Planning and designing of an inpatient isolation facility for hematopoietic stem cell transplant patients.

During the last two decades the world has seen an increase in the use of Hematopoietic Stem Cell Transplant (HSCT) which has led to its worldwide expansion. Since, HSCT unit is an advanced set up, developing and maintaining a successful hematopoietic stem cell transplant program with a properly functioning unit enhances the credibility of any tertiary level medical facility especially for a country like ours which is in its early expanding phase of providing transplant services. The underlying principle for designing any HSCT facility is to maintain the highest possible level of aseptic environment for patients undergoing the transplant in order to prevent healthcare associated infections. Basic premises of designing the entire HSCT unit was to ensure restricted access to the facility and having an aseptic environment by implementing infection control parameters in design elements, which are explained subsequently in the article. The present manuscript describes the project experience of creating a positive pressure isolation facility for HSCT patients at a tertiary care hospital, India, which is a resource limited setting with an emphasis on need assessment, key elements in planning and designing along with the challenges associated with it.

"Constrained Medical Oxygen Supply Chain in India During COVID-19: Red-tapism, the Elephant in the Room?"

BACKGROUND: Recent disruption of medical oxygen during the second wave of coronavirus disease 2019 (COVID-19) has caused nationwide panic. This study attempts to objectively analyze the medical oxygen supply chain in India along the principles of value stream mapping (VSM), identify bottlenecks, and recommend systemic improvements. METHODS: Process mapping of the medical oxygen supply chain in India was done. Different licenses and approvals, their conditions, compliances, renewals, among others were factored in. All relevant circulars (Government Notices), official orders, amendments, and gazette notifications pertaining to medical oxygen from April 2020 to April 2021 were studied and corroborated with information from Petroleum and Explosives Safety Organization (PESO) official website. RESULTS: Steps of medical oxygen supply chain right from oxygen manufacture to filling, storage, and transport up to the end users; have regulatory bottlenecks. Consequently, flow of materials is sluggish and very poor information flow has aggravated the inherent inefficiencies of the system. Government of India has been loosening regulatory norms at every stage to alleviate the crisis. CONCLUSIONS: Regulatory bottlenecks have indirectly fueled the informal sector over the years, which is not under Government's control with difficulty in controlling black-marketing and hoarding. Technology enabled, data-driven regulatory processes with minimum discretionary human interface can make the system more resilient.

Cost analysis of treating cardiovascular diseases in a super-specialty hospital.

Cardiovascular care is expensive; hence, economic evaluation is required to estimate resources being consumed and to ensure their optimal utilization. There is dearth of data regarding cost analysis of treating various diseases including cardiac diseases from developing countries. The study aimed to analyze resource consumption in treating cardio-vascular disease patients in a super-specialty hospital. An observational and descriptive study was carried out from April 2017 to June 2018 in the Department of Cardiology, Cardio-Thoracic (CT) Centre of All India Institute of Medical Sciences, New Delhi, India. As per World Health Organization, common cardiovascular diseases i.e. Coronary Artery Disease (CAD), Rheumatic Heart Disease (RHD), Cardiomyopathy, Congenital heart diseases, Cardiac Arrhythmias etc. were considered for cost analysis. Medical records of 100 admitted patients (Ward & Cardiac Care Unit) of cardiovascular diseases were studied till discharge and number of patient records for a particular CVD was identified using prevalence-based ratio of admitted CVD patient data. Traditional Costing and Time Driven Activity Based Costing (TDABC) methods were used for cost computation. Per bed per day cost incurred by the hospital for admitted patients in Cardiac Care Unit, adult and pediatric cardiology ward was calculated to be Indian Rupee (INR) 28,144 (US$ 434), INR 22,210 (US$ 342) and INR 18,774 (US$ 289), respectively. Inpatient cost constituted almost 70% of the total cost and equipment cost accounted for more than 50% of the inpatient cost followed by human resource cost (28%). Per patient cost of treating any CVD was computed to be INR 2,47,822 (US $ 3842). Cost of treating Rheumatic Heart Disease was the highest among all CVDs followed by Cardiomyopathy and other CVDs. Cost of treating cardiovascular diseases in India is less than what has been reported in developed countries. Findings of this study would aid policy makers considering recent radical changes and massive policy reforms ushered in by the Government of India in healthcare delivery.

Converting an Under-Construction Healthcare Facility into a COVID-19 Screening and Emergency Response Centre During Complete Lockdown in India.

