A wise step to manage Covid patents

Started in 1900 by Dr. Ida Sophia Scudder, Christian Medical College (CMC), Vellore was as a single bed dispensary. Now 120 years later, it is a 3000 bed tertiary care university affiliating teaching hospital that offers the spectrum of medical services for patients from across the globe…….
By Dr. Lallu Joseph,/ Dr. Binila Chacko

Today the CMC is the largest institution accredited by NABH for excellence in patient safety and quality standards. CMC has always responded to the healthcare needs in India, whether it was the response to the ‘mother and child’ in 1900s or providing niche services such as renal and bone marrow transplantation or dealing with infectious diseases or starting training programs. When the pandemic was declared, CMC responded by creating capacity for COVID, establishing processes and policies to ensure smooth function and created training modules to ensure a scientific approach to COVID. It started by allocating 150 beds for COVID in March 2020 and the capacity was rapidly enhanced to meet the demand for COVID care.

During the peak of pandemic, CMC had 924 beds including 96 ICU beds, dedicated for COVID patients, which makes it one of the largest private hospitals that provided COVID care, that supported 4 districts around Vellore and so far over 10000 COVID patients have been treated in CMC Vellore.

We asked the Director of CMC Vellore about the contributions of CMC during COVID and he said- CMC is not restricted by boundaries. Its contributions go beyond the state to the nation and the globe. Dr. J. V. Peter, the Director of CMC Vellore stated that CMC’s contribution to dealing with the pandemic can be considered into three major areas – the local community and state, national and global.

1. Contributions to the local community and state:
The institution has been actively engaged with the district administration in managing the crisis. We received approval for COVID testing in early phase of the pandemic along with the first list of approved institutions by ICMR. CMC managed the first patient in Vellore District. As the numbers increased, in order to support the district administration, CMC opened many wards and ICUs. The beds are classified into L1, L2 and L3 where L1 are for mild and asymptomatic, L2 for more sick patients requiring oxygen but not intensive care, and L3 for very sick patients requiring intensive care.

Even before the announcement of the pandemic by the World Health Organization (WHO), the Hospital Infection Control Committee (HICC) started preparing protocols for receiving patients. Staff Training Department and Nursing Service initiated training of all staff in the form of simple videos. Our protocols were widely distributed, shared by the healthcare fraternity and appreciated by various agencies that included the Andhra Pradesh Government. Representatives from CMC are also part of the expert group of the Tamil Nadu State. They have given their inputs and recommendations for COVID management and control in Tamil Nadu.

2. National Level Contribution:
CMC’s contribution at the National Level has been substantial. Dr. Priya Abraham, Clinical Virologist of CMC Vellore is in a key role at “National Institute of Virology (NIV)”, Pune on special leave from CMC Vellore. Dr. Gangandeep Kang has contributed immensely in “Translational health sciences and technology” and has been part of various committees. Dr. Jayaprakash Muliyil, former Principal of CMC Vellore and Epidemiologist, Dr. Jacob John, former head of Virology, Dr. O.C. Abraham, ID Specialist, Dr. Jeyaseelan, former head of Biostatistics and others have contributed to polices and expert inputs at the national level.

CMC is involved in training healthcare workers of other government and mission hospitals on COVID management. The institution trained over 5000 doctors and nurses using an online platform with support from “TATA Trust”. CMC’s Distance Education Unit in partnership with the Azim Premji Foundation trained 10,000 grass root levels workers (like ASHA workers) and the program was developed in English, Hindi, Tamil and Kannada.

3. Contributions to the Global Community
Our Alumnus Dr. Ankit Bharat, conducted the first lung transplant on a COVID patient in USA. Significant research is being conducted by our Alumni Dr. Priya Sampath, ID specialist in Mayo Clinic, USA and Dr. Vincent Raj Kumar, Haematologist. Many other CMC alumnus are involved in COVID work across the globe. CMC faculty are also involved in 50 research projects in the management of COVID.

