On Friday, India saw the largest single-day jump in patients testing positive for the coronavirus disease, taking the tally of cases to 226. The increase in cases has brought to centre stage the question of adequate health infrastructure to treat the patients. But contradictory guidelines issued by states and the Centre caused confusion among private hospitals.
In the evening, the Union Ministry of Health and Family Welfare put out an advisory that said no public or private hospital should turn away a suspected coronavirus patient and admission of such patients should be notified immediately to the government.
“The medical infrastructure in the country needs to be prepared for any possible influx of patients on account of COVID 19,” the advisory said.
However, state health officials Scroll.in spoke to said they were yet to see the advisory.
The Friday directions followed one on March 18 in which the ministry said it was enlisting the private sector in the fight against the coronavirus. This advisory elaborated on the reporting procedures to be followed by the private hospitals to notify coronavirus cases but said little about treatment.
After the March 18 advisory of the central government, many state governments issued their own guidelines for private testing and treatment of coronavirus. The state guidelines, however, did not make it mandatory for all private hospitals to treat coronavirus patients. “All private clinical establishments are hereby requested to establish isolation ward adopting norms and protocols and the same enclosed for perusal,” the Tamil Nadu advisory said.
Health is a state subject in the Constitution and for implementation of Centre’s directions, an order from the state governments is required.
The latest central advisory on March 20 asks hospitals to notify pneumonia patients “so that they can be tested”. Until now, the criteria laid down a central agency restricted tests to patients with acute respiratory illness who had travel history to affected countries or contact history with confirmed cases, and health workers caring for them. The latest advisory suggests India is expanding tests to those without travel and contact history.
As preparation for the influx of cases, hospitals are expected set aside rooms for coronavirus treatment and to ensure availability of medical equipment, including ventilators. “Hospitals must procure sufficient numbers of ventilators and high flow oxygen masks in preparation for future requirements,” said the advisory, put up on the ministry’s website. “...the following interventions are proposed up to 31st March 2020. They will be reviewed as per the evolving situation,” the document said.
But the advisory has sparked confusion on the ground. Scroll.in spoke to owners and managers of private hospitals and state officials in Tamil Nadu, Assam and Chhattisgarh.
State officials said they were yet to see the guidelines, while hospital managers said procuring equipment like extra ventilators would be difficult for smaller hospitals. They also expressed surprise that the government was not creating a single point system for the procurement of safety equipment necessary for all medical workers who interact with patients at the hospitals.
What private hospitals say
Scroll.in spoke to two private hospitals in Chennai. Both of them were under the assumption that admitting patients with the Covid-19 disease would be optional.
After going through the Centre’s Friday advisory, both the hospital owners categorically said that parts of the guidelines that talk about procurement of equipment would be impossible to fulfill on a short notice. “Ventilators are very costly equipment. Where will we get them in a few days?” said one hospital owner, requesting anonymity. “Good ventilators will cost anywhere between Rs 10 to Rs 15 lakh.”
The other hospital owner added that while advisories are being issued, there was no indication on what the government is doing to help procure things necessary to run a new coronavirus ward. “In normal course, we do not have large stock of PPE sets [personal protection equipment for health workers] because it is not necessary in non-infectious cases,” said the hospital chairman, a senior doctor himself.
Secondly, the owners said the guidelines issued by the Tamil Nadu government made offering coronavirus care optional and not mandatory. “We were of the view that if we did not have the facilities, we need not admit [coronavirus patients],” the hospital chairman said. “But the central ministry advisory is telling us it might now be mandatory.” Once it is made clear that hospitals cannot turn suspected coronavirus patients away, there is no option but to put in place the infrastructure, he added.
Under the guidelines issued by Tamil Nadu, it was mandated that private hospitals treating coronavirus patients should have dedicated staff for the wards. “Doctors, nurses and paramedics posted to isolation facility need to be dedicated and not allowed to work in other patient-care areas,” the guidelines said.
“In many hospitals, there is already staff crunch. Unless hospitals do a major recruitment drive, this is going to be difficult,” said a senior doctor in Chennai, who was formerly a head of department at a government medical college and visits some of the top private hospitals in the city for consultation. “Ideally, this advisory should have come in when the infection was in stage one. This is coming on the cusp of community transmission,” he said.
