Why delayed admissions may have resulted in deaths of over 100 COVID-19 patients in TN

At least 34 patients died within 24 hours of being admitted in a hospital.
Health officials light pyres for cremation
Health officials light pyres for cremation
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At 11.10 am on May 16, a 44-year-old woman was admitted to the Stanley Medical College Hospital in Chennai. She died just forty minutes after being brought to the government hospital at 11.50am. As per Tamil Nadu’s health bulletin the following day, the woman who had tested positive for the novel coronavirus and had a pre-existing condition of rheumatoid arthritis died due to sepsis or septic shock. She was recorded as death case number 76.  

The young woman, however, is not the only one to have died within hours of being admitted to a hospital in Tamil Nadu. TNM analysed data from May 4 onwards when the Tamil Nadu Health Department started putting out details of admissions. Here’s what we found. 

The state recorded 124 COVID-19 deaths between May 4 and May 29. Out of this,102 patients died within hours or within five days of being admitted. A closer look at the data reveals that 34 or 27% patients died in less than 24 hours.  Sixty-eight individuals or 54% died a day later or within five days of admission. 

The question is were these all a case of late or delayed admissions? Could they have survived if they were brought in earlier? 

Early testing and diagnosis

Dr K Kolandaswamy, who recently retired as Director of Public Health (DPH), says early testing is essential for diagnosis of COVID-19. “We need to test and diagnose earlier and get them admitted soon. That is one aspect. All  contacts of a confirmed case, who present with mild symptoms such as fever must be tested. All Severe Acute Respiratory Illness (SARI) cases need to be tested compulsorily. Influenza like illnesses (ILI) must be tested,” he says, adding that high-risk contacts of a positive case like the elderly and immunocompromised must also be tested. “The earlier you test, the earlier you can admit them.” 

However, there have been reports in the past of Tamil Nadu health officials refusing to test patients, who have had contact with a confirmed case and present with symptoms.  

Dr R Jayanthi, Dean of the Rajiv Gandhi Government General Hospital (RGGGH), differs on the matter of testing. She says, “It’s not a question of earlier testing. Even after symptoms, patients don’t come to the hospital. Symptoms set in after quite some time.” 

Monitoring oxygen levels

She points out that as the early symptoms of COVID-19 are insignificant - cough, and fever- patients tend to self-treat at home.The challenge for doctors like her, Dr Jayanthi, says is treating patients whose oxygen in the blood has dropped to 70%.  

“Even a dying patient walks. That is the biggest problem with COVID. They have 70% oxygen saturation, they still sit up and talk and eat," she says.

As a result, many end up staying at home till it’s very late. “So people think it is only mild symptoms, you don’t know when this immune reaction will flare up. It’s a cascade. Quickly it sets in and causes problems. In majority of our experience, 70% of oxygen saturation means death. They would have drawn a straight line in the monitor, in any other case. That is why it’s called hypoxemia (low levels of oxygen in the blood),” Dr Jayanthi explains.  

Take the case of Tamil Nadu’s 150th death. A 32-year-old Chennai man who had no pre-existing health conditions passed away at RGGGH on May 28 just 21 hours after being admitted. He had tested positive just a day earlier. His death, as per the TN bulletin, was recorded as due to  “Cardiopulmonary Arrest / COVID19 Pneumonia / Type I Respiratory Failure / Hypoxic Encephalopathy / Acute Respiratory Distress Syndrome”. 

Dr Kolandaswamy says that even for those reporting mild symptoms of COVID-19, their oxygen saturation must be monitored using a finger pulse oximeter, which is easily available.  

“Normally, the readings are close to 100% for younger people, very healthy people. For the elderly, depending on the age it may be 99, 98, 97. Anyone who has a mild cough, cold and fever, they should be tested and after getting tested, irrespective of the test result, they should keep monitoring their oxygen saturation level,” says the former DPH, “If anyone’s levels drop below 95%, they should be immediately admitted to the hospital. The hospital without waiting for further drop in the oxygen, they should immediately start non-invasive oxygen therapy.”   

