Collaboration is the Key Focus Area during this Pandemic Year for CMC Vellore
By Arunima Rajan
CMC Vellore’s holistic approach to pandemic management once again sets the bar high for healthcare delivery.
Last year, Christian Medical College Vellore, received several accolades for its contributions in combating COVID-19 pandemic. The hospital treated thousands of COVID patients and developed its own pandemic guidelines. More than that, they also trained several hundreds of doctors, nurses and community workers in remote parts of the country through capacity-building efforts.
They also explicitly stayed away from unproven drugs due to the lack of efficacy data, costs and potential side effects, even though they were willing to use them in a clinical trial platform. The hospital organised a "Manna Meal scheme" where patients and families stuck in the hospital or the lodges during the lockdown could avail of free meals. Over 15,000 coupons were distributed during the lockdown period. Further, food was distributed to families in the tribal areas (where the outreach team usually provides healthcare) during the lockdown.
Dr JV Peter,
Director of Christian Medical College, Vellore
Current and former faculty of CMC are a credible voice during COVID. This includes Dr JP Muliyil, Dr Jacob John, Dr. M.S. Seshadri, Dr. O.C. Abraham, Dr Gagandeep Kang initially as part of THSTI and subsequently from CMC, and Dr Priya Abraham deputed to National Institute of Virology, Pune from CMC.
In an exclusive telephonic interview with Arunima Rajan, Dr JV Peter, Director of Christian Medical College, Vellore, talks about how lean management and streamlining operations are vital to mitigating risks and how it can be challenging in large institutions.
What are the lessons that your hospital has learned from practising medicine in 2020, and how are you making sure that you are prepared next time?
Teamwork: We saw the value of teamwork during the pandemic. There was a sense of ownership and participation that translated to involvement in COVID related activities.
Innovation and repurposing areas: The hospital was segregated into COVID and non-COVID zones, manned by different teams. The General Superintendent's office ensured process flow from supply counters to donning zones to clinical areas and on completion of work to doffing zones and shower areas. Modifications were made to ICUs and ward areas were converted to ICUs, ensuring additional air-exchanges and exhaust systems. COVID zone was compartmentalised into screening, suspect and positive areas for medical, surgical, obstetric, neonatal and ICU patients.
Task shifting: There were task shifting and re-allocation of workforce involving medical, nursing and allied health staff from non-core medicine areas who were trained to look after patients in Level 0 and Level 1 areas while those with core medicine, infectious disease, pulmonary medicine and anaesthesia background received additional and specialised training to man Level 2 and 3 areas; all areas had 24-hour onsite medical and nursing personnel. At the pandemic's peak, there were 880 designated beds for COVID, including 90+ ICU beds. Over 10,300 patients have been admitted and treated so far at CMC.
Emphasis on staff protection: The institution placed enormous emphasis on protecting its employees despite the considerable cost in the procurement of PPE, particularly during the initial part of the pandemic. We are happy to state that despite a workforce of over 10,000 staff, although some developed COVID, mainly from the community, there was no healthcare worker fatality with COVID.
Importance of a Hospital Infection Control Committee (HICC) and healthcare workers' training: Knowledge empowers and reduces fear and panic. This was possible through the development of in-house training programs and guidelines. The hospital has an established HICC chaired by the Medical Superintendent and comprising of ID specialists, microbiologists and clinicians. By the time the first few cases of COVID were diagnosed in the country, CMC had its protocols and infection control, quarantine and treatment guidelines in place. These were updated by the clinical team weekly based on new evidence and made available on the hospital intranet site. The medical, nursing and staff training department created training platforms to train all healthcare workers in the institution. A distance education program was created for training 5000 doctors and nurses working in secondary care across the country with support from TATA trust and another program to train 10000 community level workers with support from the Azim Premji Foundation.
Communication systems: Our hospital Created a "COVID Command Centre" to coordinate several activities centrally as a 24-hour staffed facility: from testing, reporting, informing patients, contact tracing, patient admission, counselling, finance help desk and staff welfare. Clinical and community updates were done initially on a fortnightly basis, and regular updates were given. The system of communication was refined using several online platforms. Videoconferencing was also used as a tool for internal, external and patient communications and student teaching.
Telemedicine got a clinical spotlight due to COVID. Has the system adapted to telemedicine?
Telemedicine was used during the lockdown phase for helping patients with chronic illness on maintenance medications and those with inter-current medical problems. Telemedicine cannot supplant bedside clinical examination and diagnosis, particularly at a specialised tertiary care centre, and its application is limited. Surgical care and acute care can only be provided onsite, while some chronic care can be done through an online platform.
