Lecture: Systems Management Post COVID Lockdown
As a Clinician and Administrator what is the plan to guide the systems and processes and to bring a cultural shift within the hospital team to manage eye health services in Institutions. If we plan well, we shall be able to overcome this situation successfully.
Lecturer: Dr. Umang Mathur, Executive Director and Cornea Consultant, SCEH, New Delhi
Umang Mathur: Good evening, everyone, and welcome to this session on Cybersight. It's been a wonderful four days that we've had stalwart speaking on various topics related to this crisis today. And I would try to do justice to the systems management posts COVID lockdown, and a very topical subject all of us are battling with it. Unfortunately, there are no good answers, there are no right answers. It's very dynamic, the situation keeps changing, the information keeps changing. And I just run you through some of the things that are affecting us, and how we could manage that. So, we all know that this lockdown has created quite a lot of havoc, not only in our professional life but I think in our day to day existence, and from the first lockdown now we are approaching the fourth lockdown very soon. And a recent survey in the Indian Journal of ophthalmology has shown that the lockdown and the Coronavirus situation is causing a lot of stress to ophthalmologist, significant number are feeling depressed.
But I would only like to say that there are difficult these are difficult times. But I think it's the attitude that we need to have to face it. And that is what determines whether we would be able to find success or failure in this situation. So, it's very important to look at how we can deal with it and move on. So, we need to be informed. We need to be prepared, be smart and be safe, and should be ready to fight this COVID-19. I would, at this time, like to acknowledge the role of Orbis in not only having the platform Cybersight which at one point appear to be a little ahead of its time. But today as we can see in this the role of digital information, and how Cybersight is a platform that not only helps in connecting each other and having these webinars but also in management and training of pathology of doctors.
A lot of this work has been done which I'm going to be presenting with the help of Orbis which set up the Quality Resource Center at the Shroff hospital. And we have been working through our quality department, quality assurance department in developing systems to combat COVID and how these systems are going to guide us in dealing with the situation. At this point, I would like to acknowledge Dr. Sunita Dubay and Mr. AK Singh who are leading the quality initiative at the hospital.
So, we need to start right at the beginning from screening of patients. And it is very important that we don't bring in pathology inside. So, the idea is that we as clinicians first have to make sure that we remain safe and we don't get the infection. At the same time, we need to ensure that we don't spread infection. So, we have to put systems to take care of both. So, it's important that we have hand sanitizing stations available, patients should wash their hands. Face masks should be compulsory not only for the patient, but also for the attendant. Fortunately, most states today are made it mandatory. So, you can actually refuse a patient to be seen if the patient is not wearing a mask.
We also like to insist that the patient or the attendant has the Aarogya Setu app which gives you an alert and our security guards also have the app on their phone. In case there is a positive patient or somebody who's at high risk, there's a possibility that you may get an alert. Before we ask, allow the patient to go in, we make the patient sign a declaration, which basically has questions on fever, on cough, on any of the symptoms that could be associated with COVID. Of course, now a little irrelevant but traveled abroad, or any history of contact with somebody who did. And this is a declaration that they signed. Along with that we make them, we put them phone number and the name of even the attendant so that if we have to do contact tracing, we can. Of course, thermal scanning is done. And this is also the personnel has to be protected, sort of shield and gloves and a gown is a must. For this they, the thermal scanners be keep at cut off of 100 degree Fahrenheit.
So, anybody who gets a little above that, we should actually not go by just one reading if it is high because these scanners are not that accurate. Sometimes the patient may be standing in the sun, so we ask them to sit in the shade for some time, then recheck after 10 minutes, in case the patient turns out to have a temperature higher than 100, then the there's a doctor who's called to that place. And if it is a red eye and a conjunctivitis, we prefer that it is checked right there and not be taken inside. But if it's a condition that needs to be seen, then then an isolation room is created where a slit lamp is present. This is away from the rest of the patients, and the patient is examined there. There is a roster for the doctor who's going to be taking care of the emergencies that come like this.
Now, it's okay to work these systems but it's very important to see what all can go wrong. And it's been quite a struggle, because the entire staff hasn't been coming. You explain the procedure to one person today. And the next day there will be somebody else and they may fall apart again. We had some funny stories where I asked this person, what's normal temperature, and he gave a range of from 35 to 38 degrees Celsius. So, it's important that the training happens that they know what is normal.
We also had a right an emergency situation when early morning, a patient for chemotherapy for retinoblastoma came. And after two minutes of entering the security guard got an alert on the phone and says this was the only patient who had entered at seven in the morning. The patient was quickly brought down, the person who handled the person was put in isolation. And there was a lot of confusion. This is the first time that it happened. After some time, we realized that they didn't even have a smartphone. And it wasn't a lot probably from somebody across the road or somewhere. And but for one hour, there was a lot of confusion, we were making the patient go to a COVID Hospital. In the meantime, the patient got side and they left and it was quite a struggle to get the patient back in.
So, it's very important that the people who have been given the responsibility for doing these jobs are trained well. They should know what to do. And in case something comes out of the normal, then we need to ensure they are aware of what are the next steps and they shouldn't be too much panic that happens because of lack of knowledge. So, we've learnt along the way, and I'll take you through what all needs to be done to manage these situations.
If there is a patient with conjunctivitis or a red eye, it's best to be seen by a designated doctor outside. You really don't need a slit lamp if a torch light examination can be done because conjunctivitis could be a sign of COVID disease. We have readymade prescriptions for the antibiotic drop. We also tell them in case you have fever, mild dry cough, then you need to report and go to one of these COVID hospitals. So, it's all written down in a pre-printed prescription which the doctor can prescribe right there. So, these are available right outside so that there isn't too much of writing and things that happens. It's all written on a pre-printed prescription.
