Response to single-point and multi-point medical surge in emergencies: Lessons learned from two cases in China

Response to single-point and multi-point medical surge in emergencies: Lessons learned from two cases in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Response to single-point and multi-point medical surge in emergencies: Lessons learned from two cases in China Jinpeng Xu, Dongxue Wang, Jiale Sun, Weixue Yin, Lijuan Cui, Guomei Tian, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7247753/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Medical surge capacity is the ability of a medical institution to meet peak medical demand during an emergency. This study aims to explore strategies for enhancing medical surge capacity in future emergency responses to better safeguard public safety. Methods A double-case comparative analysis was conducted focusing on the characteristics and responses to the medical surge during the COVID-19 outbreak in Shanghai and the nationwide epidemic in China. Results Medical surges can be categorized into "single-point surges" and "multi-point surges". While there are differences between the two, they also share many similarities. The experiences of Shanghai and China demonstrated that medical surge capacity involves more than expanding resources. It also demands coordinated management of patient monitoring and triage, information sharing, treatment process optimization, and safety maintenance. Conclusions Enhancing medical surge capacity requires the integration of surge identification, surge diversion, and resource security. Surge identification entails the timely recognition and classification of patients. Surge diversion involves directing patients to appropriate medical institutions based on this classification. Resource security supports effective surge diversion by promoting mutual assistance among medical institutions and enabling flexible adjustments to their functions. Emergency response Single-point surge Multi-point surge Medical surge capacity Double-case comparison Figures Figure 1 Figure 2 Figure 3 Introduction Extreme weather, earthquakes, terrorism, and other disasters can lead to large populations with compromised health, requiring timely medical intervention to prevent significant risks to their lives [ 1 , 2 ]. In 2020, COVID-19 erupted as a public health emergency in multiple countries. COVID-19 is highly contagious, and as the virus spreads rapidly, the need for centralized care of large numbers of patients arises [ 3 , 4 ]. In China, between January 25 and February 23, 2020, the cumulative number of confirmed COVID-19 cases in Wuhan, Hubei Province, surged from 618 to 46,607 [ 5 , 6 ]. As of the end of November 2020, the United States reported a cumulative total of 13 million cases, with 180,000 new cases daily [ 7 ]. In less than a month of the outbreak, the number of COVID-19 patients in Italy exceeded 40,000 [ 8 ], forcing general practitioners and nurses to make extraordinary decisions about who to save [ 9 ]. Emergencies can disrupt the normal operations of medical institutions, forcing them to function under exceptional conditions. This is particularly evident during major incidents, where the number of casualties can surge to dozens or even hundreds of times the usual volume. Patient treatment in such scenarios is typically characterized by its urgency, sudden onset, large scale, and centralized nature [ 10 ]. When a sudden influx of patients far exceeds a medical institution's normal capacity to provide care, a severe medical surge occurs. Such surges often compromise treatment effectiveness and place an overwhelming strain on the healthcare system [ 11 ]. Consequently, strengthening the healthcare system's medical surge capacity during emergencies is critical to safeguarding lives in the face of diverse disasters. "Surge capacity" is originally a physics term. "Surge" mainly refers to the strong pulse generated at the moment when the power supply is just turned on, which is likely to cause the circuit to burn out [ 12 , 13 ]. In the healthcare field, many scholars interpret medical surge capacity as the ability of a medical institution to effectively respond to sudden, large-scale patients in an unanticipated range [ 14 , 15 ]. In 2003, the Joint Commission on Accreditation of Healthcare Organizations provided one of the earliest definitions of medical surge capacity, describing it as the legal ability to triage, manage, vaccinate, sterilize, or place patients, and to provide healthcare services beyond the usual scope [ 16 ]. Sheikhbardsiri, Raeisi (17) identified four key components of medical surge capacity: personnel, resources, infrastructure, and systems. The interaction between these components ultimately dictates the effectiveness of the medical surge response. Combining the various studies on medical surge capacity, this study believes that medical surge capacity can be understood as the ability of a medical institution to meet peak medical demand during an emergency, which is a core competency of the medical institution's emergency response. In 2006, the International Conference on Academic Emergency Medicine outlined key priorities for enhancing medical surge capacity during catastrophic events. These priorities included: defining criteria and methods for allocating scarce resources, identifying effective triage options, designating key decision-makers for capacity planning, establishing methods to evaluate the effectiveness of the response, and developing strategies for effective communication and information sharing [ 18 ]. Hick, Koenig (19) constructed the CO-S-TR model that can be implemented immediately after an event, where "CO" stands for command, control, communications, and coordination, "S" takes into account staff, stuff, space, and special considerations, and "TR" includes tracking, triage, treatment, and transportation. Shen, Jiang (20) proposed emergency strategies for medical response after a major disaster, including triage of catastrophic medical surges, scalability of medical surge capacity, and maintaining the functionality of medical response support systems. However, as the characteristics of emergencies and the external environment evolve, the scope of surge impact also varies, and there is limited value in discussing medical surges without considering specific scenarios. Analyzing how to enhance medical surge capacity in specific scenarios is crucial for enabling medical institutions to respond accurately and act swiftly based on the actual circumstances. Therefore, this study selected two time points for comparison: the COVID-19 outbreak in Shanghai in 2022 and the subsequent nationwide epidemic at the end of 2022, following the optimization of China's prevention and control measures. By conducting a comparative analysis using Shanghai and China as representative cases, this study develops a systematic approach to improving medical surge capacity during emergencies, aiming to offer practical insights for medical institutions to strengthen their emergency response and better safeguard public safety. Materials and methods Employing a case study approach, this research compares, analyzes, and synthesizes the characteristics of medical surges and the corresponding responses across two typical scenarios to propose strategies to enhance medical surge capacity during emergencies. The case study methodology begins with a real-world problem and, through comprehensive and in-depth descriptions and analyses of a phenomenon, derives theoretical insights from representative cases to construct a conceptual model that addresses the questions of how and why [ 21 ]. In contrast to a single case study, this study opted for a double-case comparative analysis method to observe activities occurring in different scenarios at a deeper level and to improve the accuracy and generalizability of the findings [ 22 ]. Cases selection Based on the changes in the epidemic characteristics of COVID-19 in China, this study classified medical surges into two categories: "single-point surge" and "multi-point surge" based on the characteristics of medical surges. A single-point surge is defined as a medical surge occurring in a single city or localized area, while a multi-point surge refers to a surge affecting multiple cities or areas simultaneously. The criteria for selecting a typical case for this study are as follows: 1) the case should encompass the entire process, from the onset of the medical surge to the response; 2) the case should have received significant attention from both the academic community and the media, providing access to ample secondary information; and 3) the case should be based on the author's personal experience, allowing for the validation of secondary information through case review. Based on these criteria, this study examines the COVID-19 outbreak in Shanghai, China, from March to May 2022, as a case of a single-point surge under the dynamic zero-COVID strategy. Although cities across China implemented various measures to curb the spread of COVID-19, Shanghai was selected as a representative case for two main reasons. First, the city maintained a relatively low number of locally transmitted cases and a high recovery rate, serving as a model for other cities and provinces. Second, as one of the largest and most densely populated cities in China, Shanghai's surge response strategies and experiences are particularly