In view of the COVID-19 surge, the construction of the Burns and Plastic Surgery Block at AIIMS, New Delhi was expedited at war footing level and converted into a COVID-19 Emergency response Centre (ERC). Engineering works were completed in a speedy manner and various patient care areas were equipped as deemed necessary for providing tertiary care to COVID-19 patients. A highly spirited team comprising of Emergency Medicine Specialists, Anesthesia and Critical Care specialist, Hospital Administrators and Nursing Officers was formed. Effective segregation of patient care areas into clean, contaminated, and intermediate zones was done using physical barriers and air conditioning modifications. The screening area for patients suspected of having COVID-19 was created in addition to a 2-step process i.e., Triage 1 and Triage 2, thereafter, patients requiring admission would be referred to the emergency area. An in-house designed and fabricated sampling booth was created to bring down the use of PPEs and for better infection control. The ERC has a general ward and state of the art intensive care units. Mobilizing resources (machinery, manpower, consumables etc.) during the lockdown required commitment from top leadership, motivated teams, expeditious procurement, coordination with multiple agencies working on site, expediting statutory clearances, coordination with police services, transportation of labor etc.

National guidelines for sanitation services: Addressing the unmet need of standardizing cleaning practices in tertiary care public health facilities of a developing country.

BACKGROUND: Cleanliness is one of the main reasons for poor satisfaction among the patients and their attendants visiting healthcare facilities. OBJECTIVE: To elevate and transform the sanitation in public sector facilities, a committee was constituted by Ministry of Health and Family Welfare, Government of India to study the existing system of Housekeeping in Central Government Hospitals and draft the Guidelines for house-keeping services, since no such literature is available in context of the healthcare facilities in India. METHODS: The committee ascertained the housekeeping services in three tertiary care hospitals of Central Government and simultaneously conducted the literature review of the best practices in hospital sanitation and housekeeping. RESULTS: Formulated national guidelines focus on various aspects of sanitation services in health facilities, i.e., hospital infrastructure; organization of sanitation services; human resource requirements; qualification, experience and training needs of sanitation staff; roles and responsibilities of different personnel; risk categorization of hospital areas; mechanized cleaning; cleaning agents; cleaning standards and standard operating procedures; effective supervision and monitoring; procurement of these services, etc. CONCLUSION: Formulated guidelines can be adopted by developing countries aiming for standardizing cleaning practices in public health facilities.

War on waste: Challenges and experiences in COVID-19 waste management.

COVID-19 has posed formidable challenges including overwhelming bio-medical waste. Guidelines have been rapidly changing along with mounting pressure of waste generation. These challenges were managed by smart re-engineering of structure and processes for desired outcomes. Dedicated staff in PPE with appropriate training were deployed to collect waste using dedicated trolleys. A dedicated route plan was drawn with a dedicated lift meant for COVID-19. A new temporary holding area was created. Dedicated trucks with requisite labels were deployed to transport COVID-19 waste to CBWTF. Communication challenge was addressed through timely circulars, which were further reinforced and reiterated during various on-going training programs.Before the onset of COVID-19 pandemic Bio-Medical Waste generated was 1.93kg/Bed/Day and currently the quantum of COVID-19 biomedical waste generated is 7.76Kg/COVID Bed/Day. Daily COVID-19 waste generation data is maintained and uploaded in an android Application. Till date none of the worker handling COVID-19 waste has acquired Healthcare associated COVID-19 infection which reflects on the soundness of the new system and the infection control practices in the Institute. A responsive leadership harmonizing with a robust communication and training system has augmented timely re-engineering of structure and processes for better outcomes in the war on waste.

Mechanized laundering of mops for floor cleaning can reduce infection transmission through hospital floor.

PURPOSE: Hospital floors are underappreciated reservoir for microbes; therefore, floor cleaning should warrant reduction of microbial load for decreasing risk of infection transmission and has to be aesthetically acceptable. It was aimed to study the impact of mechanized laundering of floor mops in reducing microbial load compared to manual washing. METHODS: An interventional study was conducted from January to July 2019 in various inpatient areas of All India Institute of Medical Sciences, New Delhi. Culture of floor mops were taken after manual washing (pre-intervention) and mechanized laundering(intervention). During intervention, mops were equally divided into two piles, with one pile soaked in sodium hypochlorite for 15-20 min before mechanized laundering and other were put directly for mechanized laundering. Bacterial load in floor mops was observed in each group. RESULTS: Significant difference (P Value 0.001) in bacterial load was observed in manually washed (502 cfu/plate) and mechanized laundering (278 cfu/plate) of floor mops. Presoaking of floor mops with sodium hypochlorite (262 cfu/plate) did not show any significant difference (P-value 0.59) in reduction of bacterial load compared to mops which were cleaned using mechanized laundering (294 cfu/plate). The bacterial load of floor mops which were manually washed showed increase in mean value of microbial load from 609 cfu/plate from day one to 4015 cfu/plate on day five. CONCLUSION: Mechanized laundering of floor mops standardizes the mop cleaning process and brings down the microbial load significantly compared to manual washing. Disinfection of floor mops before mechanized laundering using sodium hypochlorite did not have significant impact on reduction of microbial load.

