Command centre, Uber-like ambulance service — how Kerala’s Ernakulam has kept Covid toll low

Kerala's Ernakulam district currently has the most number of active cases in the state, but has seen only 80 deaths so far.

Health workers checking on a patient at a second-line treatment centre for Covid-19, in Ernakulam (Representational Image) | Photo: Praveen Jain | ThePrint

Ernakulam: Sitting in his office at the Kochi Smart City Command and Control Centre, Dr Akshay Dinesh knows the status of every Covid patient in Ernakulam — whether they need to be shifted to a higher centre, the ambulance/rental car that is closest and can be assigned for the purpose, and if the destination has a room to accommodate the patient. All of this is projected on a giant screen in front of him — a take-off of the Emergency Operations Centre at the Centers for Disease Control and Prevention.

At some distance, a private hospital, that was closed about a year-and-a-half ago because it ran into massive debts, has been taken over by the district administration using the powers vested in it under the Disaster Management Act. It is seeing frenzied activity once again and currently houses 51 patients on its 50 beds.

At the towering headquarters of the Indian Medical Association in Kaloor, almost the entire space has been taken up by staff and volunteers from the Covid team. There is a telemedicine facility for doctors that clears their doubts about Covid patients under their treatment, and also calls back patients who leave queries. There is also a call centre that started in March and was informally called the “breaking the bad news” unit, but is now simply the Covid triage centre, where patients are informed about their positive status and it is decided whether they can stay at home or need to be shifted out to a first line or second line treatment facility or to an apex centre.

These are the snapshots of the integrated Covid care network that Ernakulam has put in place.

This integrated network has ensured that Ernakulam district, which currently has the most number of active cases in the state — 11,692, higher than capital Thiruvananthapuram, a hotspot — has seen only 80 deaths so far. As many as 25,219 cases have been reported till date in Ernakulam. The case fatality rate stands at 0.31 per cent as against a national average of 1.55 per cent.

On 8 October, District Collector S. Suhas issued eight-page guidelines detailing everything — when and how often patients should be tested, when to conduct antigen or RT-PCR test, cleaning and biomedical waste management at the centres, and that patients’ details should be deleted from the Care portal — that has all the names and numbers — once they are discharged.

“They will just be numbers after that,” he tells ThePrint, sitting in his office at the Ernakulam Civil Station where he has been holding meetings to set up four post-Covid care clinics.

Advantage of an early start

Ernakulam started preparing for Covid early on, largely because both the first and second confirmed coronavirus cases in India, flown in from Wuhan, were in the neighbouring districts of Thrissur and Allapuzha.

Dr Atul Joseph Manuel, medical officer at the Ernakulam General Hospital, who has been an important part of the state Covid team, recalls the early days when nobody had a clue about the virus.

“We bought 500 litres of alcohol from Gujarat thinking we will make hand sanitisers, and then realised you need a drug licence for that…when the first patients started coming in at the airports for screening, we were there to finish all the preparations before they came and when the flight arrived we realised we were the only ones without PPEs. So we started running to get out of the airport before the sea of passengers behind us caught up,” he recalls.

Like the rest of the state, Ernakulam is now in the process of setting up nurse-managed domiciliary care centres for people who are asymptomatic but cannot be at home due to social or other problems.

“We introduced the concept of Covid first line treatment centres, and were the first to set one up. We also sent out the first Vande Bharat train to Odisha…we set up a telemedicine centre, took over a defunct private hospital, roped in ambulances and willing private taxis, a sort of a Uber for Covid patients, and ensured that every patient’s status is tracked on a dashboard real time. I can go online and call any patient right now. And all of this was done using an open source software so that we hardly spent any money on,” Suhas says.

The numbers are high partly because the district is the medical destination for people from the neighbouring districts of Alappuzha and Idukki as well, he says.

Telemedicine centre

The telemedicine centre is the backbone for both treatment and for clearing patients’ doubts. It has only been eight months since the outbreak of the disease and physicians still tend to get flummoxed occasionally.

