Shwaas
A Chikitsa Sathi App for Community Level Training for COVID-19
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Problem Statement:
With the ongoing second wave of COVID–19 pandemic, we have been seeing a large number of suspected and confirmed COVID cases in every nook and corner of the remote forest and forest fringe villages. One of the reasons for the high death rate is indecision; delay in decision about when to seek medical care. We see at least 4 to 5 patients coming to our referral centre in Ganiyari everyday with severe hypoxia (saturation below 70%). Such patients require significant medical expertise for management thus requiring a longer hospital stay with oxygen support and despite that, they end up having poorer outcomes as compared to their counterparts who reach a hospital when their oxygen saturation falls just below 90%. There has also been a large number of sudden home deaths especially in patients with comorbidities. We sensed the need for a tool to identify such patients early to be referred to hospital and treated in time in order to combat the common observation of villagers that “Patients are not coming back alive from hospitals”.
Trained frontline health workers are the need of the hour. It takes a significant amount of time to train a lay person in thorough basic medical assessment and make them capable enough to decide referral needs at the right time for their own family as well as their fellow villagers. With one year through this pandemic, enough medical literature is available to timely identify people at high risk of mortality, and they should ideally be advised for admission with non-oxygen beds in COVID care centres. However, presently this is unavailable for rural, poor people and remains a neglected aspect in urban areas. This calls for involving local people from within the community to assist health personnel which is stretched beyond its capacity. We have therefore been training volunteers in key medical skills like pulse oximetry, checking respiratory rate and blood pressure. It was felt that supplementing these with a decision support tool could better equip them to increase their effectiveness and confidence. Therefore, we developed and introduced a support tool in the form of a mobile application called “Shwaas- A Chikitsa Saathi”.
The lack of awareness is also one of the reasons for unrest and panic among people, and is leading to crowding of health facilities by people who could have been well managed by themselves/their relatives at home. Thus, it has become a double-edged sword- on the one hand, people requiring immediate care cannot be identified and arrive late and on the other hand, people who could have stayed home arrive too early at a facility depriving the needy of the time, attention, and care by medical personnel in an in-patient/out-patient setting.
Solution:
Jan Swasthya Sahyog has created an easy-to-use application, which helps to guide “trained” frontline healthcare workers and caregivers, in collaboration with Samanvay Foundation. “Shwaas- A Chikitsa Saathi” is an android mobile application currently available in six languages viz, English, Hindi, Kannada, Telugu, Tamil, and Bangla. This app does not require signing up or logging in. It is freely accessible for all users. It works offline. It is like a simple tool guide which enables early identification of patients with COVID-like symptoms at the primary level (where a doctor may not be available at all times). It has the ability to diagnose the early compensatory phase of lung involvement by taking into account respiratory rate with an inbuilt breath counter. It was designed to be used by organisations and health systems which have a cadre of community level health workers working at the grass roots in interior villages, mostly forest fringe villages and neglected urban slums. In these difficult times when our healthcare system is stretched beyond its limits, simple interventions like this one, of using the app by neo-literates and ensuring the safety of people with COVID like symptoms, provides a great support to the community.
One of the main features of the app is to capture danger signs such as happy hypoxia which has proved to be one the main reasons for many young people to die during this second wave of COVID. Since this condition does not show any symptoms like respiratory distress or other alarming symptoms, it becomes very difficult to manage patients when they arrive at health facilities with severely low Oxygen levels. We have therefore included a special feature in the app known as “Six minute walk test” along with other questions which suggest if a person needs to be referred immediately or not based on the colour code Red, ellow, or Green that pops up at the end. The app also has an inbuilt breath counter to measure respiratory rate which helps the users identify whether the person is suspected to have Pneumonia or not. The app basically works as a personal guide.
Philosophy behind Design tradeoffs: While finalising the decision making algorithm, we had to face a difficult trade off between simplicity and thoroughness. On the one hand we were trying to come up with an easy to use tool, while on the other hand we did not want to trivialize medical assessment for remotely located rural/ tribal populations. With our experience of training village health workers and middle level health workers for the last 21 years along with the commitment to provide high quality healthcare at the lowest possible cost, we chose the option of a complex algorithm over popular simple algorithms. With this background, we commit to the responsibility of offering training to frontline workers of any organisation.
