Modification of Management Strategies, And Innovations, During SARS Cov2 Pandemic Improved the Quality, Criticality and Outcomes in In-Patients
“Rising to the occasion”, the mantra for success in the COVID -19 pandemic
TR. Muralidhara*, HR. Madhusudan, R. Nagesh, Devang Gautam, NA. Manoj, MR. Yashaswi, Mohammed Zain, Wilfred Samson, Vijaya Bhaskar
Kauvery Hospital, Electronic City, Bengaluru, India
*Correspondence: tr.muralidhar@yahoo.co.in
Background
The COVID-19 pandemic has resulted in more than 2 million deaths globally. SARS COVID 2 is highly infectious and although most are either asymptomatic or mild to moderately ill, a substantial proportion of patients faced severe life-threatening disease. The mortality risk with large population outbreaks has a major effect on lives, economies and health care systems across the world.
COVID pandemic has challenged the health care system in its ability to handle a sudden surge in patients with a major infectious disease. The first phase passed off without much challenges, aided by the complete lock down which helped to stagger the arrival of patients who needed hospitalization, a gradual understanding of the virus transmission and personnel protective measures, and the start of the vaccination programme.
The second wave of the pandemic exposed the unpreparedness of many hospitals to handle sudden and substantial surge in patients who needed to be hospitalized. This was due to lack of infrastructure to handle the relentless inflow of patients whilst also running short of beds, oxygen, ventilators, BIPAP and HFNC machines, trained health care workers, personal protection equipment (PPE), medications and other essentials. The second wave of COVID-19 in India thus had severe consequences, and increased deaths, particularly in the younger population.
It was clearly poor anticipation of the magnitude of the COVID-19 pandemic that led to misgovernance in timely production of the necessary materials, and vaccination uptake by people, that led to surge in cases in the second phase.
We have documented here how rising to the occasion by working together, prioritization, and careful resource- utilization made things work smoothly, and achieved better quality of care and gratifying outcomes.
We faced great challenges in securing better supplies and in ensuring judiciously use of the available resources.
The aim of this prospective study was to use judiciously the available resources, fine tune the patient care, reduce the work load and burden of HCWs, optimize patient care, improve the outcomes and to see whether this fine tuning would facilitate better care and outcomes. This study was done at our tertiary care centre.
The following innovations or fine-tuning were done at our hospital:
(1). Infrastructure
Due to surge in cases the need of beds, with supporting equipment, became the primary need. Due to the lockdown and increasing demand, organizing these things was a challenge. Restrictions for transportation with lockdown in place, workload pressures and limitations for regular meetings, things didn’t fall in place without every one’s involvement- management, administration, operations, doctors, nurses, medical technicians and supporting human power.
We, at our centre, accommodated more patients by increasing the number of beds. We increased ICU beds from 20 to 50 in a short time without much civil work and extra cost.
(2). Availability of trained Staff
As the patients load increased, recruiting additional trained staff on time was practically not possible as they were in demand at every other hospital. Most trained staff have notice periods to serve and could not get relieved in time to join our hospital. With few available trained staff, training them as leaders, who in turn where able to supervise newly recruited staff (nursing) in each shift, was immediately called for. This system worked well in the pandemic, as there were minimal interventions by the staff. Treatment charts were simplified to reduced workload and to make time for patient care. The responsibility of ventilator/O2/care was given to respiratory therapist and designated health care workers – O2 providers. This reduced workload on nursing staff and they had time for monitoring and troubleshooting. Interestingly, we also found less stress and anxiety among HCW with these models.
(3). Ventilator and provision of Oxygen
O2 is lifesaving in COVID-19. The shortage of O2 as well as the delivering systems have been partly due to unanticipated demand by manufacturers and partly due to lack of knowledge, state of preparedness and inappropriate use by hospitals. Robust O2 systems that would support the pandemic would take time to be put in place. So, conduct of rapid refresher training programmes for HCWs in optimal usage, and in avoiding inappropriate use, misuse or wastage of O2, was done in relatively short time, with good planning and management.
Most patients with mild to moderate COVID-19 require a good basic care with supportive measures and time for healing, so we added extra beds. With single O2 port, attaching extensions, we were able provide O2 for more patients.
With this expansion, second challenge was O2 supply. We had two challenges; one was to improve and maintain O2 supplies and other was to optimise and reduced the wastage.
COVID-19 is a long game and it was vital to move quickly and start implementing effective O2 systems. For better supplies, within a short period, oxygen generators were installed. Understanding the limitations in O2 delivery with generator, we mixed generated O2 with industrial O2 in suitable proportions.
