Modification of Management Strategies, And Innovations, During SARS Cov2 Pandemic Improved the Quality, Criticality and Outcomes in In-Patients
“Rising to the occasion”, the mantra for success in the COVID -19 pandemic
TR. Muralidhara*, HR. Madhusudan, R. Nagesh, Devang Gautam, NA. Manoj, MR. Yashaswi, Mohammed Zain, Wilfred Samson, Vijaya Bhaskar
Kauvery Hospital, Electronic City, Bengaluru, India
*Correspondence: tr.muralidhar@yahoo.co.in
Background
The COVID-19 pandemic has resulted in more than 2 million deaths globally. SARS COVID 2 is highly infectious and although most are either asymptomatic or mild to moderately ill, a substantial proportion of patients faced severe life-threatening disease. The mortality risk with large population outbreaks has a major effect on lives, economies and health care systems across the world.
COVID pandemic has challenged the health care system in its ability to handle a sudden surge in patients with a major infectious disease. The first phase passed off without much challenges, aided by the complete lock down which helped to stagger the arrival of patients who needed hospitalization, a gradual understanding of the virus transmission and personnel protective measures, and the start of the vaccination programme.
The second wave of the pandemic exposed the unpreparedness of many hospitals to handle sudden and substantial surge in patients who needed to be hospitalized. This was due to lack of infrastructure to handle the relentless inflow of patients whilst also running short of beds, oxygen, ventilators, BIPAP and HFNC machines, trained health care workers, personal protection equipment (PPE), medications and other essentials. The second wave of COVID-19 in India thus had severe consequences, and increased deaths, particularly in the younger population.
It was clearly poor anticipation of the magnitude of the COVID-19 pandemic that led to misgovernance in timely production of the necessary materials, and vaccination uptake by people, that led to surge in cases in the second phase.
We have documented here how rising to the occasion by working together, prioritization, and careful resource- utilization made things work smoothly, and achieved better quality of care and gratifying outcomes.
We faced great challenges in securing better supplies and in ensuring judiciously use of the available resources.
The aim of this prospective study was to use judiciously the available resources, fine tune the patient care, reduce the work load and burden of HCWs, optimize patient care, improve the outcomes and to see whether this fine tuning would facilitate better care and outcomes. This study was done at our tertiary care centre.
The following innovations or fine-tuning were done at our hospital:
(1). Infrastructure
Due to surge in cases the need of beds, with supporting equipment, became the primary need. Due to the lockdown and increasing demand, organizing these things was a challenge. Restrictions for transportation with lockdown in place, workload pressures and limitations for regular meetings, things didn’t fall in place without every one’s involvement- management, administration, operations, doctors, nurses, medical technicians and supporting human power.
We, at our centre, accommodated more patients by increasing the number of beds. We increased ICU beds from 20 to 50 in a short time without much civil work and extra cost.
(2). Availability of trained Staff
As the patients load increased, recruiting additional trained staff on time was practically not possible as they were in demand at every other hospital. Most trained staff have notice periods to serve and could not get relieved in time to join our hospital. With few available trained staff, training them as leaders, who in turn where able to supervise newly recruited staff (nursing) in each shift, was immediately called for. This system worked well in the pandemic, as there were minimal interventions by the staff. Treatment charts were simplified to reduced workload and to make time for patient care. The responsibility of ventilator/O2/care was given to respiratory therapist and designated health care workers – O2 providers. This reduced workload on nursing staff and they had time for monitoring and troubleshooting. Interestingly, we also found less stress and anxiety among HCW with these models.
(3). Ventilator and provision of Oxygen
O2 is lifesaving in COVID-19. The shortage of O2 as well as the delivering systems have been partly due to unanticipated demand by manufacturers and partly due to lack of knowledge, state of preparedness and inappropriate use by hospitals. Robust O2 systems that would support the pandemic would take time to be put in place. So, conduct of rapid refresher training programmes for HCWs in optimal usage, and in avoiding inappropriate use, misuse or wastage of O2, was done in relatively short time, with good planning and management.
Most patients with mild to moderate COVID-19 require a good basic care with supportive measures and time for healing, so we added extra beds. With single O2 port, attaching extensions, we were able provide O2 for more patients.
With this expansion, second challenge was O2 supply. We had two challenges; one was to improve and maintain O2 supplies and other was to optimise and reduced the wastage.
COVID-19 is a long game and it was vital to move quickly and start implementing effective O2 systems. For better supplies, within a short period, oxygen generators were installed. Understanding the limitations in O2 delivery with generator, we mixed generated O2 with industrial O2 in suitable proportions.
O2 misuse was significantly reduced by identifying O2 boys whose work was to monitor O2 and saturation round the clock. This was achieved in a short time with good training and planning. They were to supervise and avoid excessive wastage off O2.
We selected a HCW and a respiratory therapist as O2 providers and as watch-keepers of optimal ventilation delivery all the time. Their job was only checking O2 delivery and monitoring saturation while assuring adequacy of ventilator connections and ventilation. Most of the patients were treated with BIPAP instead of HFNC machines, to conserve O2. They were given SpO2 targets to maintain. When they adjusted O2 delivery, keeping the targets in view, we found that care was better, O2 wastage was reduced and less pressure was exerted on HCWs and hospital administration department on the supply of O2. They also continuously monitored O2 and BIPAP connections on patients who were on prone positions and would alert the doctors whenever necessary, or take corrective measures themselves.
(4). Foley’s catheters and diapers
Due to shortage of ICU/HDU beds during the peak of pandemic, moderate to severely ill patients were managed in wards with close monitoring. In initial stages we faced problems in patients with high O2 requirements when they had to be mobilized to restrooms. At those times continuous O2 delivery to patients was interrupted, along with disruption of prone positions and de-recruitment of lungs which provoked symptoms, severe hypoxia and few near- Code Blue situations. So, we started catheterizing the patients with high O2 requirements/elderly, and diapers were used when very hypoxic patients refused cauterization or when it was contraindicated. After these changes the episodes of unexpected desaturations and code-blues were less, while the compliance for care was more, and complaints from the patients were less!
