Innovative solutions for India to manage critically ill #COVID-19 patients, a five point agenda by Dhruv Joshi and Dileep Raman, @cloudphysician

The truth of the Indian healthcare system

The present onslaught of COVID-19 has delivered to the fore quite a few points that healthcare programs face worldwide. India, with its COVID-19 case load trailing China, Europe and the US by just a few weeks, is nearly sure to come across its healthcare system’s limitations within the coming weeks to months. Many nations at this time have witnessed a geometrical rise within the variety of circumstances of the virus owing to its infectiousness and distinctive transmission traits. Barring unknown climatic results or vital mutations within the virus, it’s more likely to comply with the same course within the Indian inhabitants. The similarities sadly finish right here. 

India’s projected responses by way of deploying healthcare personnel, infrastructure to isolate sufferers, availability of ventilators, use of superior strategies to handle sufferers, making certain acceptable protecting gear and air flow in healthcare services bear no similarities to what Western nations have in place. Because of this it will not be farfetched to anticipate mortality and morbidity charges larger than what different nations have seen. It’s a grim image. 

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Confronted with this doable actuality, it’s crucial that we take an in depth take a look at the inhabitants stage implications of COVID-19 and formulate our methods within the context of what we have now out there at our disposal, by way of personnel, coaching, gear and infrastructure and make a blueprint that will reduce the widespread an infection and mortality that comes with COVID-19.

On the outset, each measure to comprise the illness MUST be taken. Social distancing, lockdowns, curfews, and so on., and different measures that are beneath the purview of authorities have to be leveraged to restrict the unfold of the virus. Moreover, widespread testing, case discovering and isolation, ‘ahead triaging’ – utilizing telemedicine to triage sufferers at dwelling, dwelling testing kits and vaccine growth have to be extensively deployed and accelerated. On this article, we are going to give attention to the implications of managing critically ailing sufferers who will must be admitted to hospitals or ICUs and measures we will soak up India to reduce the lack of life.

Many state governments have scaled up mattress capability or are planning to take action primarily based on ICMR information beneath. The projections point out a major improve in ICU and HDU beds. These beds will want ability and manpower, which is finite, to ship high quality care. 

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The necessity to discover a resolution that works for us – Frugal innovation!

Whereas scarcity of ventilators goes to be a significant downside, we can not focus solely on the procurement of ventilators to assist our critically ailing sufferers. Europe, USA and different comparable nations have extremely skilled workforces, nurses, respiratory therapists and Intensivists who’re conversant in the administration of extreme respiratory failure which is seen in COVID-19. Sadly in India this experience solely exists in just a few massive facilities, predominantly in metro cities. Placing superior machines resembling ventilators within the arms of untrained and inexperienced personnel will doubtless end in larger than anticipated mortality charges. Coaching massive numbers of personnel goes to take months to years and isn’t a possible resolution within the short-to-medium time period. 

On the similar time, critically ailing sufferers on ventilators require shut monitoring, typically 1 nurse to 1 to 2 sufferers, which not solely will increase the staffing wants and utilization of PPE, but additionally will increase the publicity of healthcare personnel to the virus. Our shortcomings are frequent data and dropping lives to COVID-19 amongst healthcare employees goes to check their motivation to come back to work.

Additional, in relation to fundamental infrastructure, only some hospital buildings in metro cities conform to requirements that require good air flow, making it unattainable, given the time constraint to have remoted models that defend sufferers and healthcare employees.

Preserving these elements in thoughts, it’s crucial that we play to our strengths and innovate options that greatest make the most of the workforce and infrastructure that we have now out there to handle massive numbers of critically ailing sufferers to the most effective of our potential whereas holding our healthcare employees protected and dedicated.

Caveats and classes from the remainder of the world

Early experiences from nations which have been coping with critically ailing COVID-19 sufferers have proven that they’ve extreme hypoxia (scarcity of oxygen within the blood). There are lots of modalities of remedy of extreme hypoxia and we should select those that match our system the most effective. Excessive stream oxygen by way of nasal cannulas requires tubes connecting oxygen sources to sufferers noses delivering a excessive content material of oxygen beneath stress which can in lots of circumstances be enough to handle loads of sufferers and likewise keep away from having to place them on ventilators. The coaching and ability required to position sufferers on nasal cannulas and monitor them is far lesser in comparison with ventilators, thereby maximizing our nursing ratio which in flip reduces the necessity for PPEs and publicity of extra healthcare employees to an infection. The flexibility to create massive numbers of open air arenas with oxygen sources beneath stress can be simpler to do than to transform our present buildings into effectively ventilated/isolation models. Our tropical local weather and skill to have open air models have to be leveraged within the face of our incapability to scale our buildings to be adequately ventilated. 

Addressing the huge scale of this downside would require coordination throughout many areas. Manufacturing of monitoring units, medication, laboratory gear, to call just a few. Our proposed options give attention to the supply of care and the way it may be extra efficacious with some fundamental infrastructure in place.  

The 5 level agenda that we suggest to take care of the pandemic and its important care implications in India: 

  1. Authorities companies and personal enterprises MUST guarantee the provision of non-public protecting gear (PPE) and oxygen.

Rationale: PPE and oxygen are the 2 most significant sources right now. With out PPEs the finite sources of healthcare employees will likely be severely diminished. On condition that the chance of an infection to healthcare employees stands at round 10 to fifteen% (estimates from the West), we can not afford a discount on this important workforce. Oxygen provide is important when coping with a respiratory dysfunction. Industrial manufacturing should ramp as much as cater to the wants which might be projected to come up. It’s the cornerstone of supportive remedy and given the shortage of efficient remedy, it’s the “drug” that we should stockpile.