representative. In the multi-point surge case selection, on December 7, 2022, China adjusted the dynamic zero strategy, and a large number of COVID-19 patients simultaneously appeared throughout the country. Therefore, this study selected the end of 2022 as the time point to analyze the characteristics of the multi-point surge and its corresponding response measures. Sources of information The methods of information collection are as follows: 1) Public data collection. The information required for the case study was collected from public channels such as official microblogs, news reports, and government reports; 2) Experiential observation. The cases selected in this study were the authors' personal experiences, especially after the optimization of the prevention and control measures for COVID-19 in China in late 2022. Having been infected with COVID-19 and sought medical care themselves, the authors gained a direct and realistic understanding of the response to multi-point surges, thereby providing richer and more nuanced insights for this research. Results Analysis of single-point surge and its response Single-point surge characteristics In 2008, Howitt (23) proposed five dimensions of surge analysis in the field of catastrophe response, including total demand, physical size, technical complexity, time pressure, and crisis duration. Total demand refers to the resources required for surge response, physical size pertains to the geographic area impacted by the surge, technical complexity involves the specialized personnel and equipment needed for response, time pressure refers to the rigid constraints imposed by the golden hour of surge response, and crisis duration denotes the length of time the surge persists. These five dimensions define the requirements for surge capacity. Using them as a framework, this study examined the characteristics of medical surges, with results shown in Table 1 . Table 1 Characteristics of single-point surge in Shanghai. Characteristics Single-point surge in Shanghai Total demand More than 600,000 asymptomatic patients were screened; from February 26 to May 25, 57,867 cases were diagnosed, 55,387 cases were cured and discharged, 1,893 cases were treated in hospitals (of which 118 were severe cases and 34 were critical cases), and 587 cases were dead. Physical size COVID-19 outbreak in Shanghai, Single-point surge Technical complexity 1) predominantly mild/moderate cases, with a low percentage of severe cases; 2) high mortality rates for patients of senior age and those with underlying diseases; and 3) a severe shortage of medical staff, facilities, and beds. Time pressure Guaranteeing the health of life and reducing mortality. Crisis duration This medical surge in Shanghai lasted nearly three months. In 2022, the highly infectious Omicron variant spread rapidly across China. On March 1, 2022, Shanghai reported its first case of indigenous infection with no known source of transmission. Subsequently, especially in April, the number of cases increased sharply. By May 2022, the Shanghai outbreak had infected over 600,000 people, marking it as the largest wave since the COVID-19 outbreak in China [ 24 ]. Given that Shanghai has an aging population, nearly half of the critically ill patients were over 80 years old, and 67% of the fatal cases occurred in this age group. Deaths among the elderly and those with underlying health conditions posed the greatest challenge to Shanghai's response to the medical surge [ 25 ]. Single-point surge response Figure 1 illustrates the response to the single-point surge in Shanghai, which was divided into two steps: the first involved implementing information monitoring and patient classification, followed by the centralized treatment of patients to ensure unified management and orderly care. In the stage of information monitoring and patient classification, based on the scientific and professional guidance of the COVID-19 Prevention and Control Program, and with the help of the unified information monitoring platform (health QR codes and travel codes), the CDC, primary health care institutions and social volunteers had engaged in a great deal of information monitoring and patient classification [ 26 , 27 ]. At the same time, patients are pre-classified according to the National Prevention and Control Program before treatment, guiding them to seek medical care in an organized and systematic manner. This approach played a crucial role in maximizing the efficiency of limited medical resources and alleviating issues of medical overcrowding and resource shortages [ 28 ]. In the centralized treatment phase, a strategy of centralized isolation combined with stratified admission was implemented. Designated hospitals and makeshift hospitals were mainly responsible for the isolation and treatment of patients, to achieve the goal of "all those in need are hospitalized". Secondary and tertiary hospitals mainly contributed by dispatching medical staff to support clinical care in designated and makeshift hospitals, assisting with nucleic acid testing at key sites and within local communities, while also maintaining routine diagnostic and treatment services. Under the principle of stratified admission, makeshift hospitals primarily accommodated asymptomatic and mildly ill patients, whereas large designated hospitals focused on treating severe cases. Faced with a severe shortage of medical resources, particularly human resources and infrastructure, China implemented a counterpart support system to assist Shanghai [ 29 ]. The other provinces of China and the People's Liberation Army dispatched more than 50,000 people to Shanghai. Among them, a large number of specialists in ICU, infection, respiratory medicine, circulatory medicine, and anesthesiology greatly eased the pressure on medical care. At the same time, Shanghai actively expanded its infrastructure. By April 8, 2022, more than 100 square-cabin hospitals with over 160,000 beds had been renovated or newly constructed in public buildings, such as gymnasiums and exhibition centers, significantly boosting the city's medical surge capacity. Shanghai had changed from "people waiting for beds" to "beds waiting for people", truly realizing "all those in need are hospitalized or treated". In China, when the COVID-19 outbreak occurred in a city or region, the surge characteristics and response were mostly the same as in Shanghai. Through summarizing and analyzing, this study identified several key factors contributing to the successful building of medical surge capacity under a single-point surge: 1) an integrated information monitoring platform that provided essential support for the timely and accurate dissemination of medical surge data; 2) scientific and professional prevention and control programs that offered standardized guidance for patient classification and treatment; 3) counterpart support from other provinces and regions, enabling the rapid deployment of rescue personnel; and 4) the conversion of stadiums, exhibition centers, and other public buildings, along with the construction of makeshift hospitals, facilitating the rapid expansion of infrastructure. Analysis of multi-point surge and its response Multi-point surge characteristics On December 7, 2022, based on the experience of prevention and control practices and assessment data, the Chinese government released measures to optimize the COVID-19 response, which required minimizing the impact of the epidemic on economic and social development. Subsequently, China adjusted its dynamic zero-COVID policy, leading to a large-scale medical surge of COVID-19 patients across cities nationwide. Table 2 demonstrates the results of the characteristics analysis of multi-point surges in China. Table 2 Characteristics of multi-point surge in China. Characteristics Multi-point surge in China Total demand More than 200 million people have been diagnosed and treated, and 800,000 seriously ill patients have been effectively treated; medicines are in short supply, hospital beds are hard to come by, and resource replenishment across regions has been cut off. Physical size A nationwide epidemic, interregional support becomes difficult. Technical complexity 1) a decline in the incidence of serious illness, with a large number of asymptomatic or mildly infected patients; 2) a surge in the number of seriously ill elderly patients with underlying conditions; 3) a simultaneous influx of seriously ill, mildly infected, and emergency non-infected patients into hospitals or communities; and 4) a large number of healthcare staff being infected. Time pressure Ensuring people's lives and health. Crisis duration The national medical surge occurred mainly in December 2022-January 2023. The number of infections in each province peaked on December 22nd and then gradually declined until January 23rd, 2023, when it reached its lowest level. China's multi-point surge exhibited two key characteristics and posed significant response challenges. On the one hand, the number of fever-related outpatient and emergency visits increased sharply, peaking on December 23, 2022, before steadily declining [ 30 ]. In a scenario where patients could freely choose their healthcare providers, the concurrent influx of both severe and mild infections, along with urgent non-infectious cases, placed substantial strain on healthcare workers and medical facilities. On the other hand, the infection situation among medical staff