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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 216-221

Preparedness of a tertiary care hospital in Maharashtra, India on the background of CORONA pandemics 2020


1 Department of Microbiology, MGM New Bombay Hospital, Navi Mumbai, Maharashtra, India
2 MGM New Bombay Hospital, Navi Mumbai, Maharashtra, India

Date of Submission01-Jul-2020
Date of Decision15-Sep-2020
Date of Acceptance15-Sep-2020
Date of Web Publication09-Dec-2020

Correspondence Address:
Dr. Badrunnesa Khatun
Flat No. 103, Mauli Co-op Housing Society, Sector-4, Vashi, Navi Mumbai 400703, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_65_20

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  Abstract 

The coronavirus disease-2019 (COVID-19) has rapidly progressed across the nation since January 2020, with the United States having the highest number of cases in the world. On the background of the corona pandemic, it is the topmost priority to prepare a tertiary care hospital for planning a diagnostic screening, triaging, and management of patients and at the same time protecting healthcare workers and the environment. This article describes the infrastructures, hospital policy, and guidelines for giving quality and proper treatments to all needy patients. Aggressive screening at the corona screening desk and implementation of infection control measures are key elements for success.

Keywords: Corona pandemic, COVID-19, screening, tertiary care hospital


How to cite this article:
Khatun B, Sen K, Kadam N. Preparedness of a tertiary care hospital in Maharashtra, India on the background of CORONA pandemics 2020. MGM J Med Sci 2020;7:216-21

How to cite this URL:
Khatun B, Sen K, Kadam N. Preparedness of a tertiary care hospital in Maharashtra, India on the background of CORONA pandemics 2020. MGM J Med Sci [serial online] 2020 [cited 2021 Oct 21];7:216-21. Available from: http://www.mgmjms.com/text.asp?2020/7/4/216/302807




  Introduction Top


The first report of the coronavirus disease-2019 (COVID-19) outbreak was found at the Hubei province in China in December 2019. The virus has spread 213 countries and territories around the world. As of September 9, 2020, more than 27 million people affected with a death toll of 902 thousand.[1] A pandemic is a global outbreak of disease. Pandemics happen when a new organism emerges to infect people and can spread between people sustainably. Because of no preexisting immunity or very little immunity against the new organism, it spreads worldwide and becomes pandemic.

COVID-19 is caused by a new beta coronavirus. Coronaviruses are a large family of viruses that are common in people and many different species of animals including bats, cats, camels, and cattle. Earlier it was thought that the virus had an animal to human spread due to a linkage noticed between patients and seafood/live animal market in Wuhan. But later a large number of patients reportedly did not have exposure to animal markets, indicating person-to-person spread. Person-to-person spread was subsequently reported outside Hubei and in countries outside China. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when an infected person coughs or sneezes. WHO characterized COVID-19 as a Pandemic disease on 11th March 2020.[2]

Most people infected with the COVID-19 virus will experience mild-to-moderate respiratory illness and recover without requiring special treatment. Older people and those with underlying medical problems like cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop a serious illness which may cause death/fatality. Currently there are no specific vaccines or treatments for COVID-19 are established although many ongoing clinical trials on potential treatments and vaccination are under evaluation.

The first case of the COVID-19 pandemic in India was reported on January 30, 2020, originating from China. As of September 9, 2020, the MHA (Ministry of Health and Family Welfare) has confirmed a total of 42,96,238 cases with deaths of 73,890 and 33,98,844 recovered patients.[3]


  Objective Top


A scientific and evidence-based design has been made to prepare this tertiary care hospital to fight against COVID-19 pandemics with the help of inter-departmental discussions and meetings with all stakeholders like infectious disease department, Infection control department, critical care, engineering department, nursing department, departments of microbiology, hospital administration, waste disposal facilities, referral ambulance services and social workers or counselors.

The objective of this preparedness is:

  • a. To reduce patient’s morbidity and mortality through early diagnosis and appropriate treatment.


  • b. To prevent disease dissemination to hospital staffs, patients and the general community.


  • c. To preserve healthcare resources, management of essential equipment such as personal protection equipment (PPE) and ventilators.


  • d. To prepare for the patient surge.


