Ensuring Workplace safety during the COVID 19 Pandemic: Experiences of a Healthcare Organization.

Introduction

The Corona Virus Disease 2019 (COVID 19) which started in late December 2019 as a small outbreak in Wuhan province of China has spread exponentially across 213 countries, region and areas resulting in 2995758 confirmed cases and 204987 deaths globally as on 29^th April 2020 [1,2]. India has reported 29974 cases and 937 deaths [3]. Subsequently several policy changes have taken place across the globe like entry and exit screening of passengers at airports, travel restrictions, social distancing and more stringent measures like lockdown and shutting down of all non-essential services [4]. Health care is an essential service, but in order to avoid unnecessary exposure of patients to infections and to direct the health care resources towards dealing with COVID pandemic, the Indian Medical Association of respective states advised shutting down of outpatient services and continuing only with emergency services. Many significant decisions were taken to enable delivery of health care services by leveraging technology using Telemedicine and Health Helplines in such times of crisis to avoid overwhelming tertiary healthcare facilities [5].

Piramal Swasthya Management and Research Institute is a registered not for profit organization supported by Piramal Foundation, based at Hyderabad which believes in making health care accessible, available and affordable to all people especially the most vulnerable population in remote, rural and tribal areas by leveraging technology. The organization is implementing 35 health care projects across 21 States in India through a workforce of 2500+ employees. In this article we intend to share our experiences on the various measures taken in our projects to ensure safety of our staff at the workplace and challenges in continuation of health care delivery in community outreach projects in time of COVID crisis.

Objectives

1. To describe our experience of planning and implementing the measures to ensure workplace safety in our projects.
2. To describe the challenges faced in continuation of health care service delivery especially in community outreach projects.

An Overview of projects

Piramal Swasthya, has three verticals, including Advisory, innovations and operations. While the former involves working with NITI Ayog supporting the aspirational districts transformation (ADT) project across 25 districts in 7 states in improving the health and nutritional indicators and the Sustainable Action for Transforming Human Capital (SATH) project in Assam, innovations involves working in tribal areas of Vishakhapatnam, where six telemedicine nodes connect the tribal population to obstetric specialists based at Hyderabad, delivering primary health care services with focus on maternal, newborn health and non-communicable diseases in the largest river island of Asia - Majouli, Assam and screening people for oral, breast and cervical cancer in Kamrup district of Assam, named “DESH” Detect Early, Save him/Her.

This paper focuses on projects under operations, which are either in public private partnership with State Governments and as Corporate Social Responsibility (CSR) partner of multiple private sector companies. The projects include Health Information Helplines, Telemedicine centres and Community outreach programmes through Mobile Medical Units or Static Clinics. The Health Information Helplines include services in collaboration with the respective state governments like 104, Maternal and Child Tracking System (MCTS) and 1097 with National AIDS Control Organization. Piramal Swasthya in implementing the toll free round the clock 104 health information helpline services in Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Karnataka, Maharashtra and Sikkim, 1097 services in Assam, Himachal Pradesh, Rajasthan and Telangana and MCTS services/ Early Childhood development in Assam, Chhattisgarh, Himachal Pradesh and Karnataka. Piramal Swasthya is partnership with the Government of Himachal Pradesh is connecting the remote and rural population of Himachal Pradesh to specialist’s doctors (Obstetrics Gynaecology, Paediatrics and Medicine) through a network of 75 Telemedicine Nodes at Health Sub centres (51), Primary Health Centres (4), Community Health Centres (13) and Civil Hospitals (8) connected to a hub in Solan, Himachal Pradesh. Under the Community Outreach Programme, we deliver primary health care services through Mobile Medical Units or Static Clinic. The mobile medical units are staffed with Doctors and Paramedic staff and consultation, essential laboratory investigations and medications are provided free of cost to the beneficiaries. The community outreach projects are in collaboration with State Government in Assam through 80 Mobile Medical Units, while there are 43 Mobile Medical Units and six static clinics with eight CSR partners in fifteen states.

Methodology

Study Type: This is a descriptive study of events and policies implemented at the workplace after the onset of COVID crisis and measures taken to ensure safety at workplace.

Study settings: Head office of Piramal Swasthya, project offices in different states, projects like Helplines, Telemedicine Centres and Community outreach programmes.

The policy changes made to ensure safety of project staff, infection control and prevention procedures, travel restrictions, measures taken for social distancing and challenges faced in community outreach projects while health service delivery are described in this article.