(5). Family visits
Allowing family visits, with precautions, was very useful. Family visits made patients comfortable and more compliant to the care. Close family members were also happy. It also significantly reduced the burden on HCW’s who had to otherwise communicate multiple times with the relatives via audio or video phone calls. This also brought transparency of care. Medications of high cost were administered to patients in presence of close relatives which earned their understanding and appreciation.
(6). Simple protocols
The scarcity of HCWs and consequent strain on those at work prompted us to analyze the work flow. We found that more time was being taken on documentation and obtaining the reports than actual bedside care. So, we simplified the charts, with only two sheets, one for the doctor one for the staff. These simple changes made work easy and more efficient and also helped in collecting data.
(7). Drug’ boy!
Indenting for drugs and on- time delivery was challenging with limited staff and high workload. We selected a person only for drug delivery. Later, with drugs becoming precious and anticipating consequent problems, the drug boy was instructed to deliver medications to the patient in presence of the family. This further reduced the burden on HCW’s.
(8). Continuous monitoring by a leader
COVID is a dynamic disease process and requires continuous monitoring and timely interventions. Leaders have to take complete charge continuously, from admission to discharge. Fragmented care by multiple people worsens the situation.
(9). Support from other specialties
The fine tuning of the process of COVID care was further refined by mobilizing the support from other specialities. Cardiology consultation could be arranged, and also bed side echocardiograms. Radiologists came to our aid with bedside Doppler evaluation which aided in early diagnosis and optimal treatment. These measures helped us in saving time and serving a large number of patients. This reduced the burden of intensivists and physicians.
(10). Monitored hydration
Most patients were dehydrated from reduced appetite, and inability to frequently hydrate themselves as they were on O2 support via NIV or by invasive ventilation, from drugs and from third space loss (fluid losses into spaces that are not visible, such as the bowel lumen or the retroperitoneum). We were able to reduce the incidence of dehydration and also significantly reduce incidents of acute kidney injuries. CVP was monitored to ensure adequate hydration.
(11). DVT stockings
COVID is a pro thrombotic state. For prevention of venous thrombosis, DVT stockings were applied to all moderate to severely patients, along with chemo-prophylaxis, which substantially helped to prevent DVT.
(12). Anxiolytics, careful mobilization and spirometry
Mild anxiolytics reduced the stress, work of breathing and facilitated good compliance to the NIV.
Careful mobilization and respiratory rehabilitation with appropriate spirometers, under supervision, helped patients who passed through moderate to severe illness in early recovery from COVID-19.
(13). Proning in COVID pneumonia
In moderate and severe ARDS, patients on O2 with face mask, O2 by BIPAP support and those on invasive ventilation were subjected to prone positioning for 16-18 h/day, which helped in improving lung recruitment, improved oxygenation and yielded better outcomes while reducing the oxygen requirements.
(14). Non-invasive vs invasive ventilation
The surge in COVID-19 patients demanded a need for more ventilators and BIPAP machines as severity of ARDS related hospitalization increased during the second phase. We strategically used O2 by NRBM’s, non-invasive BIPAPs and HFNC. Invasive ventilation was used only as a last resort which helped us in managing larger numbers of patients. This reduced the requirement for more ventilators, and its complications, while reducing O2 usage. Optimal early extubation was also employed for better outcomes.
(15). Counselling and reducing financial burden
All patients’ attenders were counselled regarding the disease, the likely duration of hospitalisation, and about the limited treatment options available, at the time of admission and on a day to day basis. Patient attenders were taken into confidence, were allowed to meet and talk to patient at any time of the day at their convenience with proper precautions. Daily expenses were detailed by billing team and high cost medications were given only after consulting the relatives. Long stay patients were given financial relief while billing, with approval of management.
(16). Diet and nutrition
Most patients in COVID ICU were on non-invasive ventilation, and some on invasive ventilation because of severe ARDS. Patient on invasive ventilator were fed by Ryle’s tube. Patients on non-invasive ventilation were fed orally with small meals or snacks. Food as demanded by the patients was catered unless contraindicated.
(17). Bowel care
Most patients were not ambulant and had to evacuate bowels on the bed. Laxatives and, enema as and when required, were administered to facilitate bowel habits.
(18). Patient comfort
Frequent visits by relatives, junior doctors, consultants and ever-communicating nursing caregivers, all giving positive inputs and encouraging them, kept the patients calm, comfortable and confident of a possible recovery from COVID-19. Room temperature was maintained as per standard requirements. Disposable gowns, regular baths, regular change of sheets and provisions of blankets were arranged as per patients’ request. House-keeping staff played an important role in patient care.
(19). Vaccination
All health care workers and hospital staff were vaccinated before the surge of COVID-19 pandemic in phase 2. This prevented in transmission of corona virus among the staff, visitors and non-COVID patients thus reducing the burden on the health care system.
(21). Procurement of medications
COVID-19 is a novel virus disease with limited therapeutic options. Hospital management and department of pharmacy helped in the process of organizing and arranging drugs which were in short supply. Timely delivery of the required medications helped in better patient outcomes.
(22). Simple protocols and documentation
All data regarding COVID-19 patients – date of admission, date of illness, vaccination status, RT-PCR status, CT chest, comorbidities, results of all laboratory investigations, patients’ vital parameters, intake and output were all documented in simplified charts/s form which helped us in timely response by modifying treatments which improved the clinical outcomes. Ward secretaries were of immense help in harvesting and organizing data.
We made only two sheets for documentation purposes – for nurses and doctors, with space for writing drug treatment. Documentation could be done in a single sheet for three days while investigations chart could be followed for at least 10 days with clear trends documented. This reduced the work load, time in seeing many patients and improved the care and outcome.
(23). Positive and supportive management
Hospital was able to provide all medications, ventilators, BIPAP machines, meet oxygen requirements, and provide staff as and when their requirement increased with surge in COVID-19 cases. Daily meetings were held to address and resolve any issue.
