GOVERNMENTOFKARNATAKA

No. RD 158 TNR 2020 (1)

ORDER

Kamataka Government Secretariat, Vidhana Soudha,

Bengaluru, dated:07-05-2021

Whereas, there has been an unprecedented spike in the number of COVID 19 cases across the State, particularly in the Bengaluru area, which has overwhelmed the Health Care resources in the State.

And Whereas, to effectively combat the COVID 19 menace in the BBMP area, joint coordinated efforts are required from all stakeholders, in a decentralized manner, at the ward level.

And Whereas, the State Executive Committe~ rder No. RD 158 TNR 2021, dated 29-04-2021, constituted a team headed by e undersigned to supervise the functioning and strengthening of the War R oms in the BBMP areas in light of increasing cases.

And Whereas, the State Executive Committee vide Order No. DPAR 32 HGG 2021, dated 04-05-2021 appointed Shri. Arvind Limbavali, Hon'ble Minister for Forest and Kannada & Kannada and Culture Department, as Nodal Minister to oversee functioning of War Rooms, Help lines, physical and tele-consultation for health assistance across the State, to ensure smooth and effective functioning of same.

And Whereas, the aforementioned team after extensive deliberations with experts on the existing system/strategy to contain and mange COVID 19 spread in BBMP area in light of increased case load, under the guidance of the Hon'ble Nodal Minister, is satisfied that there is need to have a decentralized approach at ward level to tackle the current situation, hence, there is a need to form Ward Decentralized Triage and Emergency Response (DETER) Committee for COVID 19 Management (WDC) in each of the wards of BBMP with uniform structure to effectively contain the spread of COVID 19 at ward level.

Now, therefore, in the exercise of the powers conferred under the Section 24 of the Disaster Management Act, 2005, the Chairman, State Executive Committee, hereby issues guidelines to constitute Ward Decentralized Triage and Emergency Response (DETER) Committee for COVID 19 Management (WDC) in all the wards of BBMP, as below, which shall come into effect immediately, for strict implementation by Chief Commissioner, BBMP.

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1. Purpose of WDC: Bengaluru is witnessing a rapid surge in COVID-19 cases during the past weeks. Ward level planning, containment and management of the COVID 19 pandemic has become essential. This order mandates setting up of Ward Decentralized Triage and Emergency Response (DETER) Committee for COVID 19 Management (WDCs) working on COVID management at ward level in BBMP. The objective is to strengthen Government response and management of Covid through a decentralized distribution of localized action. Such a decentralized system of disaster response is to be institutionalized at the level of the Ward, to be run in coordination with the Ward Committees wherever established. These WDC committees will be a synergy of BBMP officials, Ward committee members, Government officers, Peoples representatives, volunteers RWAs, civil society organisations and disaster support initiatives. This will help in the decentralization and provide better supervision for Ward level COVID governance. Open Source technology platforms will be utilised to operationalise WDC functioning, and a suitable online .platform will be used by BBMP to support this.

2. Ward Decentralized Triage and Emergency Response (DETER) Committee for COVID 19 Management- (WDC) The Ward DETER Committees (WDCs) in all 198 wards of BBMP will be en~rusted with various activities related to COVID management in order to decentralize BBMP's efforts and reach all the citizens, especially vulnerable communities that do not have access to health care and/or information to avail health care services. WDCs will be headed by the ward Nodal Officer who will be the Chairperson of the Committee. In addition to the existing ward committee members, the WDCs will comprise of other Government officials, R W As and volunteers. As per the Rule~ pertaining to Ward Committees, the Ward DETER committees (WDCs) will now act as Ward Disaster Management Cells (WDMC). A circular has already been passed in April 2020 to this effect. In the absence of Corporators, Nodal Officers are appointed to be Chairpersons for the W a:td Committees . The Ward Engineer/Health Inspector/ Revenue Inspector has been designated as Secretary of WDC. The Secreta1?' wil~ convene the WDC committee meetings periodically, document and publish minutes on the BBMP website.

3. Key Objectives of WDC . . . To become the first point of contact for persons with COVID mfect10n m ~hat ward and provide timely, accurate information to citizens on appropnate actio~s and behaviours at ea.ch stage of the Covi<ll lifecycle, and accurate contact in.formation relating to the same (masking and physical distanci~g, s~m~toms, Testing, home isolation while waiting for test results, contact tracing, tnaging,

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i.e. identifying whether home isolation or admission to stabilization centres or hospitalization and access to hospital beds with/without Oxygen/Ventilators).