Observations

The First case of COVID 19 was reported in India on 30^th January in Kerala. By the end of first week of March there were 31 cases in India with majority of the cases being reported among Foreign Nationals in India and Indians with International travel history [3]. The Government of India started screening of travellers at airports and an advisory issued on 5^th March banned mass gatherings[6]. Our health care services continued uninterrupted initially and with the rise in the number of cases many important organizational level decisions were taken.

1. Development of content for Health Information Helplines: The 104 health helplines located across eight states provide 24x7 support for non-emergency medical conditions. Information is provided by Health Advisory Officers (HAO) on disease conditions, health facilities and medical advice by doctors and counselling through psychologist on mental health are also provided. As the call volume increased following the COVID crisis, the content on COVID-19 was developed based on the Standard guidelines and shared with these centres [2,3,7]. The documents were prepared based on frequently asked questions, the symptoms of disease, whom to test, when to seek help, precautions to be taken, measures to be taken in case of home quarantine and also covered information related to the list of testing and sample collection sites across the country. This information is constantly updated based on the new releases by Ministry of Health and Family Welfare (MOHFW), Government of India. The 104 Helplines in different States have reported three times increase in call volumes in the month of March (21,06,827 calls) when compared to the previous month (7,68,266 calls) and about 11% of these calls were related to COVID 19 (2,37,330).

2. Capacity Building: As the entire world is facing a novel virus pandemic, it is essential to provide the right information to project staff who are involved in providing health care services at various levels. It is essential to make them understand the symptoms, mode of transmission and measures for prevention so as to enable them to take adequate precautions at workplace as well as at Home. WHO and MOHFW conducted several online trainings of trainers using online platforms and disseminated training materials. Capacity building sessions started from second week of March for staff at the head office, respective State Offices, health care staff in different projects who were trained in batches using the online platforms to reach many people. The training content was prepared by the Clinical Domain team based on the guidelines by WHO and MOHFW. Apart from the team of Piramal Swasthya, the other organizations under Piramal Foundation like Piramal Education and Piramal Sarvajal team were also trained on COVID 19 through webinars. Till date 56 sessions have been conducted covering 1506 employees under Piramal Foundation.

3. Changes in Workplace: [8,9,10]

   Guidelines on Infection Control Procedures: Based on the recommendations by WHO and MoHFW, guidelines were prepared for infection control and circulated to all the State Head/ project managers. These guidelines included instructions on cleaning and disinfection of the office spaces, project offices, static clinic, recommendations on hand hygiene, cough etiquette, wearing of personal protective equipment like surgical masks and gloves when providing primary health care services in outreach programme, encouraging staff to report symptoms if unwell and stay at home till they recover, wearing surgical masks if they develop any respiratory symptoms at the workplace. Maintaining social distancing by proper seating arrangement at project offices, appropriate seating arrangement and crowd regulation at static clinic and maintaining at least one-meter distance at the service point at the MMU and Telemedicine. Guidelines were also circulated on disinfection of medical equipment and electronic devices used at Static Clinics, Mobile medical Units, Telemedicine and Helplines.

   Sanitizers: Sanitizers were kept all prominent places at office, helplines, static clinic and measures were taken to provide adequate number of sanitizers for MMU staff.

   Personal Protective equipment: There were shortage and price hike of sanitizers and PPE and the organization made sure to procure the required amount of surgical masks and gloves for staff involved in patient care.

   Posters and IEC Material:[3] In order to ensure reinforcement of messages, posters and IEC Materials were placed at prominent places at the office. These posters contained messages related to symptoms, when to get tested and also precautions to be taken. The posters were also mailed to all the project staff to get printed and paste it in prominent places in Static Clinic and in MMUs. Similar arrangements were made at all the state offices.

   Community Health Education and Mobilisation: The community health education session in the field through community mobilisers were discouraged and if required they were asked to maintain one meter distance, wear a mask and not allow more than 10 beneficiaries in the session. Four static clinics provide eye care services and people identified with cataract are mobilized to referral hospitals once or twice a month based on number of identified patients and mobilization support is offered to the beneficiaries. Mobilisation of patients for cataract surgeries to referral hospitals were stopped to avoid undue exposure and risk to elderly patients.

   Biometrics: In order to avoid contact with commonly touched surfaces, it was decided to avoid Biometry and attendance was marked by using registers. The staff were instructed to carry their own pen and mark the attendance in the register after sanitizing their hand with the sanitizer kept at the entrance.

   Greetings: Staff were instructed to avoid handshakes and exchange greeting through Namaste or Hello.

