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 Table of Contents  
PERSPECTIVES
Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 114-125

COVID-19 battle: Measures implemented at a tertiary eye care center in South India


1 Fellow, Department of Paediatric Ophthalmology and Strabismus, Pondicherry, India
2 Fellow, Department of Retina-Vitreous, Pondicherry, India
3 Chief Medical Officer, Pondicherry, India
4 Medical Officer and Head, Department of Paediatric Ophthalmology and Strabismus, Pondicherry, India
5 Manager, Aravind Eye Hospital, Pondicherry, India

Date of Submission28-Apr-2020
Date of Decision13-May-2020
Date of Acceptance01-Jun-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Dr. Iva Rani Kalita
Fellow, Department of Paediatric Ophthalmology and Strabismus, Pondicherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_48_20

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  Abstract 


The spread of severe acute respiratory syndrome-coronavirus-2 has already taken on pandemic proportions, affecting over 100 countries in a matter of weeks. A global response to prepare health systems worldwide is imperative. Specific containment measures are needed to reduce the risk of spread while simultaneously maintaining the emergency health services. The purpose of this article is to propose the simple and effective measures implemented in our institution to ensure the minimum risk of COVID spread while taking care of the emergency patients. Effectiveness of these measures is still in the early phase of testing, but in view of lack of personal protective equipment for health caregivers, these measures could be implemented with ease and will be helpful in reducing the risk of exposure in both ophthalmic and nonophthalmic institutions.

Keywords: Corona, COVID, ophthalmological measures, severe acute respiratory syndrome-coronavirus-2


How to cite this article:
Kalita IR, Singh HV, Venkatesh R, Veena K, Vengadesan N, Kalaivendan K. COVID-19 battle: Measures implemented at a tertiary eye care center in South India. Kerala J Ophthalmol 2020;32:114-25

How to cite this URL:
Kalita IR, Singh HV, Venkatesh R, Veena K, Vengadesan N, Kalaivendan K. COVID-19 battle: Measures implemented at a tertiary eye care center in South India. Kerala J Ophthalmol [serial online] 2020 [cited 2020 Sep 24];32:114-25. Available from: http://www.kjophthal.com/text.asp?2020/32/2/114/293295




  It Came Without Warning and Spread Like Wildfire! Top


Since the emergence of the COVID-19 outbreak, millions of world population has been infected and hundreds of thousand deaths have occurred till date, making it as one of the biggest pandemics of the century.[1] With numbers of positive corona cases rising rapidly, India is at a verge of entering stage 3 of the pandemic with the fear of community spread.[2]

While modes of viral transmission are still currently being researched, there have been anecdotal reports of ocular transmission.[3] The ocular transmission of virus is a possibility that should be recognized by practicing ophthalmologists around the world. Ophthalmological institutes, especially high-volume ones, should look into adopting fast-track measures to keep a balance between the patient and health-care worker safety and still providing all necessary treatment modalities without hampering the visual outcome of the patients. Aravind Eye Hospital, Puducherry, being a high-volume ophthalmic referral center in South India with lot of high-risk patients attending daily outpatient department (OPD), there is an utmost need to plan and implement brisk measures to effectively prevent COVID spread while providing emergency ophthalmic care.

The purpose of this article is to discuss few low-cost measures implemented in our institute for ensuring reduced risk of COVID spread to health-care providers and other patients from asymptomatic COVID patients.

Several practices have been undertaken during this short span:


  Patient Examination Protocol Top


Outpatient department restricted for emergency and high risk only

In order to avoid cross-infection and prevent COVID-19 spreading, the hospital has suspended all routine eye checkups and canceled all elective surgeries. Only ocular emergency services are offered.

Hand sanitization

In order to ensure the hygiene of patients and staff, a temporary wash area was created in front of the entrance [Figure 1]a. All the patients and staff are instructed to wash their hands before entering the hospital.
Figure 1: (a) Hand wash area in B block entrance, (b) temperature being checked for patients and staffs, (c) COVID-19 form for the patient

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Temperature check

Temperature is checked using a thermal scanner for both patients and staff entering the hospital [Figure 1]b. If temperature is high, patients will be referred to the nearest COVID-19 nodal center (Pondicherry Government Hospital).