O2 misuse was significantly reduced by identifying O2 boys whose work was to monitor O2 and saturation round the clock. This was achieved in a short time with good training and planning. They were to supervise and avoid excessive wastage off O2.
We selected a HCW and a respiratory therapist as O2 providers and as watch-keepers of optimal ventilation delivery all the time. Their job was only checking O2 delivery and monitoring saturation while assuring adequacy of ventilator connections and ventilation. Most of the patients were treated with BIPAP instead of HFNC machines, to conserve O2. They were given SpO2 targets to maintain. When they adjusted O2 delivery, keeping the targets in view, we found that care was better, O2 wastage was reduced and less pressure was exerted on HCWs and hospital administration department on the supply of O2. They also continuously monitored O2 and BIPAP connections on patients who were on prone positions and would alert the doctors whenever necessary, or take corrective measures themselves.
(4). Foley’s catheters and diapers
Due to shortage of ICU/HDU beds during the peak of pandemic, moderate to severely ill patients were managed in wards with close monitoring. In initial stages we faced problems in patients with high O2 requirements when they had to be mobilized to restrooms. At those times continuous O2 delivery to patients was interrupted, along with disruption of prone positions and de-recruitment of lungs which provoked symptoms, severe hypoxia and few near- Code Blue situations. So, we started catheterizing the patients with high O2 requirements/elderly, and diapers were used when very hypoxic patients refused cauterization or when it was contraindicated. After these changes the episodes of unexpected desaturations and code-blues were less, while the compliance for care was more, and complaints from the patients were less!
(5). Family visits
Allowing family visits, with precautions, was very useful. Family visits made patients comfortable and more compliant to the care. Close family members were also happy. It also significantly reduced the burden on HCW’s who had to otherwise communicate multiple times with the relatives via audio or video phone calls. This also brought transparency of care. Medications of high cost were administered to patients in presence of close relatives which earned their understanding and appreciation.
(6). Simple protocols
The scarcity of HCWs and consequent strain on those at work prompted us to analyze the work flow. We found that more time was being taken on documentation and obtaining the reports than actual bedside care. So, we simplified the charts, with only two sheets, one for the doctor one for the staff. These simple changes made work easy and more efficient and also helped in collecting data.
(7). Drug’ boy!
Indenting for drugs and on- time delivery was challenging with limited staff and high workload. We selected a person only for drug delivery. Later, with drugs becoming precious and anticipating consequent problems, the drug boy was instructed to deliver medications to the patient in presence of the family. This further reduced the burden on HCW’s.
(8). Continuous monitoring by a leader
COVID is a dynamic disease process and requires continuous monitoring and timely interventions. Leaders have to take complete charge continuously, from admission to discharge. Fragmented care by multiple people worsens the situation.
(9). Support from other specialties
The fine tuning of the process of COVID care was further refined by mobilizing the support from other specialities. Cardiology consultation could be arranged, and also bed side echocardiograms. Radiologists came to our aid with bedside Doppler evaluation which aided in early diagnosis and optimal treatment. These measures helped us in saving time and serving a large number of patients. This reduced the burden of intensivists and physicians.
(10). Monitored hydration
Most patients were dehydrated from reduced appetite, and inability to frequently hydrate themselves as they were on O2 support via NIV or by invasive ventilation, from drugs and from third space loss (fluid losses into spaces that are not visible, such as the bowel lumen or the retroperitoneum). We were able to reduce the incidence of dehydration and also significantly reduce incidents of acute kidney injuries. CVP was monitored to ensure adequate hydration.
(11). DVT stockings
COVID is a pro thrombotic state. For prevention of venous thrombosis, DVT stockings were applied to all moderate to severely patients, along with chemo-prophylaxis, which substantially helped to prevent DVT.
(12). Anxiolytics, careful mobilization and spirometry
Mild anxiolytics reduced the stress, work of breathing and facilitated good compliance to the NIV.
Careful mobilization and respiratory rehabilitation with appropriate spirometers, under supervision, helped patients who passed through moderate to severe illness in early recovery from COVID-19.
(13). Proning in COVID pneumonia
In moderate and severe ARDS, patients on O2 with face mask, O2 by BIPAP support and those on invasive ventilation were subjected to prone positioning for 16-18 h/day, which helped in improving lung recruitment, improved oxygenation and yielded better outcomes while reducing the oxygen requirements.