The teams will carry out specific functions. a. To establish trust with citizens and ensure Covid appropriate behaviours;

Contact tracing and Testing b. Support Home Isolation - to respond to citizen needs in the Ward to

minimize hospital load c. To inform and communicate based on ground realities, policies and practices

at the zonal and city levels. d. To redress grievances of citizen- address and escalate. e. Mobilization of Resources and Community Volunteers, ensure availability,

accessibility and proper utilization of resources and medical supplies in the Ward (General Practitioners, masks, pulse oximeters, essential medicines, oxygen).

f. To achieve universal vaccination. g. To connect with hearse van and crematorium team. h. Taking all above functions into account, to become the FIRST SOURCE of

data related to COVID infecta· s and response, thereby ensuring credible and timely bottom-up MIS re orting of all aspects related to Covid 'infections, management a t'd vacci ation. This can only be done if WDCs are enabled with the right tee . ol , platform to directly capture information

· related to all the above activities, and become the direct connect for patients and their families for their Covid-related information and support.

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4. Responsibilities of Nodal Officers/ Ward Secretary

a. Schedule WDC meetings, Conduct WDC Meetings once in three days or as directed by BBMP.

b. Invite all members and concerned officials from all departments. Ensure agenda items are covered in meeting within the time frame and record minutes of the WDC meeting

c. Establish a Ward War Room in the Ward as Command and Control Centre in the ward office or another suitable venue within the Ward.

d. Establish a Triage Centre in the Ward to bring in patients that need to be examined

e. Collate and verify list of all General Practitioners in the Ward f. Enlist ward volunteers (a mini.mum of 50) using online and offline methods g. Identify a location for isolation centres (COVID Care Centres) in the Ward

for those that cannot be home isolated h. Act as a btidge between the BBMP and the Ward War Room. 1. Convene daily operations rev1ew call with WDC

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J. Create a system to assign work to citizen volunteers based on evolving needs.

k. Support vulnerable communities in the Ward by proactively reaching out to them.

1. Provide the WDCs with the required support in material and logistics to undertake vaccination awareness, emphasize Covid behaviour and protocol and implement testing protocols.

5. Responsibility of WDC The . following are the responsibilities of the WDC. To begin with, WDCs should take up select responsibilities such as IEC material dissemination, triage and subsequently take up more responsibilities described in detail below.

5 (i). Resource Mapping a. WDC must upload all the General Practitioners in the Ward with names,

addresses and phone numbers. Enlist GPs in COVID care. b. Map all existing R W As, Colonies, Apartments, Slums in the Ward with

contact persons. c. Map all NGOs working in the public health sector. Work with them to

understand their resources, for example, oxygen concentrators, home oxygen setup.

d. WDCs to mobilize citizen volunteers RWAs, Apartment Communities, Slums, SC/ST, Transgender, Women. Citizens can become volunteers by contacting the ward nodal officers or secretary.

e. Upload all medical facilities, PHCs, CCCs, Hospitals and Nursing homes, Testing centres, including 30-bed hospitals that are not currently being used for COVID care.

S(ii). Training Training sessions must be held online, in the videos and disseminate through WhatsApp. for the following:

a. BBMP Staff, b. Anganwadi, c. ASHA workers, d. BLOs assigned to the Ward e. Citizen Volunteers, f. GPs.

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interest of time, record short

6. 3E strategy: Efficient Entry into hospitals (Triage), Efficient Exit (Discharge), and Empower the Hospitals in the Ward.

The most important function of WDC is to facilitate services so that effective and comprehensive management of COVID19 cases is done in the Ward. This will be done by implementing the 3 E strategy.

• Efficient Entry into hospitals facilitated by community triage services • Efficient Exit from hospitals by facilitating the optimization of bed tum over. • Empower the hospitals, doctors and their management with supportive

superv1s10n

6 (i) Efficient Entry into hospitals facilitated by community triage services The goal is to ensure that community triage is set up in each Ward so that the admission of the deserving COVID 19 patients is not delayed. Especially, those who require oxygen should find support within 2 hours. Ward Level Community Triage is seen as a successful intervention in many cities, including Mumbai. Currently, there is a delay in informing the test results to the patient due to the centralized ICMR process followed by BU (Bengaluru Urban) number generation process.