(24). Modalities of treatment
All possible options of treatment that were available were explored to augment the recovery of patient and achieve best possible outcomes. Inj. Remdesivir, Inj. Tocilizumab, Convalescent Plasma, Plasmapheresis, Steroids, anticoagulants, Ulnastatin, suitable antibiotics, and invasive ventilation as a last resort, were all made available.
(25). Infection control
Even during the peak of COVID-19 all infection control protocols were adhered to. Environmental sanitation, with frequent floor and bedside cleaning twice a day, helped in prevention of secondary infections and in improving final outcomes.
Innovations
The learning experience was “doing the basics right, with supportive care and innovations if needed.”
Innovations play a big role in pandemics. Doing basics right and “First, do no harm (Primum non nocere)” concept in mind, and conservative management, were the needs of the hour. Innovations can be done continuously, as need be, in clinical/non-clinical areas which can improve the outcomes.
Conclusion
COVID pandemic is still evolving, and continues to be very challenging. Therapeutic options are steadily emerging.
Supportive management and judicious use of available resources would continue to yield gratifying benefits and also improve outcomes.
Our innovations improved quality of care, were cost effective, were clinically effective and benefitted patients. They are easily replicable in any COVID care hospital.
Working together, prioritising the staff and optimal use of resources help in better management and outcomes.
Cost effective innovations should play a major role in a pandemic.
Dr TR. Muralidhar
Intensivist and Anesthesiologist
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- The Consultation Room
- Journal Scan
- Recommended Reading
- Diagnostic Video
- Poem from Staff Nurse
- Editorial
- March – the Month for Minds to dwell on Multiple Myeloma
- Covid Report
- Research Protocol
- New Arrows in our Quiver, to direct against SARS-CoV-2 variants
- Out-of-hospital cardiac arrest
- Last on the list: A diagnosis seldom considered in males
- Giant T wave inversion associated with Stokes: Adams syndrome
- Learning from Experience – Intra Operative, Chapters 9 and 10
- The Consultation Room
- Definitions of probability
- Journal Scan
- Recommended Reading
- Diagnostic Video
- A Thanksgiving to Cardiac Surgeons
- Editorial
- Kauverian eMedical Journal
- Research Article
- Research Protocol
- Saving the unsavable
- Case Report
- Case Report
- Letters to the Editor
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 13 and 14
- The Consultation Room
- Journal Scan
- Recommended Readings
- Editorial
- Author Instruction
- SIGARAM – The Club for Children with Diabetes
- The hope for a better tomorrow
- An unusual complication of polytrauma:
- An enigma at the ER
- Dynamic examination of airway
- Journal Club
- Journal Club
- Journal Club
- Conditional Probability
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 15 and 16
- The Consultation Room
- Journal Scan
- Recommended Readings
- EDITORIAL
- Kauverian eMedical Journal
- Junior nurses in Kauvery Hospital on the frontline against the COVID-19 pandemic
- Emergency Medicine, the Emerging Specialty: Leading Light on the entrance to the Health Care Pathway
- Battle of two drugs: Who won? – An unusual presentation
- Return of the native and a resurrected foe: A case of Rhinocerebral Mucormycosis
- Covert invader- atypical presentation of neuronal migration disorder
- Fragile heart: an unusual cause of chest pain
- Goldberger’s ECG sign in Left Ventricular Aneurysm
- Congenital absence of bilateral Internal Carotid Artery: A case report
- The Power of Purple
- Beads of Nature’s Rattle
- Case Report
- Diagnostic Image
- EDITORIAL
- Kauverian eMedical Journal
- Modification of Management Strategies, And Innovations, During SARS Cov2 Pandemic Improved the Quality, Criticality and Outcomes in In-Patients “Rising to the occasion”, the mantra for success in the COVID -19 pandemic
- Time in Range (TIR) In Diabetes: A Concept of Control of Glycemia, Whose Time Has Come
- Kauvery Heart Failure Registry- A Concept
- Shorter Course of Remdesivir In Moderate Covid-19 is as Efficacious as Compared to Standard Regime: An Observational Study
- CASE REPORT
- Lymphoepithelial Carcinoma: A Case Report of a Rare Tumour of The Vocal Cord
- Diabetic Keto Acidosis (DKA), Associated with Failed Thrombolysis with Streptokinase in Acute Myocardial Infarction
- EARNING FROM EXPERIENCE – CHAPTERS 1 AND 2
- The Consultation Room
- Journal scan
- Recommended Reading
- DIAGNOSTIC IMAGE
- Notes to Nocturne
- Editorial
- Kauverian eMedical Journal
- Caring for nobody’s baby
- Special Report
- Research Article
- The curious case of a migrating needle on the chest wall
- Foreign body: A boon at times
- Cardiorenal Syndrome
- What My Grandmother Knew About Dying
- Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022
- Letter to the Editor
- Clinical outcomes of Coronary Artery Disease in Octogenarians
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 11 and 12
- The Consultation Room
- Journal Scan
- Recommended Reading
- colours
- Editorial
- Author Instruction
- Ultrashort Case Report
- Cochlear Implantation: Expanding candidacy and Cost Effectiveness
- Spontaneous Pneumomediastinum in COVID 19 – Tertiary Care Centre Experience in South India
- Amoxycillin Induced Anaphylactic Shock: A Case Report
- An Unusual Cause of Seizures: A Case Report
- Case Report
- Educational Strategies to Promote Clinical Diagnostic Reasoning
- Rheumatic Rarities
- Types of sampling methods in statistics
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 21 and 22
- The Consultation Room
- Journal Scan
- Recommended Readings
- Editorial
- Author Instruction
- Journal Scan
- Myeloma
- Posterior Reversible Encephalopathy Syndrome (PRES)
- Prophylactic orthopaedic surgery
- Subclavian steal: An interesting imaging scenario
- Spondylo-epi-metaphyseal dysplasia (SEMD)
- The bleeding windpipe
- Learning from Experience – Intra Operative, Chapters 23 and 24
- The Consultation Room
- Diagnostic Image
- Recommended Readings
- Editorial
- Editorial Board
- Physician, Protect thyself
- Foetal Medicine, the Future is here!
