COVID-19: Risk Assessment & Mitigation Strategy

Aster DM Healthcare has been at the epicentre of managing COVID-19 pandemic in India and Gulf Cooperation Council countries ever since the pandemic hit in mid-March. This paper is a fascinating organisational case study and report about how Aster DM healthcare navigated the challenge of COVID - 19 Pandemic.

INTRODUCTION

The 2020 COVID-19 Pandemic has made society and the global economy volatile, uncertain, and ambiguous, even though high levels of preparedness have been developed for the situation. Late 2019, and early 2020, when the Coronavirus outbreak

was limited to China, there was little expectation that it would grow to such pandemic proportions. No aspect of life, including business ventures, has been left untouched by this scourge. While the world stands still due to the COVID-19 pandemic, the impact that this disease has had on healthcare systems in various countries has been profound. Healthcare organizations, along with government functionaries from across the country, have delved into innovative ways to battle the disease, and have devised policies and protocols to ensure continuity of care and therapy for both COVID and non-COVID patients, within the ambit of safety for both patient and healthcare workers.

This paper provides a case study of how ASTER DM Healthcare handled the COVID-19 situation, to keep afloat both clinical and operational functions while ensuring the safety of healthcare workers. This was achieved by adopting new protocols based on updated scientific information and guidance from thought leaders across the Aster Group, which enabled the leadership team and staff at Aster

to plan and respond swiftly to the daily dynamic uncertain environment created by the COVID-19 onslaught.

OBJECTIVES OF THE STUDY

1. It provides an insight to the reader on how Aster DM worked towards establishing best practices within the healthcare scenario and act as a foundation for action if the future again inflicts similar challenges.

2. Ensure continuity of clinical and operational functions, albeit within the ambit of safety and mitigation of the risk of cross-infection for patients and health care workers.

3. Create a base document that records the futuristic approach for handling emergency and elective cases with new protocols during this new “normal” COVID era.

4. Share the arduous journey which paved the way for new learnings, to make Aster DM battle-ready in these uncertain times.

5. Implementation of a top-down approach for clinical and nonclinical staff to stringently follow the new rules of engagement in the workplace, based on the three pillars of safety- hand hygiene, social/ physical distancing, and universal masking (along with adequate PPE).

IMPACT & COVID PREPAREDNESS

An outbreak of the respiratory disease was reported from Wuhan, a city of 11 million people in China, on 31st December 2019. The causative agent was discovered in January 2020 to be a novel envel- oped ß-coronavirus of the same sub genus as SARS- CoV,1 and has been named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) also called Coronavirus disease 2019 (COVID-19).2 Novel Corona Virus (SARS CoV2 / COVID-19) is a highly contagious infection and has been declared as a pandemic by the World Health Organization. It is important to be vigilant about the spread of the disease and be able to provide the rapid implementation of outbreak control and management measures. The lack of a proven treatment and vaccine as well as the high vulnerability of hospital staff makes it imperative to have guidelines as to how we can protect healthcare workers.

Hospitals are complex and vulnerable institutions, dependent on crucial external support and supply lines. Under normal working conditions, many of our hospitals frequently operate at near- surge capacity. Consequently, even a modest rise in admission volume can overwhelm a hospital beyond its functional reserve. Well-established partnerships with local authorities, service providers (e.g. of water, power, and means of communication), supply vendors, transportation companies, and other organizations are required to ensure the continuity of essential services.

During the current outbreak of COVID-19, well- prepared health facilities are at the center of an effective response. The rapidly evolving outbreak requires all hospitals to be able to adapt to a swift increase in demands while continuing to ensure safe environments for health workers. All hospitals need to take precautions against potential interruptions of critical support services and shortages of equipment and supplies. This document aims to provide

a Risk Assessment and mitigation strategy based on lessons learned from Aster DM Healthcare Hospitals in India & GCC.

