A multicentre point prevalence survey (PPS) of antimicrobial use amongst admitted patients in tertiary care centres in India.

OBJECTIVES: Data from point prevalence surveys (PPSs) in India are scarce. Conducting PPSs is especially challenging in the absence of electronic medical records, a lack of dedicated resources and a high patient load in resource-poor settings. This multicentre survey was conducted to provide background data for planning and strengthening antimicrobial stewardship programmes across the country. METHODS: This inpatient PPS was conducted over 2 weeks in May 2019 simultaneously across five study centres in India. Data about patient characteristics, indications for antimicrobials use and details of each antimicrobial prescribed including supportive investigation reports were collected in predesigned forms. RESULTS: A total of 3473 admitted patients in wards and ICUs were covered across five study centres. Of these, 1747 (50.3%) patients were on antimicrobials, with 46.9% patients being on two or more antimicrobials. Out of the total antimicrobials prescribed, 40.2% of the antimicrobials were prescribed for community-acquired infection requiring hospitalization followed by surgical prophylaxis (32.6%). Third-generation cephalosporins and drugs from the 'Watch' category were prescribed most commonly. Only 22.8% of the antimicrobials were based on microbiology reports. CONCLUSIONS: The survey demonstrated a high use of antimicrobials in admitted patients with a considerable proportion of drugs from the 'Watch' category. The targets for interventions that emerged from the survey were: improving surgical prophylaxis, decreasing double anaerobic cover, initiating culture of sending cultures and de-escalation with targeted therapy.

Demographic & clinical profile of patients with COVID-19 at a tertiary care hospital in north India.

BACKGROUND & OBJECTIVES: The COVID-19 pandemic emerged as a major public health emergency affecting the healthcare services all over the world. It is essential to analyze the epidemiological and clinical characteristics of patients with COVID-19 in different parts of our country. This study highlights clinical experience in managing patients with COVID-19 at a tertiary care centre in northern India. METHODS: Clinical characteristics and outcomes of consecutive adults patients admitted to a tertiary care hospital at Chandigarh, India, from April 1 to May 25, 2020 were studied. The diagnosis of SARS-CoV-2 infection was confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) on throat and/or nasopharyngeal swabs. All patients were managed according to the institute's consensus protocol and in accordance with Indian Council of Medical Research guidelines. RESULTS: During the study period, 114 patients with SARS-CoV-2 infection were admitted. The history of contact with COVID-19-affected individuals was available in 75 (65.8%) patients. The median age of the patients was 33.5 yr (13-79 yr), and there were 66 (58%) males. Of the total enrolled patients, 48 (42%) were symptomatic. The common presenting complaints were fever (37, 77%), cough (26, 54%) and shortness of breath (10, 20.8%). Nineteen (17%) patients had hypoxia (SpO2<94%) at presentation and 36 (31%) had tachypnoea (RR >24). Thirty four (29.8%) patients had an accompanying comorbid illness. Age more than 60 yr and presence of diabetes and hypertension were significantly associated with severe COVID-19 disease. Admission to the intensive care unit (ICU) was needed in 18 patients (52%), with three (2.6%) patients requiring assisted ventilation. Mortality of 2.6 per cent (3 patients) was observed. INTERPRETATION & CONCLUSIONS: Majority of the patients with COVID-19 infection presenting to our hospital were young and asymptomatic. Fever was noted only in three-fourth of the patients and respiratory symptoms in half of them. Patients with comorbidities were more vulnerable to complications. Triaged classification of patients and protocol-based treatment resulted in good outcomes and low case fatality.

Ventilator-associated pneumonia - What price does the public health system pay?

