By Govindraj Ethiraj
Mumbai: The total number of COVID-19 cases in India has now crossed the 5 million mark. In Mumbai, the number is now over 175,000 with over 8,200 deaths. The hospital beds in the city, particularly in intensive care units, seem to be under much greater pressure than they were until a few weeks ago. Why is this happening? How is the administration responding to this?
Indiaspend spoke to Gautam Bhansali, a specialist in general medicine and infectious diseases at Bombay Hospital in south Mumbai. He is also the chief coordinator between the Brihanmumbai Municipal Corporation, the civic body, and the private hospitals in the city for managing the beds.
Why is it that after a few months, we are suddenly seeing a sudden pressure on hospital beds, including intensive care units?
We were in a much better position in July and August. In September, we have definitely seen a big surge in the number of cases. There are two or three reasons for it: One is that the lockdown has almost entirely been relaxed, and people are also coming from other places for treatment. Due to that, you could say, it is like a second wave--cases have increased in Mumbai. But we need to understand why the lockdown was enforced. It was to educate people, spread awareness as to what is to be done to fight COVID-19. It is a new disease, a new challenge and a new learning for everybody. Meanwhile, we needed to prepare health infrastructure. Our health infrastructure was not ready when this disease struck us, around March. We needed to create negative pressure in the ICUs and in the ward, set up different entry and exit points (for COVID-19 and non-COVID-19 patients).
Now that the number of cases has increased, we are totally geared up with enough beds. There was some shortage of beds in between. We closed down some nursing homes one month back because there were some issues there--complaints of overcharging and high mortality rate. Those issues have been almost sorted out.
You are talking about those 73 nursing homes that were taken off COVID-19 duty. Of these, 27 have now been reopened. Is that correct?
On 14 September, we had a meeting with the municipal commissioner and the chief minister--as the number of cases has increased, and we assume that the number is going to increase further. Plus, there is an influx of patients from other places too--from Sangli, Dhule, Kolhapur, Nasik, Pune, etc. Cases are coming to Mumbai from all over the state. People want to get treated in Mumbai because they feel Mumbai has better health infrastructure, best doctors, skilled health professionals and that they will get the best treatment. So, we opened the 27 nursing homes, which have more than 25 beds each. They are well regulated, have MD doctors (with advanced medical degrees) and critical care specialists.
If you have 100 beds, for instance, how many are now occupied by people from outside Mumbai?
About 30 percent to 40 percent of the people admitted in these hospitals--nursing homes and big private hospitals--are from outside the Mumbai metropolitan region--from Bhiwandi, Thane, Kalyan, Dombivli, Navi Mumbai, Ulhasnagar, etc.
And what would that number be for pre-COVID times--for instance, at this time last year?
People come to Mumbai for treatment from across the country, and from other countries as well, because Mumbai has the best health infrastructure, especially in private hospitals. So, Mumbai is also a destination for medical tourism. So, last year at this time, about 60% to 70% of patients would have been from other parts of the country and abroad.
But now, with COVID-19, we are facing a different situation, which needs different bed arrangement, management etc., which is why it is a problem when 30 percent to 40 percent of COVID-19 beds are occupied by people from outside Mumbai.
There is a misconception that all industries have collapsed, except the hospital industry " which (people think) is flourishing. But hospitals, mainly private hospitals, are in a big loss--because of the COVID-19 situation, the rate is capped by the government. We cannot charge more than that. There are not many non-COVID-19 patients.
So proportionately today, you have a much higher ratio of patients coming from outside Mumbai, which is placing a load on the system because a fair number of beds are dedicated only for COVID-19. Is that correct?
Correct. For instance, in Bombay Hospital, we have two buildings--one for COVID, and one for non-COVID. The COVID building is always full. In the non-COVID building, people have started coming now. Earlier, they were in panic; they did not want to go to a hospital for fear of catching COVID-19. People are coming now, but still surgeries are only emergencies; a few elective surgeries are going on.
So, if a patient were to have a non-COVID situation, they are likely to get a bed, even in an ICU, in Mumbai?
Yes, non-COVID is totally open. There are beds. There is no problem with availability of beds for the non-COVID patients.
