“Kerala hospitals are in Plan C stage now,” said Dr Shameer VK of the Calicut Medical College in Kozhikode district. In March, the Kerala government had drawn up Plan A, Plan B and Plan C to meet the contingencies in COVID-19 cases, depending on the transmission stage. Plan C was meant to be operationalised in case the state entered the third stage of transmission, that is, when it is presumed that the virus is, in general, being transmitted in the community with no known source of infection, and as a result, there is a spike in cases.
On Thursday, Kerala reported 6,324 new COVID-19 cases in 24 hours, with Chief Minister Pinarayi Vijayan saying, “It’s getting serious”. This figure had been hovering between 3,000 and 5,000 in the last few days and weeks. The situation continues to look grim, especially in Thiruvananthapuram, the district that has the highest number of active COVID-19 patients (at 8,740) and even reported community transmission in two regions in August.
In view of the massive spike, hospitals in Kerala are now activating the contingency measures under Plan C, which is to further strengthen the state’s medical infrastructure. To accommodate more COVID-19 patients, per Plan C, private hospitals will be roped in and more beds in government hospitals will be freed up for critically-ill COVID-19 patients.
“Under Plan A, only medical colleges were dealing with COVID-19 patients and a few rooms were allotted for this. Under Plan B, government hospitals, too, were roped in. In addition to rooms for COVID-19 patients, two wards and two ICUs rooms were also reserved for this. Under Plan C, medical colleges have been completely freed up to accommodate sick patients who require Intensive Care Unit (ICU) treatment, district hospitals are completely treating COVID-19 patients, and private medical colleges and hospitals, too, are being used for treating COVID-19 patients,” explained Dr Shameer, adding that in Kozhikode, two private medical colleges, with 200 beds each, and two other private hospitals are currently on board.
According to the data on Kerala government’s COVID-19 Jagratha dashboard, as on September 25, a total of 49,784 beds (out of 84,532) are currently available across hospitals and first-line treatment centres (FLCTs). Of this, 36,809 treatment beds (out of 61,980) for laboratory-confirmed COVID-19 patients, and 13,520 observation beds (out of 23,037) for primary contacts who are yet to be tested, are available.
As part of the critical care infrastructure, 1,155 ICU beds (out of 2,348) and 621 ventilators (out of 836) are available, per the dashboard.
[Note: The figures on the dashboard vary with the actual number of beds, according to district medical officials. It is unclear if the data includes only medical colleges.]
According to the Directorate of Health Services (DHS) bulletin on Friday, 371 patients are in ICUs and 96 patients are on ventilator support across Kerala. In less than a fortnight (September 5 to 18), the number of patients in the ICU went from 200 to 300. The number of patients on ventilators has been varying between 60 and nearly 100 in the last two week.
According to the District Disease Surveillance Officer (DSO), Kasaragod currently has 10 ICU beds and 16 ventilators for COVID-19. “We are making arrangements to add 20 more ICU beds at the Medical College, and more ventilators. However, even if we buy more ventilators, currently, there is no space to set these machines up,” said Dr Manoj, Kasaragod DSO.
Kottayam District Medical Officer (DMO) Dr Jacob Varghese told TNM that the district has set aside 40 out of 140 ICU beds with ventilators for coronavirus patients. “As of now, the percentage of patients in need of critical care is very less, and a majority are asymptomatic,” he said. “But, if there is a rise in patients in need of ICU care, the remaining 100 non-COVID ICUs will be utilised."
However, in a district like Thiruvananthapuram, which has reported 206 deaths so far (the highest in the state) and has over 800 people testing positive for coronavirus daily, the figures are worrying.
Although the district medical officials did not provide an exact figure, the dashboard indicated that the beds are fast filling up. As on September 25, only 853 treatment beds (out of 4,443), nine ICU beds (out of 146) and seven ventilators (out of 13) are available.
“For the current pool of patients testing positive, our hospitals have adequate infrastructure, including ICU beds and ventilators. Besides, out of 100 patients, about 60 to 65 of them have moderate symptoms of COVID-19,” said Dr Arun, District Programme Manager (DPM), National Health Mission, Thiruvananthapuram.