Social distancing, again, required a lot of modifications in the way we work. We actually made multiple waiting areas. So, instead of confining patients to a few clinics because the volume is low, we said, let's spread it. So, we have multiple clinics and we actually opened up more spaces through which the patients could come. So, a lot of segregation, we open new gates in the hospital, make new patient flows, so that they were not crowding anywhere. Some of these chairs which we had were fixed with three to four seats together. And so to maintain social distancing, we put some strings so that people don't sat, or we put some tape so that there is enough space in between. Also, the floor is marked at the counters, so that people stand a respectable distance. Fortunately, there's been a lot of awareness in the society. And so people seem to be maintaining that.
In the clinic again, we don't want the patient to go through multiple people. And so the earlier system where we had some triaging of somebody doing vision, then somebody doing auto refractometer in CT and then somebody doing a refraction, then the doctor seen. We removed all that. The patient enters a room and between an optometrist and one doctor, we try to finish everything. We don't want the patient to be moving to too many people, because then there'll be that many people who can get affected. Basically, you're trying to see — you believe that every patient who comes may be positive. And so you have to take universal precautions. So, like I said, the patient should have a face mask. It's okay to do an applanation tonometry if needed, but it needs to be cleaned after every use and alcohol wipers enough. Auto refractometers, non-contact tonometer's and syringing should be avoided as they could be aerosol that these tests can generate and it's best avoided.
Well, we also created some infrastructure changes, so that our staff gets protected, and this glass was fixed on the registration counters everywhere. But we comes with new problems because the patient has a mask, this increases the distance that our staff couldn't hear what the phone number is or the addresses to register the patient. And so we had to put a PA system to allow them to hear what the patient is saying. So, these are practical issues if some things come up. While doing the examination, we got these acrylic sheets put on our slit lamp so that there is a barrier between the patient and the clinician. Of course, the patient should have the mask on and the patients have something that tendency. As soon as they come close to the slit lamp, they pull it down so you have to ensure that they put the mask up. You can guide the patient not to speak while the slit lamp examination is happening. And then you pull back and whatever discussion needs to be done can be done.
It's important that the doctor also wears a mask, good quality mask, doesn't necessarily in the OPD have to be N95. But if at least a three ply surgical mask, we wear gloves when we examine. At our place we are using water resistant gowns also, and an eye protection. We try using visors and face shields, but it's difficult to do a slit lamp examination or indirect ophthalmoscopy with that on. So, it's best to have protective glasses when you're examining. The housekeeping is instructed that the floor is mopped and the knobs and the railings are cleaned with 1% sodium hypochlorite every two hours.
The other thing that we've done in our processes and it's important to do that is that we have divided our whole hospital into three teams. So, the A team comes on Monday and Thursday, the B comes on Tuesday and Friday and the C team comes on Wednesday and Saturday. And we encourage that they don't even meet each other socially in the evening. This is to ensure that in case one, team gets compromised then we know the other teams are clean and they can take over. So, across the system, we have these three teams. One could have two teams or three teams depending on the load and the possibility of making teams. It does cause a stress in certain areas. But I think right now, the workload allows us to have three teams.
In our appointment systems also we've modified we spaced out the appointments so that there's no crowding. We still get a significant number of patients as walk-ins. And so who come traditionally in the four noon, so we left the four noon for walking patients and the patients who are seeking appointments are encouraged to come in the afternoon. And the slotting has also changed from two patients every 15 minutes to one patient every 15 minutes. This is to ensure that there is more spacing between the patients. We have extended the day so that we are able to see patients and on a longer date so that there is assurance of you know that there is no crowding in between.
The operation theatre again needs a few changes, and the SOP's have had to be modified for COVID again. In the ward three spaced out the bench, we've removed benches in between to ensure social distancing. On the day of the admission, the patient undergoes another check where the temperature is checked. Again, the history of cough or a headache or myalgia has taken. So, the system ensures that every patient gets this test and then new declaration is taken because it's possible between the time you schedule it and now that the patient may have acquired some symptoms. So, this is done in a specific location. The patient enters the OR, as well as throughout the surgery wears a mask. Surprisingly, the patients are doing quite well. There is no problem of claustrophobia that we've seen generally.
We again in the operation theater don't call a lot of patients together they are spacing between surgeries. All instruments like PPE, apparatus, stethoscope are disinfected after every use. The peribulbar block is given inside the room with full protection. There's a designated doffing area for the PPEs. The scrub nurse wears a visor for protection while the surgeon wears protective glass.
Now, the other differences that in between cases, we keep our time duration of between 20 to 25 minutes. This is to allow the air exchange, so if the previous patient had an infection, we don't want that to be passed on to the next patient. And we are keeping the HEPA filters on and the air conditioning on but we wait for 20 to 25 minutes between cases. The surgeries that could generate aerosols are done with full PPEs. I'll come to that very soon. So, they have to wear the entire full personal protective equipment while if the non-aerosol generating procedures the main differences that we are using double gloves and that is so that when you are doffing your gown, you first remove the first class and then you remove the gown after that you remove the inner glove, so that while you're removing the gown, you don't touch the gown with naked hands. And of course you should try to touch the gown only from the inside. Of course, the OT table needs to be cleaned after every case disinfected and there is daily fumigation that we are doing right now.
Now, a lot of controls on it. Although COVID test is not mandatory for surgery, but for the protection of our own personnel we have created a list where of surgeries that be insist that the patient should have a negative COVID test before we take them up. Largely, all the cases that may require incubation to GA cases 30 minutes, they undergo COVID testing. Some of the ocular plasti cases that require drilling and things like DCR would need COVID testing. There are if you're using cautery it could possibly generate aerosol so they that also comes on the list.