Emergency preparedness is a team sport:
“Realising the effect of the deadly virus, the institution initiated its response by late January 2020. We visualised challenges upfront and worked proactively with interventions as the pandemic started in China. The first preparedness policy document for the institution was released on January 23rd, 2020. The institution actually prepared itself to receive the suspect/ patients in Feb 2020”, said Dr. Priscilla Rupali, Professor IDTRC & Deputy Chair, HICC

Several teams were set up to get organised and battle the situation. CMC believes in getting the teams together and the collective synergy.
The administrative team met every morning to discuss on the progress of the preparedness. The individual subcommittees met to ensure all arrangements pertaining to their scope were organized. The institution was ready with triaging criteria for patients coming with symptoms, Isolation rooms/ wards, adequate PPEs, quarantine facilities for staff coming, updated cleaning and disinfection protocols. The cleaning frequency was increased even in the non-clinical offices to protect every one accessing the institution. The changes in protocol were conveyed to the staff through mails, intranet and training sessions to give them the confidence to handle the situation. Heads of the various departments were made responsible to ensure that the protocols were implemented.

The hospital started admitting patients who potentially fell into the criteria of suspects in early March. The first patient suspected for COVID was admitted on 25th March 2020 and he turned to be COVID positive. Initially only one ward was allotted to admit suspect patients. As the numbers started going up, many wards were converted to suspect and positive wards. Entire floor of the Main Building was converted to COVID floor and access was restricted.

COVID Command Centre:
“The increase in patient load was very challenging for the institution, as it needed to make sure all the necessary resources were available to deliver the service. The institution realised the importance of having a centralised structure for COVID operations and the COVID Command Centre (CCC) was setup. The command centre is exclusive for COVID management and has the patient help line, HR desk, admission and bed management desk, finance desk, contact-tracing desk and counselling desk. Management of the day-to-day operations became easier having the COVID Command Centre. Staff from various specialities who volunteered to help the institution were posted in COVID command centre and were given specific roles” said Dr. Joy Mammen, Associate Director (Medical)

The primary focus of the institution during this pandemic was always “patient care” and “workplace safety for staff”. The institution ventured into various strategies to ensure no compromise on these two aspects.
How are we managing COVID patients?

Patients/ patient relatives are screened at various points of the hospital before entering into the building for consultation/ test/ admission. Screening was initially done using a checklist in which patients were screened for basic symptoms like temperature, cough, cold etc and also checked whether they came from containment zone. Based on the screening, the patients are triaged and seen to ensure no cross contamination among patients and healthcare workers. If the patient required testing for COVID, they are sent to fever clinic.

Checklists are not there anymore but thermal screening continues at all the entrances. Patients with fever are sent to fever clinic for COVID testing. Any patient with symptoms directly approach fever clinic for testing.

Sample collection:
Patients are seen by the doctors in the fever clinic. Not all patients visiting fever clinic require testing. The doctors evaluate the patient and order for COVID test. Before swabbing (sample collection), the forms are filled as regulated by the government including the ICMR form. The swab test is given by the patient on the same day in fever clinic. The swab is sent to Virology lab of the institution and results are communicated to the patients within 8 hours through the COVID Command Centre that calls them in their registered mobile number. CMC Vellore was designated as the COVID testing centre during the initial stage of the pandemic in India and the testing started from 24th March 2020. Now a rapid gene expert RT PCR is available, and results are ready in 2 hours.

As soon as the test result is informed by the teams to the patient, the admission desk contacts the patient and verbally checks their status. Patients are informed about the cost of treatment by the finance desk and given the advice for payment through online modes. If the patients are not sick, they are taken as Level 1 and the beds are allotted to them. Then the patients are requested to report to the admission desk near Emergency Department. If the patient is sick, they are asked to go to Emergency Department for assessment and admission into Level 2 (wards where the patients needed close monitoring) or Level 3 (ICUs) wards as per patient requirement. For L1 patients, the COVID Command Centre communicates with the patient regarding the admission time and reporting. L2 and L3 patients are admitted to the COVID wards directly from the Emergency Department of the institution.

Level 1 patients report to the admission desk. The patients are sent to the respective wards for admission. The staff in the admission desk accompany them to the ward to ensure they follow the right route for transfer/movement of COVID patients.

Patient movement:

Comforting patients and their relatives:
Patients after admission are completely taken care by the hospital as the relatives are not allowed to stay with the patients. The patients are visited by the Social Workers, and Counsellors to make them feel comfortable and counselled during the stay. Food and snacks are provided by the institutional Dietary Department. The patient as well as the relatives are informed about the patient’s condition everyday by the treating team. Any queries/ clarification for the patient relatives are answered through the 24 hr helpline, which is in the COVID command centre. As the patients get discharged, the patients are accompanied by the staff till they reach their vehicle.