BACKGROUND: Ventilator-associated pneumonia (VAP) is the commonest healthcare-associated infection (HAI) in intensive care units (ICU), especially in trauma patients. VAP imposes a significant cost burden on the healthcare ecosystem. However, there are few data from the developing world. METHODOLOGY: We conducted this study in the trauma ICU (TICU) of PGIMER, Chandigarh, from October 2021 to December 2022. The incidence, incidence density, and average length of stay (ALOS) of both VAP and non-VAP patients were established. The health system cost was assessed using a mixed (top-down and bottom-up) micro-costing approach. We collected data for all the resources (direct and indirect costs) utilized during service delivery and estimated the health system cost per bed per day. RESULTS: In this study, 494 patients were admitted to TICU, of which 484 received Mechanical Ventilation (MV) and 47 developed VAP. We included 41 and 44 patients with and without VAP. The VAP incidence rate was 9.7% and the VAP incidence density was 10.79/1000 MV days. The ALOS for VAP patients was 21 days, and for non- VAP patients was 8.2 days. Our study estimated a total health system cost of INR 25,927 per bed per day. The health system cost of treating a VAP patient was INR 544,467 compared to INR 207,416 for a non-VAP patient. CONCLUSION: Treatment of VAP poses substantial costs for the health system and patients. There is a need to focus on preventing VAP, which would eventually reduce the length of stay and the resultant financial impact on the health system and the patient.

Obstetric Teleconsultation by Using Mobile Phone Technology in COVID Pandemic.

Introduction: Obstetrics teleconsultation is a new concept to enable health-care services in the COVID pandemic by limiting in-person visits. This study describes the methodology of mobile-based teleconsultation, preliminary findings, and the experience of the obstetricians. Material and Methods: The data of pregnant women who got registered for teleconsultation in early phase of COVID pandemic lockdown were reviewed and analyzed. A qualitative analysis was performed to assess the experience of obstetricians (consultants, senior residents, and junior residents) via an online electronic survey. Results: The majority of obstetrics teleconsultations were for routine antenatal care (75%) and fetal medicine consultation (12.3%). Out of 187 women, 29.9% were advised to continue antenatal care at local hospitals, whereas 33.6% were asked to follow up via teleconsultation. Most of the obstetricians (73.68%) felt that they were able to satisfy the pregnant women and rated the teleconsultation satisfactory. Conclusion: Obstetrics telemedicine found to be beneficial for providing routine antenatal care services via reducing physical visits and overcrowding in outpatient departments, promoting antenatal care at local hospitals, and making specialized (maternal-fetal medicine) care accessible even during COVID-19 pandemic.

Doffing Corridor: Establishing Expedited High-Volume Doffing With Exposure Reduction to Contaminated Personal Protective Equipment (PPE) in a COVID-19 Hospital in India.

Background Considering the virulent nature of the COVID-19, the safety of healthcare workers (HCW) became a challenge for hospital administrators. Wearing a personal protective equipment (PPE) kit, called donning, which can be easily done by the help of another staff. But correctly removing the infectious PPE kit (doffing) was a challenge. The increased number of HCWs for COVID-19 patient care raised the opportunity to develop an innovative method for the smooth doffing of PPEs. Objective We aimed to design and establish an innovative PPE doffing corridor in a tertiary care COVID-19 hospital during the pandemic in India with a heavy doffing rate and minimize the COVID-19 virus spread among healthcare workers. Methodology A prospective, observational cohort study at the COVID-19 hospital, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, was conducted from July 19, 2020, to March 30, 2021. The time taken for PPE doffing process of HCWs was observed and compared between the doffing room and doffing corridor. The data was collected by a public health nursing officer using Epicollect5 mobile software and Google forms. The following parameters, like grade of satisfaction, time and volume of doffing, the errors in the steps of doffing, rate of infection, were compared between the doffing corridor and the doffing room. The statistical analysis was done by the use of SPSS software. Result 'Doffing corridor' decreased the overall doffing time by 50% compared to the initial doffing room. The doffing corridor solved the purpose of accommodating more HCWs for PPE doffing and an overall saving of 50% time. Fifty-one percent of HCWs rated the satisfaction rate as Good in the grading scale. The errors in the steps of doffing that occurred in the doffing process were comparatively lesser in the doffing corridor. The HCWs who doffed in the doffing corridor were three times less likely to get self-infection than the conventional doffing room. Conclusion Since COVID-19 was a new pandemic, the healthcare organizations focused on innovations to combat the spread of virus. One of these was an innovative doffing corridor to expedite the doffing process and decrease the exposure time to the contaminated items. The doffing corridor process can be considered at a high-interest rate to any hospital dealing with infectious disease, with high working satisfaction, less exposure to the contagion, and less risk of infection.