Also, a high rate of staff absenteeism can be expected. A shortage of critical equipment and supplies could limit access to needed care and have a direct impact on healthcare delivery. Panic could potentially jeopardize established working routines. Even for a well-prepared hospital, coping with the health consequences of a COVID-19 would be a complex challenge. Despite the difficult demands and obstacles foreseen, the proactive and systematic implementation of key generic and specific actions facilitated effective hospital-based management during a rapidly evolving pandemic.

RISK, MITIGATIONS & STRATEGIES

Well-prepared health facilities

Well-prepared health facilities is the key to saving the lives of COVID-19 patients. Preparations have been well done for global outbreaks and disasters in our system with our knowledge & experience from Kerala floods and the Nipah virus

outbreak. On 30 January 2020, a public health emergency of international concern was declared by the World Health Organization (WHO). We activated our incident command centers across the group and carried out a rapid risk assessment. The overall objective was to strengthen the preventive action to reduce COVID-19 risk and enable Aster to take a timely and useful response. Priority measures

were identified based on significant references like WHO, CDC, and national guidelines. An executive council was established to cascade our business units with effective strategic plans.

KEY MEASURES TAKEN TO COMBAT SPREAD

Clinical Excellence

As the COVID-19 situation is rapidly evolving, Aster focused on developing clinical guidelines for healthcare workers in concurrence with international organizations like WHO, CDC etc. The clinical excellence was achieved by implementing updated guidelines which were constantly shared with healthcare providers in order to achieve the best patient outcomes. Our COVID dashboards helped us to monitor our outcomes and at the same time, providing insight into improvement strategies in patient care.

MANAGEMENT OF COVID CASES AT THE FIRST POINT OF CONTACT

THE EMERGENCY ROOM (ER)

On 30th January 2020, the WHO declared COVID- 19 a public health emergency which soon evolved into a pandemic. From the early days of this disaster, Aster DM has been working tirelessly with the local authorities to prepare its response to the disease.

One of the major elements of the response was the set-up of more than 4 facilities with a total capacity of 800 plus beds which helped control the spread

of the virus. Meanwhile the hospitals stopped their elective activities and focused almost entirely on the management of the suspected and confirmed cases.

The COVID response team in hospitals decided to dedicate the emergency departments to the management of suspected cases and the wards and ICUs were dedicated to the management of confirmed cases. As a consequence, the more severe cases were taken directly to the wards or the ICUs and the number of severe cases seen in the ERs remained very low. The vast majority of the patients who attended the ER’s were suspected cases that needed a confirmation or confirmed cases who required screening before isolation. Most of them were clinically well. Despite this organisation the ERs received a few severe cases and the level of response was exemplary. A few cases have been highlighted to showcase the quality of the emergency response:

Case Number 1

A 62-year-old male patient was admitted in one of the isolation hotels, having been referred directly by DHA (Dubai Health Authority). The patient did not have any identified risk factors other than being over the age of 60. He was not obese and had no co- morbidities identified at the time. He tested positive for COVID-19 after a period of persistent cough and fever. 12 hours after admission he was found to be hypoxic on room air and was promptly transferred to the ER. On arrival, he was found to be conscious and responsive, patent airway, breathing at a rate

of 24 per minute, saturation on room air was 70% and only reached 85% with 10 liters of supplemental oxygen delivered via a non-rebreathing mask. His cardiovascular parameters were within normal limits and stable with a pulse of 71 bpm and a BP of 128/62. His GCS was 15 with no neurological deficit. An arterial blood gas showed a respiratory failure of type 1. A chest X-Ray showed a picture evocative of atypical pneumonia compatible with corona virus.

The patient was immediately referred to ICU for further investigations and management. The NIV was not started in the ER due to the speed at which the patient could be moved to a more appropriate environment given the risk of contamination of staff that is associated with the procedure.

