Temporal separation

COVID-19: AVOIDING

THE SECOND BLOW

A PLEA FOR MANDATORY TEMPORAL SEPARATION IN ESSENTIAL SERVICES AS AN ADJUNT TO SPATIAL SEPARATION IN OVERALL PUBLIC INTEREST

24/3/2020 Dr Rachita Chopra MBBS, DNB (General Surgery), MRCSEd, ATLS Instructor

INTRODUCTION

Central government has brought into effect national lockdown in


view of COVID-19 pandemic

The rationale for national lockdown addresses the paramount


importance of social distancing to interrupt to spread of COVID-19

However they remain most susceptible to outbreak of the disease increasing probability of their collapse in turn making the country vulnerable to a shutdown.

Essential services continue as they form the backbone of the


country

Structured temporal separation of healthcare personnel might


be the Key to prevent healthcare collapse

SPATIAL SEPARATION- CURRENT PRACTICE

HOSPITAL

Airtight spatial separation is not a realistic expectation in persons engaged in essential services especially with paucity of PPE and community transmission of disease. Regular patients and doctors taking care of them remain at risk of COVID 19 equal to (arguably more than) the community

  

REGULAR PATIENTS ( At risk of COVID- 19)

Patients with Respiratory Dieases/ Fever (COVID 19 Patients/ Suspects)

 

Health Care Workers

WHAT IS MEANT BY TEMPORAL SEPARATION

People who can’t be separated in space because of nature of work are separated in time

   

Healthcare worker (Not in COVID 19 team)

 

At work

Home Quarantine

Day1 Day2-7

          

COVID 19 TEAM

      

WORKS FOR 1 WEEK

    

Home Quarantine for 2 weeks

No Symptoms of COVID19

Symptoms of COVID19 No Symptoms of COVID19

Day8

        

Mild-Moderate disease

Severe/ Critically ill disease

Return to work

    

Return to work

   

Home Quarantine

Admission in special ward

HOW TEMPORAL SEPARATION CAN HELP

Mandatory temporal separation of healthcare providers for a minimum period of one week will allow detection of cases within the personnel and simultaneously break the cycle of transmission to patients and colleagues.

Basis : Most patients with the disease present with symptoms


within 2-5 days though it may take upto 14 days

HEALTHCARE WOKERS

Departments with significant proportion of emergency cases

Other Departments

Support Services essential


for daily functioning

   

COVID 19 TEAM

HEALTHCARE WORKERS

TEMPORAL SEPARATION

SUPPORT SERVICES

Delegate staff for COVID Team

Remaining staff-

1. Total strength >/=14: 2 shifts, work once a week

2. If strength >/=7 but </= 14: 2 shifts, work twice a week Eg Morning, Night followed by Home quarantine

3. <7: Departmental protocol optimising temporal separation ensuring continuity of services

DEPARTMENTS WITH SIGNIFICANT

PROPORTION OF EMERGENCY CASES

(Eg General Surgery, General Medicine, Neurosurgery, cardiology etc Including departments involved in investigational support like microbiology, biochemistry, radiology etc)

Dissolution of units (HOU final point of contact on emergency days


as before)

Heads identify minimum number required to function daily and roster


aiming at temporal separation of 7 days – OPD, Ward, Emergency

If insufficient: Overlap with maximum temporal separation

If number sufficient for temporal separation: excess goes to COVID


19 team

Doctors > 50y/ with comorbidities, preferably on call, if deficiency,


included on roster

OTHER DEPARTMENTS

(Eg Psychiatry, plastic surgery, rheumatology etc including basic sciences )

DOCTORS with co-morbidites/ Age > 50 years: On call team for regular cases.

Rest Join COVID Team.

COVID 19 TEAM

WORKS FOR ONE WEEK QUARANTINE FOR 2 WEEKS

  

• Specialists in Respiratory disease management (Internal Medicine, Pulmonary medicine, Intensive care etc) TEAM LEADER

• Specialists in other fields (Paired with field specialists- capacity building)

• Residents

Three Teams 1 Subdivided

2 3

Nurses Cleaning Crew

A A BBB

• •

• Food Providers

• Wardboys

• Technicians

• Other support staff

CCC

Emergency Team

for 3 shiftsA

WARD TEAM X 3 with shifts

ICU TEAM X 3 with shifts

HELPLINES, PATIENT EDUCATION, COMMUNICATION AND COORDINATION TO SUPPORT COVID TEAM

Medical students, allied health sciences, etc can be


employed

• • •

LIMITATIONS Personnel availability is institution dependant

Leaning curve in managing cases outside area of specialty

Inertia encountered because of shift of personnel between departments

Ensuring compliance and strict clinical governance can be


challenging

Widespread acceptance and consensus

Attrition of healthcare workers to disease is not eliminated, only


decreased

POTENTIAL SOLUTIONS

Policy of temporal separation made mandatory like social


distancing

Realtime feedback to impediments in implementation to facilitate


solution finding

Pooling of resources and personnel in hospitals in geographical


proximity.

Accepting volunteers from private sectors/ doctors not working currently for several reasons – Not just for covid19 wards but other departments as well which do not have sufficient personnel to implement temporal separation- especially for forming reserve teams.

RECOMMENDATION

State task force with representatives from all institutes
( Institutional Heads with HODs) reporting to a national task force (required for oversight) composed of representatives from MOHFW facilitating logistics and drafting final policy for nationwide implementation of structured temporal separation coupled with spatial separation with addenda catering to individual state needs.

Temporal separation feasibility for essential services other


than healthcare may also be practiced on similar patterns

CONCLUDING REMARKS

Temporal Separation is a viable solution to curtail the risk of all specialists succumbing to the disease at the same time.

It can help maintain continuity of services over prolonged period with maintained efficiency

THANKYOU

“For the want of a nail the shoe was lost, For the want of a shoe the horse was lost,

For want of a horse the rider was lost,

For want of a rider the battle was lost, For the want of a battle the Kingdom was lost,

And all for the want of a horseshoe-nail.”
– Benjamin Franklin

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