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Fears of future COVID waves have triggered a ramp-up in critical care and emergency services in a race to outflank the virus. But even with access to cheaper loans thanks to the government’s fiscal stimulus packages, hospitals will have to balance expansions with fiscal prudence. The solution could well lie in better facility planning and design, leaning on flexibility and agility. Healthcare planners weigh in with some possible solutions

By Viveka Roychowdhury

India’s second wave of the COVID-19 has seen an increased number of cases requiring prolonged stay in Intensive Care Units (ICUs). Worse, some experts are predicting that this could be repeated in the third wave (estimated to be around October this year) and future waves.

The tragedies were compounded by the lack of ICU facilities and infrastructure like dedicated medical oxy- gen plants. Lest they be caught unawares again, healthcare institutions have been ramping up their critical care and emergency infrastructure, bolstered by incentives like low-interest loans. But are they on the right track? And will fiscal incentives be enough to plug the gaps in healthcare infra- structure?

Reflecting on the choices facing hospital managements, Sameer Mehta, Director of Projects at HOS- MAC says, “There are mixed opinions in the fraternity. There are some who tell us that by the time the plans currently underway get executed, COVID will have become a thing of the past. And then there are a few who believe in being prepared for future eventualities. As planners, we too are making an effort to draw a balance between what clearly translates into a need for more space, isolations etc. and better preparedness.”

The key could well lie in finding the right balance between expansion and optimising CAPEX. As Ravideep Singh, Principal, Creative Designer Architects (CDA) puts it, hospitals must reform their approach and focus on two major goals – flexibility to surge bed capacities, and safeguarding care- givers and non-infectious patients.

Cheaper finance available but….

As per an ICRA report, under the Covid Emergency Response and Health System Preparedness Package announced in April 2020 with an outlay of Rs 15,000 crores in FY2021, the government has set up ~3,900 COVID- dedicated hospitals, ~7,900 COVID health centres, 9,954 COVID care centres and increased the oxygen-sup- ported beds by 7.5x, isolation beds by 42x and ICU beds by 45x (~1.1 lakh beds). (See Table 1: Details of deployment of Rs 15,000 crores towards health infrastructure for COVID-19 treatment).

Finance Minister Nirmala Sitharaman’s June 28 announcement of a fresh infusion of funds, to the tune of Rs 23,220 crore for the healthcare sector, couldn’t have come at a more appropriate time. Heeding the warnings of healthcare experts, that the third wave might affect children adversely as this age group has not been vaccinated as yet, the Rs. 23,220 crores over one year allocated under a new scheme reportedly focuses on short-term preparedness with special emphasis on children and paediatric care/paediatric beds.

As per the ICRA report, this scheme would be used to fund short-term HR augmentation through medical students and nursing students, increase the availability of oxygen beds, ensure adequate availability of equipment and medicines, and enhance testing capacity and supportive diagnostics.

…but loans will impact balance sheets

Relatively lower-interest backed loans are available through the previously announced RBI on-tap liquidity window of Rs 50,000 crores and the Emergency Credit Line Guarantee Scheme 4.0 (ECLGS 4.0) and the current guarantee scheme. But on a cautionary note, the ICRA report also points out that hospitals will need to evaluate the demand prospects and impact of additional loans on their balance sheets before incurring capital expenditure for expansion.

Commenting on the significant infrastructural gaps in the Indian healthcare industry, Mythri Macherla, Assistant Vice President and Sector Head, ICRA, analyses that renewed focus and sup- port provided by the government for expanding and set- ting up new capacities in traditionally underpenetrated areas of the country is expected to improve health- care access in the semi-urban and rural areas of the country.

But she highlights one more worrying detail: the guarantee duration has been provided only for three years as against a typically higher breakeven period for most hospitals, which includes the time for setting up the facility. But she agrees with the general industry consensus, stating that “the guarantee will provide additional com- fort to lenders in case of borrowers with weaker credit profile.”

The caution is further justified seen in the context of the impact of COVID-19 on hospital balance sheets. On the plus side, the ICRA report points out that hospitals have witnessed an all- time high occupancy in Q1 FY2022 with the resurgence in COVID-19 cases and revival of elective surgeries in recent weeks.

However even though the revenues of hospitals are expected to witness healthy expansion in FY2022, COVID Average Revenue Per Occupied Bed Day (ARPOB) is projected to remain 30-40 per cent lower than non- COVID ARPOB for most hospitals. Thus, given the evolving nature of the pandemic, margins of hospitals would remain a key monitorable in the short term.