The doctor added that even if the hospitals procure ventilator on emergency basis, staff has to be trained to use them. “Doctors cannot sit in the ward and operate. Training use of ventilator is not simple,” he said.
What state officials say
The contradiction between the Centre and state directives is quite significant. While the Union Health Ministry on Friday made it clear that no hospital can turn away a suspected coronavirus patient, the state guidelines have so far made it voluntary for private hospitals to admit them.
Scroll.in contacted Tamil Nadu Public Health Director K Kolandaswamy after the Centre released the Friday advisory. “The Tamil Nadu guidelines are not mandatory. But if situation arises, we will revise them,” he said.
Kolandaswamy added that the state had held several meetings with private hospitals over the last month and there was no question of lack of communication. “I can assure you there is no shortage of safety equipment in the state.”
Assam’s Principal Health Secretary Samir Sinha said on Friday evening that he was yet to look into the new advisory from the Union Health Ministry.
Like Tamil Nadu, states like Assam and Chhattisgarh, governed by the Bharatiya Janata Party and Congress respectively, have issued almost identical instructions to private hospitals: If you have the resources, keep suspected cases in isolation wards till screening results are out; if you are not equipped, send them to the nearest government facility.
“We have told hospitals to set up isolation wards as per their capacities,” said Ganesh Saikia, joint director of health services in the state capital Guwahati. “We are also training lab technicians to collect swab samples.”
So far, only officials of the state’s health and family welfare department have been collecting samples, said Saikia, as private hospitals do not have the necessary equipment to transport samples to the testing centres. Samples are being tested in the government-run Guwahati Medical College and Hospital, said Saikia.
Small clinics and individual medical practitioners, Saikia said, have been instructed to refer patients with acute respiratory complaints whose symptoms cannot be attributed to other causes to the Guwahati Medical College and Hospital.
In Chhattisgarh, officials said hospitals were being given similar instructions. “Bigger hospitals should admit patients, and if they have history of contact [with anyone who has tested positive for the virus] or foreign travel or contact with any foreign traveller, they should be treated as a suspect and contained,” said Akhilesh Tripathi, deputy director at the state’s Health and Family Welfare department. “Then they should contact us.”
However, unlike Assam, in Chhattisgarh, swabs are still only being collected by officials of the state’s health and family welfare department, said Tripathi. “After they inform us, we will immediately send a team to collect the sample,” he said.
As in Assam, smaller private clinics in Chhattisgarh have been asked to refer suspected cases to government hospitals.
Big versus small hospitals
Hospitals, for their part, said they were following the guidelines laid out by the Ministry of Health and Family Welfare. “We are not refusing to admit parents with complaints of respiratory tract infection – and we have evidence to prove that,” said Navanil Barua, a senior doctor at the GNRC Hospital, one the city’s largest private tertiary-care hospitals.
“The health ministry’s guidelines are very clear about who qualifies as a suspect and in that case, we notify the government,” he added. Essentially that translated into two categories of patients with respiratory illness, said Baruah: “anyone who has travelled from those listed as affected countries or anyone who has come in contact with laboratory-proved coronavirus positive case.”
In addition, Baruah said the government had instructed them to inform about patients with respiratory complaints whose condition undertake “an unexpected turn” during the course of treatment.
Barua said his hospital was equipped to extend its isolation facilities. “God forbid if we reach stage-three of the pandemic tomorrow, we are ready to assist because government hospitals will not be able to manage by themselves then,” he said. “We are fully prepared – we have personal protection equipment. We are also ready to prepare hand sanitisers in case we run out.”
Smaller hospitals, though, said they were mostly recommending people with symptoms – but no travel and contact history – to “self-quarantine.” “I have been telling people with complaints of cough and fever to stay indoors as we don’t have enough testing capacity,” said Ilias Ali, who runs a small surgery hospital in Guwahati. “In case, symptoms do not improve and patient develops respiratory trouble, we immediately refer to GMCH [Guwahati Medical College and Hospital].”