|Ahead of print publication
COVID preparedness at a tertiary care hospital in India: A new road to travel, a long way to go
Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||19-Apr-2020|
|Date of Decision||21-Apr-2020|
|Date of Acceptance||21-Apr-2020|
Department of Cardiology, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
The sudden explosion of the coronavirus pandemic all over the world has taken everybody at all levels aback in an unprecedented manner. The health-care facilities face multiple challenges and huge responsibility for performing the herculean task of ramping up the COVID preparedness to fight the epidemic. All India Institute of Medical Sciences, New Delhi, is the apex medical institution of India and has organized a response in these testing times. This discussion brings around the important aspects of this response and the challenges faced. There is no perfect strategy to fight this pandemic, and the strategies continue to evolve as we learn from our success and failures.
Keywords: All India Institute of Medical Sciences, coronavirus disease-2019, tertiary care
|How to cite this URL:|
Bansal R. COVID preparedness at a tertiary care hospital in India: A new road to travel, a long way to go. J Pract Cardiovasc Sci [Epub ahead of print] [cited 2020 May 30]. Available from: http://www.j-pcs.org/preprintarticle.asp?id=283499
| Introduction|| |
Merely 2 months ago, every health-care worker (HCW) was busy working his/her level best toward a common goal of providing quality services to all the patients. The outbreak of coronavirus disease-2019 (COVID-19) in Wuhan, China, in December 2019 had failed to ring an alarm, with most of us living in a false sense of security that an influenza-like virus will not be able to harm us in a big way. However, the declaration of the COVID-19 as a pandemic by the WHO on March 11, 2020, has left our lives completely dismantled with a longing to pave our ways out through this gruesome situation. The want for appropriate guidance for tackling this pandemic remains grossly unfulfilled. The age-old habit of imitating the developed nations cannot be followed, after being a witness to the mayhem over there for the past 1 month. This leaves us for developing our own indigenous system for fighting the severe acute respiratory syndrome-betacoronavirus 2 (SARS-CoV2). Thankfully, the timely implementation of the lockdown of our country by the Government of India bought us some time to prepare for the imminent threat. All India Institute of Medical Sciences (AIIMS), New Delhi, is the apex medical institution India and is often looked upon as the point of reference for other institutions to follow. The following document discusses the steps taken by the institute to tackle the COVID situation, the problems that have cropped up during the process, and the solutions that are still in evolution to address the finer issues.
| Organizing the Response|| |
Organization of a planned and collective response is the first step at winning a war. The administration alone cannot be expected and held responsible to devise a strategy of tackling this huge catastrophe. Thus, key aspects of a strategic response have been identified and committees have been formed involving experts from various departments. Resource management, human resource management, and medical management were the three key areas, where committees were constituted.
Resource management committee involves the medical superintendent, faculty in charge of the medical stores, and also logically, the store officers themselves. The committee looks after procurement and effective distribution of medical resources including drugs, equipment, and personal protective equipment (PPE).
The human resource committee itself consists of two subcommittees: one for faculty members and residents and the second one for other staff. The responsibility of this committee is to tap the HCWs required for COVID in a just rotational manner, to form teams with designated leaders to take the responsibility of various COVID designated areas, arrange for adequate training of staff, and address the grievances of the staff posted in the new environment.
Finally, the Medical Management Committee is divided into various subcommittees and holds the responsibilities of management of designated COVID areas, formulation, and dissemination of adequate training among the posted hospital staff and assessment/ramping up of the currently available testing facility. It is the job of the medical management committee to assess the requirements at the local areas and then raise demands accordingly for materials and staff to the resource management and human resource management committees.
| Utilization of Hospital Infrastructure in an Effective and Safe Manner|| |
Given the propensity of the SARS-CoV2 to disseminate easily through aerosol and fomite, it is clear from the word go that it is of utmost importance to clearly separate areas which will be dealing with COVID cases from non-COVID areas. The best possible manner would be to designate a completely distinct building.
