CMAAO Corona Facts and Myth Buster 51

 548: What are the minutes of Round Table on Lockdown Exit Policy – ZOOM MEETING organized by IMA in Association with HCFI and CMAAO (11^th April 2020, Saturday, 11am-1pm)

 Participants: Dr KK Aggarwal, President CMAAO, Dr Rajan Sharma, National President IMA (On the Chair), Dr RV Asokan, Honorary Secretary General IMA, Dr AK Agarwal, Ex Dean MAMC, Dr Mahesh Verma, VC IP University, Ex Director MAIDS Govt of Delhi, Dr Suneela Garg Dir Prof MAMC, National President-Elect IAPSM, Dr Parag Rindani, CEO Wockhardt Hospital, Mumbai, Dr Girdhar Gyani, DG AHPI, Dr Atul M Kochar, CEO NABH, Dr Jugal Kishore, Head, Dept of PSM, Safdarjung Hospital, Dr T S Jain, Consultant Pediatrician, Max Smart City Hospital, Ex MS, Mr Bejon Misra, Founder Patient safety and Access, Consumer online Foundation, Dr Anita Arora, Director Medical Operations, Fortis Healthcare, Mrs Upasana Arora, Director, Yashoda Hospital, Dr Arati Verma, VP, Head Quality Maxhealthcare, Dr K Kalra, Ex CEO NABH, Director HCFI, Dr Sanchita Sharma, Editor IJCP

The following points emerged after the discussion:

• The COVID 19-19 pandemic is the first outbreak of this nature and scale in our lifetime. We commend the Prime Minister Shri Narendra Modi for taking pre-emptive timely measures to contain the pandemic at the very beginning of infection in India. Even the WHO has acknowledged India’s efforts.
• Today (13.4.20) is the 20th day of the lockdown in India (implemented on 24th March 2020 midnight). It has slowed the spread of the disease vis-à-vis the United States and European countries. But now healthcare workers are being infected and hospitals and healthcare establishments are being put under quarantine/sealing. This is creating panic like situation and overcrowding of other already overburdened public health care facilities. There is a stigma attached to a quarantined or sealed hospital. Presently there is a lot of anxiety and fear among healthcare professionals and other staff resulting in the closure of stand-alone clinics and smaller Healthcare facilities in the private sector which are catering to 80% of outpatient care.
• Majority of private Hospitals are functioning at 30% capacity resulting in sustainability issues.
• The lockdown cannot be lifted all at once, but it has to be done in a phased manner depending on the number of active cases and other parameters as per containment guidelines. There is no widespread community spread yet, there are clusters of cases and hotspots in various parts of the country. How long will the virus persist in the environment is a question, which cannot be answered at this time by anyone!
• The decision to lift the lockdown is not influenced by medical reasons alone, economical and sociopolitical reasons also to be looked into (lives and livelihood).
• There was a unanimous decision that all healthcare facilities including stand-alone clinic must remain functional at all times regardless of the stage of infection.
• Standard universal precautions and physical distancing must be practiced by all healthcare staff and professionals, regular decontamination of clinics as well as clinical areas of a hospital/nursing home should be done. IMA shall develop guidelines (Best Practices) for the same and make available to all.
• Hospitals must have a strategy for communication with their patients for follow up, information spread and to answer queries of the public with the aim to limit the physical visits of patients as far as feasible and to allay anxiety. IMA to develop FAQs based on most common queries raised by the public so as to ensure that a common message is given from all HCFs.
• Adequate quantities of quality PPE should be ensured; the cost of this additional component may be charged as additional surcharge from patients including clinics.
• All clinicians to use technology to curtail visits of patients, especially for a minor ailment and chronic patients for, follow up like teleconsultations or video chats on a charge basis since the Medical Council of India (MCI) has already come out with Telemedicine guidelines.
• All healthcare facilities (HCFs) to start system of appointments, triage, separate area for suspected COVID 19 patients or some other mechanism based on prior information sought at appointment time; this should be made applicable even in clinics.
• Training of Healthcare professionals and support staff is a must to practice best practices as well to allay their anxiety/fear. Various associations like IMA, HCFI, AHPI work out a plan for the same for medical fraternity and support staff. Accredited hospitals can take up this responsibility to train smaller HC facilities /clinics in their vicinity.
• Counseling services should be made available; IMA is already running around-the-clock helpline; counseling may be added. This is the need of the hour.
• Adequate, effective security of HCFs and staff to be ensured by the state government.
• Separate hospitals for COVID 19 -19 patients across nations. Rest of hospitals to continue to function as pre-COVID 19 infection time; these non-COVID 19 hospitals should also have a Fever screening OPD at a different area away from common areas of patient flow. Suspected cases to be referred and transported to nearby COVID 19 hospitals with full precautions in a safe manner.
• Hospitals should not be sealed or put under Quarantine by a state administration, complete decontamination of the organization using fast disinfection technology as being done for OTs and ICU in case of an outbreak should be done and hospital reopens in a day or two. 
• Testing facilities to be increased, for hotspot areas, antibody-antigen kits to be made available. All Healthcare workers (HCWs) to be tested for COVID 19 infection.
• A significantproportion of healthcare staff is getting infected as on date resulting in the spread of infection as well as further aggravating the existing shortage of human workforce at HCFs.
• Dr KK Aggarwal suggested a pilot project to study the prevalence of COVID 19-19 infection among healthcare staff using antigen-antibody test.
• Keeping in view the financial hardships faced by HCWs, it was suggested that employer contributions like ESI, PF etc. to be borne by the state government for at least 3 months or till normalcy in functioning of organizations comes.
• Alleged medical negligence cases also need a different approach from the current approach in present scenario; IMA to give suggestions for medical councils in this context.
• In the present scenario, globally there is a shortage of PPE, HCWs are getting infected, it is totally acceptable to receive quality PPEs from pharma or non-pharma sources or an NGO; this should not be taken as unethical practice in the interest of healthcare functioning and safety of frontline COVID 19 19 warriors.
• “Pradhan Mantri Garib Kalyan” insurance scheme should be extended to private practitioners also. Presently, it covers health workers engaged in direct contact and care of COVID 19-19 patients in public facilities or staff deployed from the private sector. NABH also sent a request letter to the ministry in this regard.