The patient was successfully managed conservatively in ICU without intubation before being discharged home. This case highlights the excellent level of teamwork that was displayed throughout the COVID crisis. The coordination and communication between the different teams (hotel staff, ambulance team, ER and ICU staff) was excellent, and ensured permanent safety for the patient and the members of staff in spite of the challenging circumstances.

Case Number 2

A 67-year-old male patient was brought to the ER by national ambulance in cardiac arrest. The patient was a confirmed case of COVID who was in self isolation at home and was known to suffer from diabetes, hypertension and cardiac failure. The staff members were pre alerted and had enough time to get prepared and were wearing full PPE when the patient arrived. The patient presented a trismus which was probably an early

sign of rigor mortis. He was managed following the ACLS protocol for 40 minutes with continuous CPR and adrenaline on alternate cycles, before he was declared dead in view of the lack of response to the resuscitative attempt.

Despite the poor outcome, this case highlighted the level of preparedness of the all the emergency staff members. The case was managed calmly

and professionally in full respect of staff safety measures, by the means of PPE. There was no precipitation and every step of the ACLS protocol was followed without failure.

These two examples demonstrate that, after weeks of training and with the help of the infection control team, internal medicine and intensive care, the ERs have been able to safely manage critical cases in the most professional manner.

Despite the constantly growing feeling of anxiety, and despite some serious technical challenges posed by the nature of the infectious agent, the team has shown a real level of maturity in this unique crisis management.

MANAGEMENT OF CRITICAL CARE PATIENTS IN PANDEMIC

Beginning

Medcare Hospital partnered with DHA in March 2020 and we started preparing the critical care unit to accommodate and manage such cases by increasing the number of rooms with negative pressure.

As we strongly believe that prevention is most effective at the start, we immediately took measures to prevent and limit transmissions between the hospital staff, and protect the healthcare workers

in accordance to the international and national COVID-19 precautions guidelines. This included the availability of PPE and proper use and disposal of the protective equipment. Continuous education and close communication with the infection control team have been at the core of the initial phases of our plan of facing the pandemic.

We formulated and set up guidelines and protocols derived from the recommendations of surviving sepsis guideline 2020 - special edition for COVID, World Health Organization.

The learning phase

We soon started receiving cases of different nationalities. We have noticed that we have a con- siderably higher number of male patients compared with female patients, most of them between 30 and 60 years old. But these observations have to be taken in the context of Dubai’s special demographic (higher number of male residents, most of them young or middle aged.)

Most of the patients presented with complaints of fever and some degree of difficulty in breathing.

We observed that a significant number of patients presented with low levels of PaO2 and SpO2 without clinical signs, symptoms, or visible distress - silent hypoxia.

Most of our patients showed worsening of the symptoms in the second week of disease, many times after a few days of improvement, which can give a false sense that patient is starting the recovery phase. This second phase of the disease is when most of the critical care patients end up on ventilator. A small percentage of those in respiratory failure are improving on NIV, thus we chose to initially give a trial for most of our patients with noninvasive support if tolerated before going for intubation.

Once the patient had an ET tube in place we faced one of our biggest challenges, which was sudden ET tube blocks with large clot and necrotic tissues.

Despite daily proper suctioning (closed and opened) on the ET tube, the high majority of patients required ET tube to be frequently changed due to acute block- age with clots (in some cases more than once per day). In our ICU all ventilated patients have been started on heparin nebulization and this therapy seems to offer some decrease in the need for change of ET tubes.

Although all specific ARDS ventilation recommendations have been used, we have soon realized that this is not the “classic” ARDS picture with stiff lung that we are facing, as there was not a requirement for high plateau pressures to obtain satisfactory tidal volumes (6-8 ml/kg), but despite the high volumes, patients remained severely hypoxic even at very high PEEP and hypercapnic, (situation associated more with pulmonary embolism). Prone position offered some relief in patients with refractory hypoxia (it has to alternate with supine every 8 to 10 hours).