Reception and preliminary screening

The reception counter is set up in the main entrance where every patient must be served with preliminary screening and hand sanitizer. A patient registration form was given along with the COVID-19 inquiry form to get details on patients' fever and exposure history in infected areas or with people from infected areas and record their personal information, way of contact, and residence place. Only patients were allowed to enter the outpatient complex and in case of minors or vulnerable patients one attender were allowed. Bands were provided to patients for quick identification.

Registration and screening triage

A temporary registration desk is arranged at the entrance lobby to avoid patients entering into the hospital area to avoid unnecessary patient movement. A new fully equipped triage area is set up in the entrance of the hospital to do the preliminary eye screening, and then patients are escorted accordingly. The triage area was created with all safety precautions for both staff and patients. The staff posted in the triage examination were all provided with all required protective gears [Figure 2].
Figure 2: Temporary triage area near the entrance, (a) registration for emergency patients, (b) vision testing for patient, (c) history taking and triaging, (d) ophthalmic examination in the triage area

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  Patient Flow Process Map Top


An outpatient process map was developed for triage and patient examination to ensure that all the different clinical teams posted in the lockdown period practiced the uniform care process as there were different clinical teams engaged on different days [Table 1].
Table 1: Patient flow process map

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Surgery and admission

Only emergency cases with risk of vision loss were taken for surgical procedures. Strict admission protocol was set based on inputs from the COVID-19 task force. Patients were admitted in only single rooms, and all common wards were closed. Patients were given strict admission guideline to stay in the room. Guidelines and the specific clinical team for emergency surgical procedure were to be decided by the concerned head of the department (HOD).

Patient reviews

Short-term review as per pre-covid guidelines were prolonged by upto 50% after weighing risk-benefit ratio for both patient and health-care worker safety and additional medications were prescribed accordingly to incorporate the extended follow-up period. Only emergency review is given.


  Workforce Planning and Staff Safety Top


Workforce planning

A detailed planning was done, and the clinical team was divided into different teams and posted accordingly to limit the staff to exposure. Workforce teams were reassigned based on the patient load. Doctors and staff in the triage area had restricted work timing of 4 h/day.

Staff safety

Staff safety was taken as the highest priority; all possible ways of the disease getting transmitted were identified and addressed through incremental innovations and personal protective equipment (PPE) were given accordingly [Appendix 1].



  1. Patient instructions: Patients' history and eye problem to be asked before sitting on the slit lamp. Patients to be instructed not to speak on the slit lamp
  2. Equipment: Ophthalmic equipment that were getting in close contact with patients were avoided such as Perkins tonometry. Noncontact tonometers were not used as they may lead to the chance of aerosol getting transmitted from the eye. Icare tonometer was used after changing the pin for every patient
  3. Face shield: Our staff developed a face shield through the available stationery items in the hospital in no time. All the staff in the high-risk triage area were given these shields. (https://www.youtube.com/watch?v = 6PHyM4sbZmQ) [Figure 3]a
  4. Slit-lamp protective guard: There was a high risk of direct contact of patients' face when getting to examine in a slit lamp. To make a barrier between the doctors and patients, a shield was made in the slit lamp. These were cleaned at regular intervals. These were developed in house by the biomedical engineering team [Figure 3]b
  5. PPE: A full PPE set has been provided in the triage area. Both the doctor and mid-level ophthalmic personnel (MLOP) in the triage area should be fully covered with disposable cap, mask, face shield, and operation theater gowns that are sterilized every day. No other staff shall enter the triage area
  6. Three-dimensional (3D)-printed mask: To overcome the shortage of essential mask supplies, Aravind Eye Hospital tested to print mask on the 3D printer that is on trial [Figure 3]c
  7. Staff awareness: Staff awareness program was conducted to ensure personal hygiene and to reduce contact as much as possible. MLOP were advised not to touch patients on any case and to use cotton swabs to separate eyelids and wash hand or change gloves if they touch the patient's eye
  8. MLOP engagement: The MLOP in the hostel were shifted to the hospital building to enhance social distancing, and they were engaged in different ways to keep them motivated and less stressed on being at the hospital
  9. Cleaning and disinfection: See below separate section
  10. COVINEED-2020: Initiating a novel program named COVINEED-2020 with the aim of maintaining an uninterrupted supply of essential commodities to health-care professionals during the isolation period, thus ensuring social distancing [Figure 4]b.
Figure 3: (a) In-house developed protective face shield, (b) slit-lamp protective shield, (c) 3D-printed face mask at Aravind for trial, (d) ultraviolet light in the triage area, (e) chairs placed for social distancing

