Delhi resident Mallika Kumar endured a tooth ache relying on home remedies during the lockdown. Recently she sought an online consultation with a dentist, but is apprehensive about visiting the doctor for treatment. "A friend suffered a fall injury and was compelled to go to a hospital for an X-ray following which she was wheeled in for immediate knee surgery. During post-op recovery, she was diagnosed with COVID symptoms and passed away subsequently," Mallika narrates, unable to get over the incident. The foundation of her fear is a possible hospital-acquired Coronavirus infection.
In Kolkata, Rebecca De Souza is unable to avoid hospital visits as the only caretaker of her ailing brother who requires mandatory dialysis. She’s anxious about bringing any infection home, because she lives with her elderly mother. Though we get appointment slots, wear masks, try not to touch anything, sanitise our hands, and rush for a bath after returning home, the mind is not at peace, she says.
Mallika and Rebecca are not isolated cases for the loss of confidence. An article in The Guardian published in May 2020 quoted in The British Medical Journal , reported that up to 20% of NHS patients in the UK contracted COVID-19 in hospitals while being treated for another illness.
Many requiring health check-ups and routine ongoing treatment are wary of entering hospitals that have poorly ventilated lounges, often situated in the basement of a building, and air-conditioning that will probably not pump in fresh air.
"It is a new order health crisis," says Dr.K Srinath Reddy, president, Public Health Foundation of India. "It is difficult to identify the asymptomatic and pre-symptomatic, who can disseminate the virus unintentionally," he says.
Maximum security Hospitals can be reconfigured to use ultra-violet lighting and PPEs for all healthcare staff.
What hospitals can do
To quell the uneasiness, hospitals can be reconfigured to facilitate good air flow and space utilisation, to use ultra-violet lighting to reduce microbial threats and PPEs for all healthcare staff. "The way we redesign and build our structures and follow the patient dealing processes may never be the same again," says Dr Reddy.
Mumbai-based architect Shantanu Poredi, who has done the space and medical planning of several hospitals, including Mumbai’s Kokilaben Hospital and the 250-bed multi-speciality Reliance Hospital on the Navi Mumbai-Thane highway, says the bane of modern structures is the vertical box construction without any cross-ventilation. "Ideally, we should go back to separate self-contained units, like how it is in majority of the old Government hospitals, built by the British, where each department is an independent block with the greatest amount of flexibility and ventilation," he suggests, while acknowledging that land is a luxury in cities.
To help mitigate and prevent the highly contagious virus, Poredi says the focus needs to shift from fixing the critical care infrastructure to reimagining the hospital space. “Total temperature control should not be restricted to ICUs, OTs, burns, neo-natal and few other critical care wards. Entire complexes need to go green with large windows and efficient air conditioning systems with HEPA filters, powerful exhausts, air curtains to effectively filter the circulating air."
About to complete a 250-bed hospital in Indore and start work on a 300-bed hospital in Rajkot, Poredi says he may alter the hospital architecture wherever possible depending on the client's choice and investment, but running them will be technology-dependent in future.
For instance, he is reworking his designs, introducing sliding doors and touch-free and remote controlled switches, handles, monitors and other common contact points. He’s replacing curtains and blinds with smart glass partition screens that are easy to clean and maintain with long lasting surface disinfectants, developing more pop-up triages (where decisions are taken on critical care) in open and empty areas around the hospital and installing cubicles with anti-microbial coated walls in place of open counters inside the building.
Working on existing facilities
It is a tactical war on the virus and innovation is the key to minimise pathogen transmission inside hospitals, says Prof Anil Dewan, Head of Building Engineering and Management at Delhi's School of Planning & Architecture. Along with architect Sandal Kapoor he presented a paper at a webinar on post-Covid healthcare strategies where the duo looked at potential intervention in the existing facilities. "Retrofitting old hospital buildings is tough but compulsorily everything needs to be pushed behind protective screens now," says Dewan."We have redefined the protective environment with prefabricated modular approaches and mobile constructions," adds Kapoor.
Wide shot. Doctor in protective suit talking with patient showing tablet in hospital. Professional shot. 052. You can use it e.g. in your commercial, medical, business, presentation, broadcast
The critical safety protocols, according to them, include screening of patients with robotic scanners; sanitised entries; AI enabled kiosks for registration, billing, enquiry, pharmacy; spacious and well ventilated common areas; circulation of constant fresh air; UV sanitisation sections and more isolation rooms and makeshift treatment rooms. "The adaptive reuse is to effectively segregate crisis pandemic patients from the uninfected," says Kapoor.
The Chief Medical Officer at Aravind Eye Hospital, Puducherry, Dr R Venkatesh, says hospitals are actually safer than malls, offices and hotels now on account of more rigorous sanitising. While the out patient rush has dropped by three-quarters and surgeries by a fifth during lockdown, he says the hospital is preparing to deal with more patients when they start returning (See box). "How long will they avoid treatment? Hospitals will have to take a paradigm shift in clinical and administrative management while healthcare models will continue to evolve," he says.
To begin with, we must return to the primary care doctor for the basis, “and remember, less healthcare is always better healthcare,” says Dr Puneet Bedi, a gynaecologist with Indraprastha-Apollo, Delhi.
Reshaping hospitals
Bar attendants from entering.
Set up multiple and separate entry and exit points to distribute the crowd.
Establish pop-up triages outside the main building to take the load off the hospital, so those who don’t need admission can be given a prescription and sent home.
Allow patients inside in small batches depending on the size of the waiting hall
Have the mandatory hand wash and temperature check at the entrance
Staff, patients, visitors -- all should wear fresh surgical mask while entering
Set up automated opening/closing of all doors and windows
Announce reminders over the public address system not to lean against walls or unnecessarily touch surfaces
Get the patient’s history over the phone as they wait their turn, thereby reducing doctor-patient meet time
Fix seating arrangement in waiting hall as per social distancing norms.
Make online registration and appointment mandatory for paying patients
Encourage telemedicine, strengthen primary care, day care procedures and ambulatory home care
