Improving quality and satisfaction in care of Covid-19: A patient-centric approach

In the current global pandemic of novel coronavirus disease 2019 (Covid-19), 5%–14% of patients develop moderate-to-severe disease and require hospitalization or care in the intensive care unit (ICU).^[1] Due to huge caseloads, many hospitals and ICUs are overburdened and healthcare providers (HCPs) are over-worked. This poses unique challenges to the patients as they may unfortunately be subjected to less than optimal care in such scenarios. Keeping in mind the ethical principles of medical practice, there is an urgent need for better understanding of patient’s perspective and adoption of a patient-centric approach in Covid healthcare facilities.

Based on our experience of caring for over a thousand patients in a Covid ICU and ward in the past few months, we highlight a few issues faced by patients and suggest possible solutions.

Some problems faced by the patients are as follows:

1. Alien environment: HCPs look alien clad in personal protective equipment (PPE). One elderly patient who was admitted with altered sensorium continued to think that she was put in a jail and police personnel were guarding her around for a few days till a nurse explained this to her.
2. Limited communication by doctors and nurses: HCPs are overworked and uncomfortable in PPE with reduced efficiency. Many non-regular HCPs are also posted in Covid ICUs, who are new to the environment. They are usually anxious, may have altered attitude and may not have any prior training in communicating with patients in the ICU. Since HCPs work in Covid ICUs in short shifts, they are unable to bond with the patients.
3. No visit from relatives: In many Covid ICUs, there is a blanket ban on visits from relatives for various reasons. Many relatives may be Covid suspects and in quarantine. It may not be feasible to train relatives in proper donning and doffing of PPE to send them inside the ICU. Therefore, getting trapped in an alien environment without seeing any of the family members for a long time may lead to stress among patients.
4. Mortality in the ICU: The mortality rate in Covid-19 patients admitted to ICU is high.^[2] Therefore, cardiopulmonary resuscitation and death may be common happenings inside the ICU and can adversely affect the mental health of a patient. A mentally altered patient may hear conversations of HCPs around who usually need to speak more loudly as hearing is impaired in PPE.
5. Uncertainty of the outcome due to a novel and unknown disease: Lack of any knowledge about this novel disease compounded by the aforesaid issues may make patients uncertain and depressed about their outcome.

The possible solutions that could be adopted by HCPs:

1. Daily update at the time of rounds: During the rounds, an update on the clinical condition should be provided to the patient and due assurance should be made. Important aspects such as current clinical condition, therapy instituted, progression (improvement) of his/her illness and possible time to be required for discharge from ICU should be discussed. Any intervention, which requires the patient’s cooperation, should be well explained and all attempts should be made to gain confidence. Certain interventions such as awake prone position have shown promise in improving outcome and are being commonly used in Covid-19 ICUs.^[3] A patient should be explained and repeatedly encouraged to continue awake prone positioning.
2. Communication by bedside nurses: The bedside nurses in each shift should be encouraged to communicate with the patients.
3. Audio/video call with family members: Bedside nurses should make the patient talk to the family using audio or video calls at least once a day. Specific mobile phones may be kept in Covid ICUs for this purpose. This should improve the physical and mental well-being of the patients and alleviate anxiety among family members.
4. Use of hearing aids or spectacles: Any patient who is not sedated and on mechanical ventilation can communicate better when his/her visual and auditory functions are optimal. HCPs should enquire about the use of such essential devices on admission, particularly for elderly patients. Use of these devices may improve comfort and reduce delirium in elderly patients.^[4]
5. Light and music: Patients should be oriented daily with exposure to sunlight if possible. Ambient light should be dimmed, and monitor and ventilator alarm volumes should be reduced at night. Soothing music played at the bedside and provision for watching relaxing programmes on television if available may go a long way in reducing stress.^[5]
6. Discharge education and follow-up support: Patients should be educated during discharge about the possibility of respiratory sequel, risk of post-traumatic stress disorder^[6] and any other case-specific issues and need for follow-up. Provision for telephonic/ online post-discharge follow-up support should be made.

In spite of the administrative and logistic limitations in the midst of the pandemic, every effort should be made to deliver the best possible care in all Covid wards and ICUs. With the adoption of these simple measures mentioned above, we believe the hospital stay of patients may be made more comfortable in Covid care facilities.

Conflicts of interest. None declared