How are we ensuring safety of our staff?
CMC Vellore has been very carefully framing strategies to ensure that all healthcare workers are taken care of. The fear among the staff during the initial stage of pandemic was very challenging for the institution. Reassurance with adequate PPE supply and training helped in allaying the fear. About 1644 staff, including 683 doctors and 966 nurses were posted on COVID duty apart from technicians, therapist and hospital attendants adding to 1900 staff during the peak of Pandemic in August.

COVID duty schedules were prepared for doctors, nurses, technicians, ward attenders etc. in order to ensure adequate manpower to battle this pandemic. Schedules were prepared in advance and sent to the healthcare workers. Though many healthcare workers volunteered in the initial stage, the institution strategically posted senior doctors from various specialities on COVID duty, to make the juniors feel confident of handling COVID patients. This was a positive sign for the healthcare worker’s willingness to work during this COVID period.
Training of staff:
The institution conducted various training programmes for the staff on protocols to be followed to overcome COVID. The training programmes were conducted by the Staff Training Department of the institution and Nursing Service (for Nurses). They prepared several training materials in consultation with the infection control team, and trained staff on the new/ modified protocols. They also prepared simplified training material that included videos that helped everyone understand the protocols. During the training programme, the staff were encouraged to clarify queries and express their grievances related to their safety at work. These were addressed during the session. This helped in developing confidence among the healthcare workers in COVID areas. Lectures on different crucial aspects pertaining to COVID for medical professionals across the country were conducted as COVID Public Lecture Series (COVID PULSE)-this lecture series received good feedback from various health professionals.

N95 mask for staff during the high demand period:

As the pandemic started, the demand for masks went up drastically throughout the country. The supply of surgical mask itself was a problem. What was sold for 90 paise before pandemic was sold for Rs.18/- and there was a huge shortage. However this was anticipated and hence adequate preparations were made to ensure adequate quantity of surgical masks as well as N95 masks were available. The departments were asked to use surgical masks rationally to avoid wastage.

The institution worked strategically to ensure availability of N95 mask for all staff. The institution developed a policy on re-use of N95 mask to handle the crisis. Patient care staff working in non-COVID areas were issued 6 masks for 36 days with one cycle of plasma sterilisation in-between. New masks were issued to all staff working in COVID areas. As the supply stabilized, the sterilisation of N95 mask was discontinued. The mask and supply committee headed by Dr. Vikram Mathews, Associate Director (Admin) looked at the supplies, suppliers and ensured good supply chain throughout the pandemic.

Facilitations for staff in COVID ward:
Facilities for staff working in the COVID wards was initiated to take care of the staff and boost up their confidence. Facilitations include Shower facilities after duty, Scrub counter, N95 counters, Snacks in the work areas itself etc. Adequate purchase of Scrub suits, N95 masks, PPEs etc were ensured in a short period of time. Change rooms, temporary shower areas and lockers to keep the staff belongings were arranged. Staff present for duty in their casual wear change to scrub suits, collect N95 mask and then move to their respective wards.

They donn in the donning area in the ward and start their duty. On completion of the duty, they doff their PPE in the ward. Instructions on donning and doffing were displayed in these areas and instruction videos were made available on the intranet. After doffing, they move to the facilitation counter where they drop their used N95 and collect soap, shampoo, towel to take shower and leave. While they leave, they are given surgical mask to wear.

Quarantine facility:
In the initial phase of the lockdown, staff were given leave to minimize the numbers in the hospital and only 1/3 of the staff, especially those needed for patient care were made to work in rotation. Specialised quarantine facilities for staff were arranged by institution for those who do not have facility for home isolation. Food for the quarantined staff was provided through quarantine and housing committees.

Other interventions:
Transportation facility for staff during lockdown, hand wash stations at multiple points, sanitizers at nominal price for staff, and also food for staff in COVID areas were given. Staff duties were rescheduled to 6 hours in COVID areas. Psychological support and counselling for the staff were also given.

Role of Support services:
The general services team were sincerely committed to take the challenge head on. Week after week new facilities had to be opened up to deal with the demand. The staff took up to do the work by themselves since the external work force was not available. Shops were opened up to get the materials needed. Everything happened like a Disaster Management Operation. Taking personal Risk for the sake of others was the highlight of achievement, said Er. David Chandran, General Superintendent.

Engineering services:
As the numbers increased, the institution opened up few more wards in the Main building and the work in Kannigapuram campus was rushed up to open wards to accommodate more patients including patients from adjacent districts. The institution’s engineers worked tirelessly to set up temporary showers (34 in number), change rooms, negative pressure in theatres, converting wards to ICUs to accommodate level 2 and 3 patients etc. They were also part of many innovations. Uninterrupted supply of medical gases and daily monitoring of water was ensured by this team.