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Figure 4: (a) E-consultation and E-learning services, (b) COVINEED service for providing essential commodities to in-house staffs

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  Cleaning and Disinfection Top


Equipment and instruments

The equipment such as slit lamp and others in the triage area are cleaned after examining every patient. A separate sterilizer was kept in the triage area to sterile ophthalmic instruments [APPENDIX 2].



Object surfaces and floor cleaning

The cleaning of the object surface includes tables, chairs, and other furniture in contact with the patients [APPENDIX 2].

Ultraviolet sterilization

Ultraviolet (UV) rays were evidenced to kill the virus.[4] Hence, a UV light from the hospital was immediately installed in the triage area. Every day, the high-risk triage area is sterilized after the OPD is completely cleaned and closed. UV light is switched on from 6 p.m. to 9 p.m. [Figure 3]d.

Social distancing

Chairs in all waiting areas were placed in a manner keeping in mind social distancing. The excess chairs in the unit were removed. The middle chair in the three-seater chairs was blocked to keep distance among patients. All plastic single chairs were marked on the floor to maintain social distancing among patients [Figure 3]e.

Other preventive precautions

  1. All the windows were open, and no air-conditioning system was used. Air-condition system was considered to be a high chance for virus spread
  2. All the doors were kept open to reduce patient and staff touch
  3. All window curtains were removed
  4. All unassigned areas were completely shut from patients' and staff access
  5. Single floor was allocated with individual rooms for Inpatients to reduce unnecessary mobility.



  Patient Care Initiatives Top


E-consultation

For patients to reach the doctor, e-consultation has been started through the Google Meet to enable patients do a video consultation from their home in the lockdown period. A detailed guideline for tele-advice was created with the department HOD's consent for different specialties. Follow-up patients were reviewed through details in the Electronic MedicalRecord (EMR), and patients were advised accordingly [Figure 4]a.

Link for Aravind Pondicherry:

  1. LINK1: Meet.google.com/ahw-tuju-tcp
  2. LINK 2: Meet.google.com/iuv-zssv-nzu.


Calling postoperative and high-risk patients

The list of surgical follow-up and all other high-risk follow-up patients was taken for every specialty. The patients were personally called to get the status of eye, were advised for follow-up according to their eye conditions, and were reassured. Sight-threatening ocular emergency patients were called for their follow-up accordingly and taken for surgeries. Patients were advised to use the e-consultation platform for consultation [Figure 4]a.

Awareness about COVID-19

Awareness displays of COVID-19 were kept to help patients understand the importance of social distancing and also advocate on all precautions to be taken on personal hygiene.


  Education and Training Top


Lockdown lecture series

To engage the residents and fellows of Aravind Eye Hospital and also other ophthalmology residents, we started the lockdown lectures to never stop learning. Zoom platform is used to connect as many as residents and fellows possible to attend the lectures and provide benefit while they stay safe at home [Figure 4]a.


  Way Forward: Clinical Practice in This Covid Era – a Novel and Complex Challenge Top


What to anticipate? The patients are same, the disease spectrum is same, and the treating doctors are same, but still we need to change our practice pattern in order to ensure effective social distancing and the effective triaging system to treat ones who need it most and simultaneously maintain effective sterilization. Multiple measures are implemented to reduce the effective contact periods as well as disinfecting the instrument in different subspecialties[Appendix 3], most in accordance with the All India Ophthalmological Society guidelines.[5] Few points worth mentioning are:



