Thiruvananthapuram/Kochi: India’s first war room set up to chalk out strategies to fight COVID-19 is still active even 500 days after it was constituted.
The country reported its first confirmed COVID-19 case in Thrissur, Kerala, on January 30, 2020. Before the MBBS student tested positive, the State had been under the impression that the pandemic, sweeping across several countries from its place of origin in Wuhan, China, would not wreak havoc in Kerala.
Still, the State, not one to take chances, opened its first control room on January 24, to check a possible outbreak. Kerala had before it the experience of Nipah, the zoonotic illness that had claimed 17 lives out of 18 confirmed cases in 2018.
The control room, opened at the Directorate of Health Services, with a few doctors and other staff members, soon became the war room.
War room without recess
The then Health Minister K K Shailaja used to visit the war room daily to review the situation. Her discussions had then lasted an hour, since the pandemic had not posed a serious challenge. Still the State went ahead linking all medical college hospitals and other healthcare centres with the war room.
Currently, the war room is buzzing with activity as about 100 experts, including doctors, work round-the-clock to outpace the spread.
The war room has been hosting a review meeting daily to chart out new strategies to fight the pandemic. It has also been coordinating all related activities, collecting details of those from affected areas, preparing the contact list of those who had tested positive, providing healthcare, home surveillance, ensuring the availability of medicines and equipment, awareness campaigns, testing and vaccination.
Eighteen committees are based in the war room. Each team handles one specific task, surveillance, call-centre management, training and awareness generation, media surveillance, documentation, private hospital surveillance, etc.
All districts in Kerala have such control rooms, each functioning under the supervision of a nodal officer, reporting officer and others. All the 18 committees come together for a review meeting daily to chart out the future course of action.
The Health Minister, Principal Secretary (Health), Director, National Health Mission State Mission, Director, Department of Health, Director of Health Education or Additional Directors chair the daily review meeting.
The daily meetings review the previous day’s cases and issues. The Director of Health Department holds daily meetings with all district control rooms to inform them of government-level decisions and orders, besides issuing them necessary guidelines. Additionally, experts will speak on COVID-19 to all major hospitals via video conferencing on almost all days.
The central control room has a 24x7 State Covid call centre. The centre clears doubts raised over the phone, and passes on information received to districts and departments concerned for further action.
Ernakulam, the district which handled the most number of COVID-19 cases in the State, has the most modern war room. The Integrated Command and Control Centre (IC4), functioning from the Jawaharlal Nehru Stadium Metro Station Building, was temporarily converted to the war room. The dashboard on a huge screen flashes real-time stats.
If other districts operate through the government’s Jagratha portal, the case is different in Ernakulam. The entire coordination across the district is done over the Corona Safe Network, an open source software a group of IT professionals have developed and made available free of cost.
The war room handled about 4.5 lakh phone calls over the past 1.5 years, besides taking care of 2.5 lakh COVID-19 patients and coordinating the shifting of about 70,000 patients to hospitals.
When the second COVID-19 wave tore through the State and the nation, Ernakulam fought back on the strength of its war room and a group of youngsters who worked 24x7.
Ernakulam declares war
The first COVID-19 case in the district was confirmed on March 9, 2020. The district opened its war room – though it was then not considered to be one – the same month itself. Known as the Tele Health Helpline, it functioned out of the IMA House at Kaloor as the annexe of the Collectorate-based Covid Control Room.
The district then had not declared war on COVID-19. The Helpline centre then did not have the huge screens, but eight LED television screens that flashed the dashboard.
Initial thrust: Quarantine
The war room’s task during the initial phase was to arrange for sequestering passengers arriving at the airport and seaport. It focused on monitoring the health condition of those in quarantine, conducting tests, and if found coronavirus positive, ensuring treatment.
The strategists, however, had then itself envisaged a spike in COVID-19 cases and the necessity for ‘load balancing’ to help hospital facilities handle the increase in the number of patients. Though the number of patients then were less, the cases gradually started increasing.
As the cases kept on increasing, the war room’s focus shifted to transferring quarantined patients to hospitals, and balancing the load. It soon became a war-like situation.
The world was brought to its knees when the case load increased beyond the available healthcare facilities. Kerala’s facilities have been limited, and it became imperative that the State should judiciously utilize the available facilities. Load balancing came into play at this juncture.
Not all COVID-19 patients require hospitalization. The task was to identify those who really needed hospitalization, and treat the remaining patients at their respective homes or primary health centres. Unnecessary hospitalization would deny a patient with dire need the necessary hospitalization facility.
