This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIRx Med, is properly cited. The complete bibliographic information, a link to the original publication on https://med.jmirx.org/, as well as this copyright and license information must be included.
The SARS-CoV-2 pandemic has brought substantial strain on hospitals worldwide; however, although the success of China’s COVID-19 strategy has been attributed to the achievements of the government, public health officials, and the attitudes of the public, the resilience shown by China’s hospitals appears to have been a critical factor in their successful response to the pandemic.
This paper aims to determine the key findings, recommendations, and lessons learned in terms of hospital resilience during the pandemic; analyze the quality and limitations of research in this field at present; and contribute to the evaluation of the Chinese response to the COVID-19 outbreak, building on a growing literature on the role of hospital resilience in crisis situations.
We conducted a scoping review of evidence on the resilience of hospitals in China during the COVID-19 crisis in the first half of 2020. Two online databases (the China National Knowledge Infrastructure and World Health Organization databases) were used to identify papers meeting the eligibility criteria. After extracting the data, we present an information synthesis using a resilience framework. Articles were included in the review if they were peer-reviewed studies published between December 2019 and July 2020 in English or Chinese and included empirical results pertaining to the resilience of Chinese hospitals in the COVID-19 pandemic.
From the publications meeting the criteria (n=59), we found that substantial research was rapidly produced in the first half of 2020 and described numerous strategies used to improve hospital resilience, particularly in three key areas: human resources; management and communication; and security, hygiene, and planning. Our search revealed a focus on interventions related to training, health care worker well-being, eHealth/telemedicine, and workplace organization, while other areas such as hospital financing, information systems, and health care infrastructure were less well represented in the literature. We also noted that the literature was dominated by descriptive case studies, often lacking consideration of methodological limitations, and that there was a lack of both highly focused research on specific interventions and holistic research that attempted to unite the topics within a resilience framework.
We identified a number of lessons learned regarding how China’s hospitals have demonstrated resilience when confronted with the SARS-CoV-2 pandemic. Strategies involving interprovincial reinforcements, online platforms and technological interventions, and meticulous personal protective equipment use and disinfection, combined with the creation of new interdisciplinary teams and management strategies, reflect a proactive hospital response to the pandemic, with high levels of redundancy. Research on Chinese hospitals would benefit from a greater range of analyses to draw more nuanced and contextualized lessons from the responses to the crisis.
Since the emergence of the initial outbreak in Wuhan, the SARS-CoV-2 pandemic has created serious problems for hospital resilience globally [
The response of hospitals in China to the pandemic in early 2020, particularly the situation in Wuhan, has been well publicized. As Wuhan was the source of the first major documented nosocomial outbreak, many feared that hospitals in the city and elsewhere in China would struggle to cope with the shock of the pandemic [
Defined as a system that can adapt its functioning to absorb a shock and, if necessary, transform to recover from adverse events, resilience has become an increasingly common concept within international health and development literature [
Research by the same authors [
This literature must be reconsidered in the light of the recent SARS-CoV-2 outbreak, where the resilience of China’s hospitals has been challenged by a more severe health crisis. Although the success of China’s strategy has been attributed to achievements of the government, public health officials, and the attitudes of the public [
As part of a multidisciplinary team, and with the support of two external librarians, we chose a scoping review to enable us to synthesize, with rigor and in a relatively short period of time, the state of knowledge regarding our research question, to clarify the concept of hospital resilience in the literature, and to identify and analyze relevant knowledge gaps [
In June 2020, we designed a protocol in advance of the study and published it on protocols.io [
We conducted a systematic search using two different strategies to select appropriate academic literature from each context.
For the English-language literature, we have based our research on a collection of articles related to the COVID-19 pandemic published on the World Health Organization (WHO) website [
The search terms included the following keywords, comprising the three concepts: (1) China; (2) health care systems, hospitals, and professionals; and (3) resilience. English-language search terms (see
To limit the results to peer-reviewed journals, we limited the search on CNKI to five subcategories: those included in the
The selection of evidence sources was conducted following an extended iterative process, confirming that there was complete overlap of articles with searches on other platforms (eg, Wanfang, Google Scholar, PubMed, or CDC website).