Strategies to avoid an outbreak of COVID-19

  • ❖ Training and educating all healthcare workers (HCW) using visual presentations by infection control team on
  • Transmission of COVID19 infection.


  • Management of COVID-19 patients.


  • Prevention of COVID-19.


  • ❖ Educating and managing all patients to prevent transmission of this deadly respiratory virus by
  • Limiting visits of patients to the hospital.


  • Patients are encouraged to call and speak to hospital staff, if they become ill with symptoms such as fever, cough, or shortness of breath.


  • Doctors are encouraged to conduct telephonic and teleconsultation with patients.


  • Trained staff can identify which patients can be managed by teleconsultation and advised to stay home, and which patients will require emergency care at the hospital.[4]


  • ❖ Safety precautions like
  • Proper supply and use of PPEs, tissues, alcohol-based hand sanitizers are ensured.


  • Social distancing is maintained while handling patients.


  • ❖ Notifications and liaison with Governmental bodies by
  • Maintaining a healthy and good relationship with local/state public health organizations to understand the impact and spread of the outbreak.


  • The designated officer responsible for communication with public health officials and dissemination of information to HCW.


  • Communicate information to appropriate in-house personnel before transferring patients with known or suspected COVID 19 from other healthcare facilities.


  • ❖ Staff welfare
  • Monitor HCW and ensure staff are aware of sick leave policies.


  • Encouraged to stay home if they are ill with respiratory symptoms.[5]


  • All staffs are screened for fever or respiratory symptoms before entering the hospital every day.


Strategies to deal with the patients coming for treatments/medical help

  • Hospitals’ front gate is kept open for the arrival of patients and staff and exit gate for the departure of patients and vehicles. All other gates are closed to limit unnecessary visitors to the hospital.


  • A temporary screening centre (coronavirus screening desk) is made in front of the entry gate. A doctor and a nursing staff are assigned to get a proper history of the patients and thermal scanning is done to every visitor including patients at this centre.


  • Emergency medical officer plays a major role in triaging of patients suspected for COVID-19. All these HCW are protected with wearing level 1 PPE like N95 mask, cap, gown, gloves and goggles. The washbasin is also installed for hand wash.


  • The on-duty security staffs ensure that each patient and all HCW have face masks and doing hand washing before entry to the main building of the hospital and maintaining social distance.


  • Screening centre can isolate patients who present with[6]
    • ◦ Fever and cough with a history of travel to COVID-19-affected countries;


    • ◦ HCW with fever and cough caring for patients with idiopathic pneumonia.


    • ◦ Patients with fever and cough with contact history with known COVID-19 infection.


    • ◦ Patients with fever or cough with a history of visit a healthcare facility with a case of COVID-19 infection.


  • Any patient giving a history of fever, SARI (Severe acute respiratory illness), ILI (influenza-like illness) is referred to fever OPD which is a very small room outside the main building of the hospital. Physicians check the patients in fever OPD wearing level-3 PPE (fluid-resistant Jumpsuit, N95 mask, cap, gown, gloves and goggles and face shield). Patients who have mild symptoms are given discharge with medications. Any pathological/microbiological tests if advised, the collection is done in a collection centre in the proximity of fever OPD. Nasopharyngeal swabs are taken for COVID-19 testing in COVID-19 collection area (kiosk) adjacent to fever OPD. Medicines and all payments are done there only to prohibit them to enter main building or pharmacy. Reports are communicated to the patients within a short period of time.


  • Patients requiring medical emergencies and continuous monitoring are admitted in the COVID ICU/Isolation ICCU. For time being Transplant ICU has been converted to COVID ICCU. Patients shifted to COVID ICCU by announcing GREEN CODE. For mapping the patient transfer, the path of transport and specific elevators is identified causing minimal exposure to other staffs.


  • Isolation ICCU is single-patient room at negative pressure relative to the surrounding areas and with a minimum of 12 air changes per hour.[4] This hospital has two such isolation rooms. Engineering department is monitoring and documenting the proper negative-pressure function of these rooms.


  • ICCU is a restricted area. Only Authorized persons like doctors, nursing staff and laboratory technician can go inside. The door kept closed and one security personnel appointed to restrict unwanted entries to ICCU.