At AIIMS, the trauma center is a completely separate building that is physically disconnected from the main AIIMS hospital premises and hence was a first choice for being converted into the COVID facility. Initially, only one single intensive care unit (ICU) with 18 beds on the ground floor was designated. However, later to ramp up the preparedness with a vision for the impending explosion of the epidemic, the whole building was converted into COVID designated area with approximately 270 beds (including ICU beds, high-dependency unit beds, and general ward beds). This required sequentially vacating the wards by discharging all stable patients, cessation of routine services, and accommodating sick patients elsewhere. Utmost care has been taken to design the workflows in these areas, to prevent transmission, especially to the health-care workers. Proper donning and doffing areas were created almost overnight, with designation of washrooms where the health-care workers can take showers before changing into their home clothes before going home. The building in itself has been labeled with COVID and non-COVID designated areas and lifts, thus bringing clarity over the areas where PPE needs to be donned and where it is not needed. The trauma center has the facility to take in patients who have already tested positive with SARS-CoV2. For screening patients who are suspected, a separate area has been designated in the burns and plastics department.,,
In the main AIIMS building, a ward has been designated as COVID area, where patients coming in from the emergency and who are COVID suspect are kept. If they turn out to be COVID positive, they are then shifted to trauma center, and if they are COVID negative, they are shifted to the respective specialties. There is a separate area for hospital employees who test COVID positive. The main casualty and emergency has a designated area for keeping COVID suspects and separate areas for other patients. It also has the provision of adequate PPEs to the staff posted there along with the facility for sample collection for SARS-CoV2.
Further, the National Cancer Institute at Jhajjar has been converted into a COVID facility to maximize the bed capacity to isolate and medically manage COVID-positive patients.
| Defining Testing and Management Protocols|| |
The indications for testing include symptomatic individuals with a history of international travel in the past 14 days, symptomatic contacts of laboratory-confirmed cases, all symptomatic health-care personnel, all hospitalized patients with severe acute respiratory illness defined as fever with cough or fever with dyspnea, and asymptomatic direct and high-risk contacts of a confirmed case (between 5 and 14 days after contact). These are in accordance with the Indian Council of Medical Research (ICMR) guidelines. Furthermore, care has been taken to define people who would take samples, how the samples would be collected and transported.
A workflow of the management protocol has been presented in an algorithmic manner in [Figure 1].
|Figure 1: Algorithm for management of COVID patients as per AIIMS COVID preparedness document.|
Click here to view
These guidelines are essential and are the cornerstone for the management of COVID patients by HCWs, especially those who are not involved in care of infectious diseases on a day-to-day basis. General guidance for all workers, advice to residents living in hostels, precautions for home quarantine, protocols for transport of patients, and guidelines for discharge of patients have also been issued. All the information is available freely to all at AIIMS website (www.aiims.edu). Webinars have also been conducted for proper dissemination of information in an interactive manner to most of the staff involved in COVID care.
Safe disinfection and disposal of biomedical waste along with decontamination of the hospital environment has also been stressed upon. Cleaning with freshly prepared 1% sodium hypochlorite solution with a contact time for at least 10 min every 3–4 h for high-contact surfaces and once daily for low-contact surfaces has been recommended and is being implemented. Guidelines have been created for packaging and transport of dead bodies for carrying out autopsies and for disposal of all infected biomedical waste including PPE.
Creating a detailed information and guidelines, resource base is essential to standardize protocols and promote good practices among all HCW, thus allowing for an organized best possible response to the epidemic. Curtailing the cross-infection at every possible level is also essential for the safety of the HCW and preservation of the workforce for times in the near future.