- Japanese Encephalitis: A common menace
- Carpometacarpal dislocation with impending compartment syndrome
- Heterotopic pregnancy
- Femoral Trochantric and Proximal Humerus Fracture, from Diagnosis to Rehabilitation
- My Father’s Heart Block
- EPS page
- CRT CSP Cases
- Journal scan
- Learning from Experience – Intra Operative, Chapters 25 and 26
- The Consultation Room
- Recommended Readings
- Editorial
- Editorial Board
- Multiple Sclerosis: An overview
- A flower born to blush unseen
- Guest Editorial
- Radio-frequency ablation as an effective treatment strategy in a case of VT storm post STEMI
- Lymphatic malformation of tongue
- Bilateral anterior shoulder dislocation in epilepsy: A case report and review of literature
- An unusual cause of Stridor
- Monoclonal Antibodies (mAbs) – the magic bullets: A review of therapeutic applications and its future perspectives
- Write the Talk
- Press release and Comments
- Probability Distribution of Bernoulli Trials
- Journal Scan
- Recommended Readings
- poem-v4i4
- Editorial
- Editorial Board
- Research
- Research
- Lambda-cyhalothrin and pyrethrin poisoning: A case report
- Good Enough
- The Monoclonal antibodies (mAbs): the beginning
- Comprehensive trauma course 2022: Trauma Management & Kauvery
- Comprehensive trauma course 2022: Introduction to Comprehensive trauma course
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 27 and 28
- The Consultation Room
- Recommended Readings
- Poem
- Editorial
- The Brave New World of Anaesthesia
- Anesthetic considerations in Wilson’s disease for fess: A case report
- The painful story behind modern anaesthesia
- Anesthesia considerations for Ankyslosing Spondylitis
- Total intravenous anaesthesia: An overview
- Risk stratification for cardiac patients coming for non-cardiac surgeries
- The Anaesthesiologist’s role in fluoroscopic guided epidural steroid injections for low back pain
- Awake Craniotomy
- Malpositioned central venous catheter: Step wise approach to avoid, identify and manage
- Benefits outweighing risk: Neuraxial anaesthesia in a patient with Spina Bifida with operated Meningomyelocele
- Pain free CABG: newer horizon of minimally invasive cardiothoracic surgery a walk through anaesthesiologist perspective
- Stellate Ganglion Block: A bridge to cervical sympathectomy in refractory Long QT Syndrome
- Venous Malformation in Upper Airway – Anesthetic Challenges and Management: A Case Report
- Editorial
- USG guided peripheral nerve block in surgery for hernia
- Anaesthesia and morbid obesity: A systematic review
- Patient-Controlled Analgesia
- Parapharyngeal abscess of face and neck: Anesthetic management
- 3D TEE, a boon for the diagnosis of Left Atrial Appendage thrombus!
- Anaesthetic management of difficult airway due to retropharyngeal abscess and cervical spondylosis
- Expect the unexpected – Breach in continuous nerve block catheter
- Lignocaine nasal spray: An easy remedy for Post Dural Puncture Headache
- Potassium permanganate poisoning and airway oedema
- Angioedema following anti-snake venom administration
- Editorial
- Editorial Board
- Ra Fx ablation of Atrioventricular nodal reciprocating tachycardia
- Pace and Ablate Strategy: Conduction system pacing with AV junction ablation for drug refractory atrial arrhythmia – A novel approach
- Why Cardiac Resynchronization Therapy (CRT) For complete heart block? A case discussion
- Pacemakers and Bradyarrhythmias in Diabetic Mellitus
- Outcomes of Total Knee Arthroplasty in patients aged 70 years and above
- An approach to CBC for practitioners
- Acute cerebral sinus venous thrombosis with different presentations and different outcomes: A case series
- Diet and nutritional care for DDLT: A case study
- Vaccine for Dengue (Dengvaxia CYD-TDV)
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 31 and 32
- Recommended Readings
- காவிரித்தாய்
- ATLAS OF HAEMATOLOGY AND HEMATOONCOLOGY
- Editorial
- Editorial Board
- Case reports and Case series:
- Usefulness of NEWS 2 score in monitoring patients with cytokine storm of COVID-19 pneumonia
- Treatment approach for extensively Drug-Resistant Tuberculosis (XDR-TB)
- Modified Lichtenstein mesh repair, for a patient of Coronary Artery Disease, Heart Failure and with Implanted Cardioverter- Defibrillator
- Fever-induced Brugada Syndrome
- Pulmonary Thrombo Embolism: When to Thrombolyse?