The following information was extracted from each of the selected articles: title, authors, publication type, type of resilience, whether resilience was explicitly referred to, the hospital dimension, main objectives of the article, a slightly adapted Mixed-Methods Appraisal Tool (MMAT) evaluation, a simple representation of the results, limitations and main findings, recommendations by the authors, and some subjective notes by the reviewers. The MMAT was adapted to better capture single case studies [
Articles were included in the review if they were published between December 2019 and July 2020, were published in English or Chinese, focused on the resilience of Chinese hospitals in the COVID-19 pandemic, included empirical results, included accessible full articles, and were not considered gray literature (eg, press articles, letters, or editorials). Two reviewers (anonymous) used the software Rayyan [
Articles were initially excluded based on reading the titles and abstracts, and then, for remaining articles, the full paper was evaluated. If an included article was identified as concentrating on public health systems, hospitals, or health care professionals, it was classified as such and only included in the study if it pertained to hospital resilience.
Two authors (JS and RH) used MAXQDA 2020 (VERBI Software), a qualitative data analysis tool, to code the data using a coding tree consisting of 7 larger categories, including governance, human resources, professional values, finance, security, planning and management, communication, background (pre-existing policies), and two other coding categories to map methods (including methodological limitations) and the dimensions included in our conceptual framework. A separate category for professional opinions, recommendations, and other cited articles was included to facilitate the synthesis. The quality of studies was not evaluated although we did include information on the type of study design, data collection methods, potential limitations, a summary of the results, main findings, and recommendations given within the articles (
Results from the Chinese and English articles were initially synthesized separately by JS and RH, respectively; then, the two syntheses were combined by all authors. We synthesized the literature according to the Ridde et al [
The synthesis of the articles was performed in terms of context, strategy, and impact. First, we explain the context in which a specific strategy is adopted, including the events in question and the effects of the pandemic experienced by the hospital in question. We then provide a synthesis of the strategies used, giving examples if necessary. Finally, we note the impacts of these strategies on health care access, which can theoretically be positive, negative, or neutral. The causality attributed to certain interventions is examined cautiously in the Discussion section. The right side of this resilience framework (
This framework also helps us to address the question of how hospitals anticipate or react to crises. The
A reaction: When all three factors are present (an effect is felt, a strategy is adopted, and this strategy has positive or negative impacts)
Anticipation: When strategies have an impact before a shock or are preventing a shock
Inaction: When a shock has negative effects, but there are no strategies in place to react to this
The framework identified 10 conceptual dimensions of health systems: governance, intervention level, workforce, culture and social values, finance, planning and supported guidance, systems specificities, health sector management, information systems, context, and security, which we integrate into three larger categories with which to perform the synthesis: (1) human resources, (2) management and communication, and (3) the hygiene-security-planning nexus.
Resilience framework.
As shown in
We identified 236 studies that met the criteria regarding resilience in general, of which 59 studies, 26 in English and 33 in Chinese, met the criteria for inclusion in the hospital-focused study;
The geographical distribution of the papers is described in
Our analysis revealed that 94% (n=56) of the articles were explicitly identified as peer-reviewed articles, with 1 review article, 1 commentary article, and 1 short report. In terms of methodology, the studies were dominated by single case studies using mixed methods (n=30, 51%) and descriptive quantitative studies (n=22, 37%). There were 4 (7%) qualitative studies, 2 (3%) studies using other mixed methods, and 1 randomized study. The dimensions of hospital resilience most commonly referred to were health sector management (n=44), context and security (n=47), intervention level (n=8), planning and support (n=29), system specifics (n=8), information systems (n=8), workforce (n=31), and cultural and social values (n=4). Other dimensions such as governance and finance were not covered in the selected articles.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart. CN: Chinese; EN: English.
Geographical distribution of papers.