  • 10 patients can be accommodated in COVID ICCU. It has 12–15 air changes per hour. High-efficiency particulate air (HEPA) filter is used to exhaust air from ICCU to the environment.


  • Any patients requiring admission for surgery like LSCS or other surgeries is counseled properly for COVID testing. The patients who don’t require ICU setup is admitted in day-care unit.


  • After admission in day-care or COVID ICCU nasopharyngeal /oropharyngeal swabs of all patients are sent for RT – PCR tests. After the negative confirmation report, he/she is transferred to the ward of their own choice. Patients requiring ICCU shifted to general ICCU.


  • Dialysis units
  • ◦ Patients having chronic kidney diseases require hemodialysis frequently. All such patients are screened in corona screening desk at front gate. Screening is repeated by dialysis staff outside the dialysis unit. Temperature, respiratory rate and SPO2 are checked and if the report is satisfactory then they are taken for dialysis.


  • ◦ If patients have fever and breathlessness, then the patient is taken for dialysis in isolation at ICCU and sample sent for COVID19 testing. Any patients requiring permanent catheter is instructed to do COVID19 testing before the procedure.


  • ◦ Beds are kept at a 1 m distance.


  • ◦ All staffs are given PPE like isolation jumpsuits with shoe cover, gloves, surgical 3-layer mask/N95 masks, caps and goggles/face shield. All staffs are encouraged for proper hand hygiene in between two patients.


  • Outpatients departments

  • ◦ The emergency casualty officer guides the patients having no fever but other symptoms for a consultation to OPD. The physicians/surgeons are also equipped with PPE level 1 during a medical examination.


  • Chemotherapy

  • ◦ Chemotherapy patients are admitted with negative COVID-19 testing reports. The concerned staffs prepare the medications in biosafety cabinet after donning proper PPE.


  • Operation theater

  • ◦ One minor OT (ground floor) is kept functioning for emergency surgeries. After each surgery, the OT is fumigated and environmental sample are sent to microbiology lab for testing.


  • ◦ All surgeries including general and cardiac are performed based on COVID-19 testing. Surgeons, circulating nurses, helping technicians, housekeeping staffs are donned with level 3 PPE. After surgeries PPE are doffed into a designated place.


  • ◦ Cardiac surgeries like CABG and angioplasty are avoided except acute emergency/life-saving situations.


  • Endoscopy department

  • ◦ Patients with negative COVID-19 are allowed for endoscopy. The validity of reports is only 48 hours. Every patient is instructed to do the procedure within 48 hours after getting a report from the laboratory. If it is delayed by any unavoidable circumstances the test is to be repeated. The patient is admitted in day-care units and the doctor with technical staffs can do the procedure after donning of full PPE.


  • Microbiology and pathology department

  • ◦ One designated technician is appointed in the proximity of the emergency department for blood and another technician for sample collection. The technician also provided with proper PPE.


  • ◦ All OPD patients can see the report online. The diagnostic department may send the report by email after receipt of a request from patient party.


  • ◦ Nasopharyngeal swabs are taken for rapid antigen test for both OPD and in patient department (IPD) patients. If report is positive by antigen tests, the patients are considered as COVID-19 positive patients and treated accordingly. If antigen report is negative, all IPD patients are tested by in-house RT-PCR (geneXpert) test. For OPD patients requiring RT-PCR test, nasopharyngeal/oropharyngeal swabs are sent to referral lab for COVID-19 RT-PCR test. The sample collection is done by a concerned technician from that referral lab. The technician from referral lab is equipped with full PPE. The report comes via email in official mail id which is then communicated to the patients.


  • Radiological departments

  • ◦ Screening prior to imaging procedures is mandatory. All patients are screened at the hospital entrances for COVID-19 symptoms, with a second layer of symptom screening at the radiology front desk.[7]


  • ◦ Portable radiography is the mainstay imaging tool for emergency department.


  • ◦ The technician dons personal protective equipment (PPE) consistent with the potential exposure and performs the portable x-ray in the emergency department.