For COVID testing, you have to ask the designated lab personnel to come and then they take the nasal pharyngeal swab. This is quite tedious because the patient may need to wait in the hospital, they could be a waiting of two to three hours before the lab people would come to take the swab, and the report may take 24 to 48 hours to come. So, if there is a mild threatening case like a Cornell laceration or Endophthalmitis, we take the swab in the perioperative period. We may not hold the patient if the surgery is required early. And but we will take the swab nevertheless before the patient leaves the hospital so that we are aware of what happens. And during surgery, of course, we have to take universal precautions that everybody is protected.
If you see a lot of these procedures are, if you reflect back in somewhere in the early 80s, we modified the way we worked in the operation room because of HIV. And eventually we created universal precautions. I think something similar is happening with COVID that you have to take universal precautions, simple things like hand washing. Oh, well, it's — we've been talking about hand washing for a very, very long time. But it's only now that it when it comes to saving our own lives, we have become serious about it. So, things like that, I think this COVID situation should take us to a much better safer hospital practices, and also behavioral change is what we should expect. So, eventually, this whole crisis should leave us with better practices, they should become more uniform. And this is how he should otherwise also have been dealing with our patients. So, there is a small modification that we need to do. But it's all for good, I think it all is a lot of it is common sense.
Now, like with HIV, once in a while you will have a positive patient. Once in a while you will have a needle stick injury, and you need to know your next steps. So, it's very important that in case there is a positive patient, then what are we supposed to do? So, it's important to have good systems of contact tracing. We unfortunately on the very first week, we had one patient who was for a traumatic cataract under general anesthesia, asymptomatic, the report after 24 hours tested positive. And so we had to get back to the entire group of people who that day had seen the patient. And because it was a surgical patient had undergone a P scan and A scan of pediatric ophthalmologists and Anaesthesis and various other people like counselors, registration staff who had seen the patient in between. So, it's very important that the whole thing are documented well that you are able to trace back who all saw the patient. Electronic medical records definitely helped. But sometimes you have like in this case, we found that although their physical examination was done by one doctor, the signature was actually of the fellow or somebody else. So, it's important that we follow good practices which — and we had some flaws here and there. So, we put a more robust system. We retrained everyone to use their own pen and ensure that we have all documented who all see any patient.
We've also created a nodal team, a group of people who are the experts to deal with a situation like this. It's taken as an incident, and an incident management team has been created. All these people have been asked for a home quarantine. And we have a document now, which basically decides what is the level of risk that the person has. And mostly, we will come in the mild risk since we are wearing PPE's even in the clinic. Also, most of our patients are not very high risk, and we are not very close before surgery, we are not very close to the patient. So, depending on the risk, there is different levels of quarantine that we have to ensure. So, it's important to create guidelines and have knowledge about what has to be done. So, we have an incident management team. And then we have now one person who's the person who looks after the staff safety in case something like this happens.
So, it's important to create a COVID task force. People who have a little more knowledge, they should know what has to be done, there shouldn't be any panic, they should become like a very matter of fact thing that if it happens, we should know what has to be done. So, having these team really helps. We also have among these team members, we have every day that one person is in charge. So, there is one person who's in charge of the ships and everyone is not coming every day. So, it's important that the line of hierarchy is there and decision making can take place.
Some of the challenges that we faced is that during this lockdown period is to implement, you can write a good SOP, you can have a lot of good quality assurance principles. But how do you communicate down to every person since everybody's not coming every day. And so there's a lot of things that get lost in between. Also a lot of hospitals developed silos, these are different departments. So, you may say that okay, we will wear this PPE or everybody should wear a visor or things, but you may not have communicated it to your stores department or purchase department to ensure that there are enough of these available. So, it's challenging to get the whole thing across the entire system, because people are not there every day. So, you may talk to one team and the other team may not get that information. So, creating this line of communication is very important. Fortunately, these digital platforms like Zoom might help but then everybody may not be there.
The staff is limited. Sometimes people have this problem of public transportation that they may not be able to come. Those who are not able to come out are okay, but those who come may complain that why are we getting exposed. So, you have to handle your human resource also because there is this issue of the people who are coming may complained that what about the law shows who are not coming.
So, whatever you — systems you create, it's very important that you measure and have a checklist for monitoring. So, they should be a team that is constantly monitoring that all these things that we have created are being followed. We have had these issues, like as mentioned about the Aarogya Setu App, a lot that opened up, you know, a lot of confusion. So, we were able to put systems back. Similarly, this patient who turns positive, require to be managed, and because of these incidents, we've been able to put better systems in place.
Now going forward, technology has also helped us in reaching out to our patients and having electronic medical records has really helped. So, when patients call, we can open up their records, we know what has happened. Like for me, there was a Cornell transplant patient who complained of a little pain. When I opened the records, I could see that he has stopped using a steroid drug and I was able to instruct the patient and follow the patient up on telephone. Having some video consultants help. These are just words or pictures on which we made a diagnosis of Herpes zoster and the patient will manage and the patient's pain and agony was taken care of so much so that the patient gave a pretty large donation to the hospital because he was so happy about the treatment that he received.
So, having a combination of tele of your electronic medical records and some pictures, together you can manage patients quite well. Of course, there is a need for developing much better systems for communication and video consults. I think someday we will start working on them. But even this informal system of WhatsApp and EMR has helped us a lot in our communication with the patient.
And I see that as we move on, there will be more contact lens interfaces and that we will have and telemedicine we can now see the big role of it. Through the vision centers, technicians can take pictures and we could do consults sitting over here. We can teach them how to take basic. These are pictures taken of cornea by our vision technicians through the mobile phone. Good enough for us to make a diagnosis, good enough for us to tell what's a surgical procedure, what which patient needs an urgent referral. We've even made diagnosis of dendritic keratitis based on these kind of pictures. So, having good systems like that would help in managing patients remotely. And these this is something that we need to strengthen as the days come. I think Cybersight has a great platform where you could do a lot of close room consultations with your own teams. This is something to be explored further. And EMR and WhatsApp kind of systems also informally work. But as we move along, we need to have more formal systems for doing this teleconsultation.
