Once the lockdown ends, hospitals would have to work on a hybrid model to manage COVID and other diseases at the same time. And the time for operational planning is now
Every once in a while we have a Black Swan event that changes our world forever. In December 2019, we all witnessed something of a similar magnitude, which at that time seemed to be just another disease outbreak. Since then, we have spent upwards of five months with the disease globally, experienced thousands of deaths and witnessed the collapse of economies due to extended lockdowns.
Now, governments around the world are keen on firing up the economic engines but they also understand the need to do that while respecting the limitations imposed by COVID-19. The rules of the game have to be rewritten, factoring in social distancing, hand hygiene, meeting and greeting etiquette and all other measures under the Reich, while we are still finding a cure.
While a lot of these changes will happen over the medium to long-term, some sectors need to reinvent their operations immediately and the one industry which is in the eye of the storm is the healthcare industry. Hospitals are both, a complex multi-stakeholder system catering to a plethora of different health conditions and the centerpiece of epidemic disease clinical response.
However, when all who need care rush to hospitals for treatment, the infection density in these buildings can alternatively amplify disease transmission if not managed properly. Currently, the focus of all healthcare activities has been Corona-management, not just because there is a spike in cases but also because patients suffering from other diseases are not visiting hospitals either due to the lockdown or due to the fear of contracting the virus.
Consequently, many clinicians are also reporting that patients who have missed follow-ups for chronic lifestyle diseases are coming with advanced symptoms due to discontinuity of care. But with the lockdown measures slowly being tapered down, we have to work towards thinking of managing all patients in all healthcare set-ups. Let us imagine a world where Corona and non-Corona patients are treated in the same hospital. We will use the process flow of a patient’s journey within the hospital system to see how each element needs to be adapted to the virus. A patient enters the hospital system either through the Emergency Room (ER) or outpatient department (OPD). Going forward it will become extremely important to redesign ER operations. In the light of hospital-acquired infections (HAIs), the presence of a highly-contagious virus can severely expose all other patients coming with non-Corona emergencies. So, to prevent the ER from becoming a seeding point for the virus, it will be essential to separate ERs for Corona and non-Corona cases and triage and preferably establish a person’s non-COVID status before allocating an ER.
Not only does this seem a daunting task, also consider the fact that all ER doctors will have to treat any symptomatic patient as a potential Corona patient and pre-emptively wear PPEs at all times. In the absence of extra room for separate ERs, frequent disinfection would be required for the shared set-up to prevent disease transmission.
Once the patient is stabilised, transport to the designated wards needs to be segregated as well. Separate lobbies, elevators and preferably separate wings of the hospital would require to be earmarked for COVID patients. Within the wards, to maintain adequate distancing between patients, the general wards that we now have, would see a reduction in the number of beds.
If the severity of symptoms increases, the patient would be transferred to the Intensive Care Unit (ICU), which is the most sensitive unit and needs utmost infection-control care. ICUs need to be separately allocated for COVID patients. Like in ERs, other patients in the ICU already have multiple severe conditions they are struggling with and almost always have a cocktail of lifestyle diseases, all of which increase the chances of fatality if infected with the virus. Thus, not only will ICUs need to be separate, equipment like ventilators, in an ideal situation should not be transferable between COVID and non-COVID ICUs, given the high chances of infection portability.
For all these locations, OPDs, ERs, wards, elevators, ICUs, Operating Rooms (ORs) and so on, all the staff serving the COVID patients would require PPEs at all times. Additionally, all such environment that has come in contact with COVID workflows will have to be sanitised frequently. All such operations would have an impact on the cost of care.
Hospital visits will also get impacted. Visiting hours might be reduced or completely done away with and a move towards virtual visits might be encouraged. The role of the family member as an informal caregiver to help the patient with tasks like feeding, going to the washroom, brushing, walking and so on, will be completely lost and such tasks might require support from the nursing staff. This adds to the workload of the already thin staffing line due to the rostering of staff dedicated to COVID care.
The second entry point for patients into hospitals is the OPD. This is the trickiest part since confirmation of Corona status is post-testing. Thus, any patient with symptoms of influenza-like illness can be COVID or non-COVID. Additionally, many Corona-positive patients are asymptomatic at the time of testing and thus if they are attending the OPD for a separate health event, they might still be in a position to spread the disease.
Then there are hospital activities that are not patient-facing, yet need focus, like training of staff on Corona-specific management and ramping up supervision of adherence to protocol, since the fallout of non-compliance under these circumstances, is fatal. While there is no denying the importance of all these measures, the main concern for any manager at this point is how much these measures will affect the bottomline and what proportion of the same will be passed on to the patient?
Add to this the current drying up of revenues since the lockdown began on March 25. The OPD footfall has been reduced to a trickle. Consequently, barely any admissions have happened and hospitals, especially the smaller ones, are struggling to keep their doors open. One Ernst & Young-FICCI study reports a 70-80 per cent drop in footfall and about 50-70 per cent drop in revenue in late March.
Additionally, a large number of big hospital chains also relied on international patient traffic for their profits as medical tourists accounted for anywhere between 10-25 per cent of their total revenue. In a situation of complete uncertainty of when international travel will begin again, that revenue stream will remain in limbo.
There is an indubitable increase in costs anticipated for hospitals to simply be able to open shop under regulatory conditions for Corona and manage both COVID and non-COVID patients in the same facility. There is also an undeniable need to move to a higher commitment to the standards of infection prevention and control for the virus in the industry and the nation as a whole. This is a much-needed transition for the industry, which has been plagued by HAIs, anti-microbial resistance and other issues arising from poor infection control in hospital settings. While the global HAI is pegged at seven per cent for developed and 10 per cent for developing countries, for India different studies under different settings of ICUs, ERs, OPDs and so on have seen numbers touch anywhere between 20-30 per cent. These are completely avoidable hospital stays and potential causes for death, which can be mitigated by proper disinfection and sanitisation practices of facilities and devices.
For too long we have neglected these issues with a false sense of security and patchy actions and policies to cover small breaches whenever they happened. The pandemic brings with it an opportunity to reflect upon these choices and use this as a time to rethink the way we manage hospitals wherein infection control should be a top priority for the ergonomics of such institutions. While the industry is on the brink of a shift in operations because of the pandemic, it needs time to readjust its bearings for the same.
As we wait for social mobility to resume after May 31, the clock is ticking for hospital managers to figure out how to keep their doctors from getting infected, treat their patients and ensure that profits are maintained. At the moment, patients have been denied services by smaller nursing homes under suspicion of COVID. There is a trickling crowd visiting hospitals. But once we ease the lockdown, social mobility will come back to near pre-COVID times. That is when the fear of hospitals bursting at the seams becomes real. Patients rushing to clinics, weighing their burden of other diseases with the chance of contracting Coronavirus. We do expect the virus to reach the ranks of other infectious diseases wherein the treatment can be managed at the ICUs at worst and prevented by vaccinations at best. But that time is yet to come and till then, hospitals would have to work on a hybrid model to manage COVID and other diseases at the same time.
There will be more deliberations and fine-tuning of industry practices. Some old practices will be jettisoned and new ones adopted for a new world. Till we reach that time, the healthcare industry will see some rapid, step ladder shifts in operations. The Government will have to hand-hold this transition so that the industry does not crumble under pressure while health access and equity is maintained and technology catalyses this change. How this happens is yet to be seen but the window of time available for planning is fast closing.
(The writer is a health economist and engagement manager for health projects at the International Innovation Corps, a University of Chicago programme in Delhi)
