Mumbai tweaks discharge protocol in bid to free tertiary care beds faster

City's top hospitals say average length of stay for a Covid-19 patient is now around seven days, down 50% from 14-days in the beginning of the pandemic

Mumbai is trying to free up tertiary care beds for more clinically sick Covid patients by continuously tweaking its discharge policies and aiming to have a faster turnaround in hospital beds. The city's leading hospitals say that the average length of stay (ALOS) for a Covid-19 patient is now around seven days, down by 50 per cent compared to 14-days in the beginning of the pandemic.

The city administration and its hospitals are trying to focus on the complex patients more - getting a critical care bed in Mumbai is still a challenge.

Sample this : The city has close to 30,000 active cases now and it has 10.654 isolation beds in dedicated Covid hospitals. There are another 1,400 intensive care unit (ICU) beds with 1,289 occupied as on June 28. A total of 6,007 beds with oxygen support are occupied out of the available 7,700. A total of 743 out of the 775 ventilators are already in use. The wait to get a bed if one needs hospitalisation is still an uphill task (see chart 1).

Dr. Parag Rindani, centre head, Wockhardt Hospitals in the city, one of the doctors who has himself recovered from Covid19 said that the ALOS has reduced because of two primary reasons - one is that the complexity has reduced and we are seeing lesser such critical patients coming in and secondly, BMC has now allowed swab positive patients to go home.

He added that swab (nasal and throat swabs are taken for RT-PCR testing) reports have also started coming in faster as more labs are now doing tests. "We are actively discharging positive swab patients if they have adequate quarantine facilities at home. Alternatively, we are working with the BMC to send patients to the Covid Care Centers (CCCs). Essentially, we are now freeing up the beds for patients with higher clinical needs than for patients who are in convalescence period," Rindani said.

Overall testing numbers show limited growth. Mumbai was testing 4720 cases when it crossed the 50,000 mark on 9th June. Daily testing is only slightly higher as it neared 75,000 cases. The seven-day rolling average of daily percentage growth in tests conducted has been in single-digit territory (see chart 2).

Convalescence is the period in which the body recovers from a serious illness, injury or surgery. This period may require changes in one's  lifestyle to make sure the body has enough time and rest to allow a complete recovery.

"We send some patients back home also in four days. There have been some patients (for example elderly patients with huge comorbidities) who have stayed in hospital for 20-25 days. ALOS is seven days now. Barring the ICU patients, most patients go home by the seventh day," Rindani told Business Standard.

At present, the city administration has put strict censure on admitting asymptomatic patients. "Many people think that they would not get a bed if their conditions worsen, a genuine worry. That is why they wish to be admitted early if they are Covid19 positive,"

The BMC has been continuously changing its discharge policies - earlier this week it decided to test 'low symptomatic' patients on fourth day of admission if symptoms disappear and discharge them the next day if the report is negative, instead of discharging them on the tenth day without testing.

Doctors felt that with the disease also evolving, now there is more clarity about its progression. Dr Harish Chafle, consultant intensivist and chest physician, Global Hospitals, Mumbai said, "As the disease has evolved in its natural course globally, we are becoming wiser every day. That's why the discharge process and the criteria has been changing. We are trying to redefine the process ourselves so that discharge process is facilitated. The number of days patients stay in hospital has been reducing." He added that earlier doctors were not sure till what time the virus shedding happens and when a patient becomes non-infectious to others. After the tenth day of illness, even if the swab comes positive, the viral shedding is not there.

Global Hospitals too has an ALOS of seven days now. So is Apollo Hospitals, Navi Mumbai. "As a COVID-19 Hospital, we are getting cases with very acute symptoms and with lot of co-morbidities & complexities. It still depends on various factors, how early the patients are presenting to hospital and seeking medical help. Certainly ALOS is reducing, as patients are seeking medical help early on now with screening undertaken on timely basis," said  Santosh Marathe, COO & Unit Head, Apollo Hospitals, Navi Mumbai. Fortis Hospitals, however, have an ALOS of about 10 days now for Covid patients.

Dr S Narayani, Zonal Director, Fortis Hospitals, Mumbai said, "The ALOS for non-ICU pts is about 10days; for the more critically ill patients that are admitted to the ICU, it would depend upon the severity of the infection in the patient. Earlier the discharge timeline used to be 14 days, but it is now understood that in 10 days the patient becomes non-infective so he or she can be sent home. Such patients have to continue following home care guidelines as advised by their doctor."

Has this freed up beds or has the queue reduced?

Not really - almost all leading tertiary care hospitals say that they continue to remain occupied, but the bed turnaround time has reduced. Most of them see a queue of 15-20 patients for ward admissions and about seven to ten ICU admission queries every day.

But, with Mumbai's case doubling rate at around 40-days now, the queue is shortening, they say. "Definitely lesser patients are turning up for admissions everyday,"Rindani admitted.

The BMC launched a centralised dashboard around end of May where patients would call on a helpline to know about hospital bed status, get a token, ambulance assistance. Hospitals notify the helpline once a bed is vacated and the dashboard (which is not made public) is updated accordingly so that it can allocate a bed to a patient in queue.