   Meetings: Instructions were given to maintain adequate distance of one meter between people in the meeting,avoid too many people in meetings and have virtual meetings whenever possible.

   Travel: As Piramal Swasthya is an organization with its presence in 21 states, the staff travel extensively for monitoring and supervision purpose. Instructions were provided to avoid all non-essential travels strictly and video conferencing platforms were utilised to connect with the project staff.

   Work from Home Policy: The work from Home policy was implemented from 19^th March in order to ensure safety of staff and to break the chain of transmission. This policy was applicable for staff who were in managerial, policy making, technical support, supervision and monitoring levels where work can be done remotely. Staff involved in direct health service delivery in health helplines and telemedicine centre nodes continued to work as before. The team continued to conduct monitoring, meetings and capacity building using online platforms.

4. Dedicated Helpline for the Organization: Though there is a toll free national helpline 1075 for addressing queries related to COVID, there is a huge burden on the existing helplines and prolonged waiting time. Keeping this in view a dedicated two seater helpline was set up to address the queries from employees and family members of Piramal Swasthya, Piramal Sarvajal and Piramal Education, the three initiatives of the Piramal Foundation. The callers having travel history or symptoms were connected to a team of doctors from Piramal Swasthya for further advice. Considering the need to address the mental health issues at this time of crisis a dedicated mental health helpline was also set up for internal employees of Piramal group.

Challenges in the Community Outreach Programmes

There are six static clinic and forty - three Mobile Medical Units operational across 15 states under eight CSR Projects. In mid-March, the static clinics reported an increase in the number of out-patients with the number of patients reaching even beyond 90 at few clinics. The cause of concern was the sudden spike in the number of patients which compromised the social distancing norms. The health care staff were concerned about their own safety and the safety of their family members. The staff were oriented on precautionary measures to be taken through capacity building sessions conducted using online platforms. Some CSR projects in Uttar Pradesh, Maharashtra, Andhra Pradesh and Karnataka had clinics located in areas, which were reporting maximum number of cases. This was a cause of concern among the staff who relied on public transportation services to reach the project (clinic/ MMU) offices. Following the announcement of Nationwide Lockdown on 23^rd March and subsequent shutting down of transportation, sustaining service delivery became a challenge. Following the Lockdown, out of 75 Telemedicine centres located in Himachal Pradesh, 28 centres discontinued the service due to travel restrictions. Increase in the number of beneficiaries were observed at few TMCs located at Mandi, Chamba, Kullu and Sirmaur when compared to the previous months. Advisories were issued by the state Governments recommending shutting down outpatient services and requesting people to come to hospitals only for emergency care. The community Outreach projects provide primary health care services with focus on non-communicable diseases. Half of the patients visit our MMU and Static Clinics for minor ailments, 30 percent for non-communicable diseases and 20 percent for acute infections. Following the directives of the Ministry of Health and family Welfare and the respective state Governments, the primary healthcare services through the community outreach programs especially through Mobile Medical Units and Static Clinic were discontinued till further orders.

Utilization of Project staff for COVID related activities

The doctors and paramedic staff from these projects were trained to handle the 104 helpline COVID calls as the call volume had increased at the helpline leading to increase in abandoned calls. An exit strategy to resume the operations is being planned keeping in mind the COVID situation. As the COVID situation in India and the rest of the world will linger for several months in future, the strategies are being planned to integrate COVID related screening and management in all health care delivery projects. As the number of cases in Assam were low, the project staff were engaged in various field activities like special health screening camps, follow up of home quarantine cases as per the list received from Government of Assam and also conducted awareness drives on COVID.

Conclusion

As the world is dealing with a novel virus for which no effective vaccine or treatment is known, it is essential for health care organizations to have proper policies in place so as to ensure safety of their staff while sustaining health care service delivery. It is also essential to look at alternative models like health helplines and telemedicine to ensure uninterrupted health service delivery by leveraging technology.

Ethical Approval

The study was approved by the Institutional Ethical Committee (IEC Study Ref. PSMRI/2020/14)

Conflict of Interest

None

Acknowledgements

The authors acknowledge the State heads, project managers and field teams of all the health care projects for their support.

References

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2. Coronavirus disease (COVID-19) outbreak situation. https://www.who.int/emergencies/diseases/novel-coronavirus-2019
3. Ministry of Health and Family Welfare. GOI. Available From https://www.mohfw.gov.in/
4. Travel Advisories. Ministry of Health and Family Welfare. GOI. https://www.mohfw.gov.in/
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