  • ◦ Similar measures are taken for patients imaged in a non-portable x-ray. The tables and high touched points and surfaces are cleaned after the visit of every patient with Bacillocid extra 1% solution.


  • ◦ COVID-19 prior test is mandatory for CT scan, Ultrasonography and MRI.


  • ◦ All electronic items and machines are cleaned with Saniocid (alcohol-based equipment cleaning reagent) after each patient.


  • Physiotherapy

  • ◦ Two OPD patients are allowed for physiotherapy at a time. Regular physiotherapy is going on for all IPD patients. A physiotherapist is doing their daily job after donning PPE.


  • Food and kitchen

  • ◦ Food is served on disposable crockery and cutlery in isolation ICCU / Day-care. In other patient care areas non-disposable crockery and cutlery are used, which are washed using hot water (70°C) and detergent, rinsed and dried.





  •   Strengthening of infection prevention and control Top


    All health-care providers participating in the care of the patients including doctors, nurses, paramedical staff, patient transporters, phlebotomists, laboratory technicians and housekeeping staff are trained regarding personal hygiene, hand washing, use of PPE, hospital policy, infection control guidelines.

    Standard hygiene

    Hand hygiene is very important and effective tool to prevent self-contamination. All HCW are instructed to do hand hygiene before and after touching a patient, before and after doing a procedure and touching any surroundings of the patients, before donning of PPE and doffing of PPE. It is very important to remove any pathogens that might have been transferred to bare hands during the removal processes of PPE. So, hand hygiene is mandatory after doffing of PPE.

    HCW should perform hand hygiene by using alcohol-based hand rub (ABHR) with 60–95% alcohol or washing hands with soap and water for at least 20 seconds.[4] If hands are visibly soiled, soap and water is used for handwashing.

    Personal protective equipment[4]

    HCW are trained by demonstrating and showing video clips regarding

    • when to use PPE


    • which level of PPE is required


    • Proper donning, doffing of PPE to prevent self-contamination


    • Proper disposal/disinfection of PPE


    • limitations of PPE.


    Reusable PPE must be properly cleaned and decontaminated before reuse

    N95 masks also reused after sterilising in Sterrad machines/UVC sterilizer machines. Policy for this has been made by infection control department.

    • Surgical 3-layer mask is made mandatory for all HCW


    • In isolation ward or when there is probability of aerosol generation N95 mask is provided.


    Eye protection: Eye protection by goggles or a disposable face shield that covers the front and sides of the face. Goggles and face shield are properly cleaned and disinfected before reuse.[4]

    Gloves: While entering the patients care area all HCW put on clean and nonsterile gloves. The gloves are changed immediately if it is contaminated/torn. All are instructed to remove gloves and do hand washing before leaving the patient care area.[4]

    Gowns: Clean isolation gown (fluid resistant Jump suit) are worn upon entry into the patient room or area. Gowns are changed if it becomes soiled. Separates places are designated for donning and doffing of PPE outside the isolation ward. Disposable gowns should be discarded after use. Cloth gowns are laundered after each use.

    Medical equipment

    Dedicated medical equipment is used for patients with known or suspected COVID-19. All non-dedicated, non-disposable medical equipments are cleaned and disinfected regularly according to manufacturer’s instructions and hospital policies.[4]

    Environmental cleaning

    Environmental cleaning and disinfection procedures are followed consistently and correctly[4] with Bacillocid extra 1%/1% freshly prepared sodium hypochlorite. Doorknobs and other frequently touched surfaces are cleaned two hourly with Bacillocid extra 1%/1% freshly prepared sodium hypochlorite.

    Ambulance transfer

    While transferring any positive COVID-19 patients to other hospital/home/quarantine centre strict protocol is maintained. After doing proper hand hygiene the HCW dons PPE and request the patient to wear a triple layer surgical mask (if tolerated) and advise on respiratory hygiene and cough etiquette.[8]

    After transferring the patient, HCW removes PPE and dispose off in yellow bag and perform hand hygiene. Ambulance is cleaned and disinfected properly and can be reused. Surfaces (stretcher, chair, door handles etc.) are cleaned with a freshly prepared Bacillocid extra 1%/1% freshly prepared sodium hypochlorite. Environmental sample sent for microbiological testing.