In terms of MMAT criteria, 85% (n=50) of articles contained clear questions and objectives, and addressed them appropriately. Quantitative studies adhered to the MMAT criteria to mixed degrees: the sampling strategies were often not made explicit (n=4) and many studies used some form of convenience sampling (n=5) due to accessibility and need for timeliness given the crisis context. It was often unclear whether the study was representative of the population (n=8), and in some articles (n=6), there appeared to be some overrepresentation of certain groups within the population (women and nurses in particular).
All quantitative articles were deemed to have used appropriate measurement tools, and only 9% (n=2) of the quantitative articles did not specifically mention response rates. Similarly, 7% (n=2) of the mixed methods articles were considered to have used an unclear methodology, and 17% (n=5) were identified as not integrating qualitative and quantitative data in a relevant manner. Only 36% (n=11) of articles explicitly considered limitations of the study methodology.
Studies published in Chinese were more likely to be case studies (n=21, 62%) compared to studies published in English (n=7, 27%). Chinese-language studies were also less likely to consider limitations of the methods used, with 71% (n=24) not mentioning any limitations, as opposed to 23% (n=6) of the English-language papers. Our MMAT evaluation determined that the papers published in English conformed more closely to the MMAT framework than those in Chinese.
We identified 10 different categories in which strategies to address the pandemic were used and 29 specific strategies recommended by the articles (
After the initial outbreak of COVID-19 in Wuhan, the Chinese authorities made the decision to send personnel reinforcements from all over the country to Hubei Province to fight the epidemic. Wuhan is medically well equipped (9.25 hospital beds per 1000 inhabitants in 2018) and has 110,000 health professionals, including 40,000 medical practitioners and 54,434 nurses [
Strategy 1: Standardization of nursing procedures. In one hospital in Wuhan, the 27 nurses in a ward dedicated to patients with COVID-19 had all come from different departments (eg, infectiology and cardiology) from six different hospitals in Sichuan Province. These nurses had different experiences, skills, and habits; therefore, to facilitate collaboration and improve work efficiency, the management of this hospital introduced a new work system, standardizing nursing procedures and responsibilities of each staff member [
Strategy 2: Creation of backup teams. This involved forming a team composed of staff members and external reinforcements in preparation for increased staff demand in COVID-19 infection wards and to compensate for a reduction in staff numbers due to infection. These teams were often formed strategically; for example, Jinyintan Hospital in Wuhan deliberately split nursing teams into teams comprising of backup (nonlocal) nurses and local nurses, experienced nurses and newly graduated nurses, and intensive care unit nurses and nonintensive care unit nurses to share experience, skills, and awareness of procedure [
Strategy 3: Delineating the responsibilities of each staff member. Many hospitals instituted measures such as checklist interventions [
The articles reported many positive outcomes as a result of these interventions, including how the efforts helped facilitate the integration of reinforcements into the service and deliver quality care efficiently while maintaining the mental and psychological health of reinforcement staff [
Due to the contagiousness of SARS-CoV-2, new ways of caring for patients were implemented to reduce the risk of contamination. Family visits were restricted, and the loneliness of inpatients became a substantial challenge requiring hospital staff to pay more attention to the mental health of patients. To prevent and control the spread of the virus and to avoid cross-contamination, some departments closed their ambulance services and stopped receiving patients, while lockdown and the accompanying transport control measures made it difficult for non–COVID-19 patients to travel and receive treatment [
To continue providing health care to the community and fulfill their obligations to patients, hospitals had to use other methods to provide care; therefore, a common element examined in the chosen studies was the use of telemedicine interventions. Telemedicine interventions serve the role of allowing patients to receive medical appointments, services, and treatment without having to visit a hospital; preparing and screening patients before they arrive at the hospital to facilitate their entry into the hospital and avoid contamination; monitoring patients with COVID-19 in home quarantine; and using human resources more efficiently. Additionally, mobile and digital technology was used by hospitals across China in a range of other ways to increase efficiency and reduce person-to-person contacts [