The Triage coordinator offers community triage services with the help of support staff, possibly use services of a local doctor ( or with remote access to doctors), Nurses, seniors and volunteers. A competent and trained doctor can guide to manage the triage center. The Health and Family Welfare Department and the Medical Education Department will provide the required Doctors/Interns/Final Year students of MB BS/Dental/Nursing or A YUSH Doctors required at the triage center. Currently, there is a 12-hour delay from the identification to admission due to inefficient mechjriisms. T! e WDC should set the triage center and should assign a WDC member as a Triage Coordinator. Following are the functions of the Ward level Triage se\vW

a. To reduce delay in releasing results and avoiding panic among those tested, positive cases are relayed to the Triage coordinator instantly by the PHC throughout the day.

b. The Triage coordinator will delegate numbers to relevant citizen volunteers. c. A subset of citizen volunteers must be trained to do triage to identify persons

who need to be admitted to ICU and those who require hospitalization or sent to Covid care centres or isolated at home., The triage services are done by performing colour coding (Annexure-1 ). The trial team should follow colour coding, fill up the checklist (Annexure-2), and immediately ensure hospitalization. The top priority of triage services is to ensure admission in the red code (Annexure-1). The next priority is to ensure hospitalization of the persons in the yellow code. Further, if person requires oxygen, he/she

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would be sent to stabilisation centers. Finally, the team will attend to persons that can be treated at home. For each of the positive cases one of the fiv~ o~tcomes is to be expected. The ward level triage ce~tre should mamtam the data regarding the persons sent to the following. • A. Home Isolation • B. Isolation at COVID care centre • C. Admission to Stabilisation Centres. • D. Hospital Admission • E. ICU admission

d. Tele triage will be supplemented with Physical triage at each War room triage centre. Specifically, suppose the tele triage finds that the person does not have an oxygen reading. In that case, they should be immediately sent to the nearest physical triage in the Ward for assessing oxygen saturation levels and proceed as per colour coding.

e. The medical officer and the team will examine all requiring Hospital admission, re-assess and then places a request to the central bed allocation system.

f The physical triage team will also examine all positive cases who visit, give medication and home isolation kit including pulse oximeter.

g. The triage volunteers must have information on how to submit a request for bed using the central allocation system with or without a BU number.

h. The triage volunteers must ensure all primary contacts get tested immediately and inquire about ILi/SARI symptoms for anyone that came in contact with the patient.

1. The triage coordinator/volunteers must have information to schedule the ambulance for pick up as needed.

J. The triage checklist is annexed. k. The community triages at the ward level should be strengthened by using the

whole society approach and function similar to polling booths during elections. This will include mobilizing all the volunteers to screen and send people to Home isolation or stabilization centers or direct them to · the Hospitals for beds.

1. The physical triage services should be implemented at a suitable location identified the existing BBMP ward offices, councillor offices, BBMP playgrounds should be used.

m. Adequate oxygen supply through concentrators should be made available at each centre to ensure that we do not lose people in respiratory distress.

6 (ii) To ensure that hospitals in the Ward Follow Efficient Exit Strategy.

• The goal of the Efficient Exit Strategy is to ensure that Bed turnaround time is reduced. This is done by ensuring that.

• No person with mild symptoms is admitted to the hospital. • A person with Severe illness is discharged within ten days

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• Person with Moderate illness is shifted to CCCs within five days • If the number of days is more than these, an explanation (1-2 sentence

should be provided ) • The volunteers from the coordination committee should help the aarogya

Mitras and other hospital members to ensure that the data is maintained for that efficient bed turnover.

• The WDC should work with hospitals . in their respective Ward that all the beds except requiring emergency services in all the hospitals are made available and used for COVID 19 until the pandemic is brought under control.

• The WDC should involve as many volunteers to support the hospital staff and arogya mitras for the following services in the hospitals of the respective Ward.

• Bed audits are done three times in a day • Prioritize the admissions who deserve the most • Reduce the clutter by discharging the patients with mild illness • Update the website in a real-time manner • Coordinate and Communicate with other hospitals, step down (CCC)

and family members

6(iii) To Empower the hospitals, doctors and their management with supportive supervision.

• The volunteers and committee members from the WDC should meet with heads of the hospitals or CEOs as the case may be to understand the constraints.

• The officers should be informed not to trouble the doctors and management • Volunteers need to work with the hospitals to help the Aarogya Mitras and

ensure that oxygen supplies and other resources reach the hospital.