Nursing personnel management during COVID-19 pandemic: An exemption trend in view of health reasons.

Background: In the COVID-19 pandemic, the healthcare system faced unprecedented challenges with increased number of patients and limited resources. Managing nursing resource was a major challenge for hospital administration. They had to be on the frontline, but their safety was of paramount importance. Aim: This study aims to analyze the measures taken for the management and effective engagement of nursing personnel for deployment in the COVID area of the hospital and the exemption trend based on their health status. Methodology: A retrospective cross-sectional descriptive study was carried out to analyze the requests of nursing staff received for exemption of duty in COVID patient care areas. These requests were categorized and examined by the medical board constituted for this purpose. Microsoft Excel was used to interpret the results. Results: The study evaluated the health reasons of nursing officers on the basis of which exemption was given for deployment of nursing officers in COVID areas. They were mostly medical reasons (91.1%) and few personal reasons (8.77%). The majority suffered from diseases affecting two or more than two specialties. Out of 376 applications, 223 were exempted, 81 were not exempted, 13 were given short-term exemption, and 26 were shifted to administrative assignments. Thirty-three staff members were referred to an appropriate forum.

Effect of breathing intervention in patients with COVID and healthcare workers.

Background: Regulated breathing facilitates ventilation and reduces breathlessness. However, the effect of Yogic breathing on patients with COVID remains unclear. We aimed to evaluate the efficacy of two breathing protocols, i.e., short breathing technique (SBT) and long duration breathing technique (LBDT). Methods: Three groups including COVID-positive patients, COVID-recovered patients, and healthcare workers (HCWs) were included in the study and segregated into Yoga and control groups. SBT was administered to COVID-positive patients. Both SBT and LBDT were administered to COVID-recovered patients and HCWs. A total of 18 biochemical parameters, a 6-min walk test (6MWT), and a 1-min sit-stand test (1MSST) were assessed on 0th, 7th, and 15th days, where biochemical parameters were the primary outcome. Pre-post estimation of neuropsychological parameters (nine questionnaires) and heart rate variability (HRV) were carried out. The paired t-test or Wilcoxon rank test was applied for pre-post comparison and the Student's t-test or Mann-Whitney U test was used for group comparison. Repeated measures test was applied for data recorded at three time points. Results: A significant elevation in white blood cell (WBC) count was observed in COVID-positive intervention (p < 0.001) and control groups (p = 0.003), indicating no role of intervention on change in WBC number. WBC count (p = 0.002) and D-dimer (p = 0.002) significantly decreased in the COVID-recovered intervention group. D-dimer was also reduced in HCWs practicing Yogic breathing as compared to controls (p = 0.01). D-dimer was the primary outcome, which remained below 0.50 µg/ml (a cutoff value to define severity) in the COVID-positive yoga group (CYG) and decreased in the COVID-recovered yoga group (RYG) and the HCW yoga group (HYG) after intervention. A 6-min walk test (6MWT) showed an increase in distance covered among the COVID-positive patients (p = 0.01) and HCWs (p = 0.002) after intervention. The high-frequency power (p = 0.01) was found to be reduced in the COVID-positive intervention group. No significant change in neuropsychological parameters was observed. Conclusion: Yogic breathing lowered D-dimer, which is helpful in reducing thrombosis and venous thromboembolism in patients with COVID-19 besides lowering the chances of vaccine-induced thrombotic thrombocytopenia in vaccinated individuals. The breathing intervention improved exercise capacity in mild to moderate cases of COVID-19. Further studies can show if such breathing techniques can influence immunity-related genes, as reported recently in a study. We suggest that Yogic breathing may be considered an integrative approach for the management of patients with COVID. Trial registration: http://ctri.nic.in/Clinicaltrials/login.php, identifier: CTRI/2020/10/028195.

Impaired anti-SARS-CoV-2 antibody response in non-severe COVID-19 patients with diabetes mellitus: A preliminary report.