Strategy 1: Use of online services for psychological issues in the population. A hospital in Chengdu implemented a multitiered intervention program, with online media, free hotline consultation, and targeted online video interventions provided to citizens with psychological problems, with crisis intervention provided on site [
Strategy 2: Development of online screening mechanism for potential patients. A range of strategies were suggested to provide web-based consultations, appointments, prescription services and drug delivery, and other services, as a complement to in-person hospital services. For example, in a qualitative study of patients’ experiences with online services offered to non–COVID-19 patients, one patient reported: “Use of mobile apps in this pandemic is very important. You can pay, register, and view results on your mobile phone. You don't need to queue up at the outpatient clinic, and you can chat with a doctor online after you get home, so it’s far more secure” [
Strategy 3: Using online platforms to monitor patients with COVID-19. A number of articles described a process of offering e-counselling support to patients who were struggling with the physical and psychological effects of the disease [
Strategy 4: Developing and using onsite information technology services and infrastructure. The use of nonmedical technology to improve hospital services, such as using app-based QR Codes (a machine-readable optical label, similar to a barcode) to share information and using robots for certain tasks to avoid person-to-person contact, was expanded during the pandemic [
Telemedicine interventions were reported as an effective substitute or complement to onsite health care [
At the beginning of the epidemic, medical personnel experienced panic and fear due to insufficient knowledge of the epidemiological characteristics of the virus and the need for protection, and many experienced a temporary shortage of medical supplies [
These factors intensified workload pressures and led to anxiety, insomnia, depression, pain, symptoms of posttraumatic stress disorder, and grief. Furthermore, a higher workload led to worse hygiene behavior, such as reduced adherence to handwashing guidelines [
high risk of professional exposure, the intense workload, the sharing of the patients’ anxiety, a feeling of helplessness while struggling to treat severely ill patients and many other factors can lead to high levels of psychological pressure, low confidence in one’s own work and depression among nurses, which affects their quality of work and their physical and mental health [
Strategy 1: Readjustment of health care staff schedules. For health care staff who had direct contact with patients with COVID-19, a 4- to 6-hour schedule was implemented by a number of hospitals. Protection protocols in Chinese hospitals were extremely strict, especially for health care workers who were working directly with patients with COVID-19. Once PPE was applied, it was required that the wearer avoid all potential contamination risks, including physiological needs: eating, drinking, and using toilet [
Strategy 2: Increased flexibility of working hours according to the number and condition of inpatients. During the peak period of patient admissions, the number of staff was increased to provide an appropriate nurse-to-patient ratio, which is essential to ensure that patients receive appropriate care and that the workload of caregivers or staff remains reasonable. For example, in a hospital in Wuhan, each nurse was responsible for 6 to 8 patients [
Strategy 3: Providing material and psychological support to the staff. As well as ensuring provision of essential supplies, several hospitals provided high-nutrition meals to support staff and boost their immunity. Many strategies were used to provide psychological support, either through colleagues, health professionals, or specialized psychologists [
These strategies improved working conditions for health care workers and quality of care for patients. A number of articles [
After the COVID-19 outbreak in Wuhan, China, human resources were rapidly reorganized within hospitals, between hospitals, and throughout the country. Transdisciplinary nurses without specific expertise in infectious diseases were brought in to support COVID-19 wards [
Strategy 1: Creation of new teams. Soon after the epidemic was declared, many new teams were created, such as the nursing technical support team, comprised largely of head nurses from different departments [
Strategy 2: Implementation of a plan-do-check-act (PDCA) cycle, a management tool. This consisted of a repeated four-stage model for continuous improvement in quality management [
