A Study on the Awareness and Preparedness of HealthFacilities in India to provide Clinical Care during theCOVID-19 Pandemic

Introduction

It was on 31st December 2019, Wuhan, the largest city in central China, with an estimated population of over 10 million people, began reporting an increase in pneumonia-type cases of unknown etiology. Cases were tracked back to the Wuhan seafood wholesale market with the hypothesis that patients had been infected by a virus transmitted by live animals. In the end of December 2019, a novel coronavirus, the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), was identified as the cause from the analysis of the bronchoalveolar washing fluid of a Wuhan patient¹ As of 28th January 2020, there were quickly in excess of 4,500 laboratory confirmed cases, with more than 100 known deaths. Travel-related cases have been confirmed in multiple countries and regions outside the mainland of China including Germany, France, Thailand, India, UK, USA, Canada, etc.²

In spite of the difficult demands and barriers foreseen, the dynamic and systematic implementation of key generic and specific pandemic-related action can facilitate efficacious hospital-based management during a pandemic. Multilateral agencies and medical bodies such as the WHO, NABH, AIIMS etc. have set up a taskforce to develop a management protocol for COVID19 and have constituted several committees to be able to respond to challenges which may emerge in the future due to the rising number of infections.

Hospitals thus play a censorious role within the health system in providing crucial medical care to the community, particularly in a crisis. Prolonged outbreaks can lead to the continuous spread of disease with rapidly increasing service demands that can possibly overwhelm the capacity of hospitals. To intensify the readiness of the health facilities to cope with the challenges of the outbreak, a pandemic, or any other emergency or disaster, hospital managers need to make sure the initiation of relevant generic priority steps.³

Ethical preparedness is an important component of the plan for dealing with public health emergencies or outbreaks. Preparedness here refers to the capability of the public health system, to protect and have the ability to quickly respond to by having in place a robust implementation plan.⁴ To tackle this situation, health emergency and disaster experts of the Tokyo Disaster Medical Assistance Team took the initiative in creating a brief educational course.

They established the course for expanding infectious disease care capacity by a dedicated hands-on lecture for health professionals who are unfamiliar with infectious disease care in ordinary circumstances.⁵

Understanding 2019-nCoV infection among healthcare workers and the risk factors for adverse outcomes is important not only for characterizing virus transmission pattern and risk factors for infection, but also for preventing future infection of healthcare workers and other patients, for informing and guiding measures at healthcare facilities at the national and State-levels and for reducing secondary 2019-nCoV transmission within healthcare settings.⁶

Quality improvement measures are required to be urgently initiated to improve pandemic preparedness and minimize healthcare workers infection rates. The focus should be on regular training on proper donning/doffing, fit testing, transporting of COVID-19 patients, and safe cleaning/disposal practices to ensure safe PPE use.⁷

Therefore, through this exploratory study, an attempt is being made to study and infer fromavailable resources the suggestive guidelines and expectations for a dedicated health facility and to explore the awareness regarding appropriate protocol and preparedness of hospitals to fight with COVID-19 infection among healthcare workers.

-Appropriate Strategies for Coping with the Pandemic in Hospitals:

-A hospital plan to cope with the pandemic includes implementation of measures to protect staff, patients and visitors from the infection. These must include:

-Adequate supply of PPE for frontline staff

-All healthcare staff involved in patient care should be well trained in the use of PPE

-Front line staff should be updated on the latest policies, via email on handling droplet and contact precautions with patients with instructions on the proper donning, use and removal of PPE

-The use of PPE with fluid resistant characteristics, disposable gloves with coverage over gown cuff, eye protection (including face shields or goggles) and fit tested N95 or higher face mask is mandatory when handling suspected or confirmed COVID-19 patient.

-The double glove application with the outermost layers of gloves changed between every patient

-Dual door entry with changing room and nursing station. Adequate amount of PPE should be available in the changing room with waste disposal bins to collect used PPEs. Used PPEs should be disposed as per the BMWM guidelines.

-All the departments are regularly evaluated on hand hygiene standards all around

-If single isolation room is not available beds could be placed 1 meter (3 feet) away from one another

-A specific route of transportation is used between the isolation wards & the imaging department or other departments etc.

-Thermometers were issued to staff so that they can record their temperature readings daily

-Single use equipment should be selected where feasible

-Separate staff caring for COVID-19 patients and those caring for other patients to reduce the risk of in-hospital transmission.^8-10

-Patients from COVID-19 affected area were advised to seek physician's help online rather than in-person through telemedicine, this decreases the risk of exposure and prevents potential transmission of infection to nurses and physicians.¹¹

Materials and Methods

This is a web-based study wherein a Google form was served to identify frontline workers (doctors, nurses, paramedics). The survey was carried out using a structured questionnaire adapted from WHO guidelines on COVID-19 preparedness, response and related literature. The questionnaire included 30 questions about hospital preparedness, awareness among healthcare workers and clinical protocol aspects.