- Ultra-Short Case Report
- Learning from the failure of Nebacumab
- Journal scan
- Learning From Experience Intra Operative Chapters 29 and 30
- Recommended Readings
- Poem
- Editorial
- Editorial Board
- Heart transplantation: Life beyond the end of life
- Azithromycin to Prevent Sepsis or Death in Women Planning a Vaginal
- Medial retropharyngeal nodal region sparing radiotherapy versus standard radiotherapy
- Proximie: Patient safety in surgery – the urgent need for reform
- Analysis of femoral neck fracture in octogenarians and its management
- Adult Immunisation in Clinical Practice: A Neglected Life Saver
- “Icing” The Eyes
- Doppler vascular mapping in Arterio Venous Fistula (AVF)
- Cosmesis and cure: Radiotherapy in basal cell carcinoma of the dorsum of nose – A case report
- Pulmonary Hypertension and Portal Hypertension
- Comprehensive review of Drug-Induced Cardiotoxicity
- Statistics – Data Collection – Case Study Method
- Atlas of Haematology and Hematooncology
- PRE-OPERATIVE Chapters 1 and 2 – Learning from Experience
- Chapter 2. Uncertainties in medicine in spite of advances
- No Splendid Child
- Editorial
- Editorial Board
- A Young Girl Lost in the Storm
- ECMO as a bridge to Transplant: A case report
- Renal anemia – from bench to bedside
- Mission Possible
- New kids on the block – Update on diabetic nephropathy therapy
- Infections – Trade off in Transplants
- To Give Or Not to Give – Primer on Bicarbonate Therapy
- Sialendoscopy: Shifting paradigms in treatment of salivary gland disease
- Gait imbalance in a senior due to Chronic Immune Sensory Polyneuropathy (CISP)
- Statistics – Mcnemar Test
- Atlas Of Haematology And Hematooncology
- PRE-OPERATIVE Chapters 3 and 4 – Learning from Experience
- Changing trends a challenge to the already trained
- Journal scan
- Recommended Readings
- EDITORIAL
- EDITORIAL BOARD
- PREGNANCY POST-RENAL TRANSPLANT
- BALLOON-OCCLUDED RETROGRADE TRANSVENOUS OBLITERATION
- REVERSE SHOULDER ARTHROPLASTY FOR ROTATOR CUFF ARTHROPATHY
- THE AMBUSH A TEAM APPROACH
- ENDOSCOPIC TRANS-SPHENOID APPROACH FOR PITUITARY ADENOMA EXCISION
- A STUDY ON PRESENTATION AND OUTCOME OF BULL GORE INJURIES IN A GROUP OF TERTIARY CARE HOSPITALS
- A CASE OF INTERNUCLEAR OPHTHALMOPARESIS AS THE FIRST MANIFESTATION OF MULTIPLE SCLEROSIS
- GRANULOMATOSIS WITH POLYANGITIS AND LUNG INVOLVMENT (WEGENER’S DISEASE)
- RITUXIMAB (RITUXAN, MABTHERA) IN THE TREATMENT OF B-CELL NON-HODGKIN’S LYMPHOMA
- STATISTICAL SIGNIFICANCE
- Atlas Of Haematology And Hematooncology
- PRE-OPERATIVE CHAPTERS 5 AND 6 – LEARNING FROM EXPERIENCE
- Chapter 4: Diagnostic process often reversed
- Journal scan: A review of 25 recent papers of immediate clinical significance, harvested from major international journals
- Recommended Readings
- ஆரோக்கியம் நம் கையில்
- வெற்றியின் பாதை
- Editorial
- Editorial Board
- Prevalence of vitamin D deficiency in a multi-speciality hospital orthopaedic outpatient clinic
- Esomeprazole induced Hypoglycemia
- Dynamic external fixator for unstable intra articular fractures of Proximal Interphalangeal Joint (PIP): “Suzuki” frame
- How to Practice Academic Medicine and Publish from Developing Countries? A Practical Guide, Springer Nature, 2022
- WINTNCON 2022 – Scientific Program
- Pulmonary Thrombo Embolism: A state of the art review
- Role of Artificial Intelligence in improving EHR/EMR and Medical Coding and billing
- Monoclonal Antibodies: Edrecolomab and Abciximab
- Atlas of haematology and hematooncology
- Journal scan
- Learning from Experience – Intra Operative, Chapters 31 and 32
- What doctors must learn: Doctor, look beyond science
- Recommended Readings
- I Whisper Secrets In My Ear
- EDITORIAL
- Instructions for Authors
- Mismatched Haploidentical Bone Marrow Transplantation in a 10-year-old boy with relapsed refractory acute lymphoblastic leukemia, at Trichy
- ST-Segment Elevation is not always Myocardial Infarction
- Acyanotic Congenital Heart Disease, repaired, evolves into a Cyanotic Congenital Heart Disease and presents with an atrial tachycardia
- Family medicine – caring for you for the whole of your life. A Lost and Found Art
- The Principles and Practice of Family Medicine
- Complete Heart Block
- Sick Sinus Syndrome (SSS)
- The First Ever National Award Comes to Kauvery Hospital Chennai & Heart City for Safety and Workforce Category in IMC RBNQA Milestone Merits Recognition 2022
- Diagnostic Image
- PRE-OPERATIVE CHAPTERS 7 AND 7 – LEARNING FROM EXPERIENCE
- Chapter 5: Super-specialist – boon or bane
- Journal scan: A review of 42 recent papers of immediate clinical significance, harvested from major international journals
- RECOMMENDED READINGS
- நேரம் ஒதுக்கு
- மருத்துவரின் மகத்துவம்
- EDITORIAL
- Instructions for Authors
- Surgical Management of Covid-19 Associated Rhino-Orbito-Cerebral-Mucormycosis (Ca-Rocm) – A Single Centre Experience
- Knee Joint Preservation Surgeries
- Guest Editorial Comments
- Ventricular Septal (VSR) closure with ASD device
- Newer Calcium Debulking Angioplasty technique of Orbital Atherectomy
- An hour-long CPR to restart the heart
- VT or SVT with aberrancy?