was concerning. In some large hospitals, more than half of the Intensive Care Medicine team was reduced, with nearly all on duty being mildly infected. The sharp increase in outpatient and emergency visits, combined with the ongoing attrition of medical staff, posed a significant challenge to the healthcare system. Multi-point surge response Figure 2 illustrates the response to the multi-point surge in China. Under the multi-point surge, all regions of China experienced severe medical surges, and support from other provinces or regions became increasingly difficult. As a result, they had to rely on internal personnel and infrastructure transformation to expand medical resources. At the same time, by optimizing management, they enhanced the efficiency of these resources, allowing for an effective response to the medical surges. First, primary healthcare organizations shifted from primarily conducting information monitoring during single-point surges to providing general patient care and health guidance during multi-point surges. They handled large volumes of non-critical patients and referred them to larger hospitals when necessary, thereby helping to prevent hospital resources from being overwhelmed. By December 25, 2022, China had established over 16,000 fever clinics in secondary and tertiary hospitals, along with more than 41,000 fever clinics operated by primary healthcare institutions. Meanwhile, many regions converted gymnasiums and nucleic acid testing kiosks into temporary fever clinics, equipping them with pharmacies and stocking antipyretic and analgesic medications to ensure public access to treatment and medicine. Secondly, secondary and tertiary hospitals experienced overwhelming medical surges due to the loss of coordinated access mechanisms. Among all patients, priority should be given to severely infected individuals, elderly patients with underlying conditions, and non-infected individuals requiring emergency care [ 31 – 33 ]. Accordingly, China issued policies instructing secondary and tertiary hospitals to focus on these key populations to ensure an effective surge response. At the same time, major hospitals optimized patient management and treatment protocols to maintain smooth operations during emergencies, for instance, by revising admission and discharge criteria and streamlining patient flow across outpatient, emergency, and fever clinics. In addition, to address severe shortages of personnel and beds in respiratory and intensive care units, hospitals implemented internal support measures, such as training staff from other departments and converting beds in other wards into respiratory or ICU beds. By December 25, 2022, the number of ICU beds in China had increased by 20.67% compared to December 13, while the national reserve of convertible ICU beds had risen by 26.53%, effectively strengthening manpower and infrastructure for surge response. In summary, China's efforts to build medical surge capacity under multi-point surges achieved the following successes: 1) primary healthcare institutions managed a large volume of general patient treatment and health guidance, reducing reliance on large hospitals; 2) the training and redeployment of healthcare workers from other departments within large hospitals led to a rapid expansion of staff; 3) the repurposing of beds and resources from other departments facilitated a quick expansion of infrastructure; and 4) the optimization of management processes in medical institutions focused on key populations while ensuring the safe operation of hospitals. Discussion Using Shanghai and China as representative cases, this study expands the research on medical surges in two ways. First, this study introduces the concepts of single-point surge and multi-point surge, which offer a new perspective for recognizing and responding to medical surges. To the best of our knowledge, such studies are currently unavailable. Second, this study proposes a systematic approach to enhancing medical surge capacity during emergencies. The findings can provide a solid foundation for medical institutions to improve their response to medical emergencies and safeguard public health. Through the review of Shanghai's single-point surge and China's multi-point surge, this study found that although there are differences in the characteristics of the two surges and the response measures, they also share many similarities. Medical surge capacity is not just a simple expansion of medical resources but also includes the overall collaborative management of patient monitoring, patient classification, information sharing, treatment process optimization, and safety maintenance. Based on the response measures to medical surges during emergencies, a response system for medical surges was developed, as illustrated in Fig. 3 . As shown in Fig. 3 , the response system for medical surges during emergencies is represented by an airplane-like model, consisting of three components: a surge identification system, a surge diversion system, and a resource security system. The head of the plane represents the surge identification system, responsible for recognizing patient categories during medical surges. For example, it determines how patients in a surge can be classified and which groups should be prioritized. The fuselage of the plane represents the surge diversion system. In response to medical surges, the primary function of this system is to direct patients to the two wings of the medical institution based on the results of patient classification, thereby improving the efficiency of diagnosis and treatment. The two wings of the airplane represent the flow directions in the surge diversion, such as large hospitals and primary healthcare organizations. The tail section of the airplane represents the resource security system, which balances surge triage through mutual support among medical institutions and the flexible adjustment or rapid reallocation of medical functions within them. The operation of the entire system reflects the medical surge capacity of an institution and determines whether it can achieve a soft landing in response to a medical surge. During the surge identification stage, improving monitoring efficiency is key to enhancing the effectiveness of the surge response. In Shanghai's surge response, a unified information-sharing platform enabled effective grid-based management and population monitoring, helping to identify emergencies promptly, similar to other cities [ 34 ]. The COVID-19 pandemic can be overcome by screening and quarantine strategies, even in the absence of vaccine and drug measures [ 35 ]. Following health monitoring, it is essential to conduct professional assessments of population characteristics and categorize patients by treatment priority. For example, during the COVID-19 surge in March 2020, New York City emergency departments faced overwhelming patient volumes, prompting some hospitals to establish Forward Treatment Areas outside emergency rooms. These areas enabled the triage and initial management of patients before entering the emergency department, ensuring safer and more efficient patient flow under high-volume conditions [ 36 ]. In terms of surge diversion, emergency responses typically follow two main approaches. Large hospitals focus on managing critically ill patients and conduct internal triage through temporary functional adjustments and staff training, while primary healthcare organizations, pharmacies, and similar institutions primarily handle non-critical patients. In response to China's medical surge, the COVID-19 hierarchical diagnosis and treatment system effectively triaged patients, significantly alleviating the pressure on large hospitals. Under the time pressure of safeguarding people's health, medical surges should inevitably be diverted with the help of other medical institutions in the region, the community, pharmacies, and other external forces. In future medical surges, the government should play a coordinating role by optimizing and distributing resources, and facilitating regional medical mutual assistance to ensure the smooth triage of patients [ 37 ]. Finally, the resource security system is the foundational element of the medical surge response system, responsible for ensuring the availability of material, personnel, information, and other resources to support the institution's surge response. Medical institutions are always the first line of response to surge impacts, especially when multi-point medical surges occur and inter-regional resource resupply is cut off, how to rely on their strength to withstand surge impacts is extremely critical. For example, the COVID-19 pandemic drove a rapid increase in demand for ICU bed capacity, and expanding hospital facilities were essential to support the transition away from a zero-COVID strategy [ 38 , 39 ]. This can be achieved through temporary shifts in the functioning of internal departments, such as converting the post-anesthesia care unit into a cohort ICU [ 40 ]. However, the effective deployment and implementation of such coping mechanisms require substantial engagement from hospital professionals [ 41 , 42 ]. Shortages of medical staff can limit the effectiveness of medical surge response [ 43 ]. Consistent with the findings of other studies, reorganizing workflows through staff redistribution was the primary strategy for accommodating the large influx of patients into hospitals [ 44 , 