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 Table of Contents  
EDITORIAL
Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 101-104

Dynamics of health-care professional deployment in COVID-19 pandemic


1 Department of Anesthesia, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Department of Internal Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
4 Department of Gastroenterology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
5 Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission27-May-2021
Date of Decision03-Jun-2021
Date of Acceptance03-Jun-2021
Date of Web Publication30-Aug-2021

Correspondence Address:
Dr. Prasan Kumar Panda
Department of Medicine, Sixth Floor, College Block, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_47_21

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How to cite this article:
Dhar M, Chaturvedi J, Panda PK, Patnaik I, Dhar P. Dynamics of health-care professional deployment in COVID-19 pandemic. J Med Evid 2021;2:101-4

How to cite this URL:
Dhar M, Chaturvedi J, Panda PK, Patnaik I, Dhar P. Dynamics of health-care professional deployment in COVID-19 pandemic. J Med Evid [serial online] 2021 [cited 2021 Sep 25];2:101-4. Available from: http://www.journaljme.org/text.asp?2021/2/2/101/324965



In little over a year, coronavirus disease-19 (COVID-19) has created history and changed the way we practise medicine worldwide.[1] Impact on different countries and regions has varied primarily based on their responses to the pandemic, not just the strain and of the virus. Some have done better than others, but overall, most nations learnt one way or the other. The chief combat armamentarium against this pandemic, at the basic level, was the medical infrastructure and health-care workforce. They led from the front and bore the brunt of the disease both physically and emotionally. The demands of the pandemic were different at various stages. It required a continuous and dynamic input into how the health-care workers, including attending faculty, residents, nursing and technical staff, were managed in terms of rostering to optimise medical care for patients, provide rapid training and continuous updating of skills and information for health-care professionals (HCPs), minimise their burnout as well as balance and fulfil the non-COVID requirements of the community both emergent and elective.[2] This review intends to highlight the various aspects of rostering and management of HCPs during the COVID pandemic and the issues faced during this process at All India Institute of Medical Sciences, Rishikesh, an apex tertiary care institute in North India.

Across four phases of a pandemic continuum: interpandemic, alert, pandemic and transition, there are three stages of the risk assessment: preparedness, response and recovery. As soon as an alert of a new pandemic 'unknown pneumonia, later confirmed as COVID-19' was sounded in December 2019 from Wuhan, China, it was clear that the ravages would soon reach all corners of the globe. After the initial shock, confusion and ignorance, HCPs quickly evolved to recognise and accept several facets. Clearly, they would be a high-risk group to contract the infection as they dealt with it, akin to a war front. In addition, they would have to face other hazards such as long working hours, isolation and psychological distress, fatigue, occupational burnout, stigma, physical and psychological violence and the omnipresent possibility of succumbing to the dreaded disease. They would be exposed to atypical patients, potentially infecting family members, contacts and colleagues or live among communities with on-going active transmission. In mid-March 2020, the World Health Organization (WHO) issued an interim guidance, on the rights, roles and responsibilities of health workers, including key considerations for occupational safety and health.[3] Dr. Tedros, the WHO Director-General was as saying that 'No country, hospital or clinic can keep its patients safe unless it keeps its health workers safe'. However, the type of duties of HCPs was not clearly defined in any guidelines. It was assumed that they would apply common sense while performing their duties. Uncertainty associated with COVID made each HCPs life an unplanned journey into the unknown at various levels. Adding to the uncertainty was the absence of experience of any pandemic of this scale, handled by anyone, during their lifetime. Many questions were raised incessantly, unfortunately without any quick answers. The interactions among HCPs, their administrators, and the public had conveyed the image that they would give their best efforts to save lives and minimise sufferings. To have a conducive working atmosphere in this crisis, clear strategies were required such as risk stratification, appropriate clinical monitoring, low threshold of access to diagnostics and employment health services and decision making about removal from and return to work.[4] Later data suggested a few strategies that could reduce the morbidity and mortality among HCPs, mainly focusing on reducing chance of infections, use of shorter shift lengths and engender mechanisms for mental health support.[5],[6],[7]

