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Year : 2020  |  Volume : 57  |  Issue : 2  |  Page : 123--128

The COVID-19 pandemic and the Tata Memorial Centre response

The Tata Memorial Centre COVID-19 Working Group 
 Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Correspondence Address:
The Tata Memorial Centre COVID-19 Working Group
Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra
India




How to cite this article:
T1. The COVID-19 pandemic and the Tata Memorial Centre response.Indian J Cancer 2020;57:123-128


How to cite this URL:
T1. The COVID-19 pandemic and the Tata Memorial Centre response. Indian J Cancer [serial online] 2020 [cited 2020 Aug 8 ];57:123-128
Available from: http://www.indianjcancer.com/text.asp?2020/57/2/123/281968


Full Text



 The Covid-19 Pandemic and the Tata Memorial Centre Response



The COVID-19 pandemic hit most healthcare providers globally in a way they did not anticipate. In retrospect, this is surprising because the experiences of the Chinese healthcare system should have warned us. However, most assumed that it would never reach global pandemic proportions, and therefore were taken by surprise. The rapidity of transmission (fueled by free international borders) left countries and healthcare systems struggling to cope with the burgeoning number of infected patients. The first patient in India was diagnosed in Kerala on the 30th January 2020 and was a student who had returned to India from Wuhan. By 30th March 2020, the number of diagnosed patients stood at 979, with 25 deaths.

While there was a slow but steady rise in the number of patients in the country, it was only by the second week of March that most healthcare providers became cognizant of the magnitude of the problem, and we realized that we needed to act swiftly. To understand our actions over the next two weeks, it is important to have a brief background of the Tata Memorial Centre (TMC). TMC is the oldest (established in 1941) and the largest comprehensive cancer centre in India, and is a grant-in-aid organization under the Department of Atomic Energy, Government of India. Based in Mumbai, the centre provides treatment and opinions to over 75000 new patients annually, with over 85% of patients hailing from outside Mumbai, and over 60% outside the state of Maharashtra. Consequently, most patients undergoing treatment at the hospital lack strong social and family support in Mumbai. TMC is a specialized hospital treating only patients with cancer. Over 60% of our patients are treated either completely free or at highly subsidized cost.

One of the first measures we took at the Tata Memorial Centre was to create a COVID-19 Action Group – a sort of command centre, constituted by clinicians, paramedics and nurses, and hospital administration. The series of actions and processes described in this piece are the result of intense parleys at regular (daily, and sometimes several times a day) intervals, with the sessions not very different from the “war room” concept. The rapidity with which events unfolded both with the COVID-19 pandemic and the government actions to control it, meant that we had to think on our feet constantly, decisions often needing to be changed on an hour to hour basis.

Given the sketchy data that we had about the COVID-19 outbreak (it hadn't yet been labelled a pandemic when we started our action group), we had to work on multiple fronts simultaneously to cover all eventualities. Yet, the single constant in our strategy was (and continues to be) to ensure free and transparent communication with our staff. This was done at the beginning by a series of face to face meetings (the frequency and nature of which rapidly changed as we realized the importance of physical distancing). Subsequently, we used emails, and, when we needed even more rapid dissemination to every staff member, probably the most effective tool by it's sheer ubiquity – WhatsApp and other chat apps like Telegram. In an organization as large as ours, this aspect of real-time communication with our staff is an integral part of our overall plan as we navigate through these difficult times.

We broke down our strategy into various components to make sure that different working groups took responsibility for different actions. Considering that our core competence was cancer management, we needed to quickly reorient several of our cancer experts and administrators to shift expertise (often learning on the way) to handling an infection outbreak. Some of the areas where we created working groups (with significant overlap) were a) employee education and training, b) staff health and safety, c) patient education and awareness, d) measures to contain crowding, e) triaging patient care, f) hospital preparedness for handling patients suspected with COVID-19, g) managing supply chain disruptions especially with masks and other personal protection equipment (PPE), h) meeting staffing requirements to continue optimal patient care, i) sharing information and experiences with the larger healthcare community… the list keeps evolving.

 Employee-directed Initiatives



We initiated employee education and training very early in our plan – in a series of educational sessions, and a combination of traditional and unconventional educational tools. We provided information about the novel coronavirus, known modes of transmission, precautions to minimize spread, and the hospital strategy, to close to 90% of our staff in all cadres. While the first of these sessions was initiated with didactic classroom-style teaching, we rapidly morphed to emails, webinars and chat groups as we realized the importance of physical distancing. We also realized that the COVID-19 outbreak had started off another, almost equally dangerous epidemic – fake news about COVID-19. As panic set in about the rapid spread globally, multiple, unverified bits of information exploded, again thanks to the internet, and unregulated chat groups. Our staff were repeatedly cautioned against spreading any unverified information, either within our own organization or with the rest of their contacts. Initiating these communication channels (emails and chat groups) continue to be our biggest asset in creating a culture of shared decision making with the larger group of our staff.

