DR N Subramanian, Director — Medical Services, Indraprastha Apollo Hospitals, New Delhi, shares his insights on taking the responsibility of ensuring the safety of fellow clinicians, nursing staff, paramedical and support staff, and the society at large in the times of current crisis
While the world is coming to terms with the magnitude of the COVID-19 pandemic, with each country facing newer challenges, vastly different outcomes and persistent concerns about the future, doctors and nurses have been making their way to COVID wards each day and night, treating patients even as they fight their own fears.
The first responsibility of the hospital is the care of patients, and it is crucial that during the pandemic both COVID and non-COVID medical conditions could continue to be treated, while prioritising the safety of the caregivers and preventing them from contracting or potentially spreading the disease. As administrators working at a tertiary care hospital, we have to take on a huge responsibility of ensuring the safety of fellow clinicians, nursing staff, paramedical and support staff, and the society at large. Our responses to the situation had to be made rapidly in order to stem the spread of the disease, and in response to the Government directives, which were themselves changing constantly as more information became available.
Key changes that happened during lockdown
Infrastructural Changes:
1) Changes in infrastructure to ensure complete segregation between areas providing care to COVID-positive and COVID-suspected patients, including those coming in for emergency medical conditions. These were not only essential, but had to be achieved literally overnight, sans material, sans labour, and having to do with in-house semi-skilled labour and cannibalisation of resources. These challenges also compelled us to move towards disruptive innovation without interrupting delivery of quality healthcare. While the facility management and optimal utilisation of infrastructure and manpower ensured an early and sustainable level of preparedness, modifications had to be implemented without disrupting or disturbing patient cohort areas, specifically those handling cancer, organ transplantation, neonatology and trauma care.
2) Managing emergency visits to the hospital came with additional challenges, as treatment could not be delayed or denied, pending the availability of reports to indicate the COVID status of the patient.
3) Creating areas of isolation entailed interventions to the air-handling units and creating rooms with negative air pressure to achieve maximal protection of all concerned.
4) Setting up separate screening areas and separate ICU facilities for COVID-positive and COVID-suspect patients required meticulous planning to ensure suitable segregation between these areas.
5) Even well-equipped hospitals required additional equipment, like video laryngoscopes and ultrasonic nebulisers, in addition to an adequate number of quality Personal Protective Equipment (PPE).
Protocols and Processes
Creating and continuously refining/updating protocols (given frequent modifications) based on the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), Indian Council of Medical Research (ICMR) and the Government of India. All of these guidelines were central to:
1) minimising the impact of the disease.
2) preventing transmission to staff, patients and their attendants.
3) updating/modifying treatment protocols.
4) reporting compliance to multiple government bodies.
5) analysing data for research purposes, etc.
Clarity in Communication
Frequent and appropriate communication at all levels was essential to:
1) keep the staff constantly motivated.
2) ensure adherence to protocols and laid-down processes.
3) allay the fears of possible breaches and their implications for the healthcare workers and their families.
4) dispel the varied fears and apprehensions of a heterogeneous group of people, who feared contraction of the viral disease more with families in mind rather than the self. This was perhaps the biggest challenge and the greatest learning during this period.
In addition to standard methods of communication, including emails, WhatsApp, Zoom meetings and classroom chats, personal communication proved to be of great value.
The life of a healthcare administrator is also constantly walking on the edge. With expanded work schedules, they need to be constantly updated on the existing and emerging data and scientific evidence, and to share it with all those involved in decision-making. Tackling challenges like restriction of movement and availability of materials, gathering additional manpower and ensuring travel safety of the staff, all required special arrangements. The ability to find quick solutions during these daily interactions was a true testament to the innovative abilities of every individual involved. We were able to organise emergency back-up accommodation, provision for delivery of food and beverages, and rapid rearrangement of shifts in order to meet the crisis. Even extremely unlikely scenarios were taken into consideration during the planning. For example, if a COVID-positive mother needed to deliver, with a very low likelihood of the new-born’s also being COVID-positive, arrangements had to be made for the new-born to be placed in a safe, non-COVID area, with specific protection for other new-borns and neonatologists, especially if the new-born required a neonatal Intensive Care Unit (ICU). Similarly, when a patient in the COVID ICU was critical and needed emergency interventions, the requisite equipment and expertise were made available within the ICU, thereby avoiding transfer of such a critical patient to the operation theatre.
The commitment from all levels of staff was evident from their ability to assume responsibilities beyond their normal schedules and expertise. Flexibility in assuming different roles, and often at short notices and beyond the existing rota, was something that the nursing and junior medical staff handled with tremendous willingness and courage. Senior clinicians and administrators also demonstrated an immense spirit of volunteerism.
Lastly, it is important to acknowledge the role of the government – both at the state and national levels – in bringing all the experts and expertise from within the government and private entities, comprising clinical, academic and research institutions; creating a national approach to diagnosis, treatment, testing and tracing; and reducing transmission through contact. Moving forward, with the same attention to details and planning and sustained efforts at every level, both clinical and social, we can hope that the casualties remain well below what we feared and that our healthcare-preparedness in general would be better.