A study on economic evaluation of an outreach health-care facility in Jhajjar District of Haryana: Service delivery model for increasing access to health care.

BACKGROUND: An outreach (OR) health-care facility providing broad specialty outpatient services was started by All India Institute of Medical Sciences (AIIMS), New Delhi, in rural area of district Jhajjar, Haryana. OBJECTIVES: This study aimed to ascertain the resource requirement for establishing an OR health-care facility and patient satisfaction with regard to the services being provided. METHODS: A cross-sectional study was conducted in 2017 at an OR Outpatient Department (OPD) of AIIMS, New Delhi, at Jhajjar. Service delivery model adopted for health-care delivery was hub and spoke. Traditional method of costing was used for economic evaluation. Feedback pro forma of 400 patients who attended OPD services was analyzed to measure health service accessibility. RESULTS: Capital expenditure to set up the facility was calculated to be approximately INR 17,57,49,074/- ($ 2,703,832) and operational cost per year was approximately INR 8,73,86,370/- ($ 1,344,406). Approximate per-patient cost for single OPD consultation was calculated to be INR 874 ($13.45) which included medicines and investigations. High scores for all domains of accessibility of health care were observed. CONCLUSION: The study provides a preliminary evidence that OR health-care facilities can be instrumental in increasing access to health-care delivery with lesser capital outlays, however, large-scale multicentric studies are needed to arrive at any conclusion. The services have been very well accepted by the local community members being quality medical care with highly subsidized health-care services.

Outcome of care in an apex tertiary care referral institute of North India - A study of 90,000 patients.

INTRODUCTION: Outcome of care is an important measure of quality in health care and also provides input for healthcare planning. It is an indicator which can be used for comparing performance of various hospital/Institute. AIMS: Study intended to analyze the morbidity and mortality pattern among admitted patients with respect to selected hospital indices. STUDY SETTINGS: All India Institute of Medical Sciences (AIIMS), New Delhi. SUBJECTS AND METHODS: A cross-sectional retrospective study was conducted in 93,223 patients admitted at AIIMS, New Delhi. Information provided in Management Information System (MIS) was used for analysing morbidity as per International Statistical Classification of Diseases (ICD)-10. RESULTS: Diseases related to the genitourinary system (14.25%) and neoplasms (14.18%) were the most common cause of admissions. Overall, predominance of adult age group (61.6%) followed by geriatric age group (20.5%) was observed. Male predominance was observed in diseases related to mental, behavioural, and neurodevelopmental disorders (89.2%). Overall, median length of stay was calculated to be 4 days (mean LOS-7 days), maximum for diseases related to mental, behavioural, and neurodevelopmental disorders (median 13 days). Gross and net death rate for admitted patients was calculated to be 4.3% and 3%, respectively, with maximum rate for diseases related to respiratory system (22.7% and 17%). CONCLUSIONS: Analysis of morbidity and mortality in high volume tertiary care centers and segregation of the patients according to their ailment and disease behaviour helps in establishing priorities in healthcare delivery system and thus allocating limited resources accordingly.

Outcome of Care Provided in Neonatal Surgery Intensive Care Unit of a Public Sector Tertiary Care Teaching Hospital of India.

AIMS: There is limited literature on the outcome of care in intensive care units (ICUs), especially when it comes to neonatal surgical units. Hence, this study was aimed to observe the outcome of care provided in the neonatal surgery ICU (NSICU) at an apex tertiary care teaching institute of North India. METHODS: A descriptive, observational study was carried out through retrospective medical record analysis of all the patients admitted in NSICU from January to June 2011. RESULTS: In NSICU, from January to June 2011, 85 patients were admitted. More than two-third (69.9%) patients were admitted through the emergency department. Of the total admitted patients, 69.9% were male. Mean and median age of the admitted patients were 6.31 and 2 days (range 0-153 days), respectively. The most common diagnosis was esophageal atresia with tracheoesophageal fistula (36.1%). Within a day of admission at NSICU, 88% patients underwent surgical intervention. Of the total admitted patients, 56.6% required mechanical ventilation with 3.57 days (range 0-31 days) of mean duration of mechanical ventilation. Reintubation rate (within 48 h of extubation) was observed to be 15.7%, and 27.7% (23) of the patients required vasopressor support during their NSICU stay. Patients who developed postoperative complications were 34.25%, with the most common being wound infection/discharge/dehiscence. Two patients were readmitted within 72 h of their discharge/transfer out from the NSICU. CONCLUSION: NSICU survival rate was 85.5% and net death rate was observed to be 14.5%. Sepsis was the major reason for mortality in NSICU.