Some of our staff who had returned or those whose family members had returned from countries which were on the medium to high risk for transmission list by the United States Centre for Disease Control (CDC) were kept on self-quarantine for a period of 14 days from the time they returned to India. The next step we took was to identify those of our staff who were at higher risk of contracting COVID-19, and if contracted, more likely to develop complications, and keep them off hospital duties. Based on reports from China and Italy, there was reasonable data to suggest that those who were elderly, had multiple comorbidities, immunosuppressed states, cardiovascular illnesses, uncontrolled diabetes or hypertension were more at risk to contract the infection, and if they did, developed complications more often. Staff medical records were analyzed, and those who had any of the above, and pregnant women, were given fully paid leave with the option to work from home for departments where it was possible. In addition, each department worked out a system wherein, at any given point of time, at least one-third of their staff (more in certain departments) were on paid leave with the option of working from home. This was done with the reasoning that we were exposing fewer of our staff to potential infection, avoiding overcrowding in the hospital, and sparing some staff in case those on duty needed to be mass quarantined, thereby creating a “reserve force”.

 Patient-directed Initiatives



We faced a different set of challenges when we set out to create awareness amongst our patients. While educating patients with any disease about the various aspects of COVID-19 infection and spread is more difficult because patients have their own illnesses and symptoms to worry about, we faced a far tougher challenge as the disease that all our patients had, was cancer. This was much more challenging because for a patient with cancer, nothing, not even the danger of contracting COVID-19, is more worrisome than that of compromising their cancer care. Caught in a difficult dilemma, they were (understandably) reluctant to avoid multiple trips to hospital, even if it meant breaking the concepts of physical distancing and avoiding crowds. That we were able to finally achieve it, was thanks to a combination of parallel and sequential initiatives. These included a) increasing patient awareness (prominent posters about COVID-19 and precautionary measures), b) mass text messages sent out to patients with routine appointments advising them to postpone their visit unless they had disease-specific symptoms, and c) unconventional screening “camps” just outside the hospital building to filter out patients who did not have to make a formal hospital visit. Within a week however, we had to change this strategy to contacting patients systematically on telephone, providing tele-consults to filter out unnecessary hospital visits.

Our first approach to reduce crowds was to have “screening stations” just outside the four hospital buildings we have, to filter out patients on routine follow up and those who were not on active treatment. The first level of screening was performed by the security personnel assisted by “Kevats”, a group of trained patient navigators. The Kevats enquired about a history of contact with a suspected or proven patient with COVID-19, international travel in the last 14 days to COVID-19 global hotspots and a history of fever, sore throat or cough. This screening was done with respect to the patient as well as the accompanying relative. All patients and relatives had their temperature checked by nurses screening them with infra-red thermometers before being permitted inside. Accompanying relatives or friends were restricted to one per patient other than in exceptional circumstances. Those who had any of the above history or symptoms were treated symptomatically, asked to stay at home or sent to a general hospital for managing their symptoms and evaluating the need for COVID-19 testing.

Patients who passed the first screening were seen in the screening stations outside the hospital building by their respective Disease Management Group (DMG) doctors as far as possible and assessed whether they needed to be seen in the clinic or could defer a formal hospital visit. The latter group had a basic history taken and clinical examination performed and sent back with advice to send in their test reports by email or phone and their next clinic appointment was provided to them. This was still a time-consuming process because many patients had traveled thousands of kilometers over several days and were reluctant to go back without having their routine investigations done in the hospital. The patient navigators (Kevats) played an important role here in counseling patients and reassuring them about the wisdom of deferring their routine appointment for a later date. Patients who were on active work-up and treatment along with their relatives were allowed to proceed to their respective clinics within the hospital. Outpatient clinics were also manned by several doctors with senior consultants providing on the spot decisions to avoid crowding in patient waiting areas. Multidisciplinary team meetings were done multiple times a day instead of one large meeting a day to avoid overcrowding. As far as possible, required investigations were done on the same day to avoid repeat visits. Overall, while this process was effective in decreasing crowds within the hospital by almost 35%, we realized that this required exhaustive efforts from the entire workforce and was not sustainable. This has to be seen in the context of the number of clinic visits that we get on a daily basis. It was a herculean task to screen upto 3000 patients (plus an equal number of relatives) on a daily basis at the hospital gate. By the end of the first week, we had decided to change our approach to contacting all patients who had been given appointments for subsequent weeks and initiating tele-consultations. Such changes in strategy was possible only because we monitored the situation real-time and reviewed our overall strategy in “war-room” sessions at the end of each day.