At the Covid second line treatment facility set up at some distance away from the city en route Thrissur, in what was once an exhibition hall, doctors are posted on a rotational basis for 10 days to take care of patients who are either old or have comorbidities. Many of these doctors have little experience, so, whenever in doubt, they reach out to the telemedicine facility that operates from the IMA office in Ernakulam, explains Dr Nazema, who is in charge of the facility and also the medical superintendent of the nearby Angamaly Thaluka Hospital.

There is a panel of doctors available for consultation whose opinions are conveyed to the treating doctor at the centre. On Tuesday, the telemedicine centre’s report shows, it had received 576 incoming and 356 missed calls on a number that is only available to doctors. All calls that are missed, are returned.

Kochi Smart City Command and Control Centre | Praveen Jain | ThePrint

Whenever a patient needs to be discharged after treatment or sent to a higher facility for better medical attention, the request is reflected on the screen at the control centre — locally known as IC4. Dr Akshay or one of his 30-odd colleagues would check the status of the centre — where the patient needs to be shifted in terms of bed availability, and then, from the pool of about 40 ambulances and 15 two-chambered taxis, assign one for transfer. Reflected on the giant screen is the location of the vehicle and how far it is from the destination — much like what we see on our mobile phones while waiting for an Uber. On Thursday morning, there were about 360 open requests.

The Covid triage facility began as an initiative early on, to break the bad news gently, to try and minimise the panic reaction associated with the disease.

Jacob, a retired engineer who is volunteering at the centre, says, “Those days we would strike a rapport with the person, have a little chat, get a sense of the family situation before telling them they are positive. Now, we simply call them, assess whether they have symptoms and then decide whether they can stay at home or need to be shifted out.” A data team vets all calls to ensure there is no duplication.

Roping in stakeholders

The Indian Medical Association has been one of the harshest critics of the Kerala government during the second Covid “season”. However, in Ernakulam, it is a partner of the government. Not only are the IMA’s headquarters being used for the telemedicine facility, some of its office bearers are crucial cogs in the Covid wheel of the district. They include Dr Atul, who took over as the IMA secretary a week ago, and Dr Hanish, vice president, IMA, who has been instrumental in the government takeover of the PVS hospital.

“PVS Hospital can be a PPP healthcare model for the entire country. This hospital closed because they ran into debts and, early on, as Covid cases came in, the collector started getting messages on Facebook etc, about using the facilities here. We did a little work in March, getting the electricity and water connection restored, got the lifts working. And then the numbers went down. It is only a few days back that we came back and seriously restarted operations.

Covid-19 ward at the PVS Hospital, in Ernakulam | Praveen Jain | ThePrint

“The problem is that this is a private facility currently in the custody of the Company Law Tribunal so the government cannot make any long term investments in this. We got money from private players under CSR and also got help from unions to get the place up and running. MP Hibi Eden gave us a COVID testing kiosk,” Dr Hanish says, outlining the sequence of events that led to the revival of PVS.

Hibi Eden, Congress MP from Ernakulam, is all praise for the district administration for their handling of the pandemic. It was through his Facebook post that the Kerala government found out that DC Suhas had seen his baby only once since she was born in February as he did not want to leave his charge. He was also not keen to get his family back from Bangalore with the pandemic raging.

Now, with Bangalore among one of the worst-affected cities, his family will be back in November, Suhas says.

“The district administration has done a very good job in managing the pandemic here. I am an opposition MP but I have to give credit where it is due. There were some unforeseen issues that came up, though. For example, there was a time when this entire panchayat of Chellanam was a containment zone and there was a sea attack there. There was water everywhere and no relief could be distributed because it was a containment zone. We had a very tough time then. The problem really is the loss of livelihoods. There is a need to do direct benefit transfer. If these get Rs 5,000-6,000 in their bank accounts, that will go a long way in getting the economy back on track,” Eden says.