| Hospital Staff Rostering|| |
With discontinuation of routine outpatient department (OPD) services and elective procedures for prevention of crowding in the hospitals, the work requirements have gone down drastically in all departments. Thus, hospital employees from various departments can now be utilized for COVID-designated areas. Of course, the medicine, infectious diseases, and the anesthesia departments are the frontline COVID fighters. The further requirement of HCWs in the huge COVID facility being prepared is being met with posting of approximately 25% of residents and 2 faculty members from all departments to the COVID areas for 4 weeks. It has been recommended for the departments to follow such a schedule to minimize changes in hospital shifts through allocating 12-h shifts and rotating staff between workplace and home on a weekly basis. Care has been taken to poststaff that has been exposed to ICU setting in COVID ICUs and others in the general wards to optimize managements.
| Protection for Health Care Workers|| |
Reports of HCW and their families being infected and sacrificing lives while working against COVID areas across the globe have tormented the medical fraternity to its core. Ensuring the safety of HCW is of utmost importance to instill confidence among the employees, so that they can deliver their best services and quality care to the needy in these testing times. Substantial efforts have been made to ensure the adequate availability of PPE for all health-care workers in the hospital environment. However, it remains evident that not everybody can be provided with the highest level of PPE available. It would be wasteful to do so as one requires a level of PPE in accordance with the level of exposure only, and irrational use of PPE will mean running short of the meager supplies sooner than expected. Therefore, an explicit guideline was prepared for each level of HCW in COVID as well as non-COVID areas [Table 1]. This included extent and the type of protective gear to be donned. A triple-layer mask was deemed enough for personnel working in general wards, OPDs, pharmacies, and patients in non-COVID areas. This has allowed a rational use of the PPE available in limited quantity.
Apart from availability of PPE, it remains essential to train the staff for appropriate use with careful donning and doffing. Demonstrations have been carried out among groups of HCWs to train everybody in appropriate donning and doffing [Figure 2]. Indigenous posters have been created and have been displayed in the designated donning and doffing areas for reference for all staff during the donning and doffing process. Infection control nurses have been posted in these areas to oversee the process.
|Figure 2: An example of poster of doffing steps in the doffing zone from a COVID.designated ward.|
Click here to view
The issue of preexposure of prophylaxis for those who are exposed has also been addressed. AIIMS has endorsed ICMR recommendation for the same without getting into the controversy of little data to support the claim. And thus, hydroxychloroquine has been made available for all the staff involved with COVID care. In the period of lockdown, when adequate transportation is not available, buses have been chartered on multiple routes for easing out travel from home for all the hospital staff. There was an initial concern over HCWs involved in COVID care returning home and exposing their families if they get infected. Stay-back arrangements were not initially arranged, but after multiple requests, accommodations have been arranged for those who require them.
| Dissemination of Information and Training|| |
With posting in the COVID-designated areas, the staff faces new responsibilities which they have never been exposed to. For instance, the donning and doffing process was unknown to most of the staff. Although guidelines were created, training the staff to follow them is also an essential task to realize the plans in the real-world situation. All the information has been disseminated to all through the head of the departments as well as made available to one and all through AIIMS website over internet. Importantly, webinar sessions have been created on YouTube channel, where doctors and nurses can watch a video to update their knowledge and skills. Helplines have also been established to clarify doubts. Moreover, closed group meetings with small numbers in different COVID-designated areas have helped to identify problems, appraise the administration of shortcomings, train the staff, and clarify doubts. The process has been simplified in such a manner that any MBBS doctor can take charge and act as a corona warrior.
| Management of the Non-covid Areas|| |
The non-COVID areas demand a special attention. All OPD and elective services have been stopped after the implementation of the lockdown. However, the departments continue to provide essential services. The dilemma remains of how to manage COVID-suspected patients, especially the ventilated ones. Recently, a patient admitted to neurosurgery ICU with intracranial bleed sent everybody into frenzy after testing positive for COVID and forcing quarantine of numerous doctors and hospital staff. Checklists have been prepared to suspect COVID in all patients. Few departments have come up with a plan to convert part of the department into COVID suspect area, where patients coming in from emergency can be admitted and shifted to other routine areas once their COVID status is reported negative. Furthermore, the number of visitors per patient has been restricted. Telephonic consultations are being provided to outpatients with appropriate documentation of each telephonic visit and change in treatment.