45 ]. It is also important to reduce the occupational risk of medical staff by improving their self-protection skills and awareness, dynamically adjusting shifts, and providing standardized training [ 46 ]. It is important to note that both Shanghai's and China's experiences in responding to medical surges demonstrate that medical resources are limited and there is a ceiling to surge capacity. The threshold of surge capacity depends on a medical institution's reserves of manpower, supplies, and beds, as well as its ability to rapidly reconfigure, expand, and adapt functions when a surge occurs [ 47 ]. Marcozzi, Pietrobon (48) developed the Hospital Medical Surge Preparedness Index to assess the preparedness of hospitals to respond to national pandemics and other mass casualties. Once a hospital's surge capacity exceeds its threshold, it must rely on external support for surge diversion and resource protection, such as leveraging social forces to strengthen its surge response capacity [ 49 , 50 ]. The following limitations of the study are also recognized. On the one hand, this study gathered information about China's COVID-19 surge response strategies from official websites, news reports, and social media, and the authors' personal experiences, which may not reflect an exhaustive list of all the strategies adopted in Shanghai, as well as in China. On the other hand, the analysis did not include other measures taken by the individuals themselves, by the community, and by the pharmaceutical industry that may help to control the disease. Finally, the cases used in this study are all from China, and as a next step, some empirical measures from other countries can be considered, such as the United Kingdom, France, Italy, and Sweden, to enrich and test the model [ 51 , 52 ]. Conclusions In conclusion, medical surges can be categorized as "single-point surges" and "multi-point surges" based on their characteristics. While there are differences between the two, they share many similarities in terms of surge characteristics and response measures. Medical surge capacity is not just a simple expansion of medical resources but also includes the overall collaborative management of patient monitoring, patient classification, information sharing, treatment process optimization, and safety maintenance. The response system for medical surges during emergencies consists of a surge identification system, a surge diversion system, and a resource security system. In the future, it will be crucial to enhance medical surge capacity during emergencies by addressing all three aspects in an integrated manner. Declarations Ethics approval and consent to participate The information required for the case study was collected from public channels such as official microblogs, news reports, and government reports. Therefore, ethics approval and informed consent from participants were not applicable in this study. Consent for publication Not applicable. Availability of data and materials The original contributions presented in the study are included in the article, further inquiries can be directed to the first author. Competing interests The authors declare that they have no competing interests. Funding The research was supported by: (1) National Natural Science Foundation of China (72074064) Authors' contributions J.X. wrote the draft of the manuscript and interpreted the results. D.W. and J.S. conducted the policy search and case collection. 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Risk Manage Healthc policy. 2020;13:1989–98. Moskovitz JB, Tan T, Dilip M, Khambhati K, Smith C, Sapadin J, et al. The impact and efficiency of medical screening exams in forward treatment areas at New York City public hospitals during the initial COVID-19 surge. J Am Coll Emerg Physicians open. 2021;2(6):e12598. Gooding K, Bertone MP, Loffreda G, Witter S. How can we strengthen partnership and coordination for health system emergency preparedness and response? Findings from a synthesis of experience across countries facing shocks. BMC Health Serv Res. 2022;22(1):1441. Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA. 2020;323(16):1545–6. Mallapaty S. Can China avoid a wave of deaths if it lifts strict zero COVID policy? Nature. 2022;612(7939):203. Kersten BJ, Salden R, van Klei WA, Hoff RG, Schellekens WM. Surging ICU capacity during the COVID-19 pandemic: Experiences from transforming a Post Anaesthesia Care Unit into a cohort ICU. J Clin Anesth. 2020;67:110036. Ridde V, Traverson L, Zinszer K. Hospital Resilience to the COVID-19 Pandemic in Five Countries: A Multiple Case Study. Health Syst Reform. 2023;9(2):2242112. Gupta N, Balcom SA, Gulliver A, Witherspoon RL. Health workforce surge capacity during the COVID-19 pandemic and other global respiratory disease outbreaks: A systematic review of health system requirements and responses. Int J Health Plann Manag. 2021;36(S1):26–41. Mahendradhata Y, Andayani N, Hasri ET, Arifi MD, Siahaan RGM, Solikha DA, et al. The Capacity of the Indonesian Healthcare System to Respond to COVID-19. Front Public Health. 2021;9:649819. David P-M, Gabet M, Duhoux A, Traverson L, Ridde V, Zinszer K, et al. Adapting Hospital Work During COVID-19 in Quebec (Canada). Health Syst Reform. 2023;9(2):2200566. Yasobant S, Patel K, Tadvi R, Thacker H, Bruchhausen W, Saxena D. Challenges in delivering urban healthcare services during COVID-19 pandemic: a mixed-methods study in Ahmedabad, India. BMC Health Serv Res. 2025;25(1):979. Lotfiyan A, Tabatabaee SS, Moghri J. Human resources for health during COVID-19: a qualitative analysis of strategies and challenges in Iran. BMC Health Serv Res. 2025;25(1):961. Hasan MK, Nasrullah SM, Quattrocchi A, Arcos González P, Castro-Delgado R. Hospital surge capacity preparedness in disasters and emergencies: a systematic review. Public Health. 2023;225:12–21. Marcozzi DE, Pietrobon R, Lawler JV, French MT, Mecher C, Baehr NE, et al. The Application of a Hospital Medical Surge Preparedness Index to Assess National Pandemic and Other Mass Casualty Readiness. Journal of healthcare management /. Am Coll Healthc Executives. 2021;66(5):367–78. Cheng Y, Yu J, Shen Y, Huang B. Coproducing Responses to COVID-19 with Community-Based Organizations: Lessons from Zhejiang Province, China. Public Adm Rev. 2020;80(5):866–73. Fumagalli S, Iannuzzi L, Toffolo G, Anghileri I, Losurdo A, Rovelli N, et al. Volunteering in an emergency project in response to the COVID-19 pandemic crisis: the experience of Italian midwives. Public Health. 2023;218:75–83. Warren GW, Lofstedt R, Wardman JK. COVID-19: the winter lockdown strategy in five European nations. J Risk Res. 2021;24(3–4):267–93. Carenzo L, Costantini E, Greco M, Barra FL, Rendiniello V, Mainetti M, et al. Hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Italy. Anaesthesia. 2020;75(7):928–34. Additional Declarations No competing interests reported. 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University","correspondingAuthor":false,"prefix":"","firstName":"Dongxue","middleName":"","lastName":"Wang","suffix":""},{"id":531028966,"identity":"88d39c90-3d96-4eab-8075-c5e915aa0f0f","order_by":2,"name":"Jiale Sun","email":"","orcid":"","institution":"Xuzhou Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Jiale","middleName":"","lastName":"Sun","suffix":""},{"id":531028967,"identity":"32bff0f3-5aea-49e3-a9c7-592415bdc0a8","order_by":3,"name":"Weixue Yin","email":"","orcid":"","institution":"Harbin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Weixue","middleName":"","lastName":"Yin","suffix":""},{"id":531028968,"identity":"3fe6d39d-b3cc-422a-8118-022a9c045e21","order_by":4,"name":"Lijuan Cui","email":"","orcid":"","institution":"Harbin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Lijuan","middleName":"","lastName":"Cui","suffix":""},{"id":531028969,"identity":"11b230ab-df49-4317-9932-6e0cdf624292","order_by":5,"name":"Guomei Tian","email":"","orcid":"","institution":"The Fourth Hospital of Harbin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Guomei","middleName":"","lastName":"Tian","suffix":""},{"id":531028970,"identity":"afb2dcd8-0300-46b8-bc15-2027a270d2cc","order_by":6,"name":"Zheng Kang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYBACCRDB2AAk2HsYmCFiCcRq4TlDshaJHCK1SLafPfzy5w6bPPnIt8c+F+YcZuBnzzFg+LkDtxZpnrw0C8kzacWGt/OSZ8/cdphBsueNAWPvGdxa5BhyzAwM2w4nbpydY8zMC9RicCPHgJmxDY8W/jdmBolt/xM3zjwD0WJPSIu0RI7xg4NtBxLnS/BAbZEgoEVyxhszxsa25MQNPECHzdyWziNx5lnBwV48WiTO5xh//Nlmlzi/Heiwwm3WcvztyRsf/MSjBQjYwHFjcADC4wERB/BqYGBg/gAi5RsIKBsFo2AUjIKRCwAIRFDXSSRhOgAAAABJRU5ErkJggg==","orcid":"","institution":"Harbin Medical University","correspondingAuthor":true,"prefix":"","firstName":"Zheng","middleName":"","lastName":"Kang","suffix":""}],"badges":[],"createdAt":"2025-07-30 02:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7247753/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7247753/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93915764,"identity":"e507fcfe-d134-4c40-bfd5-bf083cd225c2","added_by":"auto","created_at":"2025-10-20 08:45:45","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3467540,"visible":true,"origin":"","legend":"\u003cp\u003eResponse to Single-point Surge in Shanghai.\u003c/p\u003e","description":"","filename":"Figure1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7247753/v1/00079ce1d28d41a08197233d.jpg"},{"id":93915765,"identity":"f7646d39-91d9-4ea2-86ca-ab83dffe1840","added_by":"auto","created_at":"2025-10-20 08:45:45","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3790838,"visible":true,"origin":"","legend":"\u003cp\u003eResponse to Multi-point Surge in China.