From a secondary center, again, the comprehensive doctors could take images and a secondary center, specialists from a tertiary care center could help in managing the patient. So, I think the next step is how can we have our patients take much better picture. We recently made a video for them as instructions to take pictures and then sending to us. But I think that's the future that every time a patient comes to a hospital, at the end of the consultation, there is also a tutorial on how to take a better picture with a magnifying glass with how to take, have good lighting, use using a mirror, all these kind of things would probably be things that we need to improvise on as we move along.
Like this meeting, I think video conferencing through these different digital platforms have been very useful. In fact, I was in one of the board meetings this week. And when we were trying to schedule the next meeting, I said, hopefully the COVID situation would be out by then. And we'll have we'll be able to meet each other. Everyone said, no, no, let's not do a physical meeting, let's continue with this virtual meeting format, because it saves a lot of time. And we are able to have enough communication this way. So, these are new things that we have learned with this crisis. We can have good webinars. We are having, in fact, much more attendance in our daily classes that we have during this period. So, why not continue with the system post locked down? So, these are new learnings, all for good, that has come out of this crisis. So, we need to strengthen the digital infrastructure as we move along.
One aspect that may, which currently has taken a hit, is our community outreach programs. This recent notification that has come on 8th May very categorically says that no outreach camps must be undertaken and no mobile vans to be sent in the field. Of course, we don't want this kind of crowding in the camps and social distancing norms would not allow these camps to happen. So, how do we handle the community work that all of the community based hospitals are basically designed to do? We also know that the urban areas seem to be more affected with all these migrant problems that we are seeing. So, vision centers in both urban areas as well as urban slums as well as in the rural areas, I think that takes center stage. That's the way to go.
We have been talking about it in the last decade, Dr. Rao started the vision center concept. And I think they become even more relevant today. You have better access, so better day course services. We also feel that the rural areas are probably going to be less affected than the crowded urban areas like the Dharavi slums and the places like the big metros have. If they create access, in vision centers become the answer for taking care of blindness in the community. I think Mr. Tulsi Das also mentioned the other day that the tertiary care hospitals have shown only a 10% increase in footfalls, it was some of the locked down that was relaxed. But the vision centers have gone up to almost 60%.
And that shows that access becomes a big thing. Something that is close by, you feel safe to go to. But when you have to travel long distances or distances within big cities, it becomes a big problem. But when we are opening vision centers, we again need to have norms, we need to ensure staff safety, they need to be given protection, they need to be given training, the vision centers we need to be modified for social distancing, and including teleophthalmology in the vision centers would need a push. Because if you can avoid patients coming to the big hospital, I think it reduces the travel for the patient as well as the crowd in the hospital. So, having teleophthalmology associated with the vision center, I feel will be the next big step. We have been doing a little bit. They have been video consults. But I think that's something that needs to be strengthened as we go forward. So, vision center seemed to be — will play a big role as primary care centers for providing community care.
Now, they could be strengthened. And the existing community teams that we have that are involved in camps could possibly go into villages with door to door screening, of course, they would need their own norms and protection. This could be done around the vision centers. The teams could not only play a part in eye care awareness, they could also play a part in Coronavirus awareness, and about hand hygiene, about mask, about social distances. And that way you'll win the hearts of the community and the administration. So, including something like a door to door screening, more intensive screening around vision centers might help.
School screening I think we still don't know what new norms will come, would photo screeners help our children relatively safe and so will that work. This is something that we'll still have to see how it turns out. Most of the institutes that are into the community space also have a lot of education happening in these institutions. And the lockdown has affected hands on training. There is limited outreach activity, so the patient numbers have reduced. So, there is a lot of cause for concern among the young ophthalmologists. How does this affect my training? So, at one level, yes, the hands on training temporarily has stopped, on the other hand is newer platforms of online classes, webinars, online courses have strengthened so much that it's difficult even right now there are three or four webinars happening and one is having to pick and choose. And these are great medium for communication. You feel pretty close to the speaker as well with the video right on your face.
One would need to strengthen wet labs and dry labs so that you can reduce the need for that much of hands on surgery. Dr. Sangwan recently just last week, I think mentored a doctor in South America sitting in here in North India. Now these are all possible today with technology. So, I think there'll be a change that we need to develop. We need to get more innovative in the way we teach. And very soon I think we'll adapt to newer methods of courses for teaching. Of course, the hands on bit will still be required and hopefully these are temporary phase and we'll come out of it, so. We need to connect both emotionally and intellectually. And through these digital platforms, we need to be connected with our trainees. It's important that we give them support during this time.
Lastly, the most important thing that's dealing that we all battling with is hospitals are hit really bad. Like now it's almost like a triple whammy that we have because of Coronavirus. We have one increase expenses that we are having to incurred to the cost of infrastructure change and PPEs and all these methods that we have to adopt to, and decrease revenues because of the shutdown of regular operation, selective surgeries are stopped, patients are right now scared to come for elective surgeries. Also, the hospitals by themselves have become hotspots. And so, patients want to stay away. Then, incomes have also come down. Some of our hospitals have also been turned into quarantine facilities. So, we can't work in those places. So, the government took over, because they needed beds for quarantine.
