When did you decide on becoming a COVID care unit?
COVID was international news until February 2020; as it came closer home, question of Fortis allocating beds for COVID care came up. I had conflicting thoughts—if I transform my hospitals for COVID, will my frontline staff be ready to work? Will it reduce non-COVID patients due to the stigma? What about our financial stability?
I took a call for all my four units—Fortis Hospital, Mulund, would become one of the first in Mumbai for COVID care. My strategy involved offering critical care services (being experts in that space) and making Mulund a referral centre for the other three (Kalyan, Mahim, Vashi), continuing to run them as non-COVID units.
Did the team accept your decision?
It wasn’t easy to motivate the team especially my key clinicians, as we knewwhat we were getting into. However, I remained firm. A core team was formed to draft a process-flow and safety
measures. With an initial plan ready, I went back to finally convince them. Once they were persuaded, focus was shifted to the infrastructure and employees.
How did you ensure front-line employees’ safety?
Engaging and keeping employees safe was vital. The team designed a manpower plan and initiated discussion with every segment managing patients at close-contact (nursing, housekeeping, security) to address genuine fears. We committed fully to their care in case they got infected. Each and every department was trained with effective use of technology. Hospital provided accommodation to most staff as lockdown crippled transportation and healthcare workers were ostracised by housing societies.
Post two COVID months, I was pleased with our team’s performance and entire staff 100% safe. We were viewed as role-models within the network and by other private hospitals.
However, in May, a COVID duty doctor tested positive; within a week, few more staff got infected. My care-givers became care-seekers! We managed to keep the show running even with a depleted team. After a stressful three weeks, all staff were discharged post a full recovery.
What were the team’s main challenges?
In May, cases surged and there was a never-ending clamour for beds. Mulund was sought-after as it headlined media/press coverages; COVID patients couldn’t be refused but our routine footfall was reducing rapidly. COVID-work could no longer be Mulund- restricted; Our hospitals like Vashi transformed into a dedicated COVID centre; Mahim managed mildly symptomatic cases; Kalyan, being a small facility, couldn’t provide COVID services but became a knowledge- partner with the Corporation. Soon, we were extending treatment to cases beyond Mumbai. As beds’ demand mounted, we kept rising to the occasion; home-care scheme was launched for mildly symptomatic patients.
We were grappling with lockdown, government capping and increased cost of care. Our financials needed attention; my management team, clinicians and myself opted for compensation- related cut-backs to tide over these tough times.
What is next on the agenda for Fortis?
We are recognised as a preferred destination for COVID. A post-COVID OPD was inaugurated and the facility offers COVID immunisation. On the economic front, emphasis is required, but launch of our ‘New Age Hospital’, (hybrid care) has picked speed. Myteam is readying for the 6th JCI re-accreditation, and the hospital is all set to become the 1st hospital pan-India to be assessed on brand-new edition of JCI protocols. Life goes on.
Fortis Hospital, Mulund: Marching on the Covid Battle
Hospital’s war cry
The pandemic posed myriad challenges to the team at Fortis Hospital, Mulund, Mumbai, due to its unanticipated nature, critical ones being absence of prescribed treatment norms, vaccine unavailability and effective management of protocols of COVID and non-COVID patients. To keep up its pledge to the community “healthcare for all”, the Fortis team rose to the occasion, ready to combat this public health emergency.
A core team of experts was created. It comprised of the Zonal Director (Mumbai), Infectious Disease Specialists, Intensivists, Critical Care experts, Emergency Care experts, medical services, administration and nursing. Post extensive brainstorming sessions, the objectives were laid out:
Creation of a safe patient pathway
Development and standardisation of clinical protocols
The team mapped a chart highlighting crucial touchpoints during a patient’s hospital visit. Efforts were undertaken to ensure no cross contamination happens at any touchpoint. Multiple preparedness runs were conducted to create a safe patient movement pathway, leading to carving out a ‘hospital within a hospital’ set-up. Currently, the hospital has a ‘3-tier COVID defence structure’ with immaculate screening, Fever Clinics (FLU) and in-patient isolation facilities. All this was executed without impacting admitted patients
and OPD services.
Uniform clinical protocols
In a similar vein, transformation was needed in the COVID patients’ treatment guidelines. The team reviewed available literature, and had discussions with colleagues overseas who had managed these patients. Clinical protocols were laid down for four patient categories:
1. Confirmed COVID-19 positive
2. Suspected positive
3. Patients with upper respiratory tract infection
4. Patients seeking regular medical aid
All hospital protocols were reviewed for standardising of admission, investigations, level of care, details/ frequency of communication with relatives across wards, HDU and ICU. Consistent schedules were established for blood sample collection, diet and drug administration. Uniform Infection control practices and ICU protocols were implemented for effective functioning. Meanwhile, the hospital’s Director of Clinical Care got aboard the Maharashtra Government COVID-19 Taskforce, further synergising facility’s efforts with rest of the state. Referrals were coming from outside the city, and the hospital had to expand its bed strength to accommodate maximum number of COVID19 positive patients. The facility was gaining pan-India recognition for its “best clinical outcomes”.