ABC, VED and lead time analysis in the surgical store of a public sector tertiary care hospital in Delhi.

BACKGROUND: An efficient inventory control system would help optimize the use of resources and eventually help improve patient care. OBJECTIVES: The study aimed to find out the surgical consumables using always, better, and control (ABC) and vital, essential, and desirable (VED) technique as well as calculating the lead time of specific category A and vital surgical consumables. METHODS: This was a descriptive, record-based study conducted from January to March 2016 in the surgical stores of the All India Institute of Medical Sciences, New Delhi. The study comprised all the surgical consumables which were procured during the financial year 2014-2015. Stores ledger containing details of the consumption of the items, supply orders, and procurement files of the items were studied for performing ABC analysis and calculating the lead time. A list of surgical consumables was distributed to the doctors, nursing staff, technical staff, and hospital stores personnel to categorize them into VED categories after explaining them the basis for the classification. RESULTS: ABC analysis revealed that 35 items (14%), 52 items (21%), and 171 items (69%) were categorized into A (70% annual consumption value [ACV]), B (20% ACV), and C (10% ACV) category, respectively. In the current study, vital items comprised the majority of the items, i.e., 73% of the total items and essential (E) category of items comprised 26% of all the items. The average internal, external, and total lead time was 17 days (range 3-30 days), 25 days (range 5-38) and 44 days (range 18-98 days), respectively. CONCLUSIONS: Hospitals stores need to implement inventory management techniques to reduce the number of stock-outs and internal lead time.

Patient Involvement in Decision-Making: An Important Parameter for Better Patient Experience-An Observational Study (STROBE Compliant).

BACKGROUND AND AIM: Preferences of service users is an important consideration for developing health-care services. This study aimed to assess the experiences of the patients with substance use disorders who were admitted to a tertiary health-care facility in India. METHOD: This cross-sectional sectional study recruited adult inpatients who stayed for a period of 7 days or more. The Picker Patient Experience questionnaire (PPE-15) was used to gather information about the views of the patients about the care received at the center. RESULTS: Responses were available from 113 inpatients. Majority of the participants were males and were dependent on opioids. The experience was generally positive about being treated with respect and dignity and access to information. The participants were most satisfied with opportunity being given to discuss anxiety and fear about the condition or treatment (91.2% positive response) and least satisfied with differences in responses from doctors and nurses (43.4% positive response). Further attention seemed desired about communication with the staff and patients' involvement in their own treatment-related decision-making. CONCLUSION: Efforts need to be made to involve patients in their own treatment-related decision-making and to improve communication with the treatment team. This might lead to better involvement in treatment process, which could enhance the treatment outcomes in this vulnerable population.

National survey of infection control programmes in South Asian association for Regional Cooperation countries in the era of patient safety.

BACKGROUND: The implementation of hospital infection prevention and control (IPC) in south Asia is not well described. We aimed to assess IPC programmes in hospitals in this region and explore opportunities for improvement. METHODS: Attendees from hospitals in the South Asian Association for Regional Cooperation (SAARC) region who were at one of four National Initiative for Patient Safety workshops organised by All India Institute of Medical Sciences (New Delhi) from 2009 to 2012 were invited to complete a semi-structured questionnaire. The survey addressed six main components of IPC programmes. RESULTS: We received responses from 306 participants from 82 hospitals. Five key opportunities for improvement emerged: (1) lack of healthcare epidemiologists, (2) relative infrequency of antibiotic guidelines (53%) and prescribing audits (33%) (3) lack of awareness of needle stick injury rates (84%) (4) only 47% of hospitals were prepared for surge capacity for patients with infectious diseases, and (5) limited coordination of hospital infection control personnel with other support services (55%-66%). CONCLUSION: These results outline IPC challenges in the SAARC region and may be useful to guide future quality improvement initiatives.

Cost analysis of a disaster facility at an apex tertiary care trauma center of India.

