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

Dhruv Joshi, Dileep Raman, Cloudphysician

The reality of the Indian healthcare system

The current onslaught of COVID-19 has brought to the fore numerous issues that healthcare systems face worldwide. India, with its COVID-19 case load trailing China, Europe and the US by a few weeks, is almost certain to encounter its healthcare system’s limitations in the coming weeks to months. Many countries today have witnessed a geometric rise in the number of cases of the virus owing to its infectiousness and unique transmission characteristics. Barring unknown climatic effects or significant mutations in the virus, it is likely to follow a similar course in the Indian population. The similarities unfortunately end here. 

India’s projected responses in terms of deploying healthcare personnel, infrastructure to isolate patients, availability of ventilators, use of advanced techniques to manage patients, ensuring appropriate protective equipment and ventilation in healthcare facilities bear no similarities to what Western countries have in place. As a result it would not be farfetched to anticipate mortality and morbidity rates greater than what other countries have seen. It is a grim picture. 

Faced with this possible reality, it is imperative that we take a close look at the population level implications of COVID-19 and formulate our strategies in the context of what we have available at our disposal, in terms of personnel, training, equipment and infrastructure and make a blueprint that would minimize the widespread infection and mortality that comes with COVID-19.

At the outset, every measure to contain the disease MUST be taken. Social distancing, lockdowns, curfews, etc., and other measures which are under the purview of authorities must be leveraged to limit the spread of the virus. Furthermore, widespread testing, case finding and isolation, ‘forward triaging’ – using telemedicine to triage patients at home, home testing kits and vaccine development must be extensively deployed and accelerated. In this article, we will focus on the implications of managing critically ill patients who will need to be admitted to hospitals or ICUs and measures we can take in India to minimize the loss of life.

Many state governments have scaled up bed capacity or are planning to do so based on ICMR data below. The projections indicate a significant increase in ICU and HDU beds. These beds will need skill and manpower, which is finite, to deliver quality care. 

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The need to find a solution that works for us – Frugal innovation!

While shortage of ventilators is going to be a major problem, we cannot focus only on the procurement of ventilators to help our critically ill patients. Europe, USA and other similar countries have highly trained workforces, nurses, respiratory therapists and Intensivists who are familiar with the management of severe respiratory failure which is seen in COVID-19. Unfortunately in India this expertise only exists in a few large centers, predominantly in metro cities. Putting advanced machines such as ventilators in the hands of untrained and inexperienced personnel will likely result in higher than expected mortality rates. Training large numbers of personnel is going to take months to years and is not a feasible solution in the short-to-medium term. 

At the same time, critically ill patients on ventilators require close monitoring, often 1 nurse to 1 to 2 patients, which not only increases the staffing needs and utilization of PPE, but also increases the exposure of healthcare personnel to the virus. Our shortcomings are common knowledge and losing lives to COVID-19 among healthcare workers is going to test their motivation to come to work.

Further, when it comes to basic infrastructure, only a few hospital buildings in metro cities conform to standards that require good ventilation, making it impossible, given the time constraint to have isolated units that protect patients and healthcare workers.

Keeping these factors in mind, it is imperative that we play to our strengths and innovate solutions that best utilize the workforce and infrastructure that we have available to manage large numbers of critically ill patients to the best of our ability while keeping our healthcare workers safe and committed.

Caveats and lessons from the rest of the world

Early experiences from countries that have been dealing with critically ill COVID-19 patients have shown that they have severe hypoxia (shortage of oxygen in the blood). There are many modalities of treatment of severe hypoxia and we must choose the ones that fit our system the best. High flow oxygen via nasal cannulas requires tubes connecting oxygen sources to patients noses delivering a high content of oxygen under pressure which may in many cases be sufficient to manage a lot of patients and also avoid having to put them on ventilators. The training and skill required to place patients on nasal cannulas and monitor them is much lesser compared to ventilators, thereby maximizing our nursing ratio which in turn reduces the need for PPEs and exposure of more healthcare workers to infection. The ability to create large numbers of open air arenas with oxygen sources under pressure would be easier to do than to convert our existing buildings into well ventilated/isolation units. Our tropical climate and ability to have open air units must be leveraged in the face of our inability to scale our buildings to be adequately ventilated. 

Addressing the massive scale of this problem will require coordination across many areas. Manufacturing of monitoring devices, drugs, laboratory equipment, to name a few. Our proposed solutions focus on the delivery of care and how it can be more efficacious with some basic infrastructure in place.  

The five point agenda that we propose to deal with the pandemic and its critical care implications in India: 

  1. Government agencies and private enterprises MUST ensure the supply of personal protective equipment (PPE) and oxygen.

Rationale: PPE and oxygen are the two most vital resources at this time. Without PPEs the finite resources of healthcare workers will be severely diminished. Given that the risk of infection to healthcare workers stands at around 10 to 15% (estimates from the West), we cannot afford a reduction in this critical workforce. Oxygen supply is critical when dealing with a respiratory disorder. Industrial production must ramp up to cater to the needs that are projected to arise. It is the cornerstone of supportive therapy and given the lack of effective treatment, it is the “drug” that we must stockpile.