For the patient that required prolonged ventilation we opted for percutaneous tracheostomy which made it easier to deal with recurrent tube blockage, and difficult weaning mainly due to hypercapnia.

We have noticed that intensive chest physiotherapy is worsening the patient’s ventilation, thus we opted for mild or no chest physiotherapy in the initial phases of the disease in critical patients and to return to usual physiotherapy in the recovery phases.

Though this masquerading virus was affecting the oxygenation and ventilation of the patient, it gave us more challenging complications such as thrombotic events like ACS ischemic stroke, acute tubular necrosis and pulmonary embolism. A considerable percentage of our patients were developing myocarditis and acute coronary syndrome pictures. Thus all our patients have been started on enoxaparin therapeutic dose and Aspirin. After this protocol had been put

in place it was noticed that there was a decrease in the thrombotic complications. In one case in which Thromboembolisation was required for acute MI, a significant improvement in ventilation was noticed, but unfortunately only for 24 hours after the therapy.

We have also noticed that all patients admitted in ICU have very high levels of D dimers, Ferritin, CRP. The D- dimers levels were found to be between 3000 and more than 30000, and it looks like there is a direct correlation between these lab levels and the course of the disease. Trombocytopenia have been also noticed, but only mild to moderate decrease of platelets

levels. In one case in which thrombolization had been required for acute MI, an improvement in ventilation was also noted. Among dyselectrolytemias Phosphate levels have been found to be low in almost all critical COVID-19 patients.

OUTCOMES

It has been noticed that patients recovering from severe form of the disease are left with Chronic/ permanent lung damage. Most of the patients that have recovered from moderate/severe ARDS form of COVID 19, have been discharged with radiological images suggestive of lung fibrotic changes from

mild to extensive. In one particular case, the changes were accompanied by the presence of emphysema and large bullae which complicated with spontane- ous pneumothorax. There is a need to follow these patients in the future and assess their outcomes on a long term basis.

Managing the corona virus infected patient

◆ In accordance to the surviving sepsis guidelines, we started general management like any other septic patient . Although we were initially following the fluid restriction recommendations, we have soon decided to use the initial fluid resuscitation as per patient needs in hemodynamically unstable patients, using minimally invasive cardiac monitoring and assessing patient’s fluid responsiveness, followed by deresuscitaton when patient is out of the shock phase.

◆ Along with the specific support of functions, we included in our protocols virus specific management which included the use of antivirals as recommended by the national and international protocol. The anti-viral agents that were used included (lopnavir/ritonavir, favipiravir). Immuno- modulatory drugs such as tocilizumab, have been also used in critical patients which showed some benefit.

◆ Managing the thrombotic complications of the corona virus was a challenge we faced every day. We used subcutaneous anti-coagulants (LMWH in the therapeutic dose). We used anti-platelets including (Aspirin and Plavix). We used NOACs (rivaroxaban) in stable COVID-19 patients with mild pneumonitis.

◆ Facing the ET blocks, we used heparin nebuliza- tions with which showed some decrease in the frequency of changing ET tubes.

◆ Early tracheostomy showed a better outcome in patients on long ventilator time due to refractory hypercapnia.

◆ We used prone position for the patients with severe ARDS with refractory hypoxia. Some improvement in the oxygenation have been noticed

CONCLUSIONS

There are still many unknown aspects of the infection with SARS-Cov2 virus. These major knowledge gaps make dealing with critical patients with COVID- 19 a special and unprecedented challenge. There is a need to continuously adapt the current guidelines, as new managements with a strong evidence base and new therapeutic options are emerging.

^{_{*Disclaimer: The situation regarding COVID-19 is rapidly evolving and changes daily. Although timely policies should be implemented to facilitate objective decision-making, such directives will inevita- bly need to adapt to this fluid environment. This document content stands as on date. Visit the article page at www.theamj.org to access the full version of the Whitepaper along with the details of mitiga- tions strategies implemented by the individual Aster hospitals in India and GCC.}}