasters, the US healthcare system’s direct experience with infectious crises is limited. A fairly distinctive facet—and an asset of US healthcare—is the role of hospitalists.

Hospitalists care for the majority of medical inpatients across the United States,¹³ and as such, they currently, and will increasingly, play a major role in the US COVID-19 response. This is the case at the UCSF Helen Diller Medical Center at Parnassus Heights (UCSFMC), a 600-bed academic medical center. To learn from other’s early experiences with COVID-19, UCSF Health System leadership connected with many outside health systems including NUH. As one of its multiple pandemic responses, they engaged the UCSFMC Division of Hospital Medicine (DHM), a division that includes 117 hospitalists, to work with hospital and health system leadership and launch a respiratory isolation unit (RIU) modeled after the NUH pandemic ward. The aim of the RIU is to group inpatients with either confirmed or suspected COVID-19 patients who do not require critical care.

An interdisciplinary work group comprising hospitalists, infectious disease specialists, emergency department clinicians, nursing, rehabilitation experts, hospital epidemiology and infection-prevention leaders, safety specialists, and systems engineers was assembled to repurpose an existing medical unit and establish new care models for the RIU. This workgroup created clinical guidelines and workflows, and RIU leaders actively solicit feedback from the staff to advance these standards.

Hospitalists and nurses who volunteered to work on the UCSF attending-staffed RIU received extensive training, including online and widely available in-person PPE training delivered by infection-prevention experts. The RIU hospitalists engage with hospitalists nationwide through ongoing conference calls to share best practices and clinical cases. Patients are admitted by hospitalists to the RIU via the emergency department or directly from ambulatory sites. All RIU providers and staff are screened daily for symptoms prior to starting their shifts, wear hospital-laundered scrubs on the unit, and remain on the unit for the duration of their shift. Hospitalists and nurses communicate regularly to cluster their patient visits and interventions while specialists provide virtual consults (as deemed safe and appropriate) to optimize PPE conservation and decrease overall exposure. The Health System establishes and revises PPE protocols based on CDC guidelines, best available evidence, and supply chain realities. These guidelines are evolving and currently include surgical mask, gown, gloves, and eye protection for all patient interactions with suspected or confirmed COVID-19 and respirator use during aerosol-generating procedures. Research studies (eg, clinical trials and evaluations), informatics efforts (eg, patient flow dashboards), and healthcare technology innovations (eg, tablets for telehealth and video visits) are continually integrated into the RIU infrastructure. Robust attention to the well-being of everyone working on the unit includes chaplain visits, daily debriefs, meal delivery, and palliative care service support, which enrich the unit experience and instill a culture of unity.

The structures and systems born out of the 2003 SARS experience and the “test, trace, and isolate” strategy were arguably key drivers to flatten Singapore’s epidemic curve early in the pandemic.³ Even with these in place, Singapore is now experiencing a second wave with a significantly higher caseload.¹⁴ In response, the government instituted strict social distancing measures on April 3, closing schools and most workplaces. This suggests that the COVID-19 pandemic may fluctuate over time and that varying types and levels of interventions will be required to maintain long-term control. The NUH team describes experiencing cognitive overload given the ever-changing nature and volume of information and fatigue due to the effort required and duration of this crisis. New programs addressing these challenges are being developed and rapidly deployed.

Despite early testing limitations and newly minted systems, San Francisco is cautiously optimistic about its epidemic curve. Since the March 17, 2020, “shelter in place” order, COVID-19 hospitalizations have remained manageable and constant.¹⁵ This has afforded healthcare systems including UCSF critical time to evolve its clinical operations (eg, the RIU) and to leverage its academic culture coordinating its bench research, global health, epidemiology, clinical research, informatics, and clinical enterprise scholars and experts to advance COVID-19 science and inform pandemic solutions. Although the UCSF frontline teams are challenged by the stresses of being in the throes of the pandemic amidst a rapidly changing landscape (including changes in PPE and testing recommendations specifically), they are working together to build team resilience for what may come.

