The government is mulling a change in policy on care of patients of novel coronavirus, limiting hospitalisation to only those who really need it.
So far, all positive patients have been kept in hospital, but as numbers rise, discussions are being held about sending the milder cases to home quarantine and monitoring them over phone.
Highly placed government sources said this was being discussed as much to rationalise the use of hospital beds as to minimise exposure of healthcare workers, who are most at risk of contracting the disease. India has recommended hydroxychloroquine as post-exposure prophylactic medication (preventive medicine after exposure) for healthcare workers, but has so far not given out a consolidated list of the number of infections among doctors, nurses etc.
While there are no definite protocols for hospitalisation of a symptomatic patient (fever, cough, and shortness of breath), the guidelines are clear on two aspects: the final decision to admit a patient is the discretion of the treating physician; and till the time laboratory results are received, the suspected patient has to be kept in isolation at a health facility and given symptomatic treatment.
As per the guidelines on clinical management of COVID-19 issued by the Ministry of Health and Family Welfare, patients with mild symptoms — low-grade fever /cough /sore throat without shortness of breath — “may not” require hospitalisation “unless there is a concern for rapid deterioration”. However, government sources said, these guidelines are “not meant to replace clinical judgment or specialist consultation”.
Optimising use of beds, cutting risk
As the all but inevitable spike in the infection comes, it will be critical to rationalise the use of hospital beds, so that the limited capacity can be utilised for patients who need it most. Keeping the milder patients at home will also go some distance in lowering the risk for frontline healthcare workers.
Asked about a change in hospitalisation protocol, Joint Secretary, Health, Lav Agarwa, had said Monday: “All positive cases are sent to the hospital, none of them is in home quarantine. Even after discharge they are monitored for 14 days.”
The idea now is to extend the model for the post-discharge 14-day monitoring over phone to include patients with mild symptoms who are at home and in isolation.
A government source said, “There are four categories of COVID-19 patients — ones who just need to be watched and be kept in isolation so that they do not infect others; those who need care in a high-dependency unit, maybe need oxygen; a third category who needs ICU care and constant monitoring; and the last group that needs to be on ventilators. Reports suggest 80-85% have mild symptoms and just need symptomatic relief. We are planning to keep such patients at home. They will be monitored over phone daily. If need arises, they will be shifted to the hospital immediately.”
The source underlined that more than a bed-rationalisation effort, the change being considered was about minimising contact of doctors and other hospital staff. “The lone recommendation currently is to avoid exposure. Why should I expose my doctors and healthcare workers for a person who can very well be taken care of at home? In fact, we are also thinking there should be different designated hospitals for the fourth category of patients.”
There are an estimated 1.26 lakh isolation beds earmarked for COVID-19 patients in the country. This includes 17,631 beds in Central government institutions and 1.09 lakh in states. The Railways has been tasked with creating 3.2 lakh isolation and quarantine beds, including in coaches.
The hospitalisation policy so far, though unwritten, is so stringent that a foreign national who had tested positive on arriving in India was issued a limited visa and provided hospital care.
The Health Ministry’s clinical management guidelines state that early identification of those with severe symptoms “allows for immediate optimized supportive care treatments and safe, rapid admission (or referral) to the intensive care unit”.
On discharge of coronavirus patients from hospital, the guidelines state, “Discharge after chest radiograph has cleared and two specimens turn negative within 24 hours.” However, the treating physician still holds the right to take a call. For symptomatic patients whose sample test results are negative, discharge is “governed by provisional/confirmed diagnosis” by a treating physician, and the patient has to be monitored for 14 days from their last contact with a confirmed case.
Sources in government hospitals currently managing COVID-19 patents say “the general guidance” regarding whom to admit is based on the patient’s respiratory rate, blood pressure, blood oxygen saturation level, age, cardio-vascular risk including hypertension, chronic lung/liver/kidney disease, diabetes and other immune-compromised states. A decision on ICU admission is taken based on the need for mechanical ventilation, if a patient’s mental status is worsening, and if a patient is experiencing multi-organ dysfunction syndrome.
In the US, currently the worst-hit country in the world, 21%-31% of COVID-19 patients between February 12 and March 16 were hospitalised, with 5%-12% admitted to ICU, as per a report by the Centers for Disease and Control. Some US hospitals have even started ‘Do Not Resuscitate’ policies for coronavirus patients.
In Italy, at the peak of the outbreak in places like the badly-hit Bergamo, only the very gravely ill were being admitted in hospitals.
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