So, how do we deal with this crisis? I think we have to reduce our fixed costs temporarily. And of course, the major chunk of that would be salaries. And I think right now, most organizations unfortunately are having to deduct salaries. Now when you're doing that, I think it's very important to have the right communication, get the employees involved, get them involved in the situation. They will understand that better instead of just sending an email about it. So, we need to be very sensitive, we need to get them involved, we need to have good communication and be sensitive to individual needs. There will be some people who may have a problem. So, one would need to have channels open for communication.
It's best to be done graded, where the ones who get the least salary are least affected. People with better salaries have a little cushion, and hopefully they can handle a few months of lower salary. Of course, nobody has the right answer. But when asked to do some kind of mathematical model, the June see 20% improvement, will July see a 30% or 40%? Until that one makes some kind of calculation as to what kind of a hit one can take. It's probably better to hit hard in the beginning. And then if situation improves, you can always relax it. It would be more difficult to do a graded later, where you give more salary this month. And next month, you say, we're going to cut even more. So, it's best to do some modeling and do it in the beginning. We've generally found that employees have been very supportive and they have shown great understanding of the situation, but it's early days. Let's hope the situation improves in the coming months.
We would need to see what all other places we can reduce our fixed costs, say rentals can probably be negotiated. Today, I think all landlords are aware that the – it'd be difficult to find new tenants. So, if you are in some rented premises, they can be negotiated. Some of the contractual employments can again be negotiated. How can we get some of our pending money that may have got stuck? Fortunately, the government has become very proactive right now. To our surprise, we suddenly find money coming from TBCS, not just in one location but in multiple locations. We also were able to push and get an income tax refund which normally remains pending for three years. We caught it very easily during this period.
So, I think the government is very sensitive right now. And all these kind of areas where you may have some money stuck, you should push it and try to get them released. If you have projects going and the money is already there, I think it's time to be reach back to the funder and negotiating that can be repurposed for something that you need right now. It's important. And I think everybody will understand it's very important that these hospitals stay afloat during this crisis. And of course, go back to your donors, your – and ask if they can assist during that time. I bet they'll say no. But it's very important that the fundraising activity continues and you ask for support wherever possible, and you'll be surprised that they are people who will come out and support. Of course, a lot of corporates themselves are facing a crisis and the government is pushing them to give money for Corona. So, all these problems are there internationally. Also, this is a problem. But wherever possible, try your best.
So, it is important to be prepared. And from that, you can reorganize yourself and learn from it and improve upon what you're doing. And it's – I would say that we need to reconnect. They will go closer to the patient. I think vision centers, secondary centers are going to recover faster before the large multi-speciality hospitals are metros. And that's why it's important to train good, comprehensive doctors who are closer to the patient and can deliver even some bit of speciality work over there. So, as we move ahead, I think we need to go back and get better comprehensive trained doctors who look beyond cataract. Digital initiators need a big push. Tele-ophthalmology would be very important for this initiative. Find local employment, very important to look at financial sustainability through patient accruals and not just grants.
And another push that we saw the Prime Minister make is in – on making India. And I think that's where we as ophthalmologists also need to play a part, use more Indian products, position them better and use them proudly. I think it's important but we do that. These differentials that we create, maybe that needs to be questioned. There are some good signs in some of the green zones. I think the patient footfalls have increased, where the lockdown has eased about 90 to 100 patients we are seeing in our hospital. In the last five days, we've done about 30 surgeries. So, fortunately, the patient psyche isn't that affected in these places, and they are confidently coming despite not very stable public transportation.
Also, important to diversify during the lockdown period as well. Other than cataract surgery, some surgeries continued to happen because they need to be done. The injections for retina need to be put regularly. Retinal detachments need to be fixed. So, it's important to diversify beyond a single surgery of cataract. And so with that, we see the need to modify the way we work. And eventually, we will come out of this crisis. I see a light at the end of the tunnel. Government seems to be putting more focus on health care. And that should have in the long term, a big impact on work. We've seen the government being very sensitive right now. The hospital that [inaudible] [00:48:45] for quarantine [inaudible] [00:48:50] and sanitized it. And the way they work there was very impressive on the work being done by the medical health workers. And I think this – if it continues with the impact on healthcare in general.
So, stay calm. This time is good. You're staying with own family. You are eating right. The air in Delhi and other places have cleaned up. You've seen birds and all the different animals on the street. Sometimes, we had a peacock walking in the open the other day. Discover your own talents. And of course, it's important to live within your means. And I'm sure we will come out of this Coronavirus crisis much stronger. Thank you.
Interviewer: So, sir how do we manage the follow procedures especially in an emergency eye disorders given this current COVID outbreak?
Umang Mathur: So, follow – I would imagine the problem is of travel for the patient, and how do we continue to remain in touch with the patient. So, I think once you manage the emergency, whether it's a surgical management or a medical management. If the patient needs to come, I think today the lockdown three allows patients to come back to the hospital if you are able to give them a letter that they need a consultation, the police would allow them to travel. After, say the first day of follow-up if you think, the patient is okay to be seen by an image, maybe we train the patient to take an image and they can send it and you can respond to that, or they go to we connect them to a local practitioner who does the follow-up and with whom you can be in touch. So, if somebody is coming from far off from another city, I think it will be important that we give a contact of a local practitioner there that the patient could fall.
Interviewer: And sir, there are many — I mean, is there a portable UV sterilization unit that can be used to sterilize some of the items that are, you know, that are continuously being used or is there a better alternative to it?
Umang Mathur: So, what we have done is we've created one of our exam rooms for the UV light. And at the end of the day, all are 90 days and 20 days indirects and retinal scopes and things like that, we put in that room that the UV light. But we have seen smaller contraption and they can be made in house as well with the UV light, say, the – there are things that people have created for taking currency notes and putting them in UV light for sterilization. So, but generally, the vaping with disinfectant like alcohol swab or hypochlorite is generally very sufficient. So, depending on what kind of instrument it is, mopping with disinfectant can work. Some of the sensitive instruments like your OCT and instruments like that, you can put a clean film that you use for packing your food on the lens, and that could protect and then you can replace it after the patient has been seen. So, those are the kind of things that have been done, but you could use any of these sterilizers to help in cleaning the instruments.