Why lockdown is extended till 3 May

Prioritization of clinical services

Since most of clinics and healthcare establishment are closed, there is a need to restart after a gap with a fresh mind and attitude and protection. Following is list of services for priority: 

• Doctor should wear an N95/surgical mask and disposable gloves at all times and all PPE as IPC Guidelines of Government. Nurse and support staff also wear PPE.
• Every patient and surface should be considered as potential COVID 19 positive until proved otherwise and all standards precautions to be taken like PPE, hand hygiene, respiratory etiquette and physical distancing.

Vaccination for prevention of communicable diseases

• Pediatric immunization must go on as per national schedule /Paediatric association guidelines 
• Adult vaccination: This is an opportunity to promote adult vaccination, especially for the elderly. Since they are a high-risk category for COVID 19-19 infection, vaccination against pneumonia, flu should be must for this group to minimize the severity of COVID 19 symptoms.

Children

• Minor routine problems can be taken care of on Teleconsultation.
• Any alarming symptom observed by parents or fever to be attended in the clinic. After first visit, thorough assessment is done and documented, instructions given to parents when to contact in an emergency, follow up can be on video or telecall.

Care of Pregnant woman and childbirth

Acute Medical / Trauma Emergencies requiring time-sensitive interventions

Care of vulnerable populations, such as young infants and older adults;

Continuity of critical inpatient therapies

Care of cancer patients

Dialysis centers

Auxiliary services, such as diagnostic imaging, laboratory services, and blood bank services

Supply chain in respect of medicines, devices to be ensured at all levels

For many chronic diseases, follow up remotely if no new symptom

Patients can monitor their BP, sugar levels, weight, and temperature at home

Remote monitoring of Homecare patients using remote mentoring devices

Certain routine elective surgeries can be differed for some time if not affecting life adversely

Key consensus points

• Healthcare services to remain functional; none of healthcare establishments including clinics should be closed regardless of stage of COVID 19 infection.
• This is the right time to adopt the best practices.
• Lockdown should be lifted in a phased manner.
• Medical services/health sector should be the first to resume as clinical care has to continue even for non-COVID 19 patients.
• Presume every patient is potential COVID 19 19 infected and all precautions to be taken as per uniform protocols.
• Healthcare workers should adopt and practice standard universal precautions at all times not just during the time of COVID 19. Use appropriate PPE of good quality as per guidelines.
• All clinics to practice and promote hand hygiene, respiratory etiquettes, frequent disinfection of clinical areas including clinics.
• Hospitals including stand-alone clinics to follow necessary protocol related to COVID 19-19 management as prescribed and restrict family/friends/children visiting patients in hospitals.
• Adopt best practices for Biomedical waste management
• Sensitize auxiliary and other support staff at the clinic to build up their morale and confidence.
• Capacity building (training and retraining) of doctors, nurses and support staff including Ambulance drivers is mandatory.
• NABH accredited hospitals can be teaching institutes for capacity building of nearby solo establishments.
• Communication with patients and attendant’s mandatory to allay fear and anxiety. The exit plan should have enhanced communication between the patient and the doctor for follow up, answer their queries and give them updated information.
• Mental health issues need redressal. IMA is running a psychological helpline in collaboration with UNFPA.
• Doctors need to feel safe, with no fear of violence against them.
• The financial sustainability of health institutions is of paramount importance. The private sector may now charge 10% surcharge for additional expenses on account of PPE, disinfectants etc. Employer contribution in respect of PF and ESI etc. may be contributed by the state government for 3 months or till normalcy comes.
• Development and sharing of Best Practice guidelines with its members.

Exit Policy Part II

Stage III and IV are both considered Red zone

Duration of follow up is 28 days (14=14)

Perimeter around index case or cluster is 3 km (to be reassessed upon number of cases) and buffer zone is 5 km and 7 km in peripheral areas (rural)

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

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