Tuesday, October 27

Mandatory CT-Chest Pre-Hospitalisation. Are Mumbai Hospitals Flouting Norms?

Mrs. Niranjana, a seventy-nine-year-old lady, was lying on the stretcher, outside a private hospital in Mumbai, waiting for admission. She was a case of urinary tract infection and does not exhibit any signs and symptoms suggestive of a chest infection. The hospital wouldn’t admit her until the relatives allow the patient to undergo a CT-Chest along with the COVID 19 RT-PCR to screen for possible asymptomatic COVID infection. The story doesn’t end here, the hospital forces them to sign a high-risk consent form with a clause that anything may happen during the procedure.

In a state of panic, the relatives call me for advice to know if there is a rule like this exists. Of Course, it was more to allay their fears than anything else, sitting a thousand kilometers away, I couldn’t be expected to help anymore. To seek clarification I had a word with Dr. Raghav(name changed), the man-in-charge of the case. The revelations were shocking to me, to say the least.

Most of the bigger private hospitals have made it a mandatory requirement to screen all patients with a combination of RT-PCR for COVID 19 and a CT Scan chest before admitting them in their facility irrespective of whether they have any symptoms suggestive of COVID. So, in simple words, if a patient of renal colic is admitted for the pain relief he/she will be subjected to Ct Chest before the hospital decides to take him/her in.

This is actually as absurd as it sounds.

What do the guidelines say?

Well, the currently available guidelines clearly point to the contrary to the practices employed by these hospitals.

The WHO’s rapid advice guide, 11th June 2020, Use Of Chest imaging in COVID 19 recommends;

  1. For asymptomatic contacts with patients of the COVID 19, WHO suggests not using chest imaging for the diagnosis of COVID 19: RT-PCR should be done.
  2. For symptomatic patients with suspected COVID 19, WHO suggests not using chest imaging for the diagnostic workup of COVID 19 when the facility for RT-PCR is available with timely results.

The reports from other sources including that of china have similar suggestions to make:

Chest CT to screen COVID-19 may not be sensitive. Initial reports have been focused on severe patients and reported a high chest CT positive rate. For milder cases, the chest CT positive rate will be much lower (5). To our knowledge, chest CT positive rate among asymptomatic COVID-19 patients remains unknown (6,7). Moreover, a negative chest CT does not rule out this disease for COVID-19 patients during their contagious latency period. 

Author’s views

To my mind, the reason behind the necessary incorporation of such practices by the hospitals seems forced more to avoid administrative and bureaucratic castigation than guided by scientific knowledge and ethics.

One very senior doctor working in one the big municipal hospital in Mumbai said on condition of anonymity, that this is done to safeguard the interest of the hospitals since many fear lockdown should a Corona case be identified from there. Of course, the monetary benefit the hospital are extracting out of this is a welcome plus to them.

  • Not only the method is imperfect, but it also imposes the huge risk of radiation exposure to many patients who otherwise do not need it.
  • Due consideration needs to be given for the other patients like the pediatric and ANC patients. Surely this practice can not be employed to screen them. So where does this lead us to? Where is the uniformity, and what about the mixing of these patients with the other hospital manpower?
  • There are also concerns regarding the spread of the virus transmission because of the logistics involved in the procedure itself.
  • We should also give due consideration to the increased cost of medical treatment because of this. I understand that most of the patients visiting these hospitals are covered under some form of medical insurance and their out-of-pocket expenditure is negligible, but is this a reason good enough? I have my concerns regarding the nexus between the corporate hospitals and these insurance companies and do not endorse their methods and even need for them. But I reserve these thoughts of mine for the next blog to come.

Even if one was to disregard these factors the sheer impact of these counterfactual policies is causing a serious dent in the already wailing doctor-patient relationship and warrants discontinuation.

 

 

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