\u003c/p\u003e","description":"","filename":"Figure2.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7247753/v1/88040ef763511ff012eb1246.jpg"},{"id":93916459,"identity":"a25e1220-ebba-4f76-9a8a-a0aef3e9b148","added_by":"auto","created_at":"2025-10-20 08:53:45","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3453576,"visible":true,"origin":"","legend":"\u003cp\u003eThe Response System for Medical Surges during Emergencies.\u003c/p\u003e","description":"","filename":"Figure3.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7247753/v1/a2086c7787a48217eccfedd6.jpg"},{"id":93916886,"identity":"01c727c9-6830-4f7c-98fc-f0c5c2566e98","added_by":"auto","created_at":"2025-10-20 08:54:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":11339381,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7247753/v1/172528e4-9da0-49bd-8037-54565b4a677d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Response to single-point and multi-point medical surge in emergencies: Lessons learned from two cases in China","fulltext":[{"header":"Introduction","content":"\u003cp\u003eExtreme weather, earthquakes, terrorism, and other disasters can lead to large populations with compromised health, requiring timely medical intervention to prevent significant risks to their lives [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In 2020, COVID-19 erupted as a public health emergency in multiple countries. COVID-19 is highly contagious, and as the virus spreads rapidly, the need for centralized care of large numbers of patients arises [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In China, between January 25 and February 23, 2020, the cumulative number of confirmed COVID-19 cases in Wuhan, Hubei Province, surged from 618 to 46,607 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As of the end of November 2020, the United States reported a cumulative total of 13\u0026nbsp;million cases, with 180,000 new cases daily [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In less than a month of the outbreak, the number of COVID-19 patients in Italy exceeded 40,000 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], forcing general practitioners and nurses to make extraordinary decisions about who to save [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEmergencies can disrupt the normal operations of medical institutions, forcing them to function under exceptional conditions. This is particularly evident during major incidents, where the number of casualties can surge to dozens or even hundreds of times the usual volume. Patient treatment in such scenarios is typically characterized by its urgency, sudden onset, large scale, and centralized nature [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. When a sudden influx of patients far exceeds a medical institution's normal capacity to provide care, a severe medical surge occurs. Such surges often compromise treatment effectiveness and place an overwhelming strain on the healthcare system [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Consequently, strengthening the healthcare system's medical surge capacity during emergencies is critical to safeguarding lives in the face of diverse disasters.\u003c/p\u003e\u003cp\u003e\"Surge capacity\" is originally a physics term. \"Surge\" mainly refers to the strong pulse generated at the moment when the power supply is just turned on, which is likely to cause the circuit to burn out [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the healthcare field, many scholars interpret medical surge capacity as the ability of a medical institution to effectively respond to sudden, large-scale patients in an unanticipated range [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In 2003, the Joint Commission on Accreditation of Healthcare Organizations provided one of the earliest definitions of medical surge capacity, describing it as the legal ability to triage, manage, vaccinate, sterilize, or place patients, and to provide healthcare services beyond the usual scope [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Sheikhbardsiri, Raeisi (17) identified four key components of medical surge capacity: personnel, resources, infrastructure, and systems. The interaction between these components ultimately dictates the effectiveness of the medical surge response. Combining the various studies on medical surge capacity, this study believes that medical surge capacity can be understood as the ability of a medical institution to meet peak medical demand during an emergency, which is a core competency of the medical institution's emergency response.\u003c/p\u003e\u003cp\u003eIn 2006, the International Conference on Academic Emergency Medicine outlined key priorities for enhancing medical surge capacity during catastrophic events. These priorities included: defining criteria and methods for allocating scarce resources, identifying effective triage options, designating key decision-makers for capacity planning, establishing methods to evaluate the effectiveness of the response, and developing strategies for effective communication and information sharing [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Hick, Koenig (19) constructed the CO-S-TR model that can be implemented immediately after an event, where \"CO\" stands for command, control, communications, and coordination, \"S\" takes into account staff, stuff, space, and special considerations, and \"TR\" includes tracking, triage, treatment, and transportation. Shen, Jiang (20) proposed emergency strategies for medical response after a major disaster, including triage of catastrophic medical surges, scalability of medical surge capacity, and maintaining the functionality of medical response support systems.\u003c/p\u003e\u003cp\u003eHowever, as the characteristics of emergencies and the external environment evolve, the scope of surge impact also varies, and there is limited value in discussing medical surges without considering specific scenarios. Analyzing how to enhance medical surge capacity in specific scenarios is crucial for enabling medical institutions to respond accurately and act swiftly based on the actual circumstances. Therefore, this study selected two time points for comparison: the COVID-19 outbreak in Shanghai in 2022 and the subsequent nationwide epidemic at the end of 2022, following the optimization of China's prevention and control measures. By conducting a comparative analysis using Shanghai and China as representative cases, this study develops a systematic approach to improving medical surge capacity during emergencies, aiming to offer practical insights for medical institutions to strengthen their emergency response and better safeguard public safety.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eEmploying a case study approach, this research compares, analyzes, and synthesizes the characteristics of medical surges and the corresponding responses across two typical scenarios to propose strategies to enhance medical surge capacity during emergencies. The case study methodology begins with a real-world problem and, through comprehensive and in-depth descriptions and analyses of a phenomenon, derives theoretical insights from representative cases to construct a conceptual model that addresses the questions of how and why [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In contrast to a single case study, this study opted for a double-case comparative analysis method to observe activities occurring in different scenarios at a deeper level and to improve the accuracy and generalizability of the findings [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eCases selection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBased on the changes in the epidemic characteristics of COVID-19 in China, this study classified medical surges into two categories: \"single-point surge\" and \"multi-point surge\" based on the characteristics of medical surges. A single-point surge is defined as a medical surge occurring in a single city or localized area, while a multi-point surge refers to a surge affecting multiple cities or areas simultaneously. The criteria for selecting a typical case for this study are as follows: 1) the case should encompass the entire process, from the onset of the medical surge to the response; 2) the case should have received significant attention from both the academic community and the media, providing access to ample secondary information; and 3) the case should be based on the author's personal experience, allowing for the validation of secondary information through case review.\u003c/p\u003e\u003cp\u003eBased on these criteria, this study examines the COVID-19 outbreak in Shanghai, China, from March to May 2022, as a case of a single-point surge under the dynamic zero-COVID strategy. Although cities across China implemented various measures to curb the spread of COVID-19, Shanghai was selected as a representative case for two main reasons. First, the city maintained a relatively low number of locally transmitted cases and a high recovery rate, serving as a model for other cities and provinces. Second, as one of the largest and most densely populated cities in China, Shanghai's surge response strategies and experiences are particularly representative. In the multi-point surge case selection, on December 7, 2022, China adjusted the dynamic zero strategy, and a large number of COVID-19 patients simultaneously appeared throughout the country. Therefore, this study selected the end of 2022 as the time point to analyze the characteristics of the multi-point surge and its corresponding response measures.