Frontline warriors’ engagement
Adequate medical personnel were needed to manage the patient load. A 7-on-7 schedule (7 days’ duty followed by 7 days’ of isolation) was prepared for the clinical staff. The staff was required to have extensive awareness to manage COVID patients. Training sessions incorporated blended-learning approach with webinars, e-learning modules, certificate courses and classroom training (maintaining safety standards). Initially, sessions were conducted on COVID-19 awareness, hand/respiratory hygiene reinforcement,infection control practices, PPE donning/ doffing, etc. As treatment norms became clearer, training focussed on COVID-related medications, transmission- based precautions, specific training on positive patients’ critical care, COVID-related documentation/consent and emphasis on mental health (stress management, maintaining appropriate sleep cycle, coping with behaviours in a social-setting, etc.) were incorporated.
Digital mode for patient care!
Treatment shifted from a majorly offline to a digital mode. This seamless transition was customised for patients needing assurance due to COVID fear/ myths, and those infected, requiring treatment. Multiple technological interventions were undertaken like online counselling on a dedicated COVID helpline that was managed by medical experts, tele/video consultations and AI chat-bot for risk-screening. Homecare services were launched for mildly symptomatic patients, thus restricting patients’ hospital visits. Community awareness on COVID was generated through specially-curated content on social-media, live interactive discussions with the hospital’s COVID19 experts, broadcast of informational videos, along with recovered patients’ testimonials. As the lockdown eased, ‘new normal’ advisory series were circulated, to enable the community to adapt better, depicting regular activities like ATM-visits, grocery-shopping, managing special conditions like diabetes, dialysis etc.
A ‘new age hospital’
The hospital continued rendering care to non-COVID patients even amid the pandemic. The emergency department, designed with negative pressure rooms within the existing infrastructure, provided uninterrupted service for COVID and non-COVID patients. Initially, digital/online consults were extensively utilised. Soon, regular OPDs and set schedules for dialysis and chemotherapy resumed. Treatment of patients especially with serious ailments like cardiac conditions, Cancer, remained unhindered; this included surgeries in the OT, while ensuring that all protocols were followed.
Aiming to tackle short and long-term implications for patients who emerged winners post their COVID battle, the hospital launched the city’s first dedicated post-COVID OPD. Driven by Intensive Care Specialists and Infectious Disease Specialists along with Mental Health Experts, the OPD continues to provide focused care based on three pillars—clinical assessment, psychological intervention and rehabilitative care. This model is being adopted at other civic and private hospitals as well.
The hospital marches on in its fight against the deadly virus by becoming a COVID-19 vaccination centre, further strengthening its partnership with the Government and the allied civic bodies. An inoculation zone was identified within hospital premises, where about 500 citizens have been receiving the vaccination each day; the team hopes to intensify this crusade over time.
Fully equipped as a hybrid-care hospital with expertise to manage diverse ailments offering uncompromised care and safety, including the dreaded COVID, Fortis Hospital Mulund has emerged to be a trailblazer in the fight against COVID-19
Critical care: The Core of Covid Management
patients early. Meanwhile, I was appointed as a member of the Maharashtra Government COVID-19 task force. The Fortis ICU protocols were deliberated by the task force, to be included as a part of the state’s COVID management protocol.
Many aspects of our clinical care differed from how other ICUs were managing the disease. The high flow nasal cannula device became the standard of care for non-invasive ventilation of COVID patients. Its efficiency, ease of use, patient comfort facilitated recovery of many patients, aiding several others to progress on to invasive ventilation. For the patients needing invasive mechanical ventilation, the team followed a strict protocol—no hesitation in ventilating patents when essential, unlike ICUs where ventilator outcomes were questioned. Prone ventilation became the norm. The clinical outcomes spoke for themselves; lowest mortality rates were seen among our ventilated patients. The proof of the pudding was when the medical community recognised Fortis Mulund as their preferred destination for COVID treatment. More than 200 doctors, several paramedical and nursing staff have been treated at the unit, successfully.
Support was extended to patients unable to reach Fortis, admitted in other hospitals on ventilator, with their condition continuously deteriorating. We became one of the few teams in the country to initiate an Extra Corporal Membrane Oxygenator (ECMO) retrieval program, wherein the team would visit, start ECMO at the referring hospital and aid patient transfer (on ECMO) to Fortis. It was a gratifying experience for the hospital; the service was widely acknowledged by the doctors and the community at large.
The virus was predominantly affecting the lungs. There was a small group of patients whose condition was not improving despite maximal care. Lung transplant was their only hope. We decided to resume our lung transplant program and it’s in top gear right now.
This journey has been one of crests and troughs, bringing to the fore our abilities as a team, establishing Fortis Hospital, Mulund, as one of the leading health-care providers in the country, during the most unprecedented time, with Fortis ICU at the core of care delivery.
Cancer Care During Covid-19