How has the pandemic impacted your financial bottom-line? How can one mitigate such risks in the future?
Pandemic affected finances significantly since healthcare organisations such as ours are heavily dependent on a single income source, patient care. Since medical, nursing and allied-education, at the undergraduate, postgraduate and higher speciality levels, is heavily subsidised at CMC, it accounts for less than 0.5% of the annual revenue. On the expenditure side, fixed salary expenditure remained the same, and variable expenditure such as additional PPE costs put an additional strain on the resources. Higher cost for oxygen and some lifesaving medications and a cap on hospital charges for COVID care, placed enormous stress. Staff contributed around four crores for COVID work and opted for deferment of part of the salary. This enabled CMC to continue to do charitable work which was higher at 20% of the total turnover during COVID than during other times (around 16%). Some charitable work was offset by staff donations, alumni, well-wishers, friends and some contributions through CSR for additional lifesaving ICU equipment and an oxygen concentrator. Lean management and streamlining operations are vital to mitigating risks. However, this can be challenging in large institutions.
What changes do you foresee in the healthcare delivery business model?
Telemedicine might be used to reduce hospital visits and associated costs. This would be suitable mainly for follow up for chronic diseases. Use of data management systems, online systems for services (e.g. payment portals, appointments etc.) to improve services and lean management could also become more popular in the future.
Enumerate three structural changes to improve healthcare delivery in India?
More investment in public health
Strengthening of public health systems, mainly secondary health care -this is probably the level that needs investment – HR, training and capacity building.
Invest in research into re-emerging and newly emerging infections (not enough being done) and focus on reducing deaths in communicable disease
What role should the Government play going forward?
Investment in public health strengthening
Data management Systems– Digital India needs careful and considered investment and regulation
What are the measures you are adopting in your hospital to protect against COVID beyond masking and social distancing?
Vaccination: There was some vaccine hesitancy at the start of the vaccination program. However, the administrators took the lead, and all of them got vaccinated in the first two days of the program. This has enhanced the confidence of the healthcare workers, and to date, over 60% of the healthcare workers have been vaccinated with the first dose, and by the end of this week, we hope that a large proportion of the staff would be vaccinated. Several programs were organised to provide information to the staff that included interactive sessions. Other scientific information was provided in a simple manner on hospital intranet to increase vaccine uptake.
Education and capacity building: As articulated earlier, knowledge empowers. The evidence on the approach to COVID has rapidly evolved, and it is vital to keep pace with new knowledge. It broadly involves three domains - policy, science and people. In terms of the policy, the key elements are testing and treatment policies and policies on balancing COVID and non-COVID work. Our testing policies have been revised continuously to protect healthcare workers from acquiring infection in the hospital and protect patients under our care. Early detection "breaks the chain of transmission" and it is crucial to identify patients early and screen contacts and quarantine them if there is significant exposure. The initial treatment policies that were recommended nationally put an enormous strain on the health system as asymptomatic COVID positive patients had to be admitted. With the revised policy now, we have created special facilities where positive healthcare workers can be quarantined till they are safe to get back to work. The over-emphasis on COVID resulted in other diseases to be neglected, and hence policies have been revised in the hospital to balance COVID and non-COVID work. In the scientific domain, we were fortunate to have a team of biostatistics experts who tracked the infection and looked at projections every week. Their predictions were reasonably accurate and coincided with the 1st peak in September 2020. This helped with resource allocation. Treatment protocols have been refined based on scientific evidence, and with good outcomes and much less stigma now, people are coming early for treatment. There is also confidence among staff and the public in our protocols for COVID management. These factors help break the chain of transmission. The last domain is critical - people. The pendulum has swung from one extreme during the pandemic's initial phase, fear and panic, to now casualness. There is pandemic fatigue, and people want to get back to "normalcy"- whatever that means. There is always a risk of a 2nd peak as it has happened in the USA and several European countries. We have kept up the pressure to adhere to all infection control practices, including "no mask, no entry" policy. The HICC monitors adherence to these.
What were some of the tech innovations that helped your organisation in the battle? Anything that you want to acquire or is on your wishlist?
One of the significant innovations that helped us was in engineering and general services section, especially air-conditioning and converting existing wards to ICU areas and making operating theatres safer by increasing air-exchange filters. We also created kiosks, temporary shower area and used fire engines for surface spraying and disinfection. We have also used teleconferencing and videoconferencing for communication to relatives of COVID patients, particularly ICU patients. Since relatives were also quarantined, this was necessary.