2. Shift focus from ventilators to highflow devices and continuous positive airway pressure devices.

Rationale: The time to create ventilators with the levels of reliability and safety required for mechanical ventilation is too short. It may take 8-12 months to get there but it will not happen in the immediate future. We will end up spending valuable time, energy and resources in manufacturing ventilators that do not directly help heal the lungs. As mentioned above, simpler devices and strategies such as heated high-flow devices, and CPAP will likely be more cost effective and will help a larger number of COVID-19 patients. Some may argue that there is a risk of these devices enhancing airborne spread, however, this is largely speculative and theoretical and the rationale is not based on sound evidence. A central unit that generates the pressure and required flow is relatively easy to connect to patients by means of standard piping and simple mechanical parts. We need to enlist the support of our colleagues in engineering and manufacturing to create a system that would enable us to provide a large flow of oxygen to patients via canulas (much easier to do than making ventilators). In many cases even electricity may not be required. This would be a huge upside in our country. High flow devices are evidence based and are the first line treatment of respiratory failure. We should focus on them. 

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

Rationale: India will never have enough negative pressure rooms to cater to a large volume of patients. Most of our ICUs do not have optimal air conditioning systems to clear the air of droplet infectious particles. Being a tropical country with milder climate we can set up open-air or highly ventilated environments where patients can be treated. As long as PPE supply is adequate the droplets generated will be cleared by natural ventilation. This will further allay the concern of high flow device related risks mentioned above. These open-air ICUs/HDUs can be set up close to the traditional hospitals and when patients do require advanced therapies they can be moved to the traditional ICU setup. Locations such as airport hangars, sports stadiums and convention centers would be ideal sites to plan something like this. The simplicity of highflow systems and CPAP enables us to set up piping at scale to help treat these patients. 

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4. Use tele-ICU technology as a force multiplier.

Rationale: Trained healthcare workers needed to treat a large influx of COVID-19 patients are limited. Even more scarce are ICU specialists (intensivists) who will need to be involved in the care of these patients. Transitions from HDU to ICU will need to be triaged and supervised by them. Patients who need advanced therapies will require their services at a moment’s notice. Such coordination and decentralization of care is only possible if superspecialists are connected to as many beds as possible so that their skill and experience is maximally utilized. With a tele-ICU system it is possible for 1 intensivist to cater to the needs of 60-80 sick patients as opposed to the current ratio of 1:15, where an intensivist is seeing a patient at bedside. The command center can either be a part of a “hub and spoke” model where it covers multiple smaller ICUs or be a part of a “hive” model where a large 1,000 bed open air ICU is covered by tele-ICU providers remotely. Another advantage is that healthcare staff at the bedside can also use monitoring technology to reduce their exposure and risk of infection. In this way the specialists in the command centers can determine which patient cannot be managed using merely nasal oxygen under pressure and would require ventilators thereby ensuring appropriate triaging of patients for a limited number of ventilators. If required these patients can then be moved to a separate/same unit where they are placed on ventilators for further care. These units too will be under tele observation ensuring patients are appropriately managed on ventilators.

5. Continue to reduce inflow into hospitals.

Use tele-triage at home or “short range telemedicine” from the hospital to a site just outside a hospital premises to keep more people out of the hospital. Active case finding and isolation strategies for early detection of hotspots and to reduce incidence of new cases must continue. This may require a “central war room” that can monitor and alert the health care team to prepare for a future increase in case load.

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Much of the above can be carried out in the coming days. From various statistical models the best estimate is that we may see a surge in India around mid-May. Strategies we employ must be cost effective, efficacious and should be deployable in a short time span. We started Cloudphysician Healthcare, a tele-ICU company, with the goal of increasing access to quality healthcare for every patient in need, no matter the setting or the location. The danger is clear and present.

The time to act is now. 

Dhruv Joshi and Dileep Raman are Pulmonary and Critical Care specialists who trained and worked in the US before relocating to India to start Cloudphysician Healthcare, a healthcare technology company.

Cloudphysician remotely provides ICU expertise to hospitals that do not have access to ICU specialist doctors.

SUPPORTING EVIDENCE

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

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

Hobday, The open-air factor and infection control

Atkinson, et al., Natural Ventilation for Infection Control in Health-Care Settings

Hobday, et. al, Roles of sunlight and natural ventilation for controlling infection: historical and current perspectives

More resources will be added to the Cloudphysician’s COVID-19 resources folder from time to time. 

The White paper was first published on the Author’s LinkedIn Pulse Blog, it has been republished here with the Author’s permission.

CloudPhysician Website: Link

Dhruv Joshi
Dhruv Joshi

Director – Cloudphysician Healthcare Pvt Ltd

Dileep Raman
Dileep Raman

Director – Cloudphysician Healthcare Pvt Ltd

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