I have been closely following the approaches and experiences of other countries, and having continuing discussions with India's eminent virologist Dr Jacob John. Based on the above, l have some suggestions:
-If we are to handle a catastrophe of the magnitude the world is facing right now, we need a high level of commitment, cooperation, and coordination. In order to achieve this, we need to have a centralised command centre which is staffed round the clock, where data is studied, trends are analysed, and recommendations made.
- We need to assign hospitals/health care facilities exclusively for COVID-19 patients. This is based on the experience of other countries, as well as what has happened recently in two hospitals in India, where healthcare personnel became infected with SARS-CoV-2 from emergency surgical procedures.
Carlo Borghetti, the vice premier of Lombardy in Italy, said, "The biggest mistake we made was to admit patients infected with COVID-19 into hospitals throughout the region. We should have immediately set up separate structures exclusively for people sick with coronavirus. I recommend the rest of the world do this, to not send COVID-19 patients into health care facilities that are still uninfected."
If we do not take this approach, the virus will exploit the centralised health care systems of the current era in a large number of countries in order to spread. If sick patients with high viral loads are admitted in multiple hospitals, these hospitals become reservoirs of the virus. Health care personnel acquire infection and unwittingly become vectors who spread the infection to other patients, and this leads to further community spread. So hospitals become hotbeds of SARS-CoV-2 infection.
Having designated centres for the admission of covid patients will help to minimise this, while also having many other benefits:
- Highly trained healthcare workers can be assigned to these centres.
- Equipment like ventilators, CPAP machines, and PPE can be diverted to these centres from other hospitals.
- Since all patients are known to be COVID-19, all attending health care workers can work in full PPE. Valuable, and limited PPE will be optimally utilised, and not wasted trying to take universal precautions against COVID-19 with patients in each and every hospital.
- Support services for frontline staff such as counselling can be made available.
However, in order for this to be possible, testing has to be widely and easily accessible, with results available within a couple of hours. Once the results are available, positive patients requiring admission can be transported to the designated centres using designated ambulance services with adequately protected personnel.
Those who are not sick enough to be admitted can be followed up with instructions to report to the designated centres in case of deterioration in their condition so that they don't visit multiple hospitals/clinics and spread the infection.
Along with the above, we should modify our existing healthcare services in a number of ways:
- Ensure free prioritised treatment for infected healthcare workers and their immediate families. With the grim reality of doctors and nurses losing their lives in the line of duty, this will provide some reassurance to those working in the frontline, and is the bare minimum of what they deserve for what they are called upon to do.
- Make COVID-19 testing easily and widely available.
- Set up outdoor fever clinics with good ventilation and sunlight. These can be staffed by young doctors and nurses with relatively less experience than is needed to manage sick patients. This minimises the chance of infection being carried to patients and staff inside the hospital.
- Shutdown regular OPDs for chronic illness. These are vulnerable people who should not be coming to hospital, both for their own safety, as well as to reduce hospital crowding and the workload of an already stressed group of healthcare staff.
- Multiple hotlines should be set up and be staffed round the clock by appropriate personnel, including medical professionals, both for medical advice and for counselling for emotional and moral support.
- Telephone/telemedicine based counselling for patients with chronic illnesses through their usual caregiver, with the understanding that if there is a medical emergency they will have to access a safe hospital not frequented by COVID-19 patients.
- Home delivery of medications and equipment such as home nebulisers and glucometers and their accessories.
The above will go a long way in ensuring the elderly and those with chronic conditions do not go to hospitals. For example, acute exacerbation of asthma can be managed at home with home nebulisers and telephone consultation.
When absolutely necessary, healthcare providers wearing protective equipment should make home visits instead of patients coming to hospitals when their illness is of low/moderate severity and not life-threatening.
The above are broad outlines, and l have many more details and suggestions on how to go about their implementation.
I believe that all these are possible with our current resources, and will go a long way in helping India to minimise the effects of this devastating pandemic.
Dr. Prabhu Mayakesavan is the Director Medical Services at Chettinad Super Speciality Hospital in Chennai.