Beyond testing and isolation, fatality mitigation has emerged as a new focus area of the government’s Covid containment plan, as highlighted by the Centre during meetings with representatives of states last week.
A top government functionary told The Indian Express that to keep the fatality rate under control, there have been deliberations with states on three sub-aspects of the clinical management of patients: the time taken for patients to reach the hospital and the call refusal rate of ambulances; the average time the positive patient spends in the triage area before being assigned a bed; and the response of the hospitals in providing non-invasive oxygen to patients. These ‘sub-aspects’, sources said, often make the difference between life and death for serious patients.
In the June 11 meeting with health secretaries of states, Cabinet Secretary Rajiv Gauba had highlighted that 82 per cent of the deaths were from five states — Maharashtra, Delhi, Gujarat, West Bengal, and Madhya Pradesh; and that 65 districts have a case fatality rate higher than 5 per cent, much higher than the national case fatality rate of 3.22%.
Focus on clinical management
In the Centre's deliberations with states, fatality mitigation has been a key focus area. Epidemiologists and experts have also been saying that deaths, not rising numbers, is a key metric to understand the effectiveness of Covid containment plans. The government's focus on clinical management of patients is a step in that direction.
“Certain states have fatality rates of around just one per cent, and some have rates that are higher. For instance, despite the huge spike in daily cases in Tamil Nadu, the state’s Covid fatality rate hovers around 1 per cent and Karnataka’s is a little over 1 per cent. The number of deaths being reported tells us about the effectiveness of clinical management. And that something is not happening right in states which are reporting high fatality rate as far as clinical management of hospitalised patients is concerned,” the source said.
On the first sub-aspect of clinical management – the time taken by patients to reach hospitals and the response of ambulance services – the source pointed out that there has been “substantial improvement” in the national Capital in the last one week.
“The time to reach the hospital from the patient’s residence is an important aspect, especially for patients with severe symptoms. Also, call refusal rate of ambulances is a very important data that would reveal how fast the patient is reaching the hospital. For instance, in Delhi, data points out that there has been a substantial improvement in (the response of ambulances) in the last one week,” the source said.
On the second sub-aspect — the average time spent by the patients in the triage area before being assigned a bed — the source said. “This is also very crucial. A suspected patient could spend five minutes or even five hours in the triage area. If a patient spends five hours, the chances of that person dying are that much more. Also, the chances of the patient infecting people in the triage area are higher,” the source said, adding state governments, “are reviewing these two important data on a daily basis”.
The triage, often the emergency department of hospitals, is usually the patient’s first point of contact with health professionals. It’s here that a clinical investigation of the patient is done for Covid symptoms. The government has mandated that in the triage area, the suspected patient should be given a triple-layer surgical mask and directed to an isolation room, if available.
On the third sub aspect, the source pointed to the effective clinical management of states such as Tamil Nadu and Karnataka, which have a case fatality rate of less than 2%, in providing non-invasive oxygen support to patients.
“Once the patient is assigned a bed, the focus shifts to how responsive the hospital is in providing ventilator or non-invasive oxygen support to the person. In TN and Karnataka, oxygen has saved people, not ventilators,” the source said.
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