Perhaps this is why Charu Sehgal, Partner, Deloitte India reminds us that, “it is equally important to ensure that these funds are in fact utilised and a clear time- bound investment plan is laid out. Often we have seen that budgeted allocations are not used.”

Sehgal does however welcome the allocation of funds to create infrastructure in tier 2 and 3, the easing of availability of cheap finance for private sector investment in the sector and hopes that the specific focus on paediatric care will cater to some long-term improvements in this segment. Another critical gap is the acute shortage of healthcare resources, as infrastructure without staff and equipment is of limited use. “It is good to see that there is a provision for some short-term solutions to this issue as well,” she says.

Design planning for future pandemics

Healthcare planners are a vital part of this retrofitting exercise, which could broadly be divided into two parts: short-term and longer-term measures.

CDA’s Singh posits that in the context of the Indian healthcare system, hospitals need to emphasize three crucial activities – triaging, segregation, and surge capacity. Triaging and segregation essentially entail a carefully planned Emergency Department which could immediately screen and seclude infectious patients within the facility minimizing risk for caregivers and uninfected patients. ‘Segregation’ here refers to the physical separation of various areas within the hospital, as well as mechanical isolation of the air conditioning and mechanical systems.

Singh cautions that HVAC systems could pose challenges in case the segregated zones do not have separate Air Handling Units (AHU), causing return air from the infected zones to be recirculated into other hospital areas. To mitigate this, he suggests that hospitals could potentially block off the return air from the areas for the infectious patients and enable outdoor air intake for the AHUs, such that it exceeds the supply, creating negative pressurisation of at least 2.5Pa. This measure also requires decentralized exhausting air from ‘COVID’ areas through ways such as HEPA filtration, chemical disinfection or heating.

Handling the COVID surges

One of the most talked-about post-pandemic responsive measures for a hospital is the surging capacity, narrates Singh. Harking back to how The American Nursing Association defines the components of ‘Surge Capacity’ as the four S’s: Staff, Stuff, Structure, and Systems, he says that while ‘Staff’, ‘Stuff’ and ‘Systems’ are primarily logistical aspects, ‘Structure’ availability of space and its optimisation, is something health planners have significantly tackled during the pandemic.

In response to the anticipated third wave, Singh suggests that hospitals can adopt various measures to surge bed capacities such as expanding ICUs by adding critical care beds in soft spaces or in adjacent non- clinical areas. Additional beds can also be accommodated in other areas that have a discreet ventilation system. He emphasises that hospitals must ensure that as many beds as possible must be converted to ‘acuity adaptable’ beds with necessary equipment and systems required for critical care, and appropriate spatial and air segregation.

Singh cautions that increased bed count warrants additional medical staff. Health facilities should also factor in additional spaces to support caregivers with areas such as break rooms, refuge areas and other support areas. Programmatic inclusions such as these create a humane and equitable care environment. Significant evidence is available that improving caregivers’ well- being indicates a positive impact on patient experience, decreased medical errors and enhances staff retention rates.

He points out that as hospitals are highly susceptible to exposing their occupants to high viral load levels com- pared to other building typologies, adopting and implementing effective technology that can mitigate the spread of air-borne infections is crucial. In addition to human-to-human transmission of SARS CoV-2, evidence shows aerosols and PM 2.5 and PM 10 dust as two primary potential mediums. Aerosols or droplets less than five microns in size from an infected person can potentially remain in the air for hours or even days, in some cases.

Citing recommendations of The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) and Indian Society of Heating, Refrigerating and Air- Conditioning Engineers (ISHRAE), to install UVGI (Ultraviolet Germicidal irradiation) filters in the air ducts and AHUs, Singh says, “This could be the only potential measure in cases where air conditioning system rezoning is not feasible. Another prevalent measure is using Electronically Charged Filtration (ECF) for PM2.5 matter with ‘trap and kill’ technology. This can be retrofitted in ducts or Air Handling Units and even in home air-conditioning systems.”

From an infra point of view, Singh reasons that one advantage of UVGI filters is that their installation in existing hospital ducts and AHUs is a relatively straight- forward process that could be implemented within a few hours. Therefore, he suggests that these systems can be added in parts by phasing out areas or zones available during periods of turnarounds or inoccupancy for functioning healthcare facilities.

