CMAAO CORONA FACTS and MYTH BUSTER 51

CMAAO CORONA FACTS and MYTH BUSTER 51

Dr K K Aggarwal

President Confederation of Medical Associations of Asia and Oceania, HCFI and Past National President IMA

 548: What are the minutes of Round Table on Lockdown Exit Policy – ZOOM MEETING organised by IMA in Association with HCFI and CMAAO

11^th April 2020, Saturday, 11am-1pm

Participants

Dr K K 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 significant proportion 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.

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 deffer or 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

Criteria	Stage III (High vulnerability)	Stage II (Moderate vulnerability)	Stage I (Low vulnerability)
No. of active cases in the past 7 days	Greater than or equal to 20 but less than 50	Less than 20 cases with new cases in the past 7 days	Less than 5 active cases with no new cases in the past 7 days

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)

Activity	Red	Yellow		Green
Closure of all educational establishments (schools, universities, coaching institutes, etc), gyms, museums, cultural and social centres, swimming pools, theatres and workplaces. Online education to be promoted. Initially for 28 days, to be reassessed based on risk	Yes	Yes		No
Possibility of postponing exams may be explored. Ongoing exams to be conducted only after ensuring physical distance of one meter amongst students	Yes	Yes		No
Encourage organizations/employers to allow employees to work from home wherever feasible. Meetings, as far as feasible, shall be done through video conferences.	Yes	Yes		No
All mass gatherings events and meetings in public or private places in the containment zone and buffer zones shall be cancelled /banned till lockdown is lifted	Yes	Yes		No
Restaurants, Pubs, Malls, markets shall remain closed except take away services for food Restaurants to ensure handwashing protocol and proper cleanliness of frequently touched surfaces. Ensure physical distancing (minimum 1meter) between tables; encourage open air seating where practical with adequate distancing. Similar practices to followed by cinemas, malls and pubs	Yes Yes	Yes Yes		No Yes
Keep already planned weddings to a limited gathering; postpone all non-essential social and cultural gatherings. Hand Hygiene, Physical distance between chairs to be maintained, No sofa sets, Fabric face mask	Yes Yes	Yes Yes		Yes Yes
Local authorities to have a dialogue with organizers of sporting events and competitions involving large gatherings and they may be advised to postpone such events.	Yes	Yes		Yes, with limit of number of people
Local authorities to have a dialogue with opinion leaders/panchayat and religious leaders to avoid mass gatherings and should ensure no overcrowding/at least one metre distance between people. Use this opportunity for mass awareness and advocacy in community	Yes	Yes		No more than 20 Physical distance To be ensured Sanitizer available
Local authorities to have meeting with traders associations and other stakeholders to regulate hours, exhibits Dos and Don’ts and take up a communication drive in market places like sabzi mandi, anaj mandi, bus depots, railway stations, post-offices etc., where essential services are provided	No Yes	No Yes		Yes Yes
All commercial activities to remain closed except essential commodities & services All commercial activities for essential goods and services must keep a distance of one meter between customers. Measures to reduce peak hour crowding in markets.	Yes Yes	Yes Yes		Yes Yes
Cancellation of public transport (bus/rail/air) Non-essential travel should be avoided. Minimum Transport facility for HCWs should be available around shift times to reach hospitals	Yes	Yes		50% Sanitization, Distance between seats to be ensured Posters displayed Disinfection of vehicle
Healthcare services to remain functional, HCWs to take standard precautions, use appropriate PPE of good quality as per guidelines. Practice and promote hand hygiene, Respiratory etiquettes, disinfection of clinical areas frequently including clinics. Every patient to seen as potential COVID 19 patient and all precautions to be taken as per uniform protocols Hospitals including stand-alone clinics to follow necessary protocol related with COVID 19-19 management as prescribed and restrict family/friends/children visiting patients in hospitals. Training of nurses and support staff Best practices for Biomedical waste management and communication with patients and attendants	Yes, in all stages
Agricultural activities	Yes, With precautions regarding hygiene of workers, minimum workers from same locality, training of farmers must
Special protective measures for delivery men/ women working in online ordering services.	Yes	Yes		Yes
Keep communities informed consistently and constantly	Yes, at all times and stages Community awareness & engagement is essential
COURTS AND JUDICIARY	Hearing of matters   of constitutional nature with minimum staff present		Courts must function normally, but a revision of the timetable should be undertaken to mark and eliminate dates with extra congestion.   Procedure for digital hearing should be attempted
Identify mechanisms to maintain availability of essential medications, equipment, and supplies	Yes
Non- medical essential services, food, vegetables, fruits, groceries, milk Electricians, Plumbers, salons, auto mechanics, Construction workers, home helps *Construction activity can be allowed in unaffected districts provided labour is available   locally. No construction activity shall be permitted in affected districts.	Ensure use of face mask, social distancing Few may be allowed for few hours a day, workers are from locality
Surveillance Perimeter control and movement of vehicles within the containment zone will be prohibited except for those issued passes for providing essential services as per guidelines/orders from administration	Yes, both active & Passive			Yes Passive only
Care of Elderly and vulnerable groups like immunocompromised, on dialysis, chemotherapy, chronic neurological disease etc.	Yes