Interviewer: Sir, is PRP laser therapy possible or not possible at this time?
Umang Mathur: So, there is this thing about lasers both YAG laser and PRP and excimer lasers that they will disrupt the TR film and cause some aerosol generation. I think putting a shield, having – wearing N-95 mask, wearing gloves, having eye protection, with these, you are reasonably safe to do those procedures. But if it's something that can be avoided for some time, you could avoid. But if the patient needs an urgent treatment, taking precautions and doing it, I think should be reasonably safe. Now, these are gray zones. I mean, there's no right answer. So, we don't have enough study to say how much is the risk and how little or what can happen. But if you take precautions, I think it should be fine to do the procedure.
Interviewer: Why should we avoid air and NCT during this period?
Umang Mathur: Again, the same – the release – that puff of air disrupts the TR film and spreads aerosol. So, that's why it's avoided. So, you should avoid NCT and air because of the disruption and the TR film that can happen. And since you have alternators available, that can be done and not expensive. Like a retinoscopy instead of autorefractor meter, it should be fine to avoid it.
Interviewer: Yes. So, interestingly in India, we have people visiting along with the patient. So, we have family members visiting. So, is there like a systematic change that we can sort of do in the hospital to manage, you know, to let just the patient is allowed inside or something?
Umang Mathur: Of course. I think one has to have a very, very strict one patient, one attendant policy. I think the only exception would be some disabled kind of person who needs to be – needs to have an attendant more than one. And so at the entrance, we've actually created a barrier that allows only one person in. So, only one at a time, and there is somebody watching that nobody more than that enters. They also ensure that they have washed their hands before going in and check whether they have a mask and also the declaration that they have to sign. So, one has to make small changes in the patient flows right at the entrance of the hospital that only one person enters the – one attendant comes with the patient. So, these changes have to be made. We've just made – put some chairs under some trees that if there's an extra attendant, they are asked to wait there.
Interviewer: Okay. Thank you, sir. You know, sir, you talked elaborately on the outreach model that has obviously changed given the government regulations right now in terms of community outreach. So, what can we sort of look at – what kind of model can we look at post this lockdown is [inaudible] [00:56:05].
Umang Mathur: So, I have a feeling that camps may not be – the permissions for camps may not come for a very long time because generally, one would avoid any collection of people. So, I would imagine for the next six to 12 months, we are not going to get permissions to do camps. So, we will need to modify the way we work. I think the vision center model is probably going to need strengthening where you have control number of patients that come, you can paste them. With that, one can probably go into more intensive door-to-door screening instead of collecting people in one place. You go out and screen them. It may – will be a different game. But I think that camp based models at least for some time may not come unless we all work together and create social distancing norms and create safety during the camp and then present it to the authorities, but I think it will – it's going to take some time before that happens. I think the authorities are not going to be convinced immediately and won't allow camps to happen. So, I think we will have to modify the way we do the community work.
Interviewer: So, you repeatedly pointed out that vision centers will play a very critical role reaching out to the patients as of now. But, you know, there's a, like a challenge, a little bit of challenge of space issues there. So, how do we…
Umang Mathur: Yes.
Interviewer: [Inaudible] [00:58:01] in such a scenario? Is there a type of…
Umang Mathur: Yes. So, I think we are also in the process of developing a document, we have created the SOP for it. There will be a problem of space. Vision centers are generally not that large, which can have a lot of chairs for social distancing and things. We will have to probably also create some kind of an appointment system maybe, that you are able to space patients out and have limited number of patients coming in at a particular time. When it comes to PPEs, again, we'll have to – we are looking at, it's a challenge because it would be very expensive to have everything disposable. If you have gowns which are reusable and we've been able to get some very nice water resistant gowns, which can be reuse. But then they're dauphine and then subsequent cleaning, innovation center kind of scenario is not going to be very easy.
So, these are newer challenges that people have – we'll be be able to bundle them in a yellow bag and get them cleaned in a sterile in a safe way. We are still working on these details, but I think we will find answers. We will have to find local answers for these because the staff would need to be protected when they are seeing patients and we'll also need to put good monitoring systems because they are working remotely. We have to have good monitoring systems that whatever systems we put are followed. So, we are finding local places which can safely clean these and how do you do the doffing and then put them in a bag that the gowns can be cleaned safely. So, I think these answers can be found, but we'll need to put thermal scanners. The vision center equipment is going to change because all these norms would have to be put there as well.
Interviewer: Sir, conjunctivitis patients, if they're also asymptomatic, then how, like should we do the COVID testing first for them? How do we treat the – such patients?
Umang Mathur: A conjunctivitis patient – not everyone is going to be COVID positive. So, they're not all COVID positives. So, if you have a conjunctivitis, I think our torch light examination outside the waiting area itself should be adequate. We give them an antibiotic prescription and we ask them for teleconsultation after five days. If during this period they recover, very good, if during this period they develop fever and cough and any symptom, then they are advised to go to a COVID hospital for further testing. If the conjunctivitis is improving, they just continue with the antibiotics for some more time. So, after five days, we do teleconsultation with them. They are given that information on how to contact, and that seems to be working. We basically avoid dating them inside the system than the torchlight examination outside the waiting area.
Interviewer: Sir, does the temperature ladies with exercise of ambient temperature as long as home uses is maintained by the body?