Strategy 3: Implementation of regular training for health care workers. Given the speed of SARS-CoV-2 spread, health care staff required rapid training to properly apply the protection protocols and needed continuous information regarding the evolution of knowledge about the virus. In addition, reinforcements who were unfamiliar with the workplace also needed to familiarize themselves with their new colleagues and the work environment. Many hospitals in our study implemented a dual training system including online training and face-to-face training on topics such as “COVID-19 hospital infection prevention and control, hospital air purification management specifications, medical institution disinfection technical specifications, and personal protection requirements for disinfection and isolation” [
Several articles quantitatively measured the effectiveness of different aspects of management interventions, finding that they succeeded in making staff aware of their roles and responsibilities, as well as clarifying the staffing structure and handover procedures [
During the early stages of the outbreak, as knowledge of the virus rapidly evolved and the number of patients in the hospital increased daily, hospitals were required to react immediately to the situation and readjust strategies accordingly, whether in terms of protection protocol, patient care, or organization of work. The situation was more complex in hospitals with external reinforcement from other provinces because, according to one article, “each medical team has its own process and philosophy of care, the only way to provide quality care to patients is to coordinate and standardize and homogenize care” [
Strategy 1: Implementation of regular meetings between the different team members for daily briefings. For example, in Tongji Hospital in Wuhan where national medical aid teams served in a “whole-system-takeover model,” nursing department staffers worked in partnership to establish a range of measures including smoothing communication channels through daily meetings. According to one author: “In the early stages, we held daily nursing council meetings to shorten the adjustment period and standardize the work in order to shift from a ‘wartime state’ to a daily routine” [
Strategy 2: Promotion of the use of new information and communication technologies to aid communication between colleagues. Use of communication platforms, usually WeChat groups, and occasionally telephone exchanges, was identified in a number of articles. In Tongji Hospital, to provide an effective communication and information mechanism, a WeChat group with all the nursing staff was set up to enable communication at any time. In addition, the hospital set up a daily nursing information system: the progress of nursing work as well as problems encountered in the quality control of care were analyzed and then sent to everyone in image/text form [
Strategy 3: Promotion of the use of visual materials to better convey information to health care staff. This involved the use of physical signs such as multicolored arrows indicating the different hospital zones and posters of protection protocols displayed in different zones [
Some evidence in the articles indicates that the aforementioned communication measures were effective in improving the psychological health and efficiency of health care workers. In the People’s Hospital of Wuhan University, 1 week after a
As well as analyzing the number of infected staff, a large number of articles in the scoping review examined the reasons for infection of health care workers and presented hospital strategies to reduce the risk of nosocomial infections.
The issue of contamination risk is one of the most frequently discussed topics in the articles and relates to many dimensions of hospital resilience, such as human resources, management, communications, and information. The risk of nosocomial infection was extremely high in Wuhan, especially in the early phase of the outbreak. One study found that 84.5% (1426/1688) infected health personnel believed that their infection had been acquired in the hospital wards [
Strategy 1: Strict management of hospital space. Access to the hospital analyzed in Lu et al [
Strategy 2: Focus on environmental contamination with routine disinfection. In the COVID-19 unit, strict measures were applied regarding the disinfection of medical instruments (stethoscopes, thermometers, etc). This was described in detail in 1 article, which explained how floors, tables, chairs, and diagnostic and treatment beds were wiped and disinfected regularly with 1000 mg/L of chlorine disinfectant and that this behavior was regularly monitored [
Strategy 3: Encouraging health care workers to apply personal equipment protocols appropriately, according to their role and their level of contact with patients with COVID-19. To help staff to properly apply the protocols, hospitals proposed regular training for staff and the establishment of a 24-hour supervisor position to verify the appropriate application of protocols when entering and leaving the buffer zone. Hospitals often introduced comprehensive management plans involving screening, personnel management, disinfection and hygiene procedures, and training and supervision of employees, as well as PPE supply chains.