• Volunteers should work with each hospital in shifts

• To coordinate with the at the community triage centres • To refer people to get ICUs when they get worse • To help discharge when saturation 96%

7. Contact tracing and Testing a. To take up contact tracing of every case in the Ward and complete Testing as

per Health and Family Welfare Department protocols. b. There are 600 testing units in BBMP, including PHCs and mobile test units.

The WDC must deploy these test units to increase test coverage. c. The War Room/WDC has access to testing centres and contact numbers for

the Ward. The WDC must ensure that the patients are isolated while waiting for test and while waiting for test results to arrive.

d. For every positive case, all the immediate family members must be tested.

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8. Home Isolation a. Identify all cases under home isolation and follow up as required under the

Health and Family Welfare Department protocol. b. WDCs must ensure that people with symptoms must be isolated even while

waiting for the test result. Asymptomatic positive cases must be isolated. c. The nodal officer must set up mini COVID Care Centers (isolation centres

for those without the means to isolate in their own homes). Then, based on triage, the WDC will decide who needs to be sent to the Care Centres.

d. Pamphlets - Regarding which lab the sample has gone for Testing, how to know the results - whom to approach in case of Non-receipt or reports -BBMP Helpline, what needs to be done if they are positives.

e. Supply of basic drug kit/ pulse oximeter has to be given at least one to each tested home and Do's and don't.

9. Vaccination Ensure maximum vaccination coverage in the Ward by holding vaccination drives and working with residential colonies to bring vaccination closer to people. Set up vaccination centres separately from COVID care centres or hospitals testing and treating COVID patients.

10. IEC Material Dissemination a. Educate citizens of the Ward about masking and social distancing,

symptoms, using a pulse oximeter, prone position etc. b. Use public announcements to highlight the importance of isolation,

information about how to get the test done and usage of pulse oximeters, proning etc.

c. Use hyper-local social media such as WhatsApp groups to reach out to residents. Create a network of citizen volunteers to relay the information to everyone, including those that do not have access or digital literacy.

d. Printed IEC material in multiple languages should be distributed to all grocery stores.

11. WDC Meeting Agenda The standing agenda of every WDC meeting: a. Status of Testing, tracing, triage b. Review of cases needing isolation, hospitalization. c. Which clinics, hospitals in the Ward need to be brought into COVID care. d. Training of new volunteers and staff. . k e. Analyze data from the call centre to identify hotspots m the Ward and ma e

micro plans to contain the spread. f. Medical equipment distribution to hotspots in the Ward.

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12. Role of RW As, CSOs and other social organization a. Resident groups and CSOs will have to play a critical role in making ward

committees functional. The first responsibility is to review this document and suggest changes to improve the process.

b. All organizations working in the COVID relief efforts or even otherwise are requested to join the WDC to strengthen ward-level COVID management efforts.

c. Organizations with a city-wide presence are requested to ask their members to join the WDCs in their respective wards.

13. Role of Health Sector NGOs a. To bolster the efforts inward level, health sector NGOs must attach their

resources toward level teams. b. Health Sector NGOs must play a key role in training the community

volunteers. c. Health Sector NGOs help address special cases that are marked by triage

volunteers.

14. Resources available at each Ward Office/War Room Once the war room or command and control centre is established at the ward level, it must be equipped with the following. a. Call centre b. Training must be given on proper usage of oxygen, pulse oximeters etc. c. Posters about the pulse oximeter and prone position in multiple languages d. IEC Material that can be distributed in the community, affixed to grocery

stores. e. Vaccination related information booklets, myth busters, locations of

vaccination centres. f. Physical space for volunteers to make calls while maintaining social

distancing g. Thermometer, Oxygen Concentrators and other equipments required for

Triage services.

15. Data Gathering and Dissemination The effectiveness of the WDC will be substantially dependent on the WDC becoming the direct source of data capture. All higher levels of data and reporting related to COVID should be aggregates of WDC data and MIS reporting, rather than the current practice of data being assembled at the higher levels and then being disaggregated to the ward level. Reporting on COVID will fall into two broad buckets:

- STOCK DATA: Examples of stock data reporting include, as on a particular date/time:

• Number of COVID infected residents in the Ward • Number of Home isolated patients

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• Number of patients isolated in Covid Care Centres/Stabilisation centres.

• Capacity left in Covid Care Centres ( and other facilities) • Number of patients on Oxygen support • Number of patients in ICU • Number of recovered patients • Number of deceased • Number of vaccinated residents • Etc.

