Governments around the world are rapidly expanding their healthcare capacity in response to the coronavirus pandemic. In India, however, hospitals are faced with a different kind of threat. Instead of being at the frontline providing treatment to Covid-19 patients, healthcare professionals themselves are falling prey to the disease. And overcautious local health authorities – in an attempt to limit the virus spread — have shut down many hospitals with infected staff such as Wockhardt, Jaslok, Bhatia, Hinduja Khar, and Breach Candy among others, and designated them as ‘containment zones’. This has shaken public faith in the healthcare system.
Unlike in China’s Wuhan, where healthcare workers (HCW) were infected while treating Covid-19 patients, many unsuspecting Indian healthcare workers have been infected by asymptomatic patients visiting for non-Covid treatments. For instance, a patient in Mumbai visiting Jaslok Hospital for a routine dialysis treatment later tested positive and may have infected others at the hospital.
Why did this happen?
Although many will brand these unfortunate incidents as unforeseen, they represent a broad systemic failure. While it remains a matter of probe, the reasons for these cases are a mix of the refusal to accept community spread of Covid-19, the lack of official guidelines to private hospitals in treating asymptomatic patients, and a lack of foresight from hospital administrators in setting up personal hygiene and social distancing norms within hospitals.
One can draw comfort from Wuhan’s experience. After an initial spurt of infections among healthcare workers, improved understanding of the virus’ transmission mechanism, official guidelines on hand hygiene and the use of Personal Protective Equipment (PPE) reduced the incidence of accidental infections.
Good intentions can lead to bad consequences
India’s guidelines on the use of PPEs need to be examined. A cap, goggle, mask, face shield, water-resistant coverall, gloves and shoe cover are all vital components. Instructions on re-use of PPEs are not based on any significant scientific study and must be withdrawn immediately in the interest of safety of healthcare workers. Instead, the use of PPEs and N95 masks by civilians and government functionaries must be discouraged to ensure their exclusive availability for healthcare workers.
In response to the hospital closures, the central government has also issued an advisory to hospitals for managing non-Covid patients. Healthcare workers in different parts of a hospital are exposed to different levels of risk of exposure. Therefore, advising mandatory use of N95 mask in all clinical settings is not rational. In contrast to the UK’s National Health Service’s guidelines for health professionals, the Indian advisory is highly ambitious and doesn’t account for the limited availability of N95 masks and PPEs in the country. We must not allow fear to overrun science.
What should be done?
Every patient or their relative entering a hospital should be presumed to be Covid-positive, irrespective of their lack of symptoms or health certificate. This is needed since some antibody tests may come negative even in the presence of coronavirus and an antibody test provides a positive result only after eight days of catching the infection.
Barrier nursing protocols, increased payouts
Healthcare workers and hospital management are well-versed with barrier nursing protocols for managing patients infected with previous viruses, such as H1N1. Extending these protocols for all patients is definitely not an insurmountable logistical exercise for hospital administrators. The cost of care is likely to significantly increase with the use of PPEs, social distancing between patients, and increased time required for sanitisation of the operation theatre and common areas between procedures. The Insurance Regulatory and Development Authority (IRDA) should allow a 30-50 per cent increase in the payout for procedures for at least one year.
Avoid hospital shutdowns, set up ‘back up zones’
Local health authorities must resist shutting down hospitals with infected staff, as each bed and healthcare worker is an essential resource in India’s battle against the coronavirus pandemic. Protecting vulnerable healthcare workers from infection should be the foremost priority. A comprehensive staff evaluation must be undertaken and healthcare workers over the age of 65 and with co-morbidities must be asked to work from home or take up administrative responsibilities for the duration of the pandemic.
Keeping at least 30 per cent workforce away from the hospital can provide a back-up for infected staff in a situation faced recently by hospitals in Mumbai and Delhi. As consultations and planned procedures are on hold in hospitals all over the country, the implementation of this measure shouldn’t be challenging. Similarly, a strategy to lock up and conserve non-essential floors can help build a ‘hospital back-up’ while infected areas are being sanitised after a diagnosed contamination.
Simplifying care protocols is essential for reducing the risk of infection. In Wuhan, the basic training of hand hygiene, avoidance of touching face and use of PPEs helped protect HCWs from catching the infection.
A financial package
Besides manpower training and sensitisation, hospitals will need investments to deliver consistently safe outcomes, even for non-Covid patients. These include the construction of assessment zones, dedicated patient lift, conversion of positive pressure operation rooms into negative pressure ones, and particle arresters for surgeries to protect surgical teams and to prevent cross-infection of future patients. A financial package for private health care providers combined with massive investment in public healthcare should be high on the government’s agenda.
Protection from unfair media and legal scrutiny
In Italy, doctors were forced to choose which patients could avail the limited ventilators and beds. During the course of this pandemic, healthcare workers and hospitals in India can be compelled to make difficult choices too, exposing them to unfair media and legal scrutiny. It is therefore essential that the healthcare system is insulated from union pressure, official probes, unfair media scrutiny and litigations during this period, in line with their counterparts protecting India’s borders.
The author is Director of Bariatric Surgery at Wockhardt Hospital, Mumbai; and President of the Indian Association of Gastrointestinal Endo-Surgeons. Views are personal.
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