Strategy 4: Restricting family visits to avoid patient-family contact. Family visits were restricted, as they increased the risk for nosocomial transmission; however, many hospitals implemented a video visit system to facilitate exchanges between patients and their families. One article quoted a staff member: “For people who come to the hospital to visit patients, the warden enables the video visit with an iPad connected to the nurses’ iPad at the patient’s bedside, which enables exchange with the visitors” [
Only a few articles evaluated the impact of these strategies on infection rates, with most concluding that no medical staff member was contaminated by SARS-CoV-2 during this period. With regards to PPE use, a regression analysis in self-reported compliance with security protocols [
In the response to the COVID-19 outbreak, the supply of PPE was a substantial challenge globally. This problem was also present in China, where several regions had a shortage of PPE and disinfection products [
Strategy 1: Implementation of an inventory register for important materials while standardizing the process of managing and using these materials. In many hospitals, a physical security team leader was put in charge of recording the real-time use of equipment and strictly controlling the receipt and distribution of materials [
Strategy 2: Avoiding overconsumption and waste of materials. The presence of the hygiene team and the supervisor in the application of caregiver protocols was to make sure that staff wore PPE correctly and avoided PPE overuse [
Strategy 3: Decrease in the protection level for the provision of certain non–COVID-19 services in view of the shortage of medical resources. Some studies examined decreased protection measures to identify the minimal level of protection needed in different hospital areas. For example, a study in the Huaxi Hospital of Sichuan University suggested that the staff in non–COVID-19 intensive care units did not need to wear full body protective overalls, thus saving on PPE [
Overconsumption of PPE was a common problem in hospitals, particularly in the early and midstages of the outbreak. However, according to surveys from a hospital in Shenyang, the aforementioned strategies contributed to the optimization of PPE and disinfection supplies, allocating based on needs and stock while ensuring that frontline personnel were well protected [
During the outbreak, hospitals had to reorganize their services to both increase capacity and reduce the risk of contamination. The changes in infrastructure, hospital procedure, and protocols in Chinese hospitals involved substantial changes. For example, a hospital in Wuhan revised 32 items on its regular hospital procedures to transform a general hospital into a designated COVID-19 treatment hospital [
Strategy 1: Transformation of non–COVID-19 hospital areas into specialized COVID-19 wards. Many hospitals lacked a negative pressure chamber to provide a buffer zone; therefore, many large non–COVID-19 hospital areas were required to be transformed into specialized COVID-19 wards to accommodate the growing number of patients with COVID-19 [
Strategy 2: Reorganization of space. In designated COVID-19 hospitals, necessary infrastructure changes were implemented, which included setting up fever tents, ward renovation, unidirectional channels for patients, and converting sections of the hospital for patients with COVID-19. These were done to minimize contact between infected and uninfected individuals, reduce patient flow throughout the hospital, and maximize the shared space available to patients with COVID-19. Another example is the creation of the “three zones and two passages” system (Chinese: 三区两通道) that included a contaminated zone, potentially contaminated zone, and a clean zone, as well as two separate passages for medical staff and patients.
Strategy 3: Reorganization of inpatient rooms. Certain hospitals decided to convert double rooms into single rooms, whereas for hospitals that were forced to put several patients in the same room, a distance of more than 1 meter between beds was maintained.
The impacts of these strategies were not examined in detail in the included studies. Gao et al [
In this scoping review, we identified 59 studies that addressed resilience in hospital settings across China in the context of the initial SARS-CoV-2 outbreak in the first half of 2020. Our findings indicate a wealth of research describing certain strategies used to improve hospital resilience, particularly those concerning human resources: management, communication, security, hygiene, and planning. We found that much attention was focused on training, health care worker well-being interventions, eHealth and other technology-related interventions, and work organization interventions, while training and management interventions were also subject to more rigorous quantitative analysis. Some themes, such as information systems and reinforcements, were mentioned in a small number of studies and lacked rigorous analysis, while others, such as hospital financing and the development of new health care infrastructure, were neglected in the literature despite being mentioned explicitly in Chinese official policy papers [
In terms of the “Effects—Strategies—Impacts” framework, there were some cases of inaction, anticipation, and reaction represented in the literature. Only a handful of studies examined cases of inaction; for example, Gao et al [
The majority of the included studies provided details on the effects and strategies with an appropriate methodology, whether quantitative, qualitative, or mixed. However, few studies performed any kind of systematic analysis to evaluate the impacts of these strategies and were more descriptive in nature. The goal of a large portion of the studies was to share knowledge as quickly as possible, but the lack of rigorous analyses provides issues in identifying effective strategies. An important characteristic in the interpretation of a strategy or a specific intervention was that most studies were written by health care workers working directly in a given hospital during the outbreak. Participation by health care workers in the process of knowledge creation can be an invaluable tool, demonstrating what Alexander et al [