The world is facing a pandemic of tremendous proportions, and the United States is in the midst of a wave the height of which is yet to be seen. As Fisher and colleagues wrote in 2011, “Our response to infectious disease outbreaks is born out of past experience.”⁴ Singapore and NUH’s structures and systems that were put into place demonstrate this—they are timely, have been effective thus far, and will be tested in this next wave. “However, no two outbreaks are the same,” the authors wrote, “so an understanding of the infectious agent as well as the environment confronting it is fundamental to the response.”⁴ In the United States, hospitalists are a key asset in our environment to confront this virus. The UCSF experience exemplifies that, by combining new ideas from another system with on-the-ground expertise while working hand-in-hand with the hospital and health system, hospitalists can be a critical facet of the pandemic response. Hospitalists’ intrinsic abilities to collaborate, learn, and innovate will enable them to not only meet this challenge now but also to transform practices and capacities to respond to crises into the future.

Acknowledgment

Bradley Sharpe, MD, Division Chief, Division of Hospital Medicine, University of California, San Francisco, California, for his input on conception and critical review of this manuscript.

One of the worst public health threats of our generation, coronavirus disease 2019 (COVID-19), first emerged in Wuhan, China, in December 2019 and quickly spread to Singapore, Hong Kong, and Taiwan. These three countries have been praised for their control of the pandemic,^1,2 while the number of cases worldwide, including those in the United States, has soared. Political alignment, centralized and integrated healthcare systems, small size, effective technology deployment, widespread testing combined with contact tracing and isolation, and personal protective equipment (PPE) availability underscore their successes.^1,3-5 Although these factors differ starkly from those currently employed in the United States, a better understanding their experience may positively influence the myriad US responses. We describe some salient features of Singapore’s infection preparedness, provide examples of how these features guided the National University Hospital (NUH) Singapore COVID-19 response, and illustrate how one facet of the NUH response was translated to develop a new care model at the University of California, San Francisco (UCSF).

Singapore, a small island country (278 square miles) city-state in Southeast Asia has a population of 5.8 million people. Most Singaporeans receive their inpatient care in the public hospitals that are organized and resourced through the Singapore Ministry of Health (MOH). In 2003, severe acute respiratory syndrome (SARS) infected 238 people and killed 33 over 3 months in Singapore, which led to a significant economic downturn. Singapore’s initial SARS experience unveiled limitations in infrastructure, staff preparedness, virus control methodology, and centralized crisis systems. Lessons gleaned from the SARS experience laid the foundation for Singapore’s subsequent disaster preparedness.⁶

Post-SARS, the MOH created structures and systems to prepare Singapore for future epidemics. All public hospitals expanded isolation capacity by constructing new units or repurposing existing ones and creating colocated Emergency Department (ED) isolation facilities. Additionally, the MOH commissioned the National Centre for Infectious Diseases, a 330-bed high-level isolation hospital.⁷ They also mandated hospital systems to regularly practice mass casualty and infectious (including respiratory) crisis responses through externally evaluated simulation.⁸ These are orchestrated down to the smallest detail and involve staff at all levels. For example, healthcare workers (HCW) being “deployed” outside of their specialty, housekeepers practicing novel hazardous waste disposal, and security guards managing crowds interact throughout the exercise.

The testing and viral spread control challenges during SARS spawned hospital-system epidemiology capacity building. Infectious diseases reporting guidelines were refined, and communication channels enhanced to include cross-hospital information sharing and direct lines of communication for epidemiology groups to and from the MOH. Enhanced contact tracing methodologies were adopted and practiced regularly. In addition, material stockpiles, supplies, and supply chains were recalibrated.

The Singapore government also adopted the Disease Outbreak Response System Condition (DORSCON) system,⁹ a color-coded framework for pandemic response that guides activation of crisis interventions broadly (such as temperature screening at airports and restrictions to travel and internal movements), as well as within the healthcare setting.