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSources of information\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe methods of information collection are as follows: 1) Public data collection. The information required for the case study was collected from public channels such as official microblogs, news reports, and government reports; 2) Experiential observation. The cases selected in this study were the authors' personal experiences, especially after the optimization of the prevention and control measures for COVID-19 in China in late 2022. Having been infected with COVID-19 and sought medical care themselves, the authors gained a direct and realistic understanding of the response to multi-point surges, thereby providing richer and more nuanced insights for this research.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eAnalysis of single-point surge and its response\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSingle-point surge characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn 2008, Howitt (23) proposed five dimensions of surge analysis in the field of catastrophe response, including total demand, physical size, technical complexity, time pressure, and crisis duration. Total demand refers to the resources required for surge response, physical size pertains to the geographic area impacted by the surge, technical complexity involves the specialized personnel and equipment needed for response, time pressure refers to the rigid constraints imposed by the golden hour of surge response, and crisis duration denotes the length of time the surge persists. These five dimensions define the requirements for surge capacity. Using them as a framework, this study examined the characteristics of medical surges, with results shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of single-point surge in Shanghai.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle-point surge in Shanghai\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal demand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMore than 600,000 asymptomatic patients were screened; from February 26 to May 25, 57,867 cases were diagnosed, 55,387 cases were cured and discharged, 1,893 cases were treated in hospitals (of which 118 were severe cases and 34 were critical cases), and 587 cases were dead.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical size\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCOVID-19 outbreak in Shanghai, Single-point surge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTechnical complexity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1) predominantly mild/moderate cases, with a low percentage of severe cases; 2) high mortality rates for patients of senior age and those with underlying diseases; and 3) a severe shortage of medical staff, facilities, and beds.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime pressure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGuaranteeing the health of life and reducing mortality.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCrisis duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThis medical surge in Shanghai lasted nearly three months.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn 2022, the highly infectious Omicron variant spread rapidly across China. On March 1, 2022, Shanghai reported its first case of indigenous infection with no known source of transmission. Subsequently, especially in April, the number of cases increased sharply. By May 2022, the Shanghai outbreak had infected over 600,000 people, marking it as the largest wave since the COVID-19 outbreak in China [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Given that Shanghai has an aging population, nearly half of the critically ill patients were over 80 years old, and 67% of the fatal cases occurred in this age group. Deaths among the elderly and those with underlying health conditions posed the greatest challenge to Shanghai's response to the medical surge [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eSingle-point surge response\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the response to the single-point surge in Shanghai, which was divided into two steps: the first involved implementing information monitoring and patient classification, followed by the centralized treatment of patients to ensure unified management and orderly care.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn the stage of information monitoring and patient classification, based on the scientific and professional guidance of the COVID-19 Prevention and Control Program, and with the help of the unified information monitoring platform (health QR codes and travel codes), the CDC, primary health care institutions and social volunteers had engaged in a great deal of information monitoring and patient classification [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. At the same time, patients are pre-classified according to the National Prevention and Control Program before treatment, guiding them to seek medical care in an organized and systematic manner. This approach played a crucial role in maximizing the efficiency of limited medical resources and alleviating issues of medical overcrowding and resource shortages [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the centralized treatment phase, a strategy of centralized isolation combined with stratified admission was implemented. Designated hospitals and makeshift hospitals were mainly responsible for the isolation and treatment of patients, to achieve the goal of \"all those in need are hospitalized\". Secondary and tertiary hospitals mainly contributed by dispatching medical staff to support clinical care in designated and makeshift hospitals, assisting with nucleic acid testing at key sites and within local communities, while also maintaining routine diagnostic and treatment services. Under the principle of stratified admission, makeshift hospitals primarily accommodated asymptomatic and mildly ill patients, whereas large designated hospitals focused on treating severe cases.\u003c/p\u003e\u003cp\u003eFaced with a severe shortage of medical resources, particularly human resources and infrastructure, China implemented a counterpart support system to assist Shanghai [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The other provinces of China and the People's Liberation Army dispatched more than 50,000 people to Shanghai. Among them, a large number of specialists in ICU, infection, respiratory medicine, circulatory medicine, and anesthesiology greatly eased the pressure on medical care. At the same time, Shanghai actively expanded its infrastructure. By April 8, 2022, more than 100 square-cabin hospitals with over 160,000 beds had been renovated or newly constructed in public buildings, such as gymnasiums and exhibition centers, significantly boosting the city's medical surge capacity. Shanghai had changed from \"people waiting for beds\" to \"beds waiting for people\", truly realizing \"all those in need are hospitalized or treated\".\u003c/p\u003e\u003cp\u003eIn China, when the COVID-19 outbreak occurred in a city or region, the surge characteristics and response were mostly the same as in Shanghai. Through summarizing and analyzing, this study identified several key factors contributing to the successful building of medical surge capacity under a single-point surge: 1) an integrated information monitoring platform that provided essential support for the timely and accurate dissemination of medical surge data; 2) scientific and professional prevention and control programs that offered standardized guidance for patient classification and treatment; 3) counterpart support from other provinces and regions, enabling the rapid deployment of rescue personnel; and 4) the conversion of stadiums, exhibition centers, and other public buildings, along with the construction of makeshift hospitals, facilitating the rapid expansion of infrastructure.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAnalysis of multi-point surge and its response\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMulti-point surge characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOn December 7, 2022, based on the experience of prevention and control practices and assessment data, the Chinese government released measures to optimize the COVID-19 response, which required minimizing the impact of the epidemic on economic and social development. Subsequently, China adjusted its dynamic zero-COVID policy, leading to a large-scale medical surge of COVID-19 patients across cities nationwide. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates the results of the characteristics analysis of multi-point surges in China.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of multi-point surge in China.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMulti-point surge in China\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal demand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMore than 200\u0026nbsp;million people have been diagnosed and treated, and 800,000 seriously ill patients have been effectively treated; medicines are in short supply, hospital beds are hard to come by, and resource replenishment across regions has been cut off.