How to Triage COVID Patients: What Delhi Must Learn From Mumbai

‘Deaths from lack of oxygen is unacceptable in a country that produces enough. Delhi needs urgent triage centres.’

Almost three weeks into a national COVID crisis, Delhi is still in SOS mode.

(Photo: The Quint)

Almost three weeks into a national COVID crisis, Delhi is still in SOS mode. Indians are in collective mourning, and everyone is reeling from a deadly, heartbreaking second COVID-19 wave.

And yet, as desperate pleas still flood our social media timelines, there is not much decisive action from the authorities.

Other cities like Mumbai or indeed states like Kerala, which are also suffering from a high number of COVID cases, are seemingly staying afloat. So, what are they doing differently? And what does Delhi need to do right now to help its citizens?

“We need to get a structured system in place,” says Dr Anant Bhan, Adjunct Professor & Researcher in Bioethics at Mangaluru’s Yenepoya University.

Here’s how:

What Delhi Needs to Do

Social media platforms have become helplines and triage centres all in one. And while this is remarkable, it’s not sustainable. “Good quality healthcare does not work through social media,” says Dr Bhan.

What is Triaging?

Put simply, it’s the prioritising of medical emergencies to decide the order of treatment in a large number of cases. Authorities in Delhi have directed that dedicated COVID hospitals ensure no delay in transferring a patient from a triage area to an ICU to reduce the mortality rate.

Often patients in critical condition lie waiting in ambulances while looking for beds or oxygen – and since ambulances have a limited supply of oxygen, it's a risky situation to be in. Doctors have reported that many patients of differing severity wait in the waiting areas, and so the most urgent cases don’t get the immediate help they need.

As per the latest COVID protocol, patients suspected of COVID-19 are to be given immediate medical attention. This is especially helpful given the dearth of RT-PCR tests and delays in getting reports.

Dr Sumit Ray, a critical care specialist and medical superintendent at Holy Family Hospital, a 345-bed facility in New Delhi that has been converted into a fully COVID hospital, says that the need is critical as without triage systems, hospital workers are “helpless”.

He says, “Being an intensivist, I have seen many deaths, but never like this. These are cases where we know that a person needs critical care but are not able to provide it. Not just here, but in any hospital. My resident doctors cry, not because they complain about the load, but because they are helpless.”

Dr Suranjit Chatterjee concurs and says to The Indian Express:

“In my 25 years of practice, I have never seen a situation like this. There are patients everywhere but we have no place or oxygen for them. They are begging us to treat them. The government must come through and provide a triage system which also has some basic facilities for patients. We have young patients in the emergency ward crashing because we don’t have any place in our ICUs. There has to be a system to save them.”

What Should Delhi Do?

“There are people who are running around in the heat trying to find a bed when their oxygen levels are 70. This should not be happening. The government must create a system where patients can go and then they are assigned hospitals. No private system can cater to them. The government will have to step in,” Dr Sumit Ray, medical superintendent at Holy Family Hospital, to Indian Express.

In an earlier FIT video, he describes the horror of patients “lying in causality for hours without beds - we want to move them to another hospital but where can they go? Our systems are getting overloaded. This is where the government has to pitch in to help with the logistics of moving patients and essentials.”

Dr Anant Bhan adds that proper planning can help quell anxieties and reduce crowding at hospitals. He says that there are multiple angles to handling the crisis – from fixing the oxygen supply issues urgently, to ensuring transportation to the hospitals, to engaging the community to explain which cases need to come into the hospitals and which can be managed at home.

The main thing doctors in Delhi have appealed for is a centralised triage system for patients who are relying on social media to check for beds.

The structured system would include:

• Entry-level triaging where severe patients are put on oxygen therapy.

“Those on ventilators on high support and high oxygen won’t sustain if the oxygen is not there even for a few minutes. Those on high oxygen without ventilators also won’t sustain for a few hours and they will be gasping for breath.”

Dr Sumit Ray

• Creating tertiary care centres to handle moderate cases and ensure no crowding at bigger facilities to prioritise severe cases
• guidance about home-based management
• Multiple COVID testing centres spread across the city to monitor mild to moderate cases
• "Helplines that work as often patients have to rely on hospital numbers that are busy or unresponsive,” says Dr Bhan. The Delhi helpline number 1031 is usually out of reach and people are directed to the Delhi Corona app which is quite exclusionary to those without access to the internet or a smartphone. Besides, the app usually displays outdated information because when patients call the hospitals they are often refused.

He adds that triaging can not only help patients who need help most, but also help ensure equitable distribution of healthcare.

Dr Bhan says that authorities should simultaneously be addressing the rise in cases, and look at the preventative side: From issuing curbs to working out vaccine supply.

So far, bureaucratic hurdles and a lack of decisive leadership from the Delhi or Central government has created a situation where the public is panicking and further straining the fragile and fragmented healthcare systems.

What it Can Learn From Mumbai

On 5 May, the Supreme Court told the Centre to “look to Mumbai and take note” of its successes in managing the supply of oxygen. So far, Mumbai has had no reported deaths from a lack of oxygen.

“Bombay Municipal Corporation (BMC) has done some remarkable work and not disrespecting Delhi but we can maybe see what was done by BMC. I understand that Maharashtra also produces oxygen, which Delhi can’t do. If you draw from experience and figure out how the holding corporations can be done in Delhi...Then we will have a module for Delhi in place based on the successful model in Bombay, which is a large metropolis.”

Justice Chandrachud

Despite reeling from high numbers, Mumbai is surviving the wave through transparent reporting and clear communication.

Additional BMC commissioner Suresh Kakani spoke to News18 about the basic robust systems they had in place.

• The basic protocol of tracking, testing and treating was largely followed and the data was clear and transparent.
• Mumbai kept up the make-up quarantine spaces and wards from the first wave despite the additional costs.
• Mumbai was also lucky to have access to oxygen plants in the state, but they boosted the supply systems and kept buffer stocks. They are developing more oxygen plants for future waves as well.
• 24 decentralised COVID war rooms run by Shiv Sena volunteers for Mumbai’s 24 civic wards to field requests for beds, oxygen, ventilators, blood plasma, Remdesivir injections, ambulances and relief in medical bills. Each volunteer here gets around 100 calls a day but this ensures citizens anxieties are handled without panic. Admissions to hospitals can be done through this as well, unlike in Delhi where it is through the hospitals directly which creates a lot of chaos. The war rooms are also equipped with doctors who can advise on home quarantine and follow up with mild to moderate patients.
• Mumbai had an active task force to authoritatively deal with the situation headed by BMC chief Iqbal Singh Chahal. One of the major changes he instituted was the banning of labs handing positive COVID reports to patients to try and control the spread.

With standardised systems and keeping its guard up, Mumbai has managed to stay mostly afloat despite its rising numbers and floating population.

Chahal told The Indian Express they were prepared and their system is now on “auto-pilot” adding, “When calamity hits, there is no time to learn, don’t have the cushion time to copy those models.”

They managed to avert any reported deaths due to a lack of oxygen, and they avoided a calamity on 16 April when 168 patients – including 40 critical – were evacuated in an emergency operation from six civic hospitals with low oxygen supplies and rushed in cardiac ambulances to Mumbai’s ‘jumbo’ COVID care facilities.

Since then, they acted fast and the BMC met with the state task force to devise a protocol for oxygen consumption which was circulated to each hospital.

It’s important to note that another state, Kerala, is a step further as it not only has the technology of war rooms but robust healthcare systems in place.

While Delhi is taking steps to address its crisis, it must move fast to address patients needs and help take the burden off hospital systems.

(The article was first published in FIT and has been republished with permission)