Introduction:
Hospitals play a critical role in the healthcare system in providing essential medical care to the community, particularly in a state of crisis. Prolonged outbreaks with progressive spread of disease, with rapidly increasing service demands can potentially overwhelm the capacity of hospitals and the health system at large. Almost all the government hospitals in J&K under normal working conditions operate at near-surge capacity. Consequently, even a modest rise in admission volume overwhelms our hospitals beyond their functional reserve. The overwhelming nature of COVID19 pandemic requires innovative approaches to tackle this problem. Without proactive capacity building, the healthcare infrastructure will collapse with the large number of infected individuals who need hospitalization.
In Kashmir SARSCoV2 virus by now is well established in the community. Hence many of the new cases coming to medical attention during these days do not have any history of travel, or high risk exposure to a confirmed COVID19 case which reflects community spread stage 4 – 5 of the pandemic. With cases coming from every district of Kashmir valley, virus is now omnipresent.Even though the day time temperature in Kashmir these days is crossing 33 degree Celsius, still close to 400 new cases are being detected daily, and the number will undoubtedly keep on increasing. This virus is not going to disappear in near future and we have to face it likely for a prolonged time. Although viral respiratory tract infections do typically come up in winter season as viruses are heat labile and do not survive increased ambient summer temperature, but in the case of COVID19 the ripples of the viral waves are extending far and wide with each passing week. And as the winter will approach by mid October – November due to fall in the temperature the longevity of the virus will increase. Winter season being more conductive to the transmission of virus, we will have to battle increasing community transmission of this virus, in addition to usual respiratory viruses. Hence we expect the daily increment in number of COVID19 patients will be much higher than the current scenario. As the worse is yet to come, here is the most important question: Are we prepared for the battle and how good are our hospitals to deal with the crisis?
Time to Act?
Healthcare policy makers have to see the approaching time in advance and gear up in advance. Epidemiologically we are seeing only tip of an iceberg as more than 70% of infected persons are asymptomatic and these unaware cases are continuing their routine like attending congregational places such as markets, worship places, family functions and gatherings – many without adhering to social distancing rules and preventive norms and measures. In our case the healthcare system is already lame, receiving just 3.6% of annual GDP. The enemy although invisible is deadly.
As the virus is spreading exponentially there seems no escape from it. A steep rise in the number of cases detected, admitted to hospitals and dying due to COVID19 illness is certain. When it comes to containment of the virus spread, the most difficult task is restriction of an asymptomatic person who moves freely into community and keeps on infecting close contacts. Contracting viral pneumonia by a novel strain is not easy for a previously healthy person but a fragile patient will be thrown off balance. While the Spanish flu was a brave virus attacking only young and pregnant, this virus is opportunistic and has a predilection for elderly, frail, sick, patients with co-morbid illnesses like Diabetes, Hypertension, Heart, Kidney & Liver ailments and immunocompromised persons. It throws them off balance with high chances of death. These fragile individuals are present in every single home of our communities.
Post Lockdown Scenario
A three month lockdown showed some effect in slowing down spread of the infection, however, due to multiple reasons lockdown had to be eased. At the start of the COVID19 pandemic in India, strategy at national level was to enforce strict lockdown and contain the viral spread. As the restrictions were eased out community spread escalated and we are now witnessing a high spike.
Are our hospitals well prepared for the COVID19 crisis?
These days our hospitals are witnessing worst times. Hospitals are complex and vulnerable institutions, dependent on crucial external support and supply lines. During the current outbreak of COVID-19, an interruption of critical support services and supplies would potentially disrupt the provision of acute health care by an unprepared health-care facility. In addition, a high rate of staff absenteeism can be expected as healthcare workers need to take off to quarantine themselves from the community; as they may themselves get infected. Patients admitted to the hospital with COVID-19 infection have an average hospital stay of 10 days. This issue is compounded by the exposure of physicians and other healthcare workers, which may lead to up to 20% of healthcare staff being unable to work for periods of time from being ill or self-isolated from high-risk exposure. Any shortage of critical equipment and supplies can limit access to needed care and have a direct impact on healthcare delivery. Even for a well-prepared hospital, coping with the health consequences of a COVID-19 outbreak is a complex challenge. A proactive and systematic implementation of key generic and specific actions can facilitate effective hospital-based management during a rapidly evolving outbreak. Our policy makers have to come to ground level in order to frame an effective policy and plan. They need to be given continuous feedback from health care workers and should be receptive to suggestions given from time to time. Any loopholes in the system will allow the virus to continue to spread.
How should our hospitals work in COVID19 crisis?
An Effective, hospital-based response in a state of crisis includes:
- Continuity of essential services
- Clear and accurate internal and external communication
- Swift adaptation to increased demands
- Effective use of scarce resources
- Safe environment for health workers.
Salient features of a dedicated COVID19 Hospital:
- Excellent communication of policy makers for COVID disaster with the hospital authorities
- Continuing and maintaining essential health care services
- Meeting the surge capacity of hospital
- Augmentation of human resources
- Management of supplies including procurement of newer anti COVID medications
- Robust ramping of laboratory services
- Providing essential support services
- Quality infection prevention and control
- Multipronged approach to case management
- Surveillance and collection of data
Current Scenario
Currently, there is a complete disruption of services at all hospitals that have both COVID and non-COVID patients, leaving both patient groups inadequately cared for. In order to face the daunting demands of this pandemic, a designated COVID-19 hospital will help standardize care, optimize resource utilization, and protect non-COVID-19 patients and healthcare workers.This hospital would treat only those with confirmed COVID-19 infections and screen those suspected to have COVID-19, serving as the pandemic’s central command center for a designated district. Such a hospital can be built afresh or an existing tertiary care referral hospital be designated as COVID19 only hospital. Simultaneously, non-COVID hospitals would focus on caring for patients’ ailments that are unrelated to COVID-19 and minimize the risk of spreading the virus. This will allow for accurate allocation of resources, efficient use of personnel, and a better understanding of the incidence, treatment efficacy, and outcomes of the COVID-19 infection in the community. This would also protect the general public from nosocomial spread of COVID-19.