Newer diagnostic protocols

  1. Glaucoma subspecialty – Replacing the use of noncontact tonometer and Goldmann's applanation tonometer with I-care for intraocular pressure, cleaning of the goniolens after each use with bacillocid solution, and avoiding the use of Humphrey visual field testing and replacing it with C3F field analyzer –virtual reality-based device-assisted visual field testing in case of utmost necessity [Figure 5]a
  2. Retina subspecialty – Use of PolyVinylChloride (PVC) shield separating the testing areas and patients from the operator and equipment [Figure 5]b. Disinfecting the PanRetinalPhotocoagulation (PRP) lens, fundus camera, and other glass surfaces with bacillocid solution after each use and cleaning other surfaces of the equipment with the standard sterillium solution
  3. Pediatric subspecialty – Use of specially modified mask for children, and use of protective plastic shields for retinoscopy [Figure 6]a and [Figure 6]b].
Figure 5: (a) Visual field testing using C3F field analyzer, (b) PVC shield compartmentalizing the operator area from patients area for diagnostic modalities – optical coherence tomography and fundus photography

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Figure 6: (a) Use of resized pediatric mask made from standard surgical mask, (b) plastic protective shield attached for retinoscopy

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Operation Theatre protocols

With relaxation in lockdown, elective procedures with limited number of cases to be operated are being planned as per the All India Ophthalmological Society guidelines

  1. Ensuring each patient and attendee wearing a proper mask, implementing hand and face washing with sterillium application, and thermal screening for each patient before entering into the OT complex [Figure 7]
  2. Draping and anesthesia to be done under proper PPE coverage [Figure 7]
  3. Ensuring single OT at a time in each room with the doctors, two assisting sisters wearing PPE all the time [Figure 7]
  4. Phaco handpiece and adjacent tubing to be cleaned after each surgery with alcohol-soaked pads (Aurorub)
  5. Use of sterile phaco tip and sleeves for each patient.
  6. Proper signed consent forms from patients considering Covid related awareness [Figure 8].
Figure 7: (a) Changes in day care room – Open windows, no air conditioning, and no extra clothes, (b) patient undergoing face and handwashing and sterillium use before entering in operation theater complex, (c) operation theater staffs restricted to four in number with respective role and personal protective equipment kits, (d) restricting to single operating table in each operation theater

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Figure 8: COVID-19 consent form for outpatient department examination and operation theater procedure

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  Conclusion Top


Coronavirus has surpassed SARS in a much shorter span of time, both in the number of fatalities and confirmed cases.[6] Still, there is a hope that the worst will soon be over. The question is When and How? The answer lies in the collective efforts and adopting to the current situation by utilizing such low-cost innovative measures in the current medical practice, thereby reducing the impact of the current pandemic. For those currently at the frontline of the battle against the novel coronavirus, the risk is still greater than imagined given the size of pandemic. However, we are confident that India will win the battle sooner or later, but at the same time, we should prepare ourselves for the worst.

Acknowledgment

The authors would like to acknowledge the assistance of all the senior consultants and medical officers along with the paramedical staffs, the maintenance department, and the housekeeping department, who made major contribution in planning and implementing these protocols.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Novel Coronavirus (2019-nCoV) Situation Reports 150 dated 18-June-2020 World Health Organization(WHO). Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200618-covid-19-sitrep-150.pdf?sfvrsn=aa9fe9cf_4. [Last accessed on 2020 Jun 23].   Back to cited text no. 1
    
2.
Coronavirus Information – India, Ministry of Health and Family Welfare, Government of India. Available from: https://www.mohfw.gov.in/. [Last accessed on 2020 Jun 23].  Back to cited text no. 2
    
3.
Wu P, Duan F, Luo C, Liu Q, Qu X, Liang L, et al. Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei province, China. JAMA Ophthalmol 2020;138:433-584.  Back to cited text no. 3
    
4.
Darnell ME, Subbarao K, Feinstone SM, Taylor DR. Inactivation of the coronavirus that induces severe acute respiratory syndrome, SARS-CoV. J Virol Methods 2004;121:85-91.  Back to cited text no. 4
    
5.
Available from: https://aios.org/pdf/AIOS-Operational-Guidelines-COVID19.pdf. [Last accessed on 2020 Jun 23].  Back to cited text no. 5
    
6.
World Health Organization. Summary of Probable SARS Cases with Onset of Illness from 1 November 2002 to 31 July 2003. World Health Organization; 21 April, 2004.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
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