Limiting the Introduction of COVID-19 in Healthcare Settings

2nd July 2020

Dr. Namita JaggiChairperson, Lab services and Infection control & Chief, Education & Research, Chair, ICC &AMSCArtemis Hospitals, GurugramHaryana, India

Artemis Hospitals

• A 400 plus bedded Tertiary care state-of-the-art Multispeciality Hospital located at Gurugram, India• 12 Centres of Excellence• Accreditations: NABH (2010), JCI (2012), NABL (2012), Green OT (2016), NABH Nursing Excellence

(2016)• Employees-1987. 805 nurses, 389 doctors ,306 paramedics and 487 administrative .AWARDS• Kayakalp Award for Excellence in promoting cleanliness , hygiene and infection control- 2019• D.L. Shah Quality Silver Award – For the case study End to End Care Delivery – 2019• FICCI Healthcare Excellence Award for Service Excellence- 2018• Best Super Specialty Hospital in Delhi – NCR- 2017 • Healthcare Transformation Awards – Mobile Innovations in healthcare- 2017• WHO Asia Pacific Hand Hygiene Excellence Award-2010-2011• Most Promising Startup of the year- 2007

DisclosureI have no financial relationships with commercial entities producing healthcare related products and/or services.

Disclaimer The content of this presentation draws from the recommendations in the WHO , CDC , APSIC and the Indian- HISI , ICMR and MOHWF . The content is subject to revision as new evidence on COVID -19 becomes available

Break

The

Chain

Visitors

Healthcare Staff

IPD

Clinics

Ambulatory care Centers (e.g. Dialysis)

Hospitals

OPD

Objectives

Patients1) To display COVID -19 statistics of the world and India as of today .

2) To outline the present state of preparedness in India

3) To present the strategies undertaken in Artemis Hospital ,India to limit the introduction of COVID -19 in Healthcare settings from Visitors , Patients ( Out patients and In patients ) and Healthcare workers

Where are we as on 2nd July 2020?

World• Total cases-10,811,206 (0.13% of the population of 7.8

billion is affected ), 90,000 HCW infected (.83%)• Deaths- 5,19,095• Recovered- 6,033527Mortality- 4.80%

Haryana• Confirmed- 14,941• Active- 4,202• Recovered- 10,499• Deaths- 240Mortality- 1.61%

Delhi• Confirmed- 89,802• Active- 27,007• Recovered- 59,992• Deaths- 2,803Mortality- 3.12%

At ArtemisTotal Tests : 1889Total Positives: 190 (10.05%)25 HCW ( 15 in Hospital ).7%Mortality: 11 (5.78% out of total positives)

India• Confirmed-6,05220.( 0.04% of the population of

1.3 billion ) ,60% cases in the <60 yrs . 2000 HCW infected (.33%)

• Active- 2,27,718• Recovered- 3,59,896• Deaths-17,848Mortality- 2.95%

89,802Delhi

33,318Gujarat

1,80,298Maharashtra

94,049Tamil Nadu

24,056Uttar Pradesh

Gurgaon• Confirmed- 5,463• Active- 1,292• Recovered- 4,079• Deaths- 92Mortality- 1.68%

COVID hospital

COVID Health care centre(Mod)

COVID care centreMild and v Mild )

Artemis Hospital

Dedicated COVID beds

Total 900 2,040 8,708 1 -

Total beds

1,79,882

1,29,689

4,93,101

400 100

ICU beds

19,272

10,349

- 103 16

Isolation beds

1,60,610

1,19,340

- 19 16

Indian Healthcare: A Snapshot

• Doctor: Patient Ratio-0.77:1000. WHO -1/1000

• Nurses ratio :1.7:1000 WHO 3/1000

Government Initiatives

Total Population: 1.3 billionTotal States- 28 States + 8 Union

Territories• Nationwide Lockdown for 68 days

(25th March- 31st May 2020)• Quick upgrade of Health

infrastructure- Hospitals & Testing labs

• Rapid Response team- Special task force designed by ICMR https://www.icmr.gov.in/crrteam.html

• Vande Bharat mission- 30,000 Indians brought back from 40 countries

• Guidelines by MoHFW on COVID 19 testing, case Management, Infection control, Quarantine, BMW etc.-Regularly updated

• Mitigating inevitable hardships-Pradhan Mantri Gareeb Kalyan Yojna-food for needy

• Medical insurance cover of Rs 5 million per healthcare worker

• INR 1.7 trillion (~USD 22 billion) relief package

• Economic stimulus measures• Aarogya Setu App

Healthcare Facilities

India Haryana

Total hospitals 81,447 2,148

Govt. hospitals 37,960Primary- 35,467Secondary- 2,258Tertiary- 235

668

Private hospitals 43,487 1,480

Dedicated Health facilities in India for COVID 19

Manpower

MagnitudeMagnitude of operational COVID testing labs• Total labs - 1047• Government labs – 760• Private labs – 287• Total samples tested up to June 29, 2020 –

83,98,362 (Upto 2 Lakh samples/day) Antigen testing started few days back. ( 7.1%)

23 lakh people quarantined in Armed forces facilities , govt centers , Hotels ,

• Transmit or acquire infection .• Discouraged /Restricted esp older

visitors and High risk patients • One attendant per patient at a time.• Movement within the healthcare facility

restricted. • No vendors allowed .• Encouraged to speak on telephone • Not allowed entry if suffering from fever

, cough or shortness of breath or directed to a fever clinic (separate entrance ).

• Hand hygiene , masking and social distancing .