Managing a COVID19 patient does not mean just respiratory issues, but a simultaneous consultations by multitude of specialties like Nephrology, Neurology, Cardiology, Hematology, Endocrinology and Interventional radiologists, Surgeons for placement of ICTD and bed sore management. Only an integrated approach in a tertiary care facility hospital can provide these services to the COVID19 patient.
After recognizing the seriousness of COVID-19, the Chinese government built two brand new hospitals strictly for COVID-19 in under two weeks, repurposed multiple hospitals to be COVID-19 only, utilized “fever-clinics,” which screened patients and selected which patients required COVID-19 testing and / or further imaging, and militantly tracked each new case, which helped guide decision making on a national scale.
COVID19 disaster checklist for hospitals
Core team heck
- A core team for the management of the event is established; it should include a member of the hospital management, the hospital infection control team, an infectious disease expert, and experts representing the intensive care unit (ICU) and emergency room (ER)
- A backup for each of the roles is established
- All the team members are informed of, and trained in, their roles and responsibilities
Key internal and external contact points
Key internal and external contact points for the different roles (e.g. administration, communication, nurse administration, security, human resources, pharmacy, biosafety officer, infection control, ICU, emergency services, infectious diseases, engineering and maintenance, laboratory, laundry, cleaning and waste management, and hospital morgue) are to be identified
Procurement and stock management
- A procurement procedure to acquire the necessary materials and supplies is in place and can be activated on short notice
- Alternative suppliers to be identified if main suppliers should run out of stock (especially for personal protective equipment (PPE))
- Buffer stock of key supplies (e.g. for hand and respiratory hygiene, PPE, isolation, ICU supplies, mechanical respirators) have to be acquired
Human Capacity
- The surge capacity of healthcare workers has to be assessed
- The surge capacity of non-healthcare workers (e.g. administration, cleaning personnel, etc.) has to be assessed
- Staff absences, in particular due to sick leave or having to care for sick people at home, has to be considered and included in the assessment of human resource capacity
- A sick-leave policy for symptomatic staff should be in place
- Staff planned to be re-allocated should be informed and trained in accordance with their anticipated roles and responsibilities
- A plan to be in place to avoid burnout among healthcare and non-healthcare workers
- Psychological support for healthcare workers to be provided
- A security team in place to ensure the safety of patients, staff and visitors
Laboratory capacity
- If the hospital has no laboratory capacity, a plan for the sampling and safe shipment of specimens is to be established
- For hospitals with in-house laboratory capacity, an appropriate amount of reagents and supplies for diagnostic testing should be available
- A plan should be in place to outsource services if capacities are exceeded
External communication
- A core communication team to coordinate external communications
- Draft key messages for different groups (journalists, general public, healthcare specialists, etc.) are available
Data protection
- There are mechanisms in place to ensure data protection in accordance with the legislation
- Mechanisms for tele-triage (e.g. phone, email, smartphone apps, telemedicine) conform to data protection rules
Hand hygiene
- Supplies of alcohol-based hand sanitizers for staff and patients, especially in waiting rooms, triage rooms, examination rooms, and areas for the removal of PPE.
- Soap and paper hand towels in sufficient quantities next to all sinks.
- A procedure to check and refill the supplies is established
PPE
- An adequate amount of PPE for protection against contact, droplet, and airborne transmission should be available in different sizes where required
- Healthcare workers and cleaning personnel to be trained in putting on ( donning ) and taking off ( doffing ) PPE
Waste management
Providing no-touch bins to dispose of tissues used by patients in waiting and triage areas
The facility should be able to manage an increased amount of infectious waste by itself or outsources its waste management
Important Takeaways
- Public & preventive medicine has a huge role in current times. Govt should activate the department of preventive medicine and launch a robust audio-visual and print media campaign to educate public on the pandemic and prevention related aspects.
- Recruitment of doctors and paramedics should be done on priority basis. It should be a continuous process. Government should also consider providing hardship allowances to the workers working in these tough times risking their lives every day. More than 300 doctors have returned to Kashmir recently from many metro cities. Hiring them is need of the hour. They have tremendous caliber and exposure.
- We need to expand our budget allocation for the health sector in general, and in the current crisis particularly, without which this fight will not be fought.
- A COVID telehealth unit, which should advise asymptomatic and mildly symptomatic patients about management at home and educate about the trigger for a hospital visit.
- Advertisement by the government about the information and address/location of outlets where masks, thermometers, and pulse oximeters are readily available, preferably at discounted rates.
Dr Junaid Rashid is Senior Resident Department of Endocrinology, at Govt Superspeciality Hospital, GMC, Srinagar
Dr Mohammad Hayat Bhat is Consultant Endocrinologist at Govt Superspeciality Hospital, GMC, Srinagar
Dr Abdul Rehman Bhat is Consultant Internal Medicine, Ministry of Interior Hospital, Riyadh