Load balancing made necessary arrangements to avoid unnecessary hospitalizations, and thereby saved the health sector from handling extra burden.
Triaging technique was employed to ensure load balancing. According to the set process, those with symptoms contacted the control room, which after filtering the calls, the phone numbers were passed on to the war room.
Once alerted, the telemedicine team at the war room contacted the caller to provide them the necessary instructions. Those with high temperature or cough were directed to the nearest health workers.
Preliminary tests were conducted at the local level. Those found positive were shifted to either their own residence (provided they have an isolation facility) or COVID-19 First-Line Treatment Centres CFLTCs).
The details of patients who could not be handled at the local level were passed on to the taluk-level control room. Those referred to the taluk level were admitted to its CFLTC or Secondary COVID Treatment Centres.
Those who still required advanced medical care were referred to the district level. By then, the number of patients would have drastically come down.
Despite having a strong public healthcare system, Ernakulam has a lesser number of government-run tertiary centres, compared to other districts. The Medical College at Kalamassery is still in the development stage. If all hospitals are set aside exclusively for treating COVID cases, those with other diseases would have nowhere to go.
The triaging technique helped the district in reducing the number of patients needing tertiary care. Private hospitals treated 70% of patients requiring tertiary care when their numbers increased.
All-out war in May
The total war began in May when the caseload kept on increasing without any control. The number of patients needing ICU. Ventilators and oxygen beds, too, increased. The frontline warriors were tested for the first time, said Dr Athul Joseph Manuel, secretary of IMA (Kochi). Each one of them toiled day and night to overcome the crisis.
The war room in the district has four major wings: Telemedicine, data-entry team, shifting control room, and oxygen war room.
The telemedicine team comprises doctors, moderators and volunteers. Calls received at the district control room (based at the DMO office) are filtered and passed on to the telemedicine team at the war room.
People cannot contact the telemedicine team directly, but the team contacts those in need based on the information passed on by the district control room. The doctors communicate with patients over the phone or video conferencing, and prescribe medicines.
The war room also has volunteers who would deliver medicines to the patients, if necessary. If the telemedicine team finds a patient requiring advanced treatment, the information would be passed on to the shifting control room.
Shifting control room
Patients are shifted from their residences or CFLTCs to hospitals or beds with oxygen supply through the shifting control room. For instance, the telemedicine team finds a patient with dipping oxygen saturation levels. Once alerted, a doctor in the shifting control room contacts the patient for confirmation, and a request for shifting is made using the software.
The software finds the nearest hospital with a bed with oxygen supply and issues instructions to shift the patient. It also finds the nearest ambulance over GPS, and the driver will be given the addresses of the patient and the destination hospital.
The hospital, meanwhile, would have received details and medical history of the patients online. The same process is followed in cases of patients requiring hospitalization, ICU or ventilator support. The process ensures that no patient visits the hospital unnecessary, besides providing the best treatment with the available facilities.
Oxygen war room
The district did not have an oxygen war room during the first COVID-19 wave. The oxygen war room became operational after the second wave became severe and several patients required the life-saving compound.
The oxygen war room monitors real-time the availability of oxygen in each hospital, and arranges for replenishment whenever required. It also ensures the judicious use of oxygen.
Different types of data form the backbone of the war room. The data entry team coordinates the data on Covid patients, those with aggravated condition, hospitals, ICUs, ventilators, oxygen beds, other available beds, ambulances and doctors.
The data entry team works in three shifts, each shift having hundreds of volunteers, including those with post-graduation in MCW, MCA and medical students. Initially, they volunteered themselves, but they were later hired on a temporary basis. They keep constant touch with healthcare facilities, including private hospitals, to ensure the data are precise.
IC4 becomes war room
The Integrated Command and Communication Centre (IC4), which would become Kochi city’s nodal unit, fuelled the war room during the second wave. It would soon be the single-contact point for all information on the activities in the city, and for coordinating personnel in various roles, including law and order, and emergency disaster management activities.
IC4 has not become completely functional since the Smart City project is still in the initial stage. It was under this circumstance that the Cochin Smart Mission Limited offered the IC4’s modern infrastructure to the war room.
Besides huge display boards, the war room also received dual-monitor computers, which made data management easy and efficient. It also helped in roping in more people into the war room, and made communication easy. The employees of IC4, too, became a part of the war room.
(With inputs from Manoj Kadambad in Thiruvananthapuram)