BACKGROUND AND AIMS: Patients with diabetes mellitus (DM) often demonstrate impaired antibody response to influenza/hepatitis B vaccines. Hence, we compared anti-SARS-CoV-2 antibody response in non-severe COVID-19 patients with and without type 2 diabetes mellitus (T2DM). METHODS: Records of non-severe COVID-19 patients admitted at our institution between April 10, 2020 and May 20, 2020 were retrieved. Qualitative detection of total (IgG + IgM) anti-SARS-CoV-2 antibody was performed using electrochemiluminescence immunoassay in plasma samples collected at least 14 days post-polymerase chain reaction (PCR) confirmation of diagnosis. RESULTS: Thirty-one non-severe COVID-19 patients were included. Nine patients (29%) had T2DM with mean HbA1c at admission of 8.3 ± 1.0%. Anti-SARS-CoV-2 antibody was estimated at a median of 16 (14-17) days post-PCR confirmation of COVID-19 diagnosis. Only three patients (10%) were seronegative, and all had T2DM. Patients with T2DM were more likely to have non-detectable anti-SARS-CoV-2 antibodies than those without DM (p = 0.019). CONCLUSIONS: COVID-19 patients with T2DM may not undergo seroconversion even after two weeks of diagnosis. Impaired seroconversion could theoretically increase the risk of reinfections in patients with DM. However, the finding requires validation in large-scale studies involving serial estimations of anti-SARS-CoV-2 antibodies in patients with and without DM.

Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.

OBJECTIVES: Healthcare personnel (HCP) are at an increased risk of acquiring COVID-19 infection especially in resource-restricted healthcare settings, and return to homes unfit for self-isolation, making them apprehensive about COVID-19 duty and transmission risk to their families. We aimed at implementing a novel multidimensional HCP-centric evidence-based, dynamic policy with the objectives to reduce risk of HCP infection, ensure welfare and safety of the HCP and to improve willingness to accept and return to duty. SETTING: Our tertiary care university hospital, with 12 600 HCP, was divided into high-risk, medium-risk and low-risk zones. In the high-risk and medium-risk zones, we organised training, logistic support, postduty HCP welfare and collected feedback, and sent them home after they tested negative for COVID-19. We supervised use of appropriate personal protective equipment (PPE) and kept communication paperless. PARTICIPANTS: We recruited willing low-risk HCP, aged <50 years, with no comorbidities to work in COVID-19 zones. Social distancing, hand hygiene and universal masking were advocated in the low-risk zone. RESULTS: Between 31 March and 20 July 2020, we clinically screened 5553 outpatients, of whom 3012 (54.2%) were COVID-19 suspects managed in the medium-risk zone. Among them, 346 (11.4%) tested COVID-19 positive (57.2% male) and were managed in the high-risk zone with 19 (5.4%) deaths. One (0.08%) of the 1224 HCP in high-risk zone, 6 (0.62%) of 960 HCP in medium-risk zone and 23 (0.18%) of the 12 600 HCP in the low-risk zone tested positive at the end of shift. All the 30 COVID-19-positive HCP have since recovered. This HCP-centric policy resulted in low transmission rates (<1%), ensured satisfaction with training (92%), PPE (90.8%), medical and psychosocial support (79%) and improved acceptance of COVID-19 duty with 54.7% volunteering for re-deployment. CONCLUSION: A multidimensional HCP-centric policy was effective in ensuring safety, satisfaction and welfare of HCP in a resource-poor setting and resulted in a willing workforce to fight the pandemic.

Transforming a General Hospital to an Infectious Disease Hospital for COVID-19 Over 2 Weeks.

Pandemics like the coronavirus disease (COVID)-19 can cause a significant strain on the healthcare system. Healthcare organizations must be ready with their contingency plans for managing many patients with contagious infectious disease. Ideally, every large hospital should have a facility that can function as a high-level isolation unit. An isolation unit ensures that the healthcare staff and the hospital are equipped to deal with infectious disease outbreaks. Unfortunately, such facilities do not exist in several hospitals, especially in resource-limited settings. In such a scenario, healthcare setups need to convert their existing general structure into an infectious disease facility. Herein, we describe our experience in transforming a general hospital into a functional infectious disease isolation unit.