Being an educational institution, AIIMS is a hub of academic activities which had come to a screeching halt with restriction of group meetings. Departments, however, have risen up to the challenge with usage of modern media. Classes are being conducted over various web-based media platforms for group meetings including Zoom, Webex, and Microsoft teams.
| Major Challenges|| |
The challenges being faced at the ground level are as follows:
- Care of the COVID-positive patients, especially in the ICU setting, without having an excessive risk of transmission, keeps on evolving on a day-to-day basis. How to carry forward aerosol-generating procedures (such as endotracheal intubation, respiratory sampling, regular endotracheal suctioning, proning, placing X-ray plates behind the thorax for portable bedside chest X-ray, performing cardiopulmonary resuscitation and tracheostomy, etc., in a safe manner remain a major challenge. Techniques such as intubation with video laryngoscope inside a box or under a plastic sheet, using closed-loop catheters for endotracheal suctioning are being suggested to address these kinds of issues. Central air conditioning without laminar flows and appropriate filters may prove to be a hazard for viral transmission and need to be switched off. At the same time, an appropriate ambient temperature needs to be maintained for those who are in PPE to work efficiently
- Allaying the inept excessive fear of SARS-CoV2 transmission among staff posted in non-COVID areas. This is the biggest hinderance in carrying out medical services deemed essential apart from care of COVID patients. Beyond doubt, stringent precautions to prevent the transmission of SARS-CoV2 should be in place for hospitalized patients. At the same time, it needs to be re-emphasized again and again that not everybody working in the hospital environment needs a full-blown PPE. Furthermore, it needs to be understood at the ground level that testing all patients, irrespective of their clinical presentation, is a useless activity and may provide both false sense of security and fear. It is a known fact that if we start testing patients without clinical suspicion for COVID, we would have a greater number of false positives and negatives as per Bayes' theorem
- Whereas it is possible to defer interventions in a selected group of patients for 30–45 days or manage them through teleconsultations medically, it is not possible in all. Patients suffering from life-threatening diseases (e.g., heart failure, angina, and cancer) may not require emergent immediate interventions, but urgency may arise any time. Therefore, striking an accurate balance on who can be deferred and who requires immediate attention is of paramount importance to minimize the collateral damage of the COVID epidemic
- Teleconsultation for OPD follow-ups needs to be standardized. In a government setup, where thousands of patients attend routine OPD daily, sudden shift to a teleconsultation system is not feasible. The portal of information sharing during teleconsultation needs to be implemented in a manner that is affordable and reachable to the poor socioeconomic strata of the society. Further, systems need to be devised to address the need of laboratory investigations and distribution of medicines to poor patients
- Prevention of lapses in implementation of protocols on ground level. The risk of transmission and disease outburst looms around in all social institutions more so in a hospital setting. Within a short time period, hospital staff has been expected to get trained and follow many new guidelines in an expert fashion. With not everybody at the same level of understanding and skill, there needs to be a check mechanism. Motivating everybody to follow protocols and also check their colleagues is essential part of maintaining a safe working environment. Everyone should be well connected to appropriate authority to notify any lapse in protocols they have witnessed.
| the Road Ahead|| |
The COVID-19 pandemic has disrupted the routine flow of the hospital machinery in a dreadful manner. The impending explosion of the epidemic in local areas will decide further course of action in the near future. If the graph follows exponential growth, the preparedness up till now may very well be exposed as inadequate and force us to plan further to ramp up the COVID facility. Organizing the resources including PPEs and isolation facilities as per available guidelines,,,,,,, creating protocols for the flow of patients within a COVID facility to prevent cross infection and also develop management protocols,, requires anticipating and planning for all the possible complications of COVID. India-specific plans have be standardized well in advance.,,,, It's time for planning our responses and be prepared for the worst of the scenarios. At the same time, we have to start planning for the road back to normalization of hospital functioning once the curve of the epidemic is successfully flattened. We should hope for the best and prepare for the worst.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]