- Pituitary Neuroendocrine Tumor (PitNET)
- VSD Device Closure
- PDA Device Closure
- Iron Deficiency Anemia, Post MVR
- Torsades de Pointes
- Quality improvement project to Reducing the Malnutrition Rate of ICU patients from 43% to 20%
- Long term use of Amiodarone in Cardiac patients: A Clinical Audit
- Statistical Independent Events and Probability
- PERI-OPERATIVE Chapters 9 and 10 – Learning from Experience
- Journal scan: A review of 40 recent papers of immediate clinical significance, harvested from major international journals
- EDITORIAL
- Kauverian Medical Journal
- First da Vinci Robotic Surgery in Carcinoma Prostate: A Case Report
- Black burden or Taylor the saviour: A case report
- Analysis of differences in Oncology practice between the United Kingdom and India
- A Case of Takayasu Arteritis
- Idiopathic Dilated Pulmonary Artery (IDPA)
- ECG Atlas
- Unusual cause of Dysphagia: A case report
- Tu Youyou: The scientist who discovered artemisinin
- Continuing Nursing Education (CNE) on Risk assessment tools, to assess vulnerable patients at Kauvery Hospital, Tennur
- DIAGNOSTIC IMAGE
- PRE-OPERATIVE CHAPTERS 11 AND 12 – LEARNING FROM EXPERIENCE
- OLD AND NEW – MAKE THE BEST OF THE TWO
- Journal scan: A review of 30 recent papers of immediate clinical significance, harvested from major international journals
- Recommended Readings
- EDITORIAL
- INSTRUCTION TO AUTHORS
- A pregnant patient with DKA, septic shock and a lactate mystery
- Radical Thymectomy in Myasthenia Gravis through Partial Sternotomy approach: A report on three patients
- In-utero blood transfusion in two etiologically distinct anaemic fetus
- RARE CAUSE OF PULMONARY HYPERTENSION
- Acute Rheumatic fever is still an enigma
- A remarkable journey: Managing LQTS in a 43-year-old female with recurrent syncope and seizure
- An unusual case of Acute Coronary Syndrome
- Reversible cause of severe LV Dysfunction in Left Bundle Branch Block
- A case study on Rhino-Orbital-Cerebro- Mucormycosis
- Snakebite and its management
- Total Elbow arthroplasty in Post Traumatic arthritis
- Wellens Syndrome: An ECG finding not to miss!
- Dr. C.R. Rao Wins Top Statistics Award a look back at his pioneering work
- PRE-OPERATIVE Chapters 13 and 14 – Learning from Experience
- Chapter 7. Doctor-patient relationship
- Journal scan: A review of 30 recent papers of immediate clinical significance, harvested from major international journals
- EDITORIAL
- INSTRUCTION TO AUTHORS
- FROZEN ELEPHANT TRUNK (FET) PROCEDURE IN A 52 YEARS OLD CHRONIC AORTIC DISSECTION PATIENT
- DIAGNOSING AND MANAGING EISENMENGER SYNDROME IN A YOUNG MALE
- STEMI EQUIVALENT BUT STEMI!
- TEMPORARY HEAL CAN POSSIBLY KILL!
- UNDERSTANDING PUBERTY
- THE IMPORTANCE OF STATISTICS IN HEALTHCARE
- JOURNAL SCAN: A REVIEW OF 44 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- DIAGNOSTIC IMAGE
- PRE-OPERATIVE CHAPTERS 15 AND 16 – LEARNING FROM EXPERIENCE
- CHAPTER 8. DOCTOR-DOCTOR RELATIONSHIP
- EDITORIAL
- GUEST EDITORIAL
- CLINICAL AUDIT: AN INTRODUCTION
- YOUNG ACS AUDIT
- CLINICAL AUDIT: ANAESTHESIA
- CLINICAL OUTCOME IN ICU PATIENTS
- RATE OF MALIGNANCY IN INDETERMINATE OVARIAN CYST – A PROCESS AUDIT
- PATTERNS OF NEEDLE DISPOSAL AMONG INSULIN USING PATIENTS WITH DIABETES MELLITUS: AN AUDIT
- CONTINUOUS PATIENT MONITORING – LIFE SIGNS
- AGE IS JUST A NUMBER!
- SVT WITH LEFT BUNDLE BRANCH BLOCK FOLLOWING GASTRECTOMY
- COMPLEX AORTIC DISSECTION WITH MULTIFACETED CLINICAL PRESENTATIONS
- EDITORIAL
- POST-OPERATIVE SORE THROAT IN GA: A CONCERN
- NEONATAL HLH: OUR EXPERIENCE
- CLINICAL REVIEW MEET 16TH NOV 2023: CHALLENGES IN SETTING UP A NEW HSCT CENTRE IN A TIER-2 CITY IN INDIA
- CARDIAC BIOMARKERS: CLINICAL UTILITY
- HIRAYAMA DISEASE: A CLINICAL-RADIOLOGICAL REVIEW
- ECG AS A WINDOW OF OPPORTUNITY: FOR HYPERKALEMIA
- EFFECTIVENESS OF ROOD’S APPROACH BASED PAEDIATRIC OCCUPATIONAL THERAPY MANAGEMENT: ON CHILDREN WITH CONGENITAL MUSCULAR TORTICOLLIS
- ELTROMBOPAG, A NOVEL THROMBOPOIETIN (TPO) RECEPTOR AGONIST: AN OVERVIEW
- HENOCH-SCHONLEIN PURPURA
- SUBMANDIBULAR GLAND SIALADENITIS SECONDARY TO SUBMANDIBULAR CALCULUS
- LEAN HOSPITALS
- STATISTICS BLACK-SCHOLES MODEL
- PERI-OPERATIVE CHAPTERS 17 AND 18 – LEARNING FROM EXPERIENCE
- CHAPTER 9. BUILDING BLOCKS OF PATIENT CARE
- JOURNAL SCAN: A REVIEW OF 30 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- EDITORIAL
- INSTRUCTIONS TO AUTHORS
- ROTATHON-SERIES OF SUCCESSFUL ROTA CASES LAST 2 MONTHS: AN AUDIT
- OUTCOMES OF AKI AUDIT IN KAUVERY
- ETIOLOGY, CLINICAL CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH ACUTE PANCREATITIS IN KAUVERY CANTONMENT HOSPITAL (KCN), TRICHY
- USE OF BLOOD PRODUCTS AND STEROIDS IN THE MANAGEMENT OF DENGUE AT KAUVERY TRICHY HOSPITALS: A CLINICAL AUDIT
- A CLINICAL AUDIT: ON THE MANAGEMENT OF ECTOPIC PREGNANCY
- DIABETIC KETOACIDOSIS WITH HIGH ANION GAP METABOLIC ACIDOSIS
- HYPOKALEMIC PARALYSIS FROM DISTAL RENAL TUBULAR ACIDOSIS (TYPE-1)
- DELAYED PRESENTATION OF INTERMEDIATE SYNDROME IN A PATIENT WITH ORGANOPHOSPHORUS POISONING: A CASE REPORT
- SCAPULA FRACTURES: DO WE NEED TO FIX THEM?