Similarly, as China’s research and medical communities are not independent from politics [
These papers also highlighted how some processes undertaken during the pandemic attempted to increase health care access in ways that could potentially lead to a positive transformation process (as mentioned in the resilience framework). For example, articles focusing on eHealth and
There are a number of recommendations offered to health care practitioners within the articles (
With articles that analyzed the impact of training interventions, both more traditional and online training interventions were associated with positive effects on knowledge and behavior of staff regarding safety procedures, when compared to results before the training. Online or massive open online course–based training is an appealing alternative to in-person training when infection risk reduction is a relevant concern. To build hospital resilience, articles argue that staff training for outbreak and infectious disease practices should continue in regions without ongoing outbreaks [
Infection control measures comprise a crucial element of hospital resilience and many recommendations were given, despite not always being supported by data. Li et al [
The results of these studies demonstrate the degree to which China’s health care system responded and adapted to the outbreak through several innovative measures. Although evidence of the effectiveness of certain interventions was not provided, the collection of studies from across hospitals in China offers strategies that, together, have likely contributed to the decrease in daily nosocomial infections from a peak of 127 new health care worker infections on January 23, 2020, to the first day with 0 new cases on March 8, 2020 [
Due to the short time frame, the lack of academic diversity in the research areas, political concerns, and publication bias, this scoping review highlights the need for more rigorous intervention research and evaluation, and the inclusion of multidisciplinary teams involving social science researchers and data scientists [
This scoping review was not intended to draw conclusions about the causality of any particular strategy; therefore, a
Our research also revealed that there are relatively few articles that have used the concept of resilience in a Chinese medical context, indicating that China’s hospitals do not consider a resilience framework as part of their research. Despite increased use in academic and professional contexts, the popular concept of
Another element that must be addressed is the trade-offs associated with the risk-averse strategy used in Chinese hospitals. Some studies noted that hospitals chose to implement a highly risk-averse strategy and that this did not allow them to determine what the minimal effective level of PPE use was to maintain effective protection [
Financial constraints, which comprise a central aspect of health systems resilience, have also been understudied in the Chinese context. Although comparative studies have examined macro-level decisions and cost-benefit trade-offs in COVID-19 policy between countries including China [
We were unable to perform a risk-of-bias test for this paper; therefore, the issues resulting from political or other biases were difficult to determine. As few of the articles were written by non-Chinese citizens or were peer reviewed by external reviewers, selection effects caused by censorship cannot be excluded.
The exclusion criteria we chose meant that we did not include gray literature in this review, but it is worth noting that media articles, social media content, and government white papers may also provide relevant sources of information that may help better understand how Chinese hospitals have sustained resilience during the SARS-CoV-2 outbreak. Additionally, we only included articles released soon after the outbreak; therefore, articles conducted later in 2020 and in 2021 related to similar topics may have reached different conclusions [
Our scoping review demonstrates that there is a wide range of studies concerning hospital resilience in the Chinese context and that this literature helps us to understand the strategies used by the hospitals in China during the SARS-CoV-2 outbreak. The literature, both in Chinese and English, can provide important lessons on reinforcements, organization of work, eHealth, telemedicine and use of technology, health care worker well-being, emergency team and nursing management, training, communication and information, protection protocols, PPE, and reorganization of services.
Although this review demonstrates that the evidence is generally insufficient to determine the effectiveness of specific strategies, some preliminary results on the effectiveness of training interventions, technology use, and management interventions, such as checklists and the PDCA cycle management, are provided. Furthermore, the study illuminates some common characteristics that have characterized what has generally been viewed as an effective strategy against the SARS-CoV-2 outbreak [
Search terms for English-language search.
Chinese-language search terms.
Mixed-Methods Appraisal Tool analysis.
Description of included studies.
Hospital resilience strategies and relevant papers.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.
Centers for Disease Control and Prevention
China National Knowledge Infrastructure
Mixed-Methods Appraisal Tool
plan-do-check-act
personal protective equipment
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
World Health Organization
None declared.