During the early days (hospital preparation just after entry of COVID into our country, beginning with the first case reported in Kerala), we were trying to identify problems and contemplating solutions. Initial spread was slow giving reasonable breathing space for planning, infrastructure building and procurement of protective wear and other equipment. With the onset of community transmission, the case burden was expected to increase significantly; the projected numbers of cases were in millions. Hence, we had to devise strategies and policies to prepare HCPs to be available for varied roles within a short time.[8] Various executive committees were formed for this purpose in a hospital. The roster committee assigned HCPs to various COVID areas stratified by need for intensity of care and maintained a balanced workforce of HCPs in COVID and non-COVID areas. HCPs with underlying pregnancy, age >60 years, immunosuppressants and/or with comorbid illnesses were identified for exemption from COVID areas and allowed to continue their work in non-COVID areas. The procurement committee was in charge of procuring personal protective equipment (PPEs) and other essential items necessary for ensuring adequate safety of HCPs and adequate medical care of COVID patients. The hospital infection control committee provided training to the HCPs on measures important in preventing airborne, droplet and contact transmissions of COVID in the hospital. Apart from regular physical training sessions, educational videos were continuously uploaded on the hospital website and rapidly created WhatsApp groups for offline training at one's convenience. Despite adequate precautions and training, non-COVID areas often became the major source of intra-hospital transmission.[9] In view of the increasing need for personnel trained in critical care, various workshops and refresher sessions were conducted for physicians, surgeons and nursing officers. Internists, physicians trained in critical care, pulmonary critical care specialists and ICU nurses were pooled and designated as first-line COVID HCPs while others were buddied or assumed admin roles. A Government approved basic protocol on various categories of HCPs was circulated – how to utilise/roster.[10] Frequent online meetings involving departmental heads, nursing in-charges, nodal officer and the hospital administration were conducted for execution and coordination among the various committees. Major difficulties faced by HCPs were dehydration, lack of adequate ventilation ('feeling hot inside'), exhaustion, dissatisfaction from change in routine duties, fear of acquiring COVID, worry of PPE failures and unavailability of appropriate size of PPE.

On 22 March, 2020, the biggest curfew (Janata-Curfew on 22 March, 2020 followed by 21-day long nation-wide curfew starting on 24 March, 2020) in history was declared, resulting in unexpected changes in citizens' lifestyles due to the pandemic itself, the countrywide lockdown and the fear factor gradually reaching a summit.[11] The doctors' skills were varying, and their response to this pandemic was also unique and individual. The task force had a challenge that they would have never faced before – to streamline the procedure for earmarking these doctors' responsibilities, with different sets of skills and perspectives, at distinct positions in the dynamic chain of COVID management. Simultaneously, the task force had to keep health-care workers motivated and provide them a sense of safeguarded mantle.[12] Providing PPE, partial or complete, was one of them. In hindsight, it may appear obvious, but it was not so simple when the pandemic was hitting humanity at its worst and PPEs had been seen mostly in science fiction films. Training sessions were required to train doctors and nurses on techniques of donning and doffing PPEs.

To paraphrase Heraclitus, dynamicity was the only stability.[13] This was dependent on various factors. Doctors and nurses were being quarantined after exposure to positive patients – initially even without breach of PPE. This affected the streamlining of the process, the most. Administrative teams responded to calls from in-charges of various wards because their subordinates were either turning COVID positive or being quarantined after exposure. There were days and nights when the numbers of such calls and providing backup workforce assumed unrealistic proportions. It was time-consuming and demanded direct interpersonal coordination with over thirty departments of the institute. HCPs alluding to various (invariably genuine) personal rationales to circumvent COVID duties were another crucial trigger although rarer. Some of them were on long-term steroids or immunosuppressants for rheumatoid arthritis or chronic medications for other conditions such as poorly controlled diabetes mellitus. Many of the young female workforces were pregnant or nursing. Unfortunately, some doctors had a personal loss in the family due directly or indirectly to COVID. Relieving them from duties and providing immediate backup was the moral demand of the hour. There were also highly motivated and dedicated HCPs who gave their utmost to deal with the pandemic. Few people volunteered to serve in various areas depending on their skills and interests, irrespective of their official duty. Ethically implementing scarce human services was the only motto, occasionally forgetting ergonomics!