In addition to prompting these notable preparedness efforts, SARS had a palpable impact on Singaporeans’ collective psychology both within and outside of the hospital system. The very close-knit medical community lost colleagues during the crisis, and the larger community deeply felt the health and economic costs of this crisis.¹⁰ The resulting “respect” or “healthy fear” for infectious crises continues to the present day.

The NUH is a 1,200-bed public tertiary care academic health center in Singapore. Before the first COVID-19 case was diagnosed in Singapore, NUH joined forces with its broader health system, university resources (schools of medicine and public health), and international partners to refine the existing structures and systems in response to this new infectious threat.

One of these structures included the existing NUH ED negative-pressure “fever facility.” In the ED triage, patients are routinely screened for infectious diseases such as H1N1, MERS-CoV, and measles. In early January, these screening criteria were evolved to adapt to COVID-19. High-risk patients bypass common waiting areas and are sent directly to the fever facility for management. From there, patients requiring admission are sent to one of the inpatient isolation wards, each with over 21 negative-pressure isolation rooms. To expand isolation capacity, lower-priority patients were relocated, and the existing negative- and neutral-pressure rooms were converted into COVID-19 pandemic wards.

The pandemic wards are staffed by nurses with previous isolation experience and Internal Medicine and Subspecialty Medicine physicians and trainees working closely with Infectious Diseases experts. Pandemic Ward teams are sequestered from other clinical and administrative teams, wear hospital-­laundered scrubs, and use PPE-conserving practices. These strategies, implemented at the outset, are based on international guidelines contextualized to local needs and include extended use (up to 6 hours) of N95 respirators for the pandemic wards, and surgical masks in all other clinical areas. Notably, there have been no documented transmissions to HCW or patients at NUH. The workforce was maximized by limiting nonurgent clinical, administrative, research, and teaching activities.

In February, COVID-19 testing was initiated internally and deployed widely. NUH, at the time of this writing, has performed more than 6,000 swabs with up to 200 tests run per day (with 80 confirmed cases). Testing at this scale has allowed NUH to ensure: (a) prompt isolation of patients, even those with mild symptoms, (b) deisolation of those testing negative thus conserving PPE and isolation facilities, (c) a better understanding of the epidemiology and the wide range of clinical manifestations of COVID-19, and (d) early comprehensive contact tracing including mildly symptomatic patients.

The MOH plays a central role in coordinating COVID-19 activities and supports individual hospital systems such as NUH. Some of their crisis leadership strategies include daily text messages distributed countrywide, two-way communication channels that ensure feedback loops with hospital executives, epidemiology specialists, and operational workgroups, and engendering interhospital collaboration.¹¹

In the United States, the Joint Commission provides structures, tools, and processes for hospital systems to prepare for disasters.¹² Many hospital systems have experience with natural disasters which, similar to Singapore’s planning, ensures structures and systems are in place during a crisis. Although these are transferable to multiple types of disasters, the US healthcare system’s direct experience with infectious crises is limited. A fairly distinctive facet—and an asset of US healthcare—is the role of hospitalists.

Hospitalists care for the majority of medical inpatients across the United States,¹³ and as such, they currently, and will increasingly, play a major role in the US COVID-19 response. This is the case at the UCSF Helen Diller Medical Center at Parnassus Heights (UCSFMC), a 600-bed academic medical center. To learn from other’s early experiences with COVID-19, UCSF Health System leadership connected with many outside health systems including NUH. As one of its multiple pandemic responses, they engaged the UCSFMC Division of Hospital Medicine (DHM), a division that includes 117 hospitalists, to work with hospital and health system leadership and launch a respiratory isolation unit (RIU) modeled after the NUH pandemic ward. The aim of the RIU is to group inpatients with either confirmed or suspected COVID-19 patients who do not require critical care.

An interdisciplinary work group comprising hospitalists, infectious disease specialists, emergency department clinicians, nursing, rehabilitation experts, hospital epidemiology and infection-prevention leaders, safety specialists, and systems engineers was assembled to repurpose an existing medical unit and establish new care models for the RIU. This workgroup created clinical guidelines and workflows, and RIU leaders actively solicit feedback from the staff to advance these standards.