What is the total number of beds you are managing, in a way, in the private hospital space in Mumbai?
Right now, in the 33 big private hospitals--like Bombay Hospital, Breach Candy, Hinduja, Lilavati, Jaslok, etc " we have 2,600 COVID-19 beds. Of these, 1,600 are oxygenated beds, and 590 ICU beds. In the 27 nursing homes we opened, we added 390 ICU beds and 1,700 oxygenated beds. In the government hospitals, we reduced the capacity of COVID beds because we opened up the non-COVID part also. For instance, Nair hospital was totally a dedicated COVID hospital. Now, 50 percent beds are for COVID and 50 percent for non-COVID.
But we have increased capacity in our jumbo facilities. We have 11,000 oxygenated beds in these facilities--like in NSCI Worli, BKC, NESCO, Dahisar, Mulund. Jumbo facilities are not isolation or quarantine centres. They are full-fledged hospitals, with oxygenated beds, ventilators, bi-pap machines, nasal cannula machine, X-ray, sonography, 2D echo and a pathology lab in every facility. They have all kinds of medication " including the likes of] remidesivir, tocilizumab " and it is totally free of cost.
We inspected the jumbo facilities to understand why people are not coming. There is a perception that these are only quarantine or isolation centres. As I said, they are full-fledged hospitals. Secondly, they feel the doctors may not be good. All the jumbo facilities will now be run by government medical college and hospital staff--like Sion, Nair and KEM hospitals. They already deployed two units each--each unit has 40-50 doctors. Further, all jumbo facilities will be monitored by big private hospitals--Bombay Hospital and Breach Candy will monitor the NSCI Worli Dome. Lilavati and Hinduja, which have top expert doctors, will look after the BKC jumbo facility. NESCO Goregaon facility will be looked after by Kokilaben and Nanavati hospitals. Mulund facility will be looked after by Fortis Hospital.
Are there enough doctors and nurses to manage the patients in private hospitals, nursing homes and the jumbo facilities?
Yes, in private hospitals and nursing homes, there is no shortage of doctors. In government [MCGM or Municipal Corporation of Greater Mumbai] hospitals too, there was no shortage of doctors and nurses. The only staff and manpower shortage we were facing was in the jumbo facilities. That is why we deployed medical college and hospital staff in these facilities. Further, we deployed top expert doctors from the private hospitals for ICU care. So from yesterday, there is no shortage of any staff in the jumbo facility.
As an infectious disease specialist, looking at the patient flow, and at the condition in which they are coming to the hospital today, what is your sense on where we are in terms of management of this disease?
This is a new disease, there are new challenges and learnings everyday. Every day, we change our guidelines. Sometimes we say that patients who are above 50 years should be hospitalised. Sometimes again, we say that for asymptomatic patients, home isolation is better.
We are seeing that the virulence of this disease has decreased. Now, patients are not as critical as they were during April-June. That was a horrible time. Maybe patients are educated enough, they are keeping their diabetes controlled, taking enough precautions--and now, enough medications such as remdesivir are available. That definitely helps us a lot--it does not stop the virus, but reduces the viral load. So I feel, with the availability of medications, beds and oxygen, [we are able to manage better]. Oxygen is more important than a ventilator. Every patient does not need a ventilator.
You are saying that most additional load that we are seeing, particularly in the ICUs, is because of patients coming from outside Mumbai. Is that likely to reduce or increase? And therefore, are we back to a situation like we had in May or June, even as the disease itself does not spread as much, but the patient load is continuing to rise?
I feel the patient load will continue to rise till the end of September. After that, things will settle down. After the first week of October, I think the number of cases may decrease. But if it increases, we are totally geared up with the facilities. We have (enough) beds. In the jumbo facilities, 30-40 percent beds are still vacant; in private hospitals, 10-20 percent beds are vacant; in ICUs, 1-3 percent beds are vacant. It does not mean they are vacant all the time; but there is constant turnover.
Earlier, we were doing only 4,000 tests per day in Mumbai. Mumbai is the first city to allow tests without a doctor's prescription. Now everyday, we are doing 15,000 to 16,000 tests. We are chasing the virus. We are not worried about the numbers. We want to decrease the mortality rate and we are able to decrease it.