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical size\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA nationwide epidemic, interregional support becomes difficult.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTechnical complexity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1) a decline in the incidence of serious illness, with a large number of asymptomatic or mildly infected patients; 2) a surge in the number of seriously ill elderly patients with underlying conditions; 3) a simultaneous influx of seriously ill, mildly infected, and emergency non-infected patients into hospitals or communities; and 4) a large number of healthcare staff being infected.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime pressure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnsuring people's lives and health.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCrisis duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe national medical surge occurred mainly in December 2022-January 2023. The number of infections in each province peaked on December 22nd and then gradually declined until January 23rd, 2023, when it reached its lowest level.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eChina's multi-point surge exhibited two key characteristics and posed significant response challenges. On the one hand, the number of fever-related outpatient and emergency visits increased sharply, peaking on December 23, 2022, before steadily declining [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In a scenario where patients could freely choose their healthcare providers, the concurrent influx of both severe and mild infections, along with urgent non-infectious cases, placed substantial strain on healthcare workers and medical facilities. On the other hand, the infection situation among medical staff was concerning. In some large hospitals, more than half of the Intensive Care Medicine team was reduced, with nearly all on duty being mildly infected. The sharp increase in outpatient and emergency visits, combined with the ongoing attrition of medical staff, posed a significant challenge to the healthcare system.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMulti-point surge response\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the response to the multi-point surge in China. Under the multi-point surge, all regions of China experienced severe medical surges, and support from other provinces or regions became increasingly difficult. As a result, they had to rely on internal personnel and infrastructure transformation to expand medical resources. At the same time, by optimizing management, they enhanced the efficiency of these resources, allowing for an effective response to the medical surges.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFirst, primary healthcare organizations shifted from primarily conducting information monitoring during single-point surges to providing general patient care and health guidance during multi-point surges. They handled large volumes of non-critical patients and referred them to larger hospitals when necessary, thereby helping to prevent hospital resources from being overwhelmed. By December 25, 2022, China had established over 16,000 fever clinics in secondary and tertiary hospitals, along with more than 41,000 fever clinics operated by primary healthcare institutions. Meanwhile, many regions converted gymnasiums and nucleic acid testing kiosks into temporary fever clinics, equipping them with pharmacies and stocking antipyretic and analgesic medications to ensure public access to treatment and medicine.\u003c/p\u003e\u003cp\u003eSecondly, secondary and tertiary hospitals experienced overwhelming medical surges due to the loss of coordinated access mechanisms. Among all patients, priority should be given to severely infected individuals, elderly patients with underlying conditions, and non-infected individuals requiring emergency care [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Accordingly, China issued policies instructing secondary and tertiary hospitals to focus on these key populations to ensure an effective surge response. At the same time, major hospitals optimized patient management and treatment protocols to maintain smooth operations during emergencies, for instance, by revising admission and discharge criteria and streamlining patient flow across outpatient, emergency, and fever clinics. In addition, to address severe shortages of personnel and beds in respiratory and intensive care units, hospitals implemented internal support measures, such as training staff from other departments and converting beds in other wards into respiratory or ICU beds. By December 25, 2022, the number of ICU beds in China had increased by 20.67% compared to December 13, while the national reserve of convertible ICU beds had risen by 26.53%, effectively strengthening manpower and infrastructure for surge response.\u003c/p\u003e\u003cp\u003eIn summary, China's efforts to build medical surge capacity under multi-point surges achieved the following successes: 1) primary healthcare institutions managed a large volume of general patient treatment and health guidance, reducing reliance on large hospitals; 2) the training and redeployment of healthcare workers from other departments within large hospitals led to a rapid expansion of staff; 3) the repurposing of beds and resources from other departments facilitated a quick expansion of infrastructure; and 4) the optimization of management processes in medical institutions focused on key populations while ensuring the safe operation of hospitals.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUsing Shanghai and China as representative cases, this study expands the research on medical surges in two ways. First, this study introduces the concepts of single-point surge and multi-point surge, which offer a new perspective for recognizing and responding to medical surges. To the best of our knowledge, such studies are currently unavailable. Second, this study proposes a systematic approach to enhancing medical surge capacity during emergencies. The findings can provide a solid foundation for medical institutions to improve their response to medical emergencies and safeguard public health.\u003c/p\u003e\u003cp\u003eThrough the review of Shanghai's single-point surge and China's multi-point surge, this study found that although there are differences in the characteristics of the two surges and the response measures, they also share many similarities. Medical surge capacity is not just a simple expansion of medical resources but also includes the overall collaborative management of patient monitoring, patient classification, information sharing, treatment process optimization, and safety maintenance. Based on the response measures to medical surges during emergencies, a response system for medical surges was developed, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the response system for medical surges during emergencies is represented by an airplane-like model, consisting of three components: a surge identification system, a surge diversion system, and a resource security system. The head of the plane represents the surge identification system, responsible for recognizing patient categories during medical surges. For example, it determines how patients in a surge can be classified and which groups should be prioritized. The fuselage of the plane represents the surge diversion system. In response to medical surges, the primary function of this system is to direct patients to the two wings of the medical institution based on the results of patient classification, thereby improving the efficiency of diagnosis and treatment. The two wings of the airplane represent the flow directions in the surge diversion, such as large hospitals and primary healthcare organizations. The tail section of the airplane represents the resource security system, which balances surge triage through mutual support among medical institutions and the flexible adjustment or rapid reallocation of medical functions within them. The operation of the entire system reflects the medical surge capacity of an institution and determines whether it can achieve a soft landing in response to a medical surge.