ManagementVisitor Management

Thermal

ScreeningScreening through

Questionnaire

Screening

Separate entrance for Visitors

Social distancing Hand hygiene &

Masking

Education and training Visual Alerts

• Visual alerts, such as banners, boards and standees have been placed for awareness of visitors on sign and symptoms of COVID-19 including instructions on who to notify if they develop symptoms

• Respiratory etiquette and hand hygiene

Education and training : By the infection control nurses

Trainings imparted on• Appropriate use of mask

and PPE • Hand hygiene, Respiratory

etiquette• Limit touching of high

touch surfaces • Social distancing• Movement within the

facility

Educational brochures

Patient Management-Out Patient

Rapid triage , Rapid identification and Rapid Isolation .

Restricting Patient visit to Hospital

Online Consultation

3rd floor

ICU Wards

ICU Wards

ICUWards

ICU Wards

Fever Clinic(Screening)

Emergency(Suspected/confirmed COVID cases)

Sample collection

Main entry

OPD( Non-COVID area)

Dedicatedlift

DedicatedLift

Pre-operative suspected

Non-COVID area

COVID area

Symptomatic patient

Positive patient

Symptomatic patient

OT

Emergency surgery

Pre-Operative patients

Elective Surgery

Grey corridor

Suspected patient –This way Home

IsolationMild symptomatic

Screening

If -ve If +ve HomeIsolation

Negative patientNegative patient

Hand Hygiene

Social distancing

Masking

Respiratory etiquette

Fever Clinic

Holding

area

Screening Room

Transfer to suspected

area

Sample collection

Testing strategy

Newer Additional Strategies 23/06/2020

•Rapid Antigen detection test – Need of the hour (chromatographic immunoassay for qualitative detection of antigens to SARS-CoV-2.)•Standard Q COVID-19 Ag detection assay.•This test only takes 15-30 minutesRT PCR App

Public Health authorities

In- patients• AIM :Infected patients should not pose a risk to other patients and

healthcare workers .

• Arrive by grey corridor . Zoning followed .

• Guidelines -MOHWF ,ICMR followed

• Clinician initiated – Testing Rapid antigen test /RTPCRand information sent to public health authorities .

• Droplet and contact precautions .PPE ,Negative pressure ,• No movement into other zones .Portable X-rays , Ultrasound ,Dialysis

.Separate timings for visit to diagnostic areas . Cleaning . Staff in PPE . Patient masked .

• Continuing education of Clinicians

Identification & Management of Healthcare workers with COVID -19 – Active strategy

• Aim :Prevent exposure of at- risk patients and staff to symptomatic COVID positive healthcare workers

• Healthcare workers Education . Masking , Social distancing , PPE Respiratory etiquette and hand hygiene .

• Self assessment by healthcare workers Encouraged to report .

• Screening of all healthcare workers at entry in each shift .

• Healthcare workers reporting of breach of PPE .Risk assessment by quarantine committee.

• If sick - leave, admission to hospital and other support is provided . No punitive action or salary cut .

Algorithm for Exposure of HCWs to COVID-19 patient

Based on the MOHWF guideline

Non-COVID area

ICU Wards

ICU Wards

ICUWards

ICU Wards

Fever Clinic(Screening)

Emergency(Suspected/confirmed COVID cases)

Main entry

OPD( Non-COVID area)

DedicatedliftDedicated

Lift

Pre-operative Suspected

COVID area

OT

Grey corridor

Screening

Location wise distribution of Infected Healthcare workers

Nurse Coordinator

Doctor

Others (Billing staff, Security)

Total Healthcare workers infected- 25 (All June cases)Hospital exposure- 15.

Chemo day care Nurse

OPD Nurse

SecurityIPD Billing PCSOPD Billing PCS

Trainings

Security

Food & Beverage

COVID Ward

ICU

Online Trainings

PPE Donning & Doffing

Mock drill team

Fight with COVID-19 at Artemis?

20th Jan 2020- Alert Raised for nCoV epidemic by e-mail and lecture taken for all HCW .

27th to 29th Jan 2020- Training imparted to 64 staff posted at point of entries

30th January 2020- Mock Drill on Preparedness for nCoVepidemic . Ist case in India – Kerala .

31st January - 1st February 2020- Sample collection Training at ICUs and 3rd B

Feb 2020- Mass Education and awareness Videos

March- Guidelines released for Case definition, BMW management, Sample collection and testing strategies,

PPE usage etc

April- COVID Action Plan released, Healthcare worker and Patient Safety Guidelines, BMW management rules

amended. Ist case in Artemis on 2nd

May and June Antigen testing - Shortage of Supplies: Reuse of mask and face shields

Geared up for

the Battle…

……

Together let’s fight

COVID-19

THANK YOU

Resources• CDC. Operational Considerations for Containing COVID-19 in non-US Healthcare

Settings https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/index.html

• CDC. Management of Visitors to Healthcare Facilities in the Context of COVID-19: Non-US Healthcare Settings https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/hcf-visitors.html

• World Health Organization https://www.who.int/health-topics/coronavirus#tab=tab_1

• Indian Council of Medical Research, New Delhi https://www.icmr.gov.in/pdf/covid/strategy/Testing_Strategy_v5_18052020.pdf

• COVID19 India: National Centre for Disease Control (NCDC) https://ncdc.gov.in/index4.php?lang=1&level=0&linkid=132&lid=549

• Ministry of Health and Family Welfare https://www.mohfw.gov.in/• Situation update for World- https://www.who.int/emergencies/diseases/novel-

coronavirus-2019/situation-reports/?gclid=EAIaIQobChMIm9jd8NWm6QIVmXwrCh3nqQDpEAAYASABEgLCJvD_BwE

• Situation update for India- https://www.covid19india.org/