- SPONTANEOUS CSF RHINORRHEA
- DANCING WITH DIABETES: AN UNUSUAL CASE OF CHOREA HYPERGLYCEMIA BASAL GANGLIA SYNDROME
- CONVALESCENT RASH OF DENGUE
- ECG ATLAS 2
- MI MIMICKER
- PERFORATION PERITONITIS-A CASE REPORT
- APPLICATION OF EVIDENCE BASED PRACTICE CARE FOR INDIVIDUALS WITH SPINAL CORD INJURY WITH FUNCTIONAL DIFFICULTIES: ROLE OF THE OCCUPATIONAL THERAPY PRACTICE GUIDELINES
- METHOTREXATE INDUCED MUCOSITIS AND PANCYTOPENIA: A CONSEQUENCE OF MEDICATION ERROR IN A PSORIASIS PATIENT
- POST OPERATIVE CHAPTERS 1 AND 2 – LEARNING FROM EXPERIENCE
- CHAPTER 10. NURTURING SELF
- விடாமுயற்சி வெற்றி தரும்
- JOURNAL SCAN: A REVIEW OF 26 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- EDITORIAL
- EDITORIAL BOARD
- LIMB SALVAGE IN EXTREMITY VASCULAR TRAUMA: OUR EXPERIENCE
- MANAGEMENT OF URETHRAL CATHETER RELATED PAIN IN RENAL TRANSPLANT RECIPIENTS: A CLINICAL AUDIT
- NO PAIN VEIN GAIN WITH PRILOX IN PAEDIATRIC POPULATION
- GUIDELINE-DIRECTED MEDICAL TREATMENT (GDMT) OF HEART FAILURE AT KAUVERY HOSPITALS: A CLINICAL AUDIT
- PATIENTS STORY: DIGNITY MATTERS
- PATIENTS STORY: DIGNITY MATTERS
- VIDEO PRESENTATION- CT CORONARY ANGIOGRAPHY
- DRUG INDUCED HYPERKALEMIA
- ADULT NEPHROTIC SYNDROME
- EXPLORING COMPLEX CARDIAC CASES: INSIGHTS FROM DIVERSE PRESENTATIONS IN MID-AGED WOMEN
- EFFECTIVENESS OF ACTIVITY CONFIGURATION APPROACH BASED OCCUPATIONAL THERAPY INTERVENTION FOR CHILDREN WITH CONGENITAL MUSCULAR TORTICOLLIS: A CASE STUDY
- CARDIOMYOPATHY AND ITS ECHO FINDINGS
- THE STRESS TEST ON THE TREADMILL
- POST OPERATIVE CHAPTERS 3 AND 4 – LEARNING FROM EXPERIENCE
- CHAPTER 11. BALANCE IN LIFE BEYOND BANK BALANCES
- JOURNAL SCAN: A REVIEW OF 30 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- காணும் பொங்கலும் மனித மன மாற்றமும்
- EDITORIAL
- INSTRUCTIONS TO AUTHORS
- PREVALENCE OF STREPTOCOCCUS PNEUMONIAE SEROTYPES IN AND AROUND TRICHY AND ITS CLINICAL RELEVANCE
- ANAESTHETIC MANAGEMENT OF A PATIENT WITH HUGE GOITER: A CASE REPORT
- EUGLYCEMIC DIABETIC KETOACIDOSIS A RARE CAUSE FOR DELAYED EXTUBATION
- SUCCESSFUL PREGNANCY IN ASD PATIENT – COMPLICATED BY SEVERE PULMONARY ARTERIAL HYPERTENSION
- ENDOCRINE COMPLICATION OF GROWTH HORMONE SECRETING TUMOR: A CASE REPORT
- EFFICACY OF EARLY DIAGNOSIS AND DEVELOPMENT APPROACHES OF PAEDIATRIC OCCUPATIONAL THERAPY ON ACUTE DISSEMINATED ENCEPHALOMYELITIS: A CASE REPORT
- POST OPERATIVE CHAPTERS 5 AND 6 – LEARNING FROM EXPERIENCE
- CHAPTER 12. MILES TO GO – BEFORE TEACHING BECOMES LEARNING
- JOURNAL SCAN: A REVIEW OF 26 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- காவேரி – 25
- POEM – மண்ணில் பிறந்தது சாதிப்பதற்குத்தான்
- EDITORIAL
- EDITORIAL BOARD
- Audit Appraisal: An overview
- Intra Ventricular antibiotics: Our experience
- Transfusion Reactions: A clinical audit
- Postoperative pain management
- Rising concerns of Carbapenem resistant Enterobacteriaceae and the options available: An overview
- Ultrashort case report on VF storm in immediate Post CABG Period—‘Angry Purkinje Syndrome’
- Lynch syndrome, diagnostic challenges and management: A case report
- Bilateral posterior shoulder fracture – dislocation due to seizure, an uncommon injury: A case report
- Navigating amlodipine overdose: A multi-disciplinary approach in a 23 year old female
- Exploring the interplay between sleep patterns and behavioural characteristics in individuals with Autism Spectrum Disorder (ASD)
- POST OPERATIVE Chapters 7 and 8 – Learning from Experience
- Chapter 13. Art of communication and counselling
- Journal scan: A review of 20 recent papers of immediate clinical significance, harvested from major international journals
- மருத்துவமனையின் தேவதையே
- மருத்துவ சிந்தனை விருந்து
- Editorial
- Instructions for Authors
- Cardiac surgery in an octogenarian Indian population
- Mycotic Aortoiliac Aneurysm: A case series
- The Scorpion Block—A Sting operation
- Arterial Thoracic Outlet Syndrome: A case report
- Infective endocarditis in adult congenital heart disease: A case report
- Takotsubo cardiomyopathy: A case report
- Cerebral Venous Thrombosis (CVT): A case report
- Hemophagocytic Lymphohistiocytosis in Dengue
- A prospective observational study on the prescription of Guideline Directed Medical Treatment (GDMT) for Heart Failure at Kauvery Heart City
- Guideline-Directed Medical Treatment (GDMT) of Heart Failure at Kauvery Hospitals: A clinical audit
- POST OPERATIVE Chapters 9 and 10 – Learning from Experience
- Chapter 14. How to keep updated in busy medical practice?