\u003c/p\u003e\u003cp\u003eDuring the surge identification stage, improving monitoring efficiency is key to enhancing the effectiveness of the surge response. In Shanghai's surge response, a unified information-sharing platform enabled effective grid-based management and population monitoring, helping to identify emergencies promptly, similar to other cities [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The COVID-19 pandemic can be overcome by screening and quarantine strategies, even in the absence of vaccine and drug measures [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Following health monitoring, it is essential to conduct professional assessments of population characteristics and categorize patients by treatment priority. For example, during the COVID-19 surge in March 2020, New York City emergency departments faced overwhelming patient volumes, prompting some hospitals to establish Forward Treatment Areas outside emergency rooms. These areas enabled the triage and initial management of patients before entering the emergency department, ensuring safer and more efficient patient flow under high-volume conditions [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn terms of surge diversion, emergency responses typically follow two main approaches. Large hospitals focus on managing critically ill patients and conduct internal triage through temporary functional adjustments and staff training, while primary healthcare organizations, pharmacies, and similar institutions primarily handle non-critical patients. In response to China's medical surge, the COVID-19 hierarchical diagnosis and treatment system effectively triaged patients, significantly alleviating the pressure on large hospitals. Under the time pressure of safeguarding people's health, medical surges should inevitably be diverted with the help of other medical institutions in the region, the community, pharmacies, and other external forces. In future medical surges, the government should play a coordinating role by optimizing and distributing resources, and facilitating regional medical mutual assistance to ensure the smooth triage of patients [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFinally, the resource security system is the foundational element of the medical surge response system, responsible for ensuring the availability of material, personnel, information, and other resources to support the institution's surge response. Medical institutions are always the first line of response to surge impacts, especially when multi-point medical surges occur and inter-regional resource resupply is cut off, how to rely on their strength to withstand surge impacts is extremely critical. For example, the COVID-19 pandemic drove a rapid increase in demand for ICU bed capacity, and expanding hospital facilities were essential to support the transition away from a zero-COVID strategy [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This can be achieved through temporary shifts in the functioning of internal departments, such as converting the post-anesthesia care unit into a cohort ICU [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, the effective deployment and implementation of such coping mechanisms require substantial engagement from hospital professionals [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Shortages of medical staff can limit the effectiveness of medical surge response [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Consistent with the findings of other studies, reorganizing workflows through staff redistribution was the primary strategy for accommodating the large influx of patients into hospitals [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. It is also important to reduce the occupational risk of medical staff by improving their self-protection skills and awareness, dynamically adjusting shifts, and providing standardized training [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIt is important to note that both Shanghai's and China's experiences in responding to medical surges demonstrate that medical resources are limited and there is a ceiling to surge capacity. The threshold of surge capacity depends on a medical institution's reserves of manpower, supplies, and beds, as well as its ability to rapidly reconfigure, expand, and adapt functions when a surge occurs [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Marcozzi, Pietrobon (48) developed the Hospital Medical Surge Preparedness Index to assess the preparedness of hospitals to respond to national pandemics and other mass casualties. Once a hospital's surge capacity exceeds its threshold, it must rely on external support for surge diversion and resource protection, such as leveraging social forces to strengthen its surge response capacity [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe following limitations of the study are also recognized. On the one hand, this study gathered information about China's COVID-19 surge response strategies from official websites, news reports, and social media, and the authors' personal experiences, which may not reflect an exhaustive list of all the strategies adopted in Shanghai, as well as in China. On the other hand, the analysis did not include other measures taken by the individuals themselves, by the community, and by the pharmaceutical industry that may help to control the disease. Finally, the cases used in this study are all from China, and as a next step, some empirical measures from other countries can be considered, such as the United Kingdom, France, Italy, and Sweden, to enrich and test the model [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, medical surges can be categorized as \"single-point surges\" and \"multi-point surges\" based on their characteristics. While there are differences between the two, they share many similarities in terms of surge characteristics and response measures. Medical surge capacity is not just a simple expansion of medical resources but also includes the overall collaborative management of patient monitoring, patient classification, information sharing, treatment process optimization, and safety maintenance. The response system for medical surges during emergencies consists of a surge identification system, a surge diversion system, and a resource security system. In the future, it will be crucial to enhance medical surge capacity during emergencies by addressing all three aspects in an integrated manner.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe information required for the case study was collected from public channels such as official microblogs, news reports, and government reports. Therefore, ethics approval and informed consent from participants were not applicable in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article, further inquiries can be directed to the first author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research was supported by: (1) National Natural Science Foundation of China (72074064)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJ.X. wrote the draft of the manuscript and interpreted the results. D.W. and J.S. conducted the policy search and case collection. W.Y. and L.C. provided comments and suggestions in revisions of the paper.\u0026nbsp;G.T.\u0026nbsp;was involved in writing-review \u0026amp; editing and supervision.\u0026nbsp;Z.K. conceptualised the study and was responsible for funding acquisition. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSohrabizadeh S, Yousefian S, Bahramzadeh A, Vaziri MH. A systematic review of health sector responses to the coincidence of disasters and COVID-19. BMC Public Health. 2021;21(1):709.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOuyang Y. Earthquake tests China's emergency system. 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Anaesthesia. 2020;75(7):928\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Emergency response, Single-point surge, Multi-point surge, Medical surge capacity, Double-case comparison","lastPublishedDoi":"10.21203/rs.3.rs-7247753/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7247753/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMedical surge capacity is the ability of a medical institution to meet peak medical demand during an emergency. This study aims to explore strategies for enhancing medical surge capacity in future emergency responses to better safeguard public safety.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA double-case comparative analysis was conducted focusing on the characteristics and responses to the medical surge during the COVID-19 outbreak in Shanghai and the nationwide epidemic in China.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eMedical surges can be categorized into \"single-point surges\" and \"multi-point surges\". While there are differences between the two, they also share many similarities. The experiences of Shanghai and China demonstrated that medical surge capacity involves more than expanding resources. It also demands coordinated management of patient monitoring and triage, information sharing, treatment process optimization, and safety maintenance.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eEnhancing medical surge capacity requires the integration of surge identification, surge diversion, and resource security. Surge identification entails the timely recognition and classification of patients. Surge diversion involves directing patients to appropriate medical institutions based on this classification. Resource security supports effective surge diversion by promoting mutual assistance among medical institutions and enabling flexible adjustments to their functions.\u003c/p\u003e","manuscriptTitle":"Response to single-point and multi-point medical surge in emergencies: Lessons learned from two cases in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-20 08:45:41","doi":"10.21203/rs.3.rs-7247753/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e86bf146-44b5-4729-aac1-2bc1420f10a4","owner":[],"postedDate":"October 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T08:45:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-20 08:45:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7247753","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7247753","identity":"rs-7247753","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}