The items in the questionnaire including open-ended, close-ended questions and multiple-choice questions as well. The time period of the study was from April 22nd 2020 to April 30th 2020. The data collected is represented in the form of table and descriptive statistics. Out of the fifty healthcare workers approached by the investigator, thirty-five of them had responded to the questionnaire indicating a response rate of 0.7%.

Study design

The study is across-sectional one and the study relies on the responses of 35 healthcare workers (mainly doctors) from different hospitals who willingly participated in the survey. Participants from different healthcare professions were included in the study to offer adequate diversity in role and understanding representativeness as well.

The respondents include healthcare professionals working in various private and public sector (secondary and tertiary care) hospitals and those working at community pharmacies located close to the hospitals. All respondents were registered healthcare professionals within their respective councils (Medical Council of India, Dental Council of India, Nursing Council, and the Pharmacy Council of India) who were managing and handling COVID-19 cases, regardless of their experience, duration of service and position with the hospital. Unregistered healthcare professionals and those returning incomplete surveys were excluded during data cleaning phase. The respondents who participated in the survey did so on a purely voluntary basis having known and understood the study, and they could choose to quit the survey at any stage. In order to obtain robust and complete information, participants were requested to respond to all questions of the survey.

Results

A total of 35 healthcare workers participated in the survey including 17 (49%) male, 18 (51%) females and most of the participants were below the age of 30 years. Each respondent represented a hospital and hence we are able to identify the characteristics of 35 different hospitals through this study.

The majority of participants were doctors and they were resident and consultants from departments such as emergency, surgical, OPD and medicine. The healthcare workers who participated were from different hospitals and spread out across manystates of India. Almost all participants were aware of the factors that could lead to and procedures required to convert normal rooms to isolation rooms for example.

It was further noted that around 94% of the hospitals reported having adequate space between two beds i.e., at least 1 meter (3 feet). Out of 35 respondents, 32 of them reported that their hospital had an isolation ward with separate ingress and egress.

Thirty-one respondents reported that their hospitals’ isolation ward had separate toilet facilities for patients with proper cleaning and supplies. It was noted that 97% of the hospitals had round the clock electricity supply. Thirty-two respondents (91%) reported that their hospital had implemented visitor’s entry restriction into the wards. The staffs in almost all hospitals were trained in the use of Personal Protective Equipment (PPE).

Twenty-six respondents reported that their (74%) hospitals’ OPD area had adequate space for physical/social distancing. Only 23 (66%) respondents reported that their hospital had adequate quantities of PPE. Only 24 (69%) respondents reported that their hospital had a triage station outside the facility to screen individuals before they enter. Only 8 (23%) respondents reported that their hospitals provide PPE for visitor’s number.

Thermal temperature sensors to check for temperature of healthcare workers was also very low i.e., only 20 respondents (57%). 30(85%) hospitals had conducted training programs on how to manage clinical services during this major pandemic.

Conclusion

COVID-19 promises to be etched in public memory as a major pandemic and will remain a discussion topic in the media and among the public for quite some time. An important concern for today that arises is that how can hospitals develop and offer a dedicated health facility to cope with this pandemic and provide care to the infected citizens while protecting their own healthcare workers. With this intention, this study was conducted to understand the awareness and preparedness of health facilities to deal with COVID-19 infections among healthcare workers.

This study has informed us that healthcare workers have sufficient knowledge about COVID-19 preparedness; however, there exist infrastructure and equipment shortages and absence of effective preparedness to handle clinical care. Healthcare workers continue to manage COVID-19 patients and carry out their duties to the best of their abilities while in a constant state of fear and ignorance about how well they are actually protected.

This study also highlights that there is actually a lack of PPE kit availability in these hospitals. Ensuring the supply of appropriate PPE with instructions and knowledge of appropriate use would reduce transmission rates, instill confidence among healthcare workers and also help save lives. This study also reports that there a very low proportion of visitors are provided PPE during their hospital visits although the criteria for visitors entry itself remains to be addressed. It is highly likely that if healthcare professionals are not aware of how to use appropriate PPE and are not motivated to protect themselves and in turn other workers, patients and their own families, there can be difficult situations for everyone. ^(12-14).

A classic example is the Bhilwara cohort in Rajasthan of how a healthcare professional needs to protect against infection since he/she is likely to transmit it to others ⁽¹⁵⁾. Proper preparedness and response and also increase awareness regarding PPE would play a major role in lowering the risk of COVID-19 infection for healthcare workers and in turn prepare them to treat patients effectively.