INTRODUCTION: For the Commonwealth Games 2010, Jai Prakash Narayan Apex Trauma Centre (JPNATC) of India had been directed by the Director General Health Services and Ministry of Health and Family Welfare, Government of India, to set up a specialized unit for the definitive management of the injured/unwell athletes, officials, and related personnel coming for the Commonwealth Games in October 2010. The facility included a 20-bedded fully equipped ward, six ICU beds with ventilator capacity, one very very important person observation area, one perioperative management cubicle, and one fully modular and integrated operating room. OBJECTIVE: The objective of this study was to calculate the cost of disaster facility at JPNATC, All India Institute of Medical Sciences, New Delhi. METHODOLOGY: Traditional (average or gross) costing methodology was used to arrive at the cost for the provisioning of these services by this facility. RESULTS: The annual cost of providing services at disaster facility at JPNATC, New Delhi, was calculated to be INR 61,007,334.08 (US$ 983,989.258) while the per hour cost was calculated to be INR 7061.03 of the total cost toward the provisioning of services by disaster facility where 26% was the capital cost and 74% was the operating cost. Human resource caters to maximum chunk of the expenditures (47%). CONCLUSION: The results of this costing study will help in the future planning of resource allocation within the financial constraints (US$ 1 = INR 62 in the year 2013).

Cost Analysis of Operation Theatre Services at an Apex Tertiary Care Trauma Centre of India.

Operating room services are one of the major cost and revenue-generating centres of a hospital. The cost associated with the provisioning of operating department services depends on the resources consumed and the unit costs of those resources. The objective of this study was to calculate the cost of operation theatre services at Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi. The study was carried out at the operation theatre department of Jai Prakash Narayan Apex Trauma Centre (JPNATC), AIIMS from April 2010 to March 2011 after obtaining approval from concerned authorities. This study was observational and descriptive in nature. Traditional (average or gross) costing methodology was used to arrive at the cost for the provisioning of operation theatre (OT) services. Cost was calculated under two heads; as capital and operating cost. Annualised cost of capital assets was calculated according to the methodology prescribed by the World Health Organization and operating costs were taken on actual basis; thereafter, per day cost of OT services was obtained. The average number of surgeries performed in the trauma centre per day is 13. The annual cost of providing operating room services at JPNATC, New Delhi was calculated to be 197,298,704 Indian rupees (INR) (US$ 3,653,679), while the per hour cost was calculated to be INR 22,626.92 (US$ 419). Majority of the expenditures were for human resource (33.63 %) followed by OT capital cost (31.90 %), consumables (29.97 %), engineering maintenance cost (2.55 %), support services operating cost (1.22 %) and support services capital cost (0.73 %). Of the total cost towards the provisioning of OT services, 32.63 % was capital cost while 67.37 % is operating cost. The results of this costing study will help in the future planning of resource allocation within the financial constraints (US$ 1 = INR 54).

Clinical-Epidemiological Profile of Influenza A H1N1 Cases at a Tertiary Care Institute of India.

INTRODUCTION: Influenza virus is a common human pathogen that has caused serious respiratory illness and death over the past century. In April 2009, a new strain of Influenza virus A H1N1, commonly referred to as "swine flu", began to spread in several countries around the world, and India confirmed its first case on 16 May 16 2009. AIM: To study the clinical and epidemiological profile of Influenza A H1N1 cases at the Government Medical College and Hospital, Chandigarh. MATERIALS AND METHODS: Clinical epidemiological characteristics of Influenza A H1N1 cases from May 2009 to April 2010 were retrospectively, descriptively analyzed using data from the Influenza A H1N1 screening center and isolation ward at the Government Medical College and Hospital, Chandigarh. Data were Analyzed using MS Excel software. RESULTS: At GMCH, till April 2010, a total of 4379 patients were screened for Influenza A H1N1, of which 365 patients were tested. The most common symptoms were fever (87.6%), cough (49.77%), sore throat (27%) and breathlessness (23.9%). The most common presentation (42.30%) of Influenza A H1N1 cases was fever and cold-like features, not cough. 29.58% (108) of the tested patients were found to be positive for the disease. Maximum cases were detected in the month of December, and the patients less than 40 years of age accounted for 81.4% (44 cases) of the cases. Influenza A H1N1 resulted in death of 54.9% (28) of the admitted cases, of which 46% (12) deaths occurred within 48 h of admission. CONCLUSION: On the basis of these findings, it can be safely hypothesized that prevalence of Influenza A H1N1 is high in the younger population, and fever, cough and sore throat are the most common symptoms with which the patients usually present.