- FLOW DATA: Examples of flow data reporting include, for the particular period (e.g past 24 hours, or 48 hours, etc.), number of

• Calls that have come in to WDC • RT-PCR tests done • Status ofRT-PCR testing (number swabs collected, number of tests

submitted to labs, number of results pending, number of infected, number of information disseminated to patient etc.)

• Number of Positive cases added to Home Isolation • Number of positive cases sent to CCC/stabilisation centres • Number of cases needing oxygen • Number of cases needing ICU • Number of cases deceased • Number of vaccinated cases • Etc.

As the STOCK MIS and FLOW MIS are inter-connected, both of these depend entirely on the quality of the data being produced at the WDC. If this is done with suitable care, then all the higher levels of data and MIS will be accurate, since the data has been captured at source itself The technology platform on which WDCs will be run will have to enable the capture of all these aspects in an easy, user-friendly manner, and also connect to the platforms used at higher levels of data management such as bed management etc.

Even with the right technology platform in place, in order for this to happen, the most critical step is the FIRST STEP, related to the connection of the patient/resident with the WDC. Once this connection has been established, all subsequent steps can be managed within the WDC itself, thereby ensuring the quality of data.

Given that residents will not be aware of the need to contact WDC, this step will require an intense effort, involving multiple aspects: IVRS systems to inform all callers to helplines to first call their WDC rather than the central helpline; possible SMS to all Bangalore residents to check their ward numbers and get WDC helpline numbers, local IEC activities through RWAs and volunteers etc.

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All activities described in the sections above can then be carried out effectively, but also published on the WDC Technology Platform to allow timely visibility of the overall Covid Management process at the WDC level, and give zonal and city-level administrators the ability to identify those wards where cases loads are heavy and additional support is needed.

To: ' \

(N Manjunatha Prasad, IAS) -r)sb,21 Principal Secretary to Govt., Revenue Department

(DM) and Member Secretary State Executive Committee

The Compiler, Kamataka Gazette, Bengaluru

Copy To:

l.Dr Manoj Rajan, IFS, Commissioner, KSDMA, Revenue Department(DM) 2. Dr Giridhara R Babu, Professor of Epidemiology, PHFI 3. Smt. Swati Ramanathan, J anaagraha 4.Dr Nagaraj, World Health Organization, 5.Dr Ravi Mehta, Pulmonologist, Apollo Hospitals . 6.Dr Pradeep Rangappa, Senior Consultant, Vice- President, ISCCM National

Vice-President

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Annexure-1 : Colour Coding

Cateaory Z -> ward admission

Sp02 90-94% (needing oxygen supplementation) Maintaining Sp02 :! 90% on nasal cannula, simple face mask or NRBM Eldf rly (.t 65yrs) :I: co-morbidities with Sp02 < 94% CT ~erity score :! 15/25 CKO patients on dialysis

Heart failure patients (LVEF < 40%) 6 minute walk test N Sp02 < 94%

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-=="lf!L:iiwr._

Annexure-2: Physical Triage Checklist

I.

2.

3.

4.

4.

Demographics

a. Name

b. Age

C. Sex

d. If female, pregnant?

e. Vaccination status with dates

Current illness:

a. Days since symptom onset

b. RT-PCR/RAT status with date

Symptoms:

Fever

Cough •

Shortness of breath •

Headache •

Runny/blocked nose •

4. Co-morbidities:

5.

5.

Diabetes Mellitus •

Hypertension •

Cardiac disease •

Respiratory illness •

Chronic kidney disease •

Psychiatric illness •

5. Examination:

Fatigue Loss of smell • • Bodyache Loss of taste • •

Loose stools Chest pain • •

Abdominal pain Coughing blood • •

Vomiting Confused status •

Chronic Liver disease

Old stroke •

Cancer •

On steroid/chemotherapy

Regular dialysis? •

Other

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•

•

--·

•

~·· a. Mental status: I. Conscious, oriented • 2. Altered sensorium •

b. HR <50/rnin • 50-110/rnin • >110/rnin •

C. RR <24/rnin • 24-30/rnin • >30/rnin •

d. Oxygen saturation 2:95% at room air • <94% at room air• < 75% Room air

e. Optional :BP _____ <I00 systolic • 2:180 systolic•

6. Action plan:

a. Home isolation Hospital referral •

Red: Dangerous signs needing possible ICU admission

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