A prescription of equitable and effective care (Solutions for COVID-19 management)

A prescription of equitable and effective care

By, Anand Zachariah is a Professor of Medicine at the Christian Medical College, Vellore. George Thomas is an Orthopaedic Surgeon at St. Isabel’s Hospital, Chennai. The views expressed are persona

Context

# Medical care has been disrupted by the novel coronavirus.

# Fear, anxiety, uncertainty and confusion have all overtaken clinical services.

# The private sector, which delivers the major part of medical services, is now functioning at a skeletal level and patients have considerable difficulty in accessing medical care.

# Tamil Nadu has one of the better health systems in the country and has demonstrated that it can provide high quality care through public-private collaboration in the areas of maternity, cardiac and trauma care.

A neglect of the primary task

# Until now, the focus of the government has been on prevention of the epidemic through testing of suspects, isolation of cases and institutional quarantine of contacts.

# Hospitals have focused their efforts on prevention by admitting asymptomatic contacts and mild infections.

# With the focus on prevention, doctors have been unable to attend to their primary task of providing good clinical care to reduce morbidity and prevent deaths.

# The majority of COVID-19 infections are mild and resolve on their own.

# Serious illness occurs in the elderly and those with multiple co-morbidities such as diabetes, heart disease and respiratory problems.

# The primary cause of death in COVID-19 pneumonia is respiratory failure.

# The mainstay of treatment in moderate and severe illness is clinical monitoring, oxygen therapy to correct hypoxemia (low oxygen levels in the blood), and good supportive care.

# Even in those above the age of 80 years, the mortality rate is only 15%.

# Patients who require ventilator treatment have a mortality rate of over 50%.

# Good supportive care for sick patients is essential in preventing deaths.

# Hospital services have to focus on in-patient management of moderate and severe pneumonia, prioritising intensive care unit (ICU) beds for potentially reversible illness.

#  We need to ensure that every patient with moderate and severe COVID-19 pneumonia has access to the optimum level of care, to prevent deaths and ameliorate suffering.

Combating fear

# Because of the labelling and stigmatisation of those diagnosed with COVID-19, the public are reluctant to come to hospital and may come late or die at home.

# We need to send out a clear message that hospitals will provide good quality care for COVID-19, at affordable cost and ensuring confidentiality.

# For this to happen, the government must work with the private sector to make care accessible and affordable.

# The Tamil Nadu government’s efforts to cap the cost for different levels of COVID-19 care in private hospitals is a positive step.

# The government should financially assist the private sector by reimbursing basic patient care costs for providing COVID-19 care.

# Medical staff taking care of COVID-19 patients are anxious that they may acquire the infection and transmit it to their family members.

# Deaths of hospital staff due to COVID-19 have been reported, although the mortality risk is lower than that of the general population.

# Medical staff involved in COVID-19 care should be adequately protected with appropriate personal protective equipment, or PPE, and should be trained in infection control and clinical care protocols.

 A wish list

# In Tamil Nadu, we should shift the discourse from the focus on prevention and reducing the number of cases to an equal priority for providing COVID-19 care.

# Towards this we suggest that:

a. all private hospitals which have the potential, should take care of COVID-19.

b. They should be given requisite incentives and subsidies to that end;

c. every patient should be able to access medical care for COVID-19 from a private or public hospital;

d.  only patients with moderate to severe COVID-19 pneumonia should be admitted;

e. ICU care should be prioritised for COVID-19 patients who have potentially reversible illness;

f. confidentiality of the patient should be protected;

g. the government should support the basic cost of COVID-19 care in private hospitals as well;

h. city hospitals should pool their ICU resources for the care of COVID-19 pneumonia;

i. staff providing COVID-19 care, should receive adequate training and be provided appropriate PPE, and,

j.  finally, families of staff who die due to COVID-19 should receive appropriate compensation.

Way ahead

# These initiatives can only be realised with appropriate leadership from the government.

# The private sector has to be fully involved in clinical care of the COVID-19 epidemic.

# We should work towards making COVID-19 treatment available, affordable and effective.

# Our response to the epidemic must combine good science, clinical reasoning and a humane response to save the lives of the people of our country.