Hospitalists and nurses who volunteered to work on the UCSF attending-staffed RIU received extensive training, including online and widely available in-person PPE training delivered by infection-prevention experts. The RIU hospitalists engage with hospitalists nationwide through ongoing conference calls to share best practices and clinical cases. Patients are admitted by hospitalists to the RIU via the emergency department or directly from ambulatory sites. All RIU providers and staff are screened daily for symptoms prior to starting their shifts, wear hospital-laundered scrubs on the unit, and remain on the unit for the duration of their shift. Hospitalists and nurses communicate regularly to cluster their patient visits and interventions while specialists provide virtual consults (as deemed safe and appropriate) to optimize PPE conservation and decrease overall exposure. The Health System establishes and revises PPE protocols based on CDC guidelines, best available evidence, and supply chain realities. These guidelines are evolving and currently include surgical mask, gown, gloves, and eye protection for all patient interactions with suspected or confirmed COVID-19 and respirator use during aerosol-generating procedures. Research studies (eg, clinical trials and evaluations), informatics efforts (eg, patient flow dashboards), and healthcare technology innovations (eg, tablets for telehealth and video visits) are continually integrated into the RIU infrastructure. Robust attention to the well-being of everyone working on the unit includes chaplain visits, daily debriefs, meal delivery, and palliative care service support, which enrich the unit experience and instill a culture of unity.

The structures and systems born out of the 2003 SARS experience and the “test, trace, and isolate” strategy were arguably key drivers to flatten Singapore’s epidemic curve early in the pandemic.³ Even with these in place, Singapore is now experiencing a second wave with a significantly higher caseload.¹⁴ In response, the government instituted strict social distancing measures on April 3, closing schools and most workplaces. This suggests that the COVID-19 pandemic may fluctuate over time and that varying types and levels of interventions will be required to maintain long-term control. The NUH team describes experiencing cognitive overload given the ever-changing nature and volume of information and fatigue due to the effort required and duration of this crisis. New programs addressing these challenges are being developed and rapidly deployed.

Despite early testing limitations and newly minted systems, San Francisco is cautiously optimistic about its epidemic curve. Since the March 17, 2020, “shelter in place” order, COVID-19 hospitalizations have remained manageable and constant.¹⁵ This has afforded healthcare systems including UCSF critical time to evolve its clinical operations (eg, the RIU) and to leverage its academic culture coordinating its bench research, global health, epidemiology, clinical research, informatics, and clinical enterprise scholars and experts to advance COVID-19 science and inform pandemic solutions. Although the UCSF frontline teams are challenged by the stresses of being in the throes of the pandemic amidst a rapidly changing landscape (including changes in PPE and testing recommendations specifically), they are working together to build team resilience for what may come.

The world is facing a pandemic of tremendous proportions, and the United States is in the midst of a wave the height of which is yet to be seen. As Fisher and colleagues wrote in 2011, “Our response to infectious disease outbreaks is born out of past experience.”⁴ Singapore and NUH’s structures and systems that were put into place demonstrate this—they are timely, have been effective thus far, and will be tested in this next wave. “However, no two outbreaks are the same,” the authors wrote, “so an understanding of the infectious agent as well as the environment confronting it is fundamental to the response.”⁴ In the United States, hospitalists are a key asset in our environment to confront this virus. The UCSF experience exemplifies that, by combining new ideas from another system with on-the-ground expertise while working hand-in-hand with the hospital and health system, hospitalists can be a critical facet of the pandemic response. Hospitalists’ intrinsic abilities to collaborate, learn, and innovate will enable them to not only meet this challenge now but also to transform practices and capacities to respond to crises into the future.

Acknowledgment

Bradley Sharpe, MD, Division Chief, Division of Hospital Medicine, University of California, San Francisco, California, for his input on conception and critical review of this manuscript.