Umang Mathur: Yes, I'm sure it does. But these non-contact thermometers are not very accurate, and they malfunction as well. They need to go back for recalibration as well. So, that's sometimes a problem. So, when you get a positive patient, let's say the temperature is over 100 but the patient feels he doesn't have fever and thinking it's happening again and again almost every other day. So, we realize that you ask the patient to sit for some time in a shaded area, have some water. After 10 minutes, you check again. And if the temperature comes normal, they're most likely normal. So, don't go by just one reading. The patient may have come in the sun and it's pretty hot outside right now. Also, our guys were checking temperature out in the sun. So, we had to modify that they have a shade over them and then they check. So, small details like that are required to get the accurate temperature.
Interviewer: How frequently should we check with a staff for COVID-19 as they are in contact with the patients on a daily basis?
Umang Mathur: As of now, the government doesn't encourage you to test a symptomatic people. So, if you're staying in an area which has a containment zone and they have a policy for random checking, that's different. As an organization, no, you don't need to. But yes, the thermal scanning and every day when the employees come in, they also have to go through this. So, they also have to go through this. They also have to be asked about any symptoms, and only then allowed entry. So, and this was again a process that had to be monitored because just because you're a doctor, they would not check it at the entrance. They would assume you're okay. So, I had to put systems that they – and that they have to go through this temperature check. So, every employee daily has to walk through the same process as the patients have to. So, that's important too. So, you have to put those systems in. It's not just for patients and for staff that the check happens.
Interviewer: Sir, for the School Eye Health Programs. Of course, schools are shut as of now. But when they are open up, you know, should we sort of innovate? Should we be like innovative models to run these Schools Eye Health Programs, or should we move around a model with the vision centers to do these programs?
Umang Mathur: No, I think we'll have to find — I think we probably will remain with school health and not the community model and below. Once the schools open, I think we may like to find models like would have something like a photo screener be used by a teacher to pick up suspects, and then the secondary screening and a limited number of children can be done with proper social distancing and stuff. So, we'll probably have to innovate and find new models for school screening. I think this is a little further away, because the schools are shut, and I don't see before the summer. Now, the summer holidays will start. So, I think we will probably have to work in the next few weeks to see what would be a safe method to do that. So, I think there'll be a need for people to put their brains to see what would be a safe method to do that. But I think once children in general are relatively safe and are not getting the disease as much as the old do. So, probably children over a period of time – what will happen is that we have to protect the vulnerable and slowly, slowly the people who are relatively safe will start going back to their normal process. So, I don't know how this this situation is going to change, but they will be a need to innovate for sure.
Interviewer: But, you know, Eye Care ecosystem in the paternity in hospitals have sort of faced challenges when it comes to government funding for Eye Care in the past, so how do you see – how do we advocate let's say, given this scenario where in – the government of the – the government's attention has moved again of course to the more critical issue of pandemic? How do you see for government funds in the future, near future for Eye Care?
Umang Mathur: So, the limited few weeks have been reasonably encouraging. I think we're not hearing that the government is going to stop Ayushman Bharat. The government is, for all you know, is only going to strengthen it further. Healthcare is going to get more focus. I think right now, of course a lot of attention is going to COVID and rightly, so. I think it's going to leave us with a much stronger system. The data that they have collected right now, how many beds in a district, how many ventilators, how many ICU beds, how many ambulances, I think there is a lot of data that has got collected. The government and everyone is looking at this whole crisis. And hopefully, hopefully, we should come out stronger, not weaker.
Also, we are encouraged by the fact on how they are releasing funds like DBCS funds which used to take, you know, months and months of persuasion, that we were surprised to find them coming to us without any difficulty. So, the government right now probably understands the situation that hospitals are facing, and I don't think that we are going to have any change in the policy. I think the bigger problem is going to be the delivery, since camps and community work is going to be withdrawn for some time. But when it could come to release of funds, hopefully I think it's not going to be affected too much. So, I'm reasonably optimistic about it.
Interviewer: Sure. Sir, let me know whenever you think the…
Umang Mathur: I'm okay. I'm okay.
Interviewer: Great. Great. Thank you, sir. So, sir, in terms of door-to-door screenings, although again the community outreach has been affected and like there's a limitation when it comes to door-to-door screening. But someone has asked, are there specific norms that you would like to suggest for the door-to -door screenings apart from…
Umang Mathur: That is still evolving, but we are seeing that the government is using ASHAs and Anganwadis as the basis for reaching out to villages and at the Grassroots level even during the pandemic even for managing an awareness building during the Coronavirus situation. So, why can't we as Eye Care professionals also have our foot soldiers going out and doing screening? Instead of collecting people in one place, we could also do that. Yes, it's not going to be as efficient. It would be a little more expensive. We may not be able to collect that many people together. But I think a more intensive program where we have our vision center and we map out the villages that we want to screen and try to make them blindness free or at least have data to do that. And the vision centers could be the nodal point through which we will deliver our care, while the screening can happen in a door-to-door way. And while these people are doing the door-to-door screening, they could also support the system for awareness building of how to manage the Corona situation, give people information about hand hygiene, respiratory hygiene, wearing a mask, social distancing and all those norms. And if there is a person who has fever or cough, knowing where to go. So, they could do a dual purpose of supporting the Corona problem as well as the Eye Care issues.
Interviewer: Sir, next is a million dollar question. When can we start routine surgery in larger cities like Delhi or Pune and…
Umang Mathur: Well, we started our surgeries this week. So, we started routine surgeries, elective surgery, the government has given a notification that elective surgeries are now allowed. So, from Monday, we started our elective surgeries at the hospital. So, including cataracts. So, of course the patient numbers are small right now. But I think from the government side – except for containment zone, red zone, orange, green, across, I think the government has given a go-ahead that elective surgeries can take place. So, taking all due precautions, we have 25-minute break between every case depending on the kind of aerosol generating or not the respective PPEs are worn. All surgeries are done with double gloves. We wear N-95 mask. We have gowns which are water resistant. We take all due precautions, but we have started — we otherwise also autoclave up hand pieces after every case, not just a tips and sleeve. That's always been our norm. So, generally, it's all universal precautions. The patient also wears a mask during surgery. We prefer not to give oxygen through a bite because that's also aerosol generating. And so, we prefer not doing that. But it has – we started in a limited way. And our secondary center, also in central UP, has started doing surgery. We are doing about five, six surgeries everyday over there as well.