- Journal scan: A review of 15 recent papers of immediate clinical significance, harvested from major international journals
- சிந்தனையே சிறப்பு
- தோல்வியே வெற்றியின் பாதை
- Editorial
- Results of Mechanical Thrombectomy in acute stroke: A case study in a Tier 2 city in India
- A clinical audit—cost effective way of managing superficial chest wound infections post sternotomy
- Dental implants: Our experience and expertise
- A non-randomized retrospective study on the management of pediatric septic arthritis
- Analysis of femoral neck fracture in octogenarians and its management
- Airway management of a huge thyroid: A case report
- Cardiac Arrhythmias in the ER setting
- Effectiveness of tactile-spatial oriented approach based paediatric occupational therapy intervention for children with Infantile Hemiplegia
- Corporate citizenship in healthcare: Nurturing social responsibility
- Guillain-Barré syndrome: A case report
- POST OPERATIVE Chapters 11 and 12 – Learning from Experience
- Chapter 15. How to be rational in practice?
- Journal scan: Elsevier’s Medicine, Current Issue, Volume 52 Issue 6, June 2024, Seminar on Poisoning
- Recommended Readings
- இயற்கை சொல்லும் செய்தி
- Editorial
- Instructions for Authors
- A rare organism causing septic arthritis of hip joint
- ICD implant in 6 year old with Jervell and Lange-Nielsen (JLN) syndrome
- A clinical audit on Bariatric/Metabolic surgery
- Clinical audit on Nil per Oral (NPO)
- A non-randomized clinical study on heat stroke
- Stress cardiomyopathy with posterior reversible encephalopathy syndrome in Eclampsia
- Intro-Reversible Cerebral Vasoconstriction Syndrome (RCVS): An ultra-short case report
- A 2 am Tamponade: Critical call to action
- Immune Checkpoint Inhibitors, and in combination with JAK inhibitors: The modelling for the future
- Optimizing the patient journey in hypertrophic cardiomyopathy—Patient and clinician perspectives: Summary of CME from Medscape
- ER Intervention
- Diagnostic Images/Videos
- A randomized controlled trial: Different types of blinding
- Journal scan – June
- Journal scan – July
- Post-Operative Chapters 13, 14
- Chapter 16. How to enjoy medical practice?
- Driving business growth with 5S and lean strategies: A transformative session for corporations in the Trichy region
- Poem: 25 – வருடங்களாக காவேரி
- Editorial
- A Data Audit: Tool for Good Clinical Practice
- Ortho rehab audit at Kauvery Hospital, Trichy
- Endovascular Thrombectomy in young patient with a stroke – surgical procedure decompressive craniotomy
- Secondary HLH (Hemophagocytic Lymphohistiocytosis): An ultra-short case report
- Prone ventilation: A case series
- Dermatologic Emergencies: A case series
- Managing DKA at the ER
- Podcast – Managing DKA at the ER
- Insertion of tunneled hemodialysis catheter through the collateral vein adjacent to the thrombosed right jugular vein.
- Access failure with dysfunctional tunnelled haemodialysis catheter in the presence of exit-site infection
- Video – A multidisciplinary approach to preventing sudden cardiac death
- Dasatinib in pediatric Chronic Myeloid Leukemia: An overview
- Dyslipidemia management: Indian perspective
- Pharmacological stress testing: Assessing heart health without exercise
- Journal scan: A review of 15 Ethics with clinical significance, harvested from a major international journal
- Post-Operative Chapters 15 and 16
- Chapter 17. How to find time for the family
- Poem – உனக்காக நீ
- Editorial
- An audit: A silent disease-Osteoporosis
- An approach to antibiotic therapy: A primer for all specialties
- Audit on pediatric Cholesteatoma
- Clinical audit: ER to ICU transit time
- A case report on Multiple myeloma: Value of pre and post-treatment MRI
- Unrelated donor bone marrow transplantation in 3 year old with Acute Myeloid Leukemia
- Infective endocarditis: A case series
- A Retrospective observational study on Scrub typhus paediatric population in Kauvery Hospitals, Trichy
- Clinical Pharmacy Approach: To a patient on multiple anticonvulsants for “Difficult to control’’ seizure disorder
- An analysis of the Urea to Creatinine Ratio (UCR) in different cardiac surgeries
- Journal scan – 1
- Journal Scan – 2
- Post-Operative Chapters 17 and 18
- Chapter 18. How to be legally safe in medical practice?
- Poem – காவேரியின் மாரத்தான்
- Poem – ஆரோக்கியம் என்னுடையது
- Editorial
- Clinical audit on antibiogram
- Renal transplantation in marrow dysfunction: A case series
- Empowering lifesavers: Impact of BLS and PALS training for PICU and critical care nurses
- Myotonia congenita: A case series
- Utilization of Inj. Sovateltide: A novel injectable formulation
- Retroperitoneal sarcoma: A report of two cases
- Traumatic simultaneous bilateral femur and tibia shaft fracture in an 8-year-old male child: An unusual case report
- Echocardiography in the assessment of shock
- Plasma combats angioedema: A case report
- A case report and video presentation on a 9-year-old boy who underwent PAPVC
- Interventional Radiology: Large gastric varices
- Interventional Radiology: A case of active PV bleeding post-D and C day 12
- Diagnostic Images: Exencephaly
- A short case report on Hyperdontia (extra teeth)
- Post-Operative Chapters 19 and 20
- Chapter 19. How to deal with incurable disease?
- CII CFO Excellence award: A recognition of exceptional leadership
- Journal scan
- Poem – மறுக்காதே மறவாதே
- Extraordinary Edition of the Kauverian