Challenges encountered while providing holistic care to a cluster of COVID-19 patients
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/IJPC.IJPC_147_20
Source of Support: None, Conflict of Interest: None
Keywords: COVID-19, cluster management, holistic care, pandemic, psychosocial
India reports its first COVID-19 case on January 30, 2020. Toward the mid of March, a surge of cases was reported from various clusters; one particular group of interest was the Nizamuddin cluster, a religious congregation in South-Central Delhi region. For the containment of infection, equipped hospital setups and quarantine centers were necessary and required to be arranged overnight. National Cancer Institute (NCI)-AIIMS, Jhajjar, took an initiative to convert its hospital wards to a dedicated COVID care center and the residential complexes into quarantine facilities.
In this article, we will be discussing the challenges faced during the management of a cluster of COVID-19 positive cases and their effective management.
The cluster was sociodemographically variable; most of the members hailed from the Southern part of India and a few from outside. A distinctive type of administrative and infrastructural challenge arose in the management of this cluster. These challenges varied from person to person and demanded a personalized approach to be resolved. Apart from medical care, these patients also had multiple psychosocial and spiritual issues. Given a very less response time, NCI-AIIMS, Jhajjar, worked day and night to organize a plan for smooth management of the same.
Administrative and infrastructural challenges
NCI-AIIMS (Jhajjar) is the country's largest cancer care hospital, which started functioning from December 2018. Since the inauguration, the hospital is dedicated to providing holistic care to the cancer patients and also to their caregivers as well as their family members. Facing this acute medical crisis, NCI came to the frontline and took the lead in managing the Nizamuddin cluster. There were huge challenges involved and needed to be addressed in a systematic manner.
Transport and accommodation
NCI-AIIMS has located roughly 60 km from the city of Delhi. Transportation of these patients was troublesome, and AIIMS ambulance services played an important role in getting all patients eventually settled in NCI. Providing accommodation to this group was the next challenge. Symptomatic patients were admitted in the wards and two residential complexes, with 13 floors each, were prepared and served as institutional quarantine centers; thus, the accommodation of around 350 patients was ensured. Every patient was provided a single room with an attached washroom. The rooms were adequately ventilated with an ample amount of sunlight coming in. Regular cleaning and disinfection of the rooms and balconies were ensured with sodium hypochlorite disinfectant. A duty mobile number and institutional Wi-Fi was provided so that each and every patient could stay in touch with the duty doctor and his/her team throughout. Their concerns and grievances were noted and prioritized accordingly.
Workforce and demand versus supply
To maintain the continuous delivery of services, adequate workforce was required. A task force of doctors, paramedical staff, nurses, multitasking staff, and security personnel were reallocated from their non-COVID duty areas to COVID designated facilities. All working staff have been provided accommodation inside the hospital premises so that their services can be utilized in this crucial time of need. Each team was assigned for a month, followed by a quarantine period of 2 weeks and this exerted huge psychosocial pressure on the members of the task force. On such short notice, they had been isolated from their families and many of them were compelled to leave their children, spouses, and parents to perform their duties.
Reallocation and training of health-care professionals
Health-care professionals are trained to work in a particular hospital setting. Working in quarantine centers was an entirely new experience for all. Concerns of patients under quarantine were different from the patients admitted in the ward. Apart from their disease-related physical symptoms, these patients had more of regional, cultural, psychological, social, and spiritual concerns. Addressing these challenges and treating them holistically was the principal focus of NCI, and each healthcare professional has contributed to his/her best capacity to overcome the challenges.
When the Nizamuddin cluster was identified, it suddenly became a topic of national debate raising questions on the measures taken by the state administration for effective control of the spread of the disease. Several administrative issues were encountered during the time and this created a negative impact on the patients' attitude. Fear was the most prevalent among all; the patients who quarantined feared that legal actions would be taken against them. The patients were initially under the impression that they were in legal custody and therefore resisted treatment. However, with time and regular interactions with health-care professionals, they became convinced and then understood the purpose of social isolation.
Region, culture, language, and food
Patients of the Nizamuddin cluster belong to various sociodemographic backgrounds. The majority of them came from the Southern states and others from outside. Holding them back was a challenge as they hailed from various regions, the cultural and food habits differed, and the social structure they belonged to was contrasting. The language was one of the most difficult barriers. Our health-care team found it difficult to communicate with them as they did not speak Hindi. This gap created a few misconceptions among our patients, which made them feel angry and frustrated at the team; this issue was eventually resolved with the help of an interpreter. Once the team started communicating with the patients, they were reassured and the anger and frustration gradually reduced. Later on, many of these patients expressed their gratitude for the services provided and volunteered for plasma donation for the treatment of other patients.
Fear, anxiety, and anger
The Nizamuddin cluster patients belong to a particular religious community and were visiting Delhi for a religious congregation. Evacuation of these patients occurred during the lockdown; therefore, a huge police force and government officials were involved in the evacuation process. This created a sense of fear among the patients. Many patients did not have their personal belongings with them when they arrived at the quarantine centers. Many patients did not have cellular phones, so they were unable to contact their family members and loved ones. In addition to this, the fear of being taken and kept under legal custody created severe anxiety among the patients. The communication gap due to language barrier had resulted in misunderstanding among the patients themselves and toward the team. They became apprehensive about their well-being. Consequently, they began to understand the whole process of management and the holistic care approach of NCI-AIIMS team.
Since the patients had been evacuated from a religious congregation, their religious and spiritual needs had to be addressed with utmost care. NCI-AIIMS, Jhajjar, undertook an initiative to provide all possible resources to the patients to perform their religious practices. The late half of April marked the beginning of the holy month of the religious ritual, and the patients demanded that they will be put to fast during the month. Quite a number of patients were diabetic, so allowing them to put fast was a threat to their health. However, NCI-AIIMS began strict monitoring of the patients who were diabetics and fasting. To perform their religious rituals, patients demanded early morning meals to start their fast. The administration had made arrangements to provide them with their meals early in the mornings. Care was taken to ensure that proper dietary regimens were followed especially for diabetic patients.
Patients who were fearful and angry during the initial days of quarantine were getting overwhelmed with the services provided by NCI-AIIMS. At the time of discharge, the patients volunteered for their plasma donation for the benefit of other sick patients. Post discharge, through telephonic conversations, patients seemed to be satisfied with the service provided overall.
It was a late April night when we witnessed a wonderful gesture of humanity and peace. Many of our patients have requested Sehri and Iftaari meals (a religious ritual feast ceremony being performed by members of the Muslim community). Timings for these meals were very odd, i. e., Sehri in the early morning hours (around 3.00 am) just before dawn and Iftari during the evening hours (around 6.00 pm) just before dusk. We have more than hundred patients who requested these meals. Considering the religious ritual as an integral component of the care of our patients, our administration dedicatedly worked throughout the night to make sure the delivery of their requested meal well within time. Later, after discharge, on telephonic conversations, our patients poured their hearts on this kind gesture of humanity – a small step toward the giant leap for the establishment of peace across the globe.
Under the efficient leadership of NCI-AIIMS, Jhajjar, administration, health-care professionals managed the effective delivery of services to their patients. Despite having multiple personal, psychological, emotional, and social challenges, the health-care team worked sincerely to fulfill the demands of their patients and the task presented to them. Thus, NCI-AIIMS, Jhajjar, has provided and will continue to provide comprehensive and integrated care for the body, mind, and soul.
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Conflicts of interest
There are no conflicts of interest.