    Management of waste

    All discarded masks and any waste contaminated with blood or body fluid (including respiratory secretions) are disposed of as infectious waste in[9] double-layered yellow bag to avoid tear and leaks as per the central pollution control board.

    Biomedical waste is collected and lifted directly from the ward to the waste collection van when it arrives. After discarding the waste, the bin is disinfected with 1% sodium hypochlorite solution. Dedicated trolleys and collection bins are used for the waste and are marked as COVID-19 waste.

    Handling and disposal of the deceased body

    HCW can handle the dead body with disposable gloves, water-resistant gown/plastic apron, and surgical mask if COVID-19 status of the deceased is positive. The body is packed in water-resistant bag and handed over the relatives for the last rite. If COVID-19 status is negative the body is handed over to relative without packing in bag.


      Conclusion Top


    Being a COVID Hospital it is a great challenge to meet the patient’s expectation every day. All patients coming to this hospital are considered as COVID suspects and all HCW are provided with proper PPE to manage and treat the patients. In the current pandemic, it is vital for all departments to partner with the emergency operations teams for planning and coordinating diagnostic algorithms, patient management and treatment.

    Mutual understanding and proper co-ordination among the nursing staffs, doctors, housekeeping staffs, security personnel, and liftman are essential to fight with COVID-19. The hospital has developed infrastructure and mobilized available resources to become a dedicated healthcare facility to counter a rapidly emerging outbreak of a highly contagious or lethal disease like COVID-19. Aggressive screening at the entry point and proper infection control strategy are the key point to fight the global threat of coronavirus in the upcoming time.

    Financial support and sponsorship

    MGMIHS.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Worldometer. COVID-19 Corona Virus Pandemic. Available from: https://www.worldometers.info/coronavirus/. [Last accessed on 2020 September 09 ].  Back to cited text no. 1
        
    2.
    World Health Organization. Novel Coronavirus (2019-nCoV) Situation Report – 10. Data as reported by 30 January 2020. Geneva, Switzerland: WHO; 2020. p. 7. Available from: www.who.int › ... › Coronavirus disease (COVID-19). [Last accessed on 2020 May 27].  Back to cited text no. 2
        
    3.
    Ministry of Health and Family Welfare. COVID-19: India. Delhi: MHFW; 2020. Available from: https://www.mohfw.gov.in/. [Last accessed on 2020 September 09].  Back to cited text no. 3
        
    4.
    US Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19). Atlanta, GA: CDC; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html. [Last accessed on 2020 April 24].  Back to cited text no. 4
        
    5.
    US Centers for Disease Control and Prevention (CDC). Preparedness Tools for Healthcare Professionals and Facilities Responding to Coronavirus (COVID-19). Atlanta, GA: CDC; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/preparedness-checklists.html. [Last accessed on 2020 May 12].  Back to cited text no. 5
        
    6.
    Chatterjee P, Nagi N, Agarwal A, Das B, Banerjee S, Sarkar S, et al. The 2019 novel coronavirus disease (COVID-19) pandemic: A review of the current evidence. Indian J Med Res 2020;151:147-59.  Back to cited text no. 6
    [PUBMED]  [Full text]  
    7.
    Mossa-Basha M, Medverd J, Linnau K, Lynch JB, Wener MH, Kicska G, et al. Policies and guidelines for COVID-19 preparedness: Experiences from the University of Washington. Radiology. 2020;296:E26-31.  Back to cited text no. 7
        
    8.
    Ministry of Health and Family Welfare. Directorate General of Health Services [Emergency Medical Relief] Coronavirus Disease 2019 (COVID-19): Standard Operating Procedure (SOP) for transporting a suspect/confirmed case of COVID-19. New Delhi, India: DGHS; 2020; p. 12. Available from: www.mohfw.gov.in  Back to cited text no. 8
        
    9.
    Biomedical waste management, Maharashtra Response and preparedness during COVID-19 times ... CP) Act,1981 And Bio Medical Waste Authorization under Bio-Medical Waste Management Rules, 2016. Available from: www.mpcb.gov.in>waste management> biomedical.  Back to cited text no. 9
        




     

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