2. Shift focus from ventilators to highflow units and steady constructive airway stress units.

Rationale: The time to create ventilators with the degrees of reliability and security required for mechanical air flow is just too quick. It could take 8-12 months to get there but it surely is not going to occur within the fast future. We’ll find yourself spending precious time, vitality and sources in manufacturing ventilators that don’t straight assist heal the lungs. As talked about above, easier units and methods resembling heated high-flow units, and CPAP will doubtless be less expensive and can assist a bigger variety of COVID-19 sufferers. Some might argue that there’s a threat of those units enhancing airborne unfold, nonetheless, that is largely speculative and theoretical and the rationale will not be primarily based on sound proof. A central unit that generates the stress and required stream is comparatively straightforward to connect with sufferers by way of normal piping and easy mechanical components. We have to enlist the help of our colleagues in engineering and manufacturing to create a system that will allow us to supply a big stream of oxygen to sufferers by way of canulas (a lot simpler to do than making ventilators). In lots of circumstances even electrical energy is probably not required. This is able to be an enormous upside in our nation. Excessive stream units are proof primarily based and are the primary line remedy of respiratory failure. We should always give attention to them. 

3. Embrace the idea of open-air ICUs or HDUs. 

Rationale: India won’t ever have sufficient damaging stress rooms to cater to a big quantity of sufferers. Most of our ICUs would not have optimum air con programs to clear the air of droplet infectious particles. Being a tropical nation with milder local weather we will arrange open-air or extremely ventilated environments the place sufferers will be handled. So long as PPE provide is satisfactory the droplets generated will likely be cleared by pure air flow. This may additional allay the priority of excessive stream gadget associated dangers talked about above. These open-air ICUs/HDUs will be arrange near the standard hospitals and when sufferers do require superior therapies they are often moved to the standard ICU setup. Places resembling airport hangars, sports activities stadiums and conference facilities can be ultimate websites to plan one thing like this. The simplicity of highflow programs and CPAP allows us to arrange piping at scale to assist deal with these sufferers. 

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4. Use tele-ICU expertise as a power multiplier.

Rationale: Skilled healthcare employees wanted to deal with a big inflow of COVID-19 sufferers are restricted. Much more scarce are ICU specialists (intensivists) who will must be concerned within the care of those sufferers. Transitions from HDU to ICU will must be triaged and supervised by them. Sufferers who want superior therapies would require their providers at a second’s discover. Such coordination and decentralization of care is simply doable if superspecialists are linked to as many beds as doable in order that their ability and expertise is maximally utilized. With a tele-ICU system it’s doable for 1 intensivist to cater to the wants of 60-80 sick sufferers versus the present ratio of 1:15, the place an intensivist is seeing a affected person at bedside. The command middle can both be part of a “hub and spoke” mannequin the place it covers a number of smaller ICUs or be part of a “hive” mannequin the place a big 1,000 mattress open air ICU is roofed by tele-ICU suppliers remotely. One other benefit is that healthcare workers on the bedside may also use monitoring expertise to scale back their publicity and threat of an infection. On this approach the specialists within the command facilities can decide which affected person can’t be managed utilizing merely nasal oxygen beneath stress and would require ventilators thereby making certain acceptable triaging of sufferers for a restricted variety of ventilators. If required these sufferers can then be moved to a separate/similar unit the place they’re positioned on ventilators for additional care. These models too will likely be beneath tele statement making certain sufferers are appropriately managed on ventilators.

5. Proceed to scale back influx into hospitals.

Use tele-triage at dwelling or “quick vary telemedicine” from the hospital to a website simply outdoors a hospital premises to maintain extra folks out of the hospital. Energetic case discovering and isolation methods for early detection of hotspots and to scale back incidence of recent circumstances should proceed. This will require a “central warfare room” that may monitor and alert the well being care crew to organize for a future improve in case load.

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A lot of the above will be carried out within the coming days. From varied statistical fashions the most effective estimate is that we may even see a surge in India round mid-Might. Methods we make use of have to be price efficient, efficacious and must be deployable in a short while span. We began Cloudphysician Healthcare, a tele-ICU firm, with the purpose of accelerating entry to high quality healthcare for each affected person in want, regardless of the setting or the placement. The hazard is evident and current.

The time to behave is now. 

Dhruv Joshi and Dileep Raman are Pulmonary and Vital Care specialists who skilled and labored within the US earlier than relocating to India to start out Cloudphysician Healthcare, a healthcare expertise firm.

Cloudphysician remotely gives ICU experience to hospitals that would not have entry to ICU specialist docs.


Hobday, et al., The Open-Air Therapy of PANDEMIC INFLUENZA

Weiss, et al., Disrupting the Transmission of Influenza A: Face Masks and Ultraviolet Mild as Management Measures

Hobday, The open-air issue and an infection management

Atkinson, et al., Pure Air flow for An infection Management in Well being-Care Settings

Hobday, et. al, Roles of daylight and pure air flow for controlling an infection: historic and present views

Extra sources will likely be added to the Cloudphysician’s COVID-19 sources folder every so often. 

The White paper was first revealed on the Writer’s LinkedIn Pulse Weblog, it has been republished right here with the Writer’s permission.

CloudPhysician Web site: Hyperlink

Dhruv Joshi
Dhruv Joshi

Director – Cloudphysician Healthcare Pvt Ltd

Dileep Raman
Dileep Raman

Director – Cloudphysician Healthcare Pvt Ltd

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