Based on our experience with the screening stations, we realized that patients were far more comfortable if they had the opportunity to talk with their treating doctors rather than those from other departments and DMGs. Therefore, we initiated a system where the respective DMG doctors would personally call every patient due for an appointment at the hospital for the subsequent two weeks, go through their electronic medical records (EMR), and assess the need for a hospital visit versus a telephonic consult. A dual mechanism of conducting these tele-consults from individual DMGs as well as from a central call-centre type of structure was implemented. The outcomes of these tele-consults were recorded both in a database and in the EMR. Patients were asked about any cancer related symptoms, and those who were assessed to not require a hospital visit were counseled and asked to fix a subsequent appointment for a formal clinic visit. If any investigations were deemed necessary, patients were asked to get these tests done locally and send the reports by email or by phone. Patients who were assessed and required a formal clinic evaluation were asked to either consult an oncologist locally or visit the hospital. Most patients were greatly comforted by having an opportunity to directly speak with their treating doctors and clinic visits were avoided in between 55 and 80% of patients varying with the DMG. We also created a hotline where patients could send a WhatsApp message and fix their next appointment.

In view of the increased risk that patients with cancer had of acquiring COVID-19, and the poorer outcomes, we did modify many of our evidence-based management protocols for cancer management. Broadly, this included the following: a) Deferring surgeries where outcomes would not be grossly inferior by postponing them, b) modifying chemotherapy regimens to minimize the chances of developing complications, c) avoiding chemotherapy protocols which did not have substantial survival benefit and d) modifying radiation protocols to minimize treatment duration and decreasing complications. A more detailed description of treatment modifications during the outbreak is beyond the scope of this paper.

 Hospital Preparedness



Simultaneously with all the above measures, we also had to deal with the reality that we would soon start seeing patients with either suspected or proven COVID-19 infection and had to prepare Standard Operating Procedures (SOP) for various scenarios. What would we do if a patient with known cancer, member centres of the National with clinical symptoms of COVID-19 presented to our outpatient clinic? How do we handle patients with international travel? What do we do when a patient with cancer was too unwell to be shifted to a general hospital? Where do we isolate these patients? How do we handle healthcare workers (HCW) who were involved in treating these patients? How do we handle HCWs who themselves developed symptoms of COVID-19? With the limited testing kits available, how could we triage who gets tested and who doesn't? How do we handle the situation when a patient with suspected or proven COVID-19 required imaging or emergency surgery? We had to rapidly create SOPs for all of these and have included the “Fever protocol” as an example [Figure 1].{Figure 1}

We identified a specific area of the hospital where the staff were trained in handling patients who required isolation (previously those with Multi Drug Resistant Tuberculosis, Methicillin Resistant Staphylococcus Aureus etc) as our isolation ward. They were re-trained in SOPs for handling patients with suspected COVID-19 infection including sample collection and transport, PPE donning and doffing, handing biomedical waste, and protocols for clinical care and shifting to the Intensive Care Unit (ICU). This ward had patients who were admitted for active treatment and hence, they had to be shifted to other parts of the hospital. Overnight, barricades were built and makeshift negative pressure environments created. This ward has facilities for non-invasive ventilation, facilities for dedicated imaging, and a separate roster of medical and nursing personnel was created to manage patients on this ward exclusively. A COVID-19 clinical group was constituted with members from the Hospital Infection Control Committee (HICC) and other clinicians to have standard criteria and decide on how patients with fever would be managed [Figure 1]. Mock drills were done to train the staff on SOPs if patients with suspected or proven COVID-19 were to be admitted. Our reasoning behind creating this ward was to have a parking bay for patients with suspected COVID-19 to be cared for while their COVID-19 testing was done. Testing was done to guide treatment but also to be able to quickly identify the vast majority that were not infected who could be safely managed in other parts of the hospital. Rapid testing remains important as any number of isolation beds would get overwhelmed by patients with “suspect COVID-19” infection, but more importantly, to be able to avoid quarantining staff who were taking care of these patients. In an effort to hasten the process, we applied to, and have been approved by the Indian Council of Medical Research (ICMR) to perform the COVID-19 RT-PCR testing within the hospital, which will decrease the uncertainty with test results.

 Impact and Handling of the Nationwide Lockdown



In the midst of this rapidly evolving situation, the Government of India announced a nationwide lockdown with very short notice on the night of 24th March. This meant that we needed to change many of our strategic decisions as newer priorities emerged. How do we handle patients on active treatment who were now finding it difficult to reach the hospital? How could we manage patients who had completed treatment at the hospital and were fit for discharge but had no place to stay outside? What could we do for those who had come for follow up, but now could not return to their hometowns because of the transportation shutdown? How could we manage to get adequate staff to run the hospital when the majority lived far from the hospital and could not access the skeletal public transport that was functional? How could the relatives of patients admitted in hospital get their food?

