Covid-19: The five elements of the Mumbai model
Mumbai, with a higher population density, faced a shortage both of beds and oxygen as the second wave surged. However, the city, with a population of at least 12.3 million, was able to cope better than Delhi
The devastating impact of India’s raging pandemic has largely been seen in Delhi, as the national Capital’s rising caseload was met with a shortage of medical oxygen and hospital beds for weeks at a stretch. Mumbai, with a higher population density, faced a shortage both of beds and oxygen as the second wave surged. However, the city, with a population of at least 12.3 million, was able to cope better earning it praise from both the Supreme Court and the Bombay High Court (HC) lauding the “Mumbai model”.
On May 5, the top court recommended that Delhi should draw from Mumbai’s methods and experiences. A few days later, the Bombay HC asked municipal corporations from different states to follow the systems put in place by the Brihanmumbai Municipal Corporation (BMC) to handle the Covid-19 pandemic.
“The Mumbai model is a mix of decentralisation, augmenting infrastructure, and keeping a close watch on the loopholes in order to plug them. For example, we realised the importance of oxygen support for Covid-19 patients during its first wave. Back then, instead of relying on a cylinder-based model, we upgraded our facilities with Liquid Medical Oxygen (LMO) tanks. By the time the second wave hit us, our dependency on the cylinders had considerably reduced,” said additional municipal commissioner Suresh Kakani.
HT spoke to several officials across the city to understand what constitutes the Mumbai model.
24/7 operational, decentralised war rooms
When Iqbal Chahal took over on May 8, 2020, as the municipal commissioner of the BMC, one of the crucial decisions he made was to decentralise the disaster control room – till then, a solitary unit — into 24 Covid response war rooms, one for each of the city’s administrative wards. They were functional in a month, each with its own dedicated helpline number that is connected to 30 lines. A mixed group of doctors, medical interns, schoolteachers, and social workers operated these lines 24/7 working in eight-hour shifts. The number of lines in each war room has not changed.
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“This system of someone from the BMC being in touch with the patients, helped avert chaos that could have occurred when the cases peaked,” Kakani said. Mumbai also made it mandatory for beds to be allotted only through these war rooms. When serious patients visited hospitals directly, the health care facilities were asked to promptly update the dashboard — a live bed tracker with details on the availability of Covid-19 bed in the public and private hospitals across the city, accessible to each war room.
As the cases peaked in April 2021, touching a single day high of 11,206 cases on April 4, the war rooms bustled to accommodate patients on beds that were being occupied within a matter of a few minutes. “The bed status would change so quickly that we had to rush to call the hospital, or the bed would be allotted to someone by then,” said Dr Dhananjay More, a Bachelor of Ayurvedic Medicine and Surgery (BAMS) who works as a war room assistant medical officer in A-ward that covers Fort, Marine Drive, and Colaba areas.
More, who was posted at a Covid-19 facility in Dharavi last year realised that this situation would only result in further panic. By the second week of April, several patients were being allotted beds that were far from their residence. In one instance, a 13-year-old girl from Fort was rushed to the NESCO facility in Goregaon, 29 km away, as her oxygen saturation dropped to 91% and there was no vacant oxygen bed in south Mumbai.
Triage and testing reports
As cases began to peak in the first wave, patients were turned away from hospitals for lack of beds, and ambulances equipped with oxygen fell short. Many hospitals also refused to accept patients without a Covid positive test results. This issue was largely addressed as the war rooms began to follow the triage system, and also streamlined the protocols surrounding test results. BMC’s war rooms played a crucial role in triaging, or determining the severity of a patient’s condition, their likelihood of recovery without treatment, and thus determining the priority of who to afford care to.
The BMC’s triaging system also hinged on another controversial decision — it had forbidden the testing laboratories to share positive reports with patients in June 2020. Only negative reports were allowed to be shared directly, while the positive reports would be routed through the war rooms. “This method helped in ensuring that hospitals are not unnecessarily crowded,” said Dr Daksha Shah, deputy executive health officer of BMC. “When the war room made the first call to inform the positive report, the patient’s health and living conditions were understood and they would be accordingly guided for home isolation or hospitalisation,” she said.
The civic body faced a backlash for forbidding laboratories to disclose the positive reports, but it refrained from giving in to the pressure. “Instead, we pressurised the laboratories to turn around the reports faster, so that there was no delay in updating the patients from our side,” said Shah. The laboratories were asked to enter data of processed samples between midnight to 6am so that patients could be told their positive status through the war rooms starting from 8am every day.