The real challenge HCPs faced came after the lockdown was lifted, and people's movements increased. The pent-up fatigue and angst of the lockdown were unleashed. Expectedly, the brunt of the sickness was observed soon after, in September and October 2020.[14] Our human resources were stretched to the maximum limits, with respect to, the time and effort put into the COVID component of the functioning. It was a great struggle to provide adequate rest to the ground workers as the number of patients and demand for resources began to overwhelm. The challenge evolved to recruit a non-frontline workforce, including surgical and pre-clinical specialities, into the core clinical areas of COVID management.[12] The vigorous and intensive training imparted during the preparation and lockdown days helped keep the residents and faculty of these specialities oriented and as efficient as possible during the pandemic's peak. The inevitable mortality audits held with the intent to improve patient care and minimize future errors sometimes resulted in loss of morale, most likely as there was no clear ownership of patients in the dis-contiguous shift and protocol-based care.[15] Yet, the ground workers, especially the nursing officers and junior and senior residents, were the backbone of the response to the pandemic. At the peak of the epidemic, they rose to the occasion, and worked tirelessly in challenging and sometimes scary environments with utmost dedication.

As decided beforehand during the planning stages, the entire workforce was utilised as per their best capabilities in the roles in which they would be most productive. The clinical medical specialities would focus more on patient care, while the pre and para-clinical specialities took care of the administrative aspect, including logistics and patient flow. This was also the time that interns were co-opted to contribute and support the residents working on the floor in various areas. As the pandemic progressed, human resources' demand was highly dynamic, warranting a frequent change in roster patterns.[8] It was challenging to keep transitioning as smoothly as possible between these rosters. Coordination with various departments and synchronising with their internal departmental rosters was another tedious and complicated task that utilised a lot of time and effort. Newer areas were allocated for COVID care, and some areas were redesignated as high dependency units depending on volume of patients in various phases of the disease. Initially, well-demarcated areas had to give in to shrinkage of each department spaces and pooling of speciality areas for non-COVID work. Some departments relocated up to six times! Doctors' frustration was inevitable and understandable as they were forced to minimise and eventually stop their routine specialised work, with the backlog of non-COVID work increasing day by day.

In teaching institutes, another essential aspect, to keep in mind, while rostering was maintaining a balance between COVID duties and academics, especially those junior and senior residents who were a part of a defined training course with academic schedules and deadlines for theses submissions and university examinations. Intermittent counselling and help to improve mental well-being were also organised, as the pandemic took a toll on many residents and faculty.[6],[7]

As the peak of the wave began to decline, the rosters and workforce utilised had to be systemically deescalated. At that time, the departments were keen to go back to the backlog of their routine work quickly. The challenge was to avoid the temptation of rapidly reverting to pre-COVID status. To recover from this pandemic year's physical and mental fatigue, leaves were sanctioned more liberally as demand for COVID was decreasing day by day. It was attempted to downgrade the rosters in the same way; they were started as COVID care areas shrunk and closed off.

As the vaccine rollout was formally started nationwide, a few HCPs were diverted to provide coverage to the vaccination centre. The non-COVID work was also systematically increased to catch up with the backlog. As things start to come back to routine gradually, HCPs were asked to tread with caution and remember that the pandemic was not yet over.

The second COVID wave struck in April 2021, even as it looked, as if the pandemic had ended nationwide. The cycle restarted again and as of going to press was in full swing with early suggestions of abatement. The HCPs have been redeployed in the same manner, only with substantially more utilisation of forces as the second wave was much worse.[16] Despite the déjà vu, despondency was substantially higher because of long-term fatigue, HCPs getting disease even after complete vaccination (although milder!), overwhelming of infrastructure as happened in the western country in the first wave itself, the fear of oxygen paucity as a Damocles sword hanging over them and lack of any clear evidence of benefit of the vast variety of pharmacological agents used, abused and misused! However, in this second surge, HCPs became more accountable and responsible as a role model to society to handle this viral pandemic. With the science surrounding the pandemic evolving day by day, if not minute to minute; and a flurry of evidenced based literature, we have become more sound in good clinical practices and better equipped to educate the public; with the intent to continue further research and study to fill the remaining void in our understanding of the COVID pandemic.



 
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