Practically,5 million people globally and one Lac 7 thousand people have been contaminated with COVID 19 in our country, close to 3500 deaths and nearly 3500 new cases in the last 24 hours. This is quiet overwhelming and yet WHO, Member, Dr. Soumya Swaminathan has applauded India’s efforts in containing the disease so far.
Prolonged outbreaks can lead to the progressive spread of disease with rapidly increasing service demands that can potentially overwhelm the capacity of hospitals and the health system at large. No doubt that due to the prompt action of Government of India in announcing the lockdown has contained the spread of COVID 19 to a considerable extent, however there is still a dearth to be filled in , in terms of the health care delivery wherein the Public health has to be complimented with a Private Partnership.
We are now in the 8th week of lockdown , yet there are gaps in terms of preparedness for facing this unprecedented crisis.
Hospitals are complex and vulnerable institutions, dependent on crucial external support and supply lines. Under normal working conditions, many hospitals frequently operate at near-surge capacity. Consequently, even a modest rise in admission volume can overwhelm a hospital beyond its functional reserve. However, it has been observed since the lockdown, most hospitals small, medium and large have a reduced inflow of patients, the inpatient admissions have come down from 70% to about 10 to 20% or may be less than that, OPD has either closed or reduced to again 15% although some of the private nursing homes are slowly opening up since the past week. So managing hospitals in times of high risk of infection and an abysmal plunging of revenue is the biggest challenge that Hospital owners, Directors, Superintendents, CEOs , and Managers face.
The enumerated challenges we face are:
# 1 challenge is to keep abreast with the changing SOPs/guidelines from the Govt/WHO/ICMR. The situations are changing rapidly and so are the ways of dealing with it.
# 2 challenge is to process the humongous data coming in through, media, peer reviewed papers about the positive cases, patients with co morbidities, clinical manifestations, deaths, recovered etc. including the countless anecdotal case reviews.
# 3 challenge is to convince Doctors and Health care worker about the “Rational use of PPE” which is a very precious commodity.
# 4 challenge is to retain our old patients. Though some hospitals might be communicating with patients over telemedicine, sms etc, we don’t know yet whether that patient is going to come back to us or has moved on?
# 5 challenge ,the biggest, is to face a revenue loss, and we are looking at a loss of 22 Thousand Crores for the Healthcare Industry.
Nonetheless, the most positive thing that COVID has ushered in is that we have all come out of our silos and are now on the same platform to fight against an unknown enemy.
Well, to enhance the readiness of the health facilities to cope with the challenges of the outbreak, a pandemic, or any other emergency or disaster for that matter, hospital managers need to ensure the initiation of relevant generic priority action.
So, what do we understand by key generic and specific actions?
The first and foremost is a Hospital Incident Command system: A wellfunctioning hospital incident management system is essential for the effective management of emergency operations. If there is no mechanism in place for coordinated hospital incident management, the hospital director should promptly convene a meeting with all heads of service in order to create an ad hoc IMS. An IMS is essential for the effective development and management of the hospitalbased systems and procedures required for successful COVID-19 response. When organizing a hospital IMS, consider including representatives from the Services dealing with: Clinical, HR, Nursing, BME, Purchase, Pharmacy, Laundry, Food and Beverage, Transport.
This IMS must oversee:
(1) Continuity of Essential services:
An outbreak of COVID-19 will not dispel an already existing need for essential medical and surgical care (e.g. emergency services, urgent surgical operations, maternal and child-care); hence, it is necessary to ensure the continuity of essential health services. List all hospital services in priority order. Identify and maintain the hospital services that your facility must provide at all times and under any circumstances. Identify the resources (human resources and logistics) needed to ensure the continuity of the identified essential hospital services.
The Hospital head needs to designate one person to manage the flow of information from the Hospital to the Government / local authority, give bites to the press etc., to the staff regarding quarantine rules, facilities made by the hospital, the decisions taken safeguarding the patients and employees. etc.
(3) Surge Capacity:
Surge capacity is the ability of a health service to expand beyond its normal capacity to meet an increased demand for clinical care. COVID-19 cases may cause rapid increase in demand over a prolonged period of time. You will need to Calculate maximal case admission capacity, determined not only by the total number of beds but also by the availability of human resources, the adaptability of facility space for critical care, isolation, cohort, the accessibility of mechanical ventilators and the availability of other resources. We need to create a facility wherein our Healthcare workers are not at risk and the patients are attended to with caution. Only 1.5% of 1.3 lac ICU beds in COVID hospitals have been used so far.