Usage of Medical gas was monitored critically so as to ensure adequate stock of oxygen as it is a very important entity to manage COVID patients. The oxygen consumption during this period went up to 4772 m3 / day from 3233 m3 / day during the pre-COVID period. A complete study on Oxygen requirement was conducted and back up oxygen concentrator was installed. Phenomenal amount of work of high technical nature was done by the engineering teams

Ambulance services:
22 Ambulances, in house as well as outsourced, were used to transfer COVID patients. It included shifting of patients from Home to hospital Between Campuses
Hospital to home Cleaning of Ambulances after every trip and PPE for the Drivers were insisted upon and monitored, as many outsourced Ambulance services were inducted as the numbers went up. On an average about 35 trips per day for patient transfer were executed through the ambulances.

Biomedical Waste Management
The protocol for biomedical waste management, linen management, CSSD management for wards in COVID floors were setup and implemented immediately. The institution was very careful to ensure that they did not mix up with regular waste, linen and CSSD.
All biomedical waste management generated in the COVID wards marked with COVID sticker on its collection cover are stored separately in the temporary storage area. The movement of the ward trolley was through the designated route and lift. On an average 2.2 tonnes of waste was collected from COVID areas during the peak.

Laundry Services:
The number of scrubs required to be washed in the institution laundry department went up tremendously as we started using scrub suits in the COVID areas. The scrubs are disinfected and then sent to laundry for washing. The scrubs are washed everyday so as to ensure the availability of the same, in the scrub issue counter for the staff. On an average 1250 scrub (shirt and pants), and 1200 towels were sent to laundry for washing and ironing that added to the existing load.

Dietary services:
Dietary services of the institution worked tirelessly to serve COVID patients, especially for those patients who need to be on therapeutic diet, as outside food is strictly avoided to prevent visitors’ entry. On an average 750 COVID patients were served food through the dietary services of the institution in a day during the peak. External food services were arranged for L1 patients to get more variety of food since loss of taste and smell is also one of the symptoms for COVID patients. The diet trolleys that serve food to patients admitted in COVID wards were moved in a designated route and lift.

How do we ensure quality and safety?
Ensuring that quality care is delivered to our patients during the pandemic is paramout and it is hence important to monitor these interventions. All interventions are being monitored through various audits conducted by various teams- Infection Control Team, Clinical Team, Nursing Team, Quality and Safety Teams, said Dr. Binila Chacko, Professor, MICU and Deputy Director (Quality).

Patient feedback
The COVID patient feedback was taken by phone calls to patients during their admission as well as after discharge. Of the 895 patients surveyed, more than 95% of the patients were satisfied with the services provided by the institution.

Staff feedback:
Staff working in COVID areas were surveyed for their feedback very regularly. Of the 320 staff who responded to the staff feedback survey, 85% of the staff were extremely satisfied and felt that the institution had taken care of them very well.

Fire Management Protocol:
The fire management committee, Quality Management Cell and Safety Cell prepared protocol for managing fire emergency in COVID wards. This included identifying alternate care sites for these patients if they had to be evacuated. The staffs in the COVID wards and the support services were trained on the protocol. The fire team of the institution rehearsed the protocol several times, during this short period to get oriented to it. Mock fire drills were conducted in some of the COVID wards to assess the effectiveness of the preparedness. The lacunae identified during the mock drill were addressed immediately. In order to prevent any fire, preventive maintenance of equipment are being carried out regularly in all COVID areas.

Neighbourhood watch:
Apart from this, there was also a dedicated team of healthcare workers, predominantly doctors, who have volunteered themselves as the safety champions for the institution. Surprise inspections were conducted and actions taken promptly on any non adherence to safety protocols like social distancing, mask usage etc.

This year 2020, we celebrate our founder Dr. Ida Sophia Scudder’s 150th birth anniversary and 120 years of CMC Vellore. Ida Scudder’s example of dedicated service to mankind continues to motivate the institution to the present day. Her talk to the very first batch of 14 medical students, all of whom were women during the Graduation Day in 1922 holds good for medical professionals particularly during the pandemic.

(The authors are Quality Manager & Associate General Superintendent and Professor, MICU & Deputy Director (Quality), CMC Vellore.)

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