(14). Non-invasive vs invasive ventilation
The surge in COVID-19 patients demanded a need for more ventilators and BIPAP machines as severity of ARDS related hospitalization increased during the second phase. We strategically used O2 by NRBM’s, non-invasive BIPAPs and HFNC. Invasive ventilation was used only as a last resort which helped us in managing larger numbers of patients. This reduced the requirement for more ventilators, and its complications, while reducing O2 usage. Optimal early extubation was also employed for better outcomes.
(15). Counselling and reducing financial burden
All patients’ attenders were counselled regarding the disease, the likely duration of hospitalisation, and about the limited treatment options available, at the time of admission and on a day to day basis. Patient attenders were taken into confidence, were allowed to meet and talk to patient at any time of the day at their convenience with proper precautions. Daily expenses were detailed by billing team and high cost medications were given only after consulting the relatives. Long stay patients were given financial relief while billing, with approval of management.
(16). Diet and nutrition
Most patients in COVID ICU were on non-invasive ventilation, and some on invasive ventilation because of severe ARDS. Patient on invasive ventilator were fed by Ryle’s tube. Patients on non-invasive ventilation were fed orally with small meals or snacks. Food as demanded by the patients was catered unless contraindicated.
(17). Bowel care
Most patients were not ambulant and had to evacuate bowels on the bed. Laxatives and, enema as and when required, were administered to facilitate bowel habits.
(18). Patient comfort
Frequent visits by relatives, junior doctors, consultants and ever-communicating nursing caregivers, all giving positive inputs and encouraging them, kept the patients calm, comfortable and confident of a possible recovery from COVID-19. Room temperature was maintained as per standard requirements. Disposable gowns, regular baths, regular change of sheets and provisions of blankets were arranged as per patients’ request. House-keeping staff played an important role in patient care.
(19). Vaccination
All health care workers and hospital staff were vaccinated before the surge of COVID-19 pandemic in phase 2. This prevented in transmission of corona virus among the staff, visitors and non-COVID patients thus reducing the burden on the health care system.
(21). Procurement of medications
COVID-19 is a novel virus disease with limited therapeutic options. Hospital management and department of pharmacy helped in the process of organizing and arranging drugs which were in short supply. Timely delivery of the required medications helped in better patient outcomes.
(22). Simple protocols and documentation
All data regarding COVID-19 patients – date of admission, date of illness, vaccination status, RT-PCR status, CT chest, comorbidities, results of all laboratory investigations, patients’ vital parameters, intake and output were all documented in simplified charts/s form which helped us in timely response by modifying treatments which improved the clinical outcomes. Ward secretaries were of immense help in harvesting and organizing data.
We made only two sheets for documentation purposes – for nurses and doctors, with space for writing drug treatment. Documentation could be done in a single sheet for three days while investigations chart could be followed for at least 10 days with clear trends documented. This reduced the work load, time in seeing many patients and improved the care and outcome.
(23). Positive and supportive management
Hospital was able to provide all medications, ventilators, BIPAP machines, meet oxygen requirements, and provide staff as and when their requirement increased with surge in COVID-19 cases. Daily meetings were held to address and resolve any issue.
(24). Modalities of treatment
All possible options of treatment that were available were explored to augment the recovery of patient and achieve best possible outcomes. Inj. Remdesivir, Inj. Tocilizumab, Convalescent Plasma, Plasmapheresis, Steroids, anticoagulants, Ulnastatin, suitable antibiotics, and invasive ventilation as a last resort, were all made available.
(25). Infection control
Even during the peak of COVID-19 all infection control protocols were adhered to. Environmental sanitation, with frequent floor and bedside cleaning twice a day, helped in prevention of secondary infections and in improving final outcomes.
Innovations
The learning experience was “doing the basics right, with supportive care and innovations if needed.”
Innovations play a big role in pandemics. Doing basics right and “First, do no harm (Primum non nocere)” concept in mind, and conservative management, were the needs of the hour. Innovations can be done continuously, as need be, in clinical/non-clinical areas which can improve the outcomes.
Conclusion
COVID pandemic is still evolving, and continues to be very challenging. Therapeutic options are steadily emerging.
Supportive management and judicious use of available resources would continue to yield gratifying benefits and also improve outcomes.
Our innovations improved quality of care, were cost effective, were clinically effective and benefitted patients. They are easily replicable in any COVID care hospital.
Working together, prioritising the staff and optimal use of resources help in better management and outcomes.
Cost effective innovations should play a major role in a pandemic.
Dr TR. Muralidhar
Intensivist and Anesthesiologist