Hospitalization coordination at the time of COVID-19 spread in Hyogo, Japan: Visualizing mutual aid for community collaboration

A new coronavirus pandemic broke out in 2020. As a countermeasure, cluster control based on active epidemiological surveys was undertaken under the jurisdiction of public health centers in Japan. However, as the number of infected people increased, the workload exceeded the processing capability of public health centers. In response to the national and prefectural government ’ s request to avoid functional failure due to overwork and understa ﬃ ng, university faculty members provided operational support to the public health center throughout the day and night. We would like to report the issues of inter-regional cooperation that emerged from our experience.

In 2020, a new coronavirus disease 2019  pandemic broke out, causing many deaths worldwide. To date, this virus has yet to show signs of an endpoint. In Japan, the presence of the disease was widely recognized by a report from a cruise ship, namely, the Diamond Princess, on which the outbreak of the virus occurred (Jimi, 2020). Despite the best efforts of the government, the virus spread throughout Japan; however, the infection rate in Japan has remained low compared to that in other developed countries (Fig. 1). One of the characteristics of the Japanese countermeasures is cluster control based on active epidemiological surveys (Oshitani, 2020). Public health centers and Japan's public health administrative organization has played a central role in these measures.
In Japan, public health centers are established in every prefecture and selected cities that meet the criteria to provide a wide-range of health services to residents. A main task of these centers originally was to provide care for those afflicted with infectious diseases. When the first public health center was established in 1947, the leading cause of death among Japanese people was tuberculosis. However, the incidence of infectious diseases decreased drastically in the 1960s with the improvement of sanitation and nutrition in Japan. Therefore, the work of public health centers has shifted from infectious disease control to prevention of lifestyle-related diseases such as malignant neoplasms, cerebrovascular diseases, and heart diseases. Since 1994, as a matter of policy, public health centers have continued to consolidate and reduce their staff (Takemura, 2020). However, to deal with the current pandemic, the following efforts are required for active epidemiological investigations: 0 Coordination of medical facilities for citizens to access medical care 0 Coordination of polymerase chain reaction (PCR) test appointments for suspected infected persons 0 Transportation of specimens to laboratories 0 Early detection of contacts by tracking their behavior 2 weeks before the onset of illness 0 Continuous monitoring of the movements of infected persons and close contacts 0 Health observations of patients receiving home treatment. To avoid functional failure due to a lack of manpower, the national and prefectural governments requested university faculty members to provide support; thus, we provided operational support to the public health centers during the day and worked on hospitalization coordina-tion throughout the night, sometimes bringing a portable bed into the university office to take a nap (Fig. 2). We report the issues and proposed countermeasures that have emerged from our experience.

Coordination system in the real world
The universal health insurance system is established to ensure that all citizens have equal access to medical care in Japan. However, in reality, there is a disparity in medical care in each region, and some regions are unable to cope with the rapid increase in the numbers of people with infections and thus are in danger of medical system breakdown. To cope with this, medical facilities throughout the prefecture cooperated to establish a system to accept patients in need of treatment, and the public health center was in charge of coordinating this system. In this system, medical institutions report the availability of beds, and patients are assigned to them by matching the requests for admission of mildly ill patients from nonmedical facilities and medical institutions. However, from a practical standpoint, just because there was an available bed on the list, it did not necessarily mean that the patient could be admitted. At night, the phone lines were sometimes not accessible, and our colleague was unable to find an available hospital even after calling more than 30 hospitals. In this case, a highly influential doctor's negotiation allowed the patient to be admitted. In coordinating the efforts, it was not enough to just make a normal request, but sometimes one had to make an appeal based on compassion for others, such as saying 'this person will die if he stays at home'. It was speculated that some medical facilities tried to keep beds for their community members rather than accept patients from other communities.
Japanese people have a culture of helping and protecting each other within the community when a crisis arises. Perhaps for this reason, Japan did not have a politically led mandatory lockdown but rather a gradual lockdown that relied on individual autonomy. However, such a policy created a situation in which medical facilities had to respond to emergencies within the normal structure. Local medical facilities may be forced to take a closed approach to avoid collapse.

Developing the visualization of mutual aid
In the event of a disaster, everyone would agree that it is necessary to build an expansive cooperation system. In such cases, if the hospital management system could be computerized, and all information could be automatically managed centrally, it might be possible to create a system where patients would be evenly assigned to available beds according to the severity of each individual's illness. However, such a system would not work well because it is not congruent with the Japanese values of prioritizing one's relatives and local communities. Especially in times of disaster, people want to save themselves and their own communities first, and the communication will be exclusively closed to those outside the communities.
Therefore, what can we do? We would like to propose an idea. In Japan, there is a concept of mutual aid called "Mochitsu Motaretsu", which means to help each other in times of need by taking on the difficulties of others and having others take on your difficulties. To promote mutual aid, we need to first be aware that we are being helped. Is it not possible to visualize this form of mutual aid and promote regional cooperation through the awareness of win-win relationships? For example, if we can visualize the number of out-of-region patients the local hospital has accepted, the number of patients accepted out-of-region, and the support received that is not just limited to medical care, mutual aid will be promoted. If we can visualize the various types of support received that are not limited to medical care, mutual aid will probably be promoted.
The visualization of the mutual aid system in a wider area beyond the community will lead to the correct method of globalization. Disaster nursing can contribute to the creation of a system where mutual aid can be visualized and experienced, and disaster nursing will be able to benefit from it.