Cautioning that the precise efficacy of these methods against the coronavirus is still evolving, according to Singh, there is sufficient evidence to conclude that these means are effective against deactivating SARS CoV-2 as a retrofit technology. He believes that the early adoption of these technologies will allow hospitals and other medical facilities to mitigate the challenges in case of a third or subsequent waves of the COVID-19 pandemic.

Setting up field hospitals HOSMAC’s Mehta cites another strategy to quickly ramp up ICU beds: setting up field hospitals that cater exclusively to COVID cases. Strategically, this is a judicious deployment of limited resources as most such set- ups have been executed beyond the conventional hospital but in proximity. Clearly, the intent is to ensure that regular operations are not disrupted, while simultaneously sharing the necessary infrastructure and personnel between the existing hospital and the field hospital.

According to him, some of these are designed to ensure a higher degree of safety for caregivers – a key to managing larger caseloads of patients when these resources are in short supply. These hospitals are complying with environmental norms inasmuch as possible within the framework of these structures and are also well equipped in terms of life- saving equipment.

He reasons that it is not clear whether a third wave really can be predicted with any degree of certainty. Mehta’s reminder that “it costs to prepare and the costs have to be borne by someone – so ramping up infrastructure in anticipation is not easy” is a stark reminder of the economics at play.

The benefits of flexibility Hospital furniture manufacturers too have responded to evolving requirements and striving to suit budget constraints, especially of healthcare facilities based in rural areas and smaller towns and cities. For example, as per a press release, Godrej Interio launched the Acura range of hospital beds at the beginning of this year. This range of hospital beds reportedly comes with an option to create a bed according to the specifications and budget, allowing customers to upgrade existing manual Acura beds to motorised functions as per the requirements and budgets available.

Sameer Joshi, Associate Vice President, Godrej Interio says, “Healthcare has become one of India’s largest sectors – both in terms of revenue and employment is growing at a CAGR of 16-17 per cent. However, health- care facilities in India are often incompatible with changing needs.”

According to Joshi, Godrej Interio Healthcare business focuses on creating environments that support patients and families in process of healing. He describes them as “ergonomically designed healing environments” that “focus on the efficiency, empathy, and well- being of all stakeholders including patients, care- givers, and doctors.” He cites the example of the newly launched Acura range of hospital beds as a highlight of the company’s design philosophy, “which is based on adopting a human-centric approach and using adaptive space solutions for improved patient-doctor interaction.”

No longer getting short shrift

All in all, a slight silver lining is that the pandemic seems to have forced a much-need- ed revamp and a rethinking of design basics, not just physical infrastructure but also in the attitudes of hospital promoters/owners.

Speaking perhaps for many hospitals owners/pro- moters, Probal Ghosal, Chairman, Ujala Cygnus Healthcare Services says that COVID-19 has changed how they have understood hospitals in the past, bringing most hospitals owners and managers to the table to rework how to deal with such pandemics and save as many as lives as possible. While outlining how his group is ramping up infrastructure, he makes the point that the Government must support hospitals in their journey of development with pricing controls and facilitate in regulatory and legal framework to be able to get a better response.

For instance, Mehta points out, “The need for isolation in emergency care and critical care settings has existed a long time. It is just that members of Infection Control Risk Assessment teams were not always a part of the planning exercise and therefore the case for isolation sometimes get short shrift. We are happy to note that owners have now become more receptive to the proposition for isolations within the hospital.”

In the same vein, insignificant though it may seem, Mehta says waiting for spaces are getting their due too. “There is an architectural standard that provides for 1.4 sq m / person to be allocated as waiting space. This has been practised more by way of deviation than compliance. But owners are now agreeing to not only provide appropriate waiting spaces but also seeking to ensure these spaces are well-ventilated too.”

Architecturally, he says they are also leaning back towards a leaner floor plate. Not so much because they will be resorting to cross- ventilation to the exclusion of air-conditioning, but because the impetus to harness natural light and the ease of incorporating fresh air intakes and exhaust at prescribed intervals are taking precedence. This is all in a bid to maintain/enhance the indoor environment at a time when the threat of infection looms large, both inside and outside hospital facilities.

Thus, even as hospitals expand to cope with increasing demand as COVID-19 cases rise and fall, they will have to carefully optimise spends. Ramping up infra- structure will have to be balanced, with a firm eye on pro- viding affordable care, with- out weighing down the balance sheet.

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