We managed the above problems with a series of unconventional solutions. First, we started a number of staff buses to transport our staff to the hospital. Overnight, bus routes were planned with meticulous attention to detail, often overcoming the conflicts between keeping transport times acceptable and providing our employees with pick-up and drop points as close to their homes as possible. This also needed to be done keeping physical distancing in mind, and literally, the number of buses and the routes were modified on a day to day basis based on the numbers travelling on each route. Employees who drove to work car-pooled with other staff who lived close to their homes; shift timings of work were modified at individual level to suit these travel arrangements. In addition, we also tied up with the government-run Brihanmumbai Electric Supply and Transport (BEST) Corporation to provide additional bus routes which could be used both by our staff and our patients. Problems did not stop with these – some of our staff were warned by their respective housing societies that they would not be allowed to go to hospital and return to their homes for fear of bringing back the COVID-19 infection to their societies. We had to counter this by advocating with the Mumbai police to issue a stern warning with penal action if housing societies harassed healthcare workers.

We were able to help some patients from Mumbai to reach home during the curfew using hospital vehicles and those provided by some Non Governmental Organizations working with us. While the transportation of staff and patients was managed as described above, it was still not optimal to manage the multiple locations of inpatients at the hospital. Moreover, patients who could otherwise be discharged continued to remain in hospital wards because they had no place to stay outside. Hence, we decided to reorganize by consolidating patients on active treatment into fewer wards, and used the emptied wards to accommodate those patients who were no longer in need of active medical and nursing care. In these wards, we had a skeletal medical/nursing staff but an enhanced hospitality staff, virtually converting it into a hospital hotel. We also created temporary accommodation facilities (including utilizing some inpatient wards) for some key hospital employees including nursing, pharmacists, intensive care physicians, anaesthesiologists on call and security. Food preparation in the hospital kitchen was rapidly ramped up to cater to relatives of patients admitted in the hospital, for our staff who lived in hostels away from the hospital, and those in temporary accommodation within the hospital.

 Supply Chain Disruptions



The rapidity of the pandemic meant that there were national (and global) shortages of basic materials like surgical face masks, N95 masks and other Personal Protective Equipment (PPE). We were fortunate in the sense that anticipating the impending shortage, we made bulk procurement of these materials at very short notice, and in this, were supported considerably by financial aid from several philanthropic organizations and companies as part of their Corporate Social Responsibility (CSR). Due to the urgency of the situation, we needed to cut through cumbersome bureaucratic processes, often using personal contacts with courier agencies and transport companies to ensure timely delivery of material. When transport agencies could not do the last mile, we sent our vehicles to their godowns to collect the supplies. We also sent some of our stock to hospitals who were unable to procure these materials themselves. Efforts were made to ensure that the material procured was of standard quality and met the necessary specifications to guard against substandard materials being supplied in these times of shortage.

 Dissemination in the National Cancer Grid (Ncg) and Beyond



As we implemented these multipronged interventions, we realized that many other hospitals had similar challenges and that there would be immense benefits to all if we shared our experiences. Towards this, we are organizing a series of weekly webinars to update each other about the ongoing pandemic. The format of these webinars include subject experts making brief presentations and is highly interactive. In addition, different hospitals share their unique ways of handling the situation, and exchange practical ideas on responding to the various challenges they faced. While we had originally planned to host our first webinar for more than 200 member centres of the National Cancer Grid, we opened it up for all as several other hospitals and organizations requested to be part of it. We are in final stages of discussing and finalizing the “NCG guidelines for cancer management during the COVID-19 outbreak”. More recently, we have been asked by the City Cancer Challenge (CCan), an international initiative launched by the Union for International Cancer Control (UICC) to share our experiences with the CCan cities to facilitate mutual learning.

 Summary



The COVID-19 pandemic has spread across the globe in a relatively short span of time, bringing unexpected challenges in tackling it, as well as unique problems in various areas. It has also enabled a learning experience in a number of ways, mainly with respect to optimizing processes, task-shifting, prioritizing, communication, and teamwork.

Healthcare systems and organizations have had to rapidly scramble together a response which is nimble and flexible to adapt to rapidly evolving political, social and economic circumstances. The battle is far from over, and governments, societies and healthcare providers have to work together to overcome the effects of this pandemic. A combination of systematic strategizing, an environment permitting healthy disagreements, rapid multipronged implementation, willingness to modify decisions at short notice, effective communication both with patients and employees, and above all, unstinting cooperation and teamwork is key to manage these unique challenges.

Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.