Dr Kolandaswamy also points out that people brush away their symptoms under the belief that it’s the common cold or the flu. “Unfortunately hypoxia, for even people who are young goes down to 80 or 70 and you won’t realise it. It’s silent hypoxia or asymptomatic hypoxia,” he says, adding, “So if oxygen saturation has gone down, depending on the individual , respiratory distress would have started. So when respiratory distress starts and you go to the hospital, it is too late. That’s why there is a death within a few hours or within a day. So in such a situation, you must test how much ever you can.”  On May 29, five out the nine reported COVID-19 deaths in Tamil Nadu were due to respiratory failure, or acute respiratory distress syndrome. Two of these patients died on the same day, one individual after four days, and two others after a week. 

Transferring dying patients

Data analysed by TNM also revealed another worrying trend among COVID-19 deaths in Chennai. At least 11 patients died within hours or days of being referred from a private hospital or another facility (Railway Hospital/ ESI/ ICF Hospital) to a government hospital. Out of this, seven patients died within hours of being transferred to a government hospital. 

While Dean of RGGGH, Dr Jayanthi says that their doors are always open to COVID-19 patients, the reasons for the transfer of patients are many. Some, however, are not ‘genuine’. 

Dr CN Raja, the Tamil Nadu President of the Indian Medical Association (IMA), says he has not received any complaints with regard to the sudden transfer of COVID-19 patients till date.  He did, however, provide some reasons as to why patients were shunted out of private hospitals, only to die hours later at a government facility. 

“I presume it’s maybe because the patient may not be willing to continue there, or the hospital may not like to have death in their hospital,” says Dr CN Raja, adding that there may be stigma attached to the hospital after a COVID-19 death. He also cites cases like Dr Simon Hercules, where residents near a burial ground in Chennai attacked the family and doctors who were present.  “It may also be from the government side,” he notes. 

Another source, who did not wish to be named, alleges that the sudden transfer of dying patients is “a usual private hospital phenomenon”. The source explains, “One reason is to not show deaths in the hospital. At the last minute, they will shift a sinking patient to transfer the liability.”  

With private hospitals charging hefty fees for the treatment of COVID-19 patients, the source notes, “Another reason is that the patient’s family would have exhausted his finances. They would have gone in the beginning thinking ‘ok i’ll spend 50,000 -1 lakh’. They would have ended up there for four days. So to escape that, they will come to the government.”

But there are genuine reasons as well to transfer patients. “A lot of private hospitals don’t have facilities - like ventilators. they will treat as much as they can and then send the patient. That’s a genuine referral. There are some genuine reasons, and some that aren’t genuine,” says the source.  

Dr Raja also points out that a number of private hospitals in Tamil Nadu are small or medium hospitals with bed strength ranging from 25 to 100. “And not every hospital has proper infrastructure in terms of isolation, manpower,  infrastructure - or has a pulmonologist, or anesthesiologist.”  As the risk of infection is high if a hospital has both COVID-19 patients and other patients, the IMA in Tamil Nadu has instead requested the state government to have standalone COVID-19 hospitals or create separate entrances or blocks in bigger hospitals for COVID-19 patients, he says.  

May spike

As of May 29, Tamil Nadu has recorded 154 deaths due to COVID-19, with over 70% from Chennai alone. More than 65% of the coronavirus cases from Tamil Nadu are also from Chennai. Both these figures increase if one were to add the neighbouring districts of Kanchipuram, Chengalpet and Thiruvallur as well. 

May has seen the maximum number of fatalities. While March saw one death and 124 cases, by April 30, Tamil Nadu had reported 27 deaths and 2323 cases. The mortality rate in the state is 0.76% - less than the national average of 2.86%. 

Explaining the spike in deaths in May, Dr Kolandaswamy says that in March and April most individuals who tested positive were healthy or active. “Earlier cases, the denominator was healthy. They were people who were active - those who returned from abroad, who attended the New Delhi conference. So the mortality among active and healthy people will be low.” 

As the disease spreads in Tamil Nadu and particularly in Chennai, however, the vulnerable have been exposed. As of May 29, 1806 patients who tested positive belonged to the age group of 60 and above. Tamil Nadu health officials have in the past pointed out that most individuals dying due to COVID-19 had comorbidities. 

Dr Kolandaswamy also points out that compared to March and April, the number of females testing positive or succumbing to the virus has also increased.  “As the disease spreads, the mortality also increases,” he says hinting at community transmission.   

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