However, he also added that this is a limited number. “In the coming weeks, if there is a surge in infections or a large cluster, we will fully activate our contingency measures, including converting the non-COVID ICU beds to COVID-19 ICUs,” he said.
Thiruvananthapuram will also rope in more private hospitals and use their ICU beds for Category C patients (with severe symptoms and comorbidities). Currently, 500 Category B patients (with substantial symptoms) have been admitted to private hospitals in Thiruvananthapuram, added Dr Arun.
Kerala is also in the process of procuring ventilators for districts that have less infrastructure. For example, Palakkad, which has fewer ventilators compared to Ernakulam, Kozhikode and Thiruvananthapuram, is slated to receive more ventilators in the coming weeks.
Palakkad Assistant DMO told TNM that the district officials have placed an order for 40 ventilators, of which they have received 28. “However, due to rising COVID-19 infections and the increased demand, it is tough to get ventilators now. We are using portable ventilators,” he pointed out.
However, according to Dr Arun NM, an Internal Medicine expert, in the current scenario, there may be a shortage of treatment beds rather than ventilators. Many COVID-19 FLTCs, especially in smaller districts like Palakkad, may not have treatment beds. These are used only for quarantine and isolation purposes. “That is why many patients from Palakkad go to other districts like Kozhikode for treatment,” he said.
He also said that the Kozhikode Medical College has been catering to patients from Kannur, Wayanad, Palakkad and Malappuram, most of whom are Category C patients and a few Category B patients.
Hospitals in other districts also refer patients who need ventilator and dialysis support to Kozhikode Medical College, added Dr Shameer, noting that FLTCs will slowly be upgraded to COVID-19 hospital, to accommodate moderately sick patients.
In the absence of accurate data from the government on the current hospital capacity in Kerala, medical experts told TNM that it cannot be said with certainty that the state health infrastructure can efficiently handle the spike in cases. They also alleged that the government could be underreporting the actual number of critical patients in the state.
“We cannot completely rule out the possibility of a situation where there will be a paucity or no beds for critically-ill patients,” said Dr Arun NM, who is based in Palakkad.
“If we have the exact numbers, we can assess where we are standing in terms of the capacity and whether we need to strengthen it further,” said Dr Padmanabha Shenoy, a rheumatologist based in Kochi.
However, with the available data, they said, the state is considerably safe for now.
This, Dr Gopikumar P, secretary of the Indian Medical Association (IMA), attributed to Kerala’s strategy that it drew up in early March, foreseeing a spike. According to him, that helped Kerala manage the pandemic so far, unlike Delhi and Mumbai, where chaos ensued after a large number of patients could not access ICU beds and ventilators.
“Once cases start rising, public hospitals will convert the existing ICU beds set aside for non-COVID-19 for COVID-19 care, and more ICUs and ventilators will be added. Additionally, secondary (taluk and district hospitals) and tertiary care centres (Primary or Community Health Centre), too, will be equipped with ICU beds,” he said.
However, pulling out the existing system for non-COVID patients will definitely lead to another crisis, pointed out experts. “In Manjeri Medical College Hospital, all non-COVID beds are being used for COVID-19. So, if a non-COVID person is sick or has an emergency (like an accident), he/she cannot be admitted. If a COVID-19 patient has to be admitted, the beds could be full. Ultimately, the hospital will not be able to cater to both the types of patients,” explained Dr Padmanabha.
In the private sector, 33 private medical colleges in Kerala have been roped in for COVID-19 treatment in a phased manner. A percentage of ICU beds in smaller private hospitals will be earmarked for COVID-19, based on the rise in infections, said Dr Gopakumar.
Yet, experts reckon the Kerala government is still not making full use of the capacity of private hospitals for COVID-19, as they have more ventilators. “Ideally, in government hospitals, there should be at least more than 1,000 ventilators and another 500 could be used in private hospitals, if needed,” said Dr Arun.
“People need to know how many beds are available and what hospitals are currently treating COVID-19 patients,” said Dr Padmanabha. “The government should provide real-time data, like Karnataka and Tamil Nadu, showing the number of beds available and names of the hospitals.”