Interviewer: Sir, is it safe to use a plastic sheet in front of a slit lamp while seeing in OPDs, or is there a better option?
Umang Mathur: So, yes, any kind of barrier is fine. Initially because things were not available, we used our transparency kind of sheet, made a hole in the eyepieces and we created a shield with that. Now, we've been able to get – make acrylic sheets. So, it's a transparent acrylic sheet where we've created this hole through which the eyepieces project out. And that kind of a barrier works quite well, actually. So, this – we haven't really — I think they are some commercial available. But actually, it can be made very easily in house. So, it – basically you need a barrier between the patient and you. So, an acrylic sheet can work quite well. I think there are quite a few WhatsApp messages with pictures and things that are doing the rounds. We tried using a visor, but I found it difficult to see this slit lamp through it. But for the rest of the staff like the assistant and OT, the registration staff, all for them, the barrier with a face shield really works well.
Interviewer: You know, sir, the outreach has been affected. So, how do we engage outreach teams when there are comms of course? And should we go only for house-to-house visit and refer to vision centers or hospitals?
Umang Mathur: Yes. So, I think we'll have to modify the way we work because I think for the next few months, the camps, I don't foresee getting permissions for them. So, engaging them in all other kinds of activity even within the hospital because for this thermal screening, monitoring a patient flows. Also because right now we are divided into two or three teams, we don't have enough staff to manage – of the stations. So, some – these outreach team can be utilized for helping within the hospital also, right in the current situation. But as the walk-in traffic improves and the situation in the hospital changes and you have staff coming every day, then the outreach teams can be used for looking at newer models of outreach, whether it's – I don't know whether it's practical to do the door-to-door for everyone, but some kind of local awareness would help.
And strengthening of vision center, getting most footfalls into the vision center, opening more vision centers, I think that will be the way to look at community outreach. As it is the – vision center is a much better model for comprehensive care of a patient. And with tele-ophthalmology, I think that would be strengthened further. So, I think vision centers offer a much better system of community outreach, more scientific way of doing it than the camp based method. But, yes, it's been a change in the model in which we are doing right now.
Interviewer: Sir, can there be any legal issues of any kind for eye doctors or hospitals? If they're providing telemedicine for conjunctivitis or such eye conditions?
Umang Mathur: So, it's very gray right now. It's very gray. We don't have – the government has come out with some telemedicine norms of even taking some kind of consent that this is a telemedicine consultation and this is not. So, I think right now, the government would be reasonably – what should I say? It doesn't have very strong norms for this. I think we should still avoid things like steroids to be prescribed on telemedicine, things like an antibiotic, lubricants and keeping it that way would be better. And in case you have to prescribe steroids, I think it's better to call the patient into the hospital. So, without examining the patient, I think one should not use medication which can potentially have more side effects.
Interviewer: Sir, how can we examine a foreign body lost in the upper fornix?
Umang Mathur: Well, I mean, very specific question. But I think in the clinic, you have to take all precautions. It's like doing a surgery. You can't be examining a patient the way you used to about three months back. When we're examining in the clinic, we have to wear protective gear, we need to take all the precautions, slit lamp after used has to be cleaned again. We have to ensure that proper hygiene is maintained. And with that, if one needs to examine, you wear the lid and use a sterile needle or whatever you're used to, to remove the foreign body. So, it's not like you're not touching the patient. When we are examining the patient, we are having to sometimes touch the patient, retract the lids. But taking all precautions, I think it should be fine. So, it's almost – when you're doing an outpatient clinic, you're almost are tired like you are in the OR. Except the gloves, you may use hand sanitizer over the gloves instead of reusing gloves every time. I think that's the only difference. Otherwise, you're pretty much tired like you are in the OR to do a surgery.
Interviewer: Sir, how can you do subjective reflection or PB, RE and others?
Umang Mathur: Some subjective refraction must be. So, when you're doing a refraction, the lenses and the trial frame has to be cleaned after every use. So, you clean it with an alcohol soap after use. And like you do your normal retinoscopy and subjective refraction, you do it. What we are doing at the end of the day, we leave the trial frame under retinoscope in the room which has the UV light, but that really is not going to work the whole day. Between every case, you have to clean and then reuse. So, it's fine to do a reflection.
Interviewer: Sir, I think we [Overlapping Conversation] [01:20:33]. Yes, sir. We also answered almost all the questions.
Umang Mathur: Okay. So, thank you for giving this opportunity. And I'll be happy to take more questions if you have more specific needs. My email can be taken through – I think Neha will help in giving the email. And I'll be more than happy to take any questions if you have. You can send it to me by email, and I'll try to answer them. It has been wonderful interaction, and thank you for giving me this opportunity. I know these are questions which are not easy. I can't say anybody is an expert on them. It's very dynamic. The situation keeps changing, and you keep evolving. And you move from doing too much to too little, and then you have to find what's just right.
So, this is the new normal. But I think it's time we adapt to it. It's not going to change very quickly. So, we have to move on. And I think the patients at least in some of the areas we're seeing are happy to come to a hospital also. So, I'm not sure of the metro cities but outside, they are. So, let's hope for the best and take all precautions and do things safely. So, thank you so much for listening in, and I hope it was useful.