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
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view of COVID-19 pandemic
The rationale for national lockdown addresses the paramount
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importance of social distancing to interrupt to spread of COVID-19
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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
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country
Structured temporal separation of healthcare personnel might
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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
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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
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within 2-5 days though it may take upto 14 days
HEALTHCARE WOKERS
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Departments with significant proportion of emergency cases
Other Departments
Support Services essential
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for daily functioning
   
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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
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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
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as before)
Heads identify minimum number required to function daily and roster
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aiming at temporal separation of 7 days – OPD, Ward, Emergency
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If insufficient: Overlap with maximum temporal separation
If number sufficient for temporal separation: excess goes to COVID
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19 team
Doctors > 50y/ with comorbidities, preferably on call, if deficiency,
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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
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challenging
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Widespread acceptance and consensus
Attrition of healthcare workers to disease is not eliminated, only
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decreased
POTENTIAL SOLUTIONS
Policy of temporal separation made mandatory like social
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distancing
Realtime feedback to impediments in implementation to facilitate
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solution finding
Pooling of resources and personnel in hospitals in geographical
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proximity.
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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.
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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
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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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