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To tackle the second wave better, each war room formed a team of doctors to visit patients and ascertain if they need immediate hospitalisation. “In some cases, panicked relatives and friends exaggerated the severity even as the patient’s parameters were normal,” said Dr More. “When in doubt, we started dispatching doctors to visit such patients and assess their condition,” he said. The primary healthcare workers were also directed for this task if doctors were unavailable. Those living in slums were strictly directed to isolation centres if they did not have access to isolate; those with separate rooms and toilets were allowed home isolation, based on their health condition.
Augmenting beds, retaining jumbo facilities
The number of hospital beds, including Intensive Care Unit (ICU) and oxygenated beds was increased to 1.5 times more than what the city had during the first wave. The jumbo field hospitals that were created during the first wave were retained even when the cases fell drastically, and the admissions dropped. For instance, in January 2021, the NESCO jumbo facility in Goregaon had only three patients admitted in its 200 bed ICU and only 29 patients in its wards with 1,900 beds. “We had to reduce our staff at that point in time, but the entire facility was retained as it is,” said Dr Neelam Andrade, dean of the NESCO facility.
A crucial decision in BMC’s war against Covid-19 was to take over 80% of beds in private hospitals in May 2020, and which was reactivated as the second wave struck. The private hospital beds were incorporated in the dashboard accessed by the war room, empowering BMC to allot beds in the public as well as the private sector. Of the 23,209 hospital beds in Mumbai for Covid-19, 7,890 are in the private sector. Of the 2,961 ICUs, 1571 are in the private sector.
Last June, the civic body also deployed 800 Sumo vehicles with aluminium partition sheets between the driver and passengers, to ferry people to the hospital. These vehicles were made available on Uber, an application for hiring cabs. However, patients requiring oxygen equipped ambulances struggled.
Oxygen supply management
In 2020, when Mumbai’s Covid-19 facilities were expanded, the civic body also began building storage tanks for Liquid Medical Oxygen (LMO). Between May and June last year, it had installed 15 LMO tanks with a capacity of 13 kilolitres each and 11 smaller tanks with a capacity of up to six kilolitres each in the city’s six civic-run hospitals and six jumbo Covid-19 centres. “Nearly half of these tanks were redundant infrastructure at that point in time,” says additional municipal commissioner P Velrasu, who was tasked to oversee Mumbai’s oxygen supply and distribution. “We were not sure if they would be used. But we took the bold decision of building them, and that saved us during the second wave,” he said.
Mumbai’s oxygen management model had a multipronged approach — in addition to building storage infrastructure, teams were appointed to ensure smooth movement of oxygen tanks reaching the city, staff was placed at a cylinder refilling station in Navi Mumbai to ensure that city’s quota of cylinders are not directed elsewhere and usage of oxygen in hospitals was closely monitored, sensitising doctors and paramedics to use it rationally.
On the midnight of April 17, 168 patients from six civic-run hospitals were shifted to its jumbo facilities after they ran out of oxygen. Of these, 30 were ICU patients. “We realised that hospitals were admitting more patients with oxygen requirements even as they did not have optimal oxygen capacity,” said Velrasu, adding that many such hospitals were pulled up by the civic body. “For example, the Parsee General Hospital in south Mumbai had only 30 oxygen beds but had admitted 80 patients on oxygen support. Many hospitals like PGH would fast deplete their oxygen and would then start the panic calls. This was all happening at the same time when many jumbo facilities had empty oxygen beds. Patients had their hospital preferences, but we strictly advised hospitals to direct patients to other facilities instead of over-admitting,” said Velrasu.
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Civic chief Iqbal Chahal formed six zonal teams in Mumbai to take over oxygen management at four wards each. These teams consisted of senior medical officers, administration staff, and oxygen suppliers. When any hospital in a particular zone sent out an SOS for oxygen, the zonal team would take charge to either direct surplus oxygen from other facilities or shift patients, if needed. In one instance, when a small hospital in the F North ward with half a dozen patients on oxygen was fast depleting its stock, the zonal team sprang into action and directed cylinders from the civic-run Sion Hospital. From 210 metric tonnes in the first wave, Mumbai’s oxygen demand shot up to 270 MT during the peak of the second wave. “But multiple, well-coordinated efforts, sustained us,” said Velrasu.
Data led the way
The civic body’s thrust on numbers helped in focusing on areas where more cases were being reported from. Data played a crucial role in forming micro-containment zones, limiting the movement of people from such areas. “We closely monitored the rise and fall of cases in wards and intensified our activities accordingly,” said Shah. “For example, when R Central (Borivali) and G South (Worli, Lower Parel) wards were reporting more cases, we directed the medical officer to intensify contact tracing, testing, and micro containment zones,” she said. The civic body also resorted to stringent steps like filing First Information Reports against people who broke the containment rules. As of May 8, the city has 581 active micro containment zones. Quick, accessible data on the dashboard that was made available to all war rooms also played an important role in making the process of bed allotment more efficacious.