“I speculate an influx of patients after the lockdown is lifted, therefore we need to prepare for a surge not just for the COVID cases but also for our regular patients who were unable to reach because of the lockdown. A very significant point is to adapt admission and discharge criteria and prioritizes patients for elective surgical interventions according to available treatment capacity and demand.” says, Prof. Dr. Nirmal Coumare, Medical Director, MGMCRI, Pondicherry.
(4) Human Resources:
One department which has proven its tenacity during these times is the HRD. HRD should address liability, insurance, salary, LOP, leaves issues to the best of their capacity. HRD will have to rebuild the trust in the employees, devise duty rotations such that the demands are met, without overcrowding, arrange for their transport, lodging and food without putting anyone at high risk. Well, it is easy for to say operate at 33% capacity etc but difficult to do so practically.
The management of supplies, including pharmacy supplies to be continuous and adequate. These are the times which will prove your relationships with the vendors.
(6) Essential Support Services:
Food & Beverage, Medical Gases, Laundry, Transport, IT, etc should be kept functional.
(7) Infection Prevention and Control:
The Hospital Microbiologist or Infection Control Nurse plays an important role in infection prevention, surveillance, training and rational use of PPE and biomedical waste management. Her intervention should aim to minimize the risk of transmission of healthcare-associated infection to patients, hospital staff, and visitors. Ensure that health care workers (HCW), patients, and visitors are aware of respiratory and hand hygiene and prevention of healthcare-associated infections. Ensure that HCW are applying standard precautions for all patients. Droplets and contact precautions are recommended for suspected or confirmed COVID19 cases. These precautions should continue until the patient is asymptomatic. Have a restrictive Visitor’s policy.
“The demand for ‘negative pressure’ isolation rooms has increased. I want to reiterate that an exhaust fan is not a substitute for ‘Droplet precautions’ and PPE just like sanitizers are not the substitute for hand-washing. Hospitals should invest in delivering service at the point of care and decongestion eg. Oxygen/suction ports for every bed, pneumatic chutes, creating a ceiling height from average 8 to 10 feet to 15 feet, etc” says, Mr. Suresh Babu, Consultant & Lead, Projects, Sri Balaji Vidhyapeeth.
(8) Case management:
An efficient and accurate triage system and an organized in-patient management strategy are required to ensure adequate treatment of COVID-19 acute respiratory infection. The idea is to cleverly identify these cohorts of patients and keep them accordingly in earmarked places. Can be done by creating SOPs/protocols of patient flows. Provide patient care following national and international guidelines. Ensure that all staff is aware of the guidelines for case management.
Health-care workers recognizing and immediately reporting unusual health events (e.g., clusters of cases, atypical clinical presentations, etc.) occurring in health-care facilities are the cornerstone of the early warning function. In addition to serving the early warning function, the laboratory and epidemiological data obtained through systematic collection and analysis allows the public health authorities to monitor the progression of COVID-19 and inform interventions on those at the highest risk of severe outcome, and helps hospital managers to plan accordingly.
(10) Laboratory Services:
Maintenance of the essential laboratory services is necessary for the appropriate clinical management of both pandemic and other patients, as well as for the hospital based surveillance of COVID-19 .Establish a laboratory referral pathway for the identification, confirmation, and monitoring of COVID-19, in case the hospital does not have an in-house RT-PCR testing facility.
So the Principles of Hospital Operations during COVID times essentially are:
✓ Continuity of essential services;
✓ Well-coordinated implementation of priority action;
✓ Clear and accurate internal and external communication;
✓ Swift adaptation to increased demands;
✓ Effective use of scarce resources; and
✓ Safe environment for health workers.
And to add to these if you succeed in applying the Lean Six Sigma tools, 5 S, then, you are one step closer to winning the fight!
(Disclaimer: Author is Dr. Swati Deshmukh Pawar, Deputy Medical Superintendent, MGMCRI, Pondichery. Views expressed are a personal opinion.)