Pilot Phase and Results:
We conducted a very small pilot of this application between 19th May and 26th May, 2021 at the fever clinic of our referral center in Ganiyari, which is a rural secondary cum tertiary care center with a 25 bedded COVID inpatient facility. Patients were first seen by a nurse using the Shwaas application, recommendations given were documented and then patients were independently seen by the doctor. The recommendations by the application and the doctor were matched. In case of discrepancy, patient records were reviewed by another doctor and the probable reasons for the different recommendations were discussed with both the nurse and the doctor who did the first consultation. . Results of the pilot are as follows: Total patients enrolled= 34 Recommendations that matched=28 (82%) Recommendations that did not match = 6 (18%)
Reasons for the mismatch:
Application related= 3 (50% of the mismatch in recommendations) namely chest pain missed by the app, Hemoptysis missed by the app, SpO2 of 90-91% known to be normal in COPD patients were marked as low SpO2 levels by the App.
Doctor related= 3 (50% of the mismatch in recommendations). Increase in respiratory rate was missed by the doctor in all 3 patients. When matched against a third person review, recommendations matching: 32 (94%), recommendations not matching 2 (6%).
Current status with next steps:
Currently, this app is available in 6 languages. We are adding translated versions as and when there is a demand for it in other regions or find volunteers who would like to help translate it. If the app is not in your language already and you think it will be useful, please send an email to us at shwaas-feedback@samanvayfoundation.org. If you are interested in volunteering to translate, please let us know that too. If you know the language, translating Shwaas is a cakewalk! We will soon add pictorial illustrations to make identifying signs easier. We are also trying for an IVR based version of the algorithm for users who might not have a smartphone. Presently the app has an algorithm suited for patients more than 12 years of age. We are working on a pediatric age group algorithm and will soon update the same.
FAQs:
1. When is this app supposed to be used?
Shwaas is primarily designed to be used by frontline workers. By frontline workers, we mean any individual who has been tasked or has accepted the responsibility of guiding people with symptoms suggestive of COVID. So, main use of the app would be in a situation when a person has fever, cough, coryza, throat irritation, severe fatigue, body-ache, loose motion, loss of taste, loss of smell, and seeks guidance from frontline health workers about next steps. With the spread of the pandemic, many non-health individuals are volunteering for this task and it’s challenging especially in a situation when medical consultation costs a significant amount of time, money and infection risk.
For the first check-up session, the app offers a detailed evaluation and helps triage a person with symptoms into Green, Yellow, or Red categories. On the recommendation page, screenshots can be taken to save information for future reference or to be shared (via WhatsApp, email etc.) with others for consultation.
During follow-up sessions, frontline workers with experience can skip a few questions and only use breath counters, pulse oximetry, and 6 minute walk test features to save time. We do not recommend this for new frontline workers in order to avoid errors.
Frontline workers can also train family members to use this app and ask them to inform the frontline worker with a screenshot only when it indicates attention/danger. This medical skills video on YouTube (link: https://youtu.be/yaKIMRvzgE0 ) can be used to train oneself or a family member.
2. Who can use this app?
We envision it can be used by trained frontline workers, caregivers and even by non-healthcare providers if they train themselves by watching the video on taking vitals, counting breaths, etc. Frontline workers can be from various government and non-government set ups.
In Villages: ASHAs (Mitanins)/Village health workers, if they have smartphones.
MPWs (Multipurpose Health Workers), ANMs (Auxiliary Nurse Midwives), ANM supervisors, ASHA facilitators, field level supervisors/coordinators, similar level staff from non-governmental organisations extending their support for health work during the pandemic– most of them use smartphones already.
At Primary Consultation centers (Health and Wellness centers/Family Practitioner Clinics/Fever Clinics): In busy fever consultation facilities, paramedic staff or volunteers can use this app to screen patients and screenshots can be shared with treating physicians in advance. This tool can also be used to limit exposure time with patients by training patients to answer questions and using features such as breath counter, pulse oximetry and 6 minute walk test which will be useful not only before the consultation but also in identifying whether a follow-up is needed and if yes, whether telephonically or in person.
At Home Though the app will be used by individuals, at a larger level it can be expected to have a significant impact on reducing hoarding of essentials/irrational use of drugs and ensuring timely care to those really in need.
3. I have COVID, can I use the app?
Yes, you can definitely use the app. You can assess your infection status by answering the questions asked by the app along with the walk test. Based on your answers and the final reading of Oxygen level, the app will categorize the action needed in Red, Yellow, or Green colour and suggest relevant next steps.
4. I suspect that I have COVID, can I use the app?
Sure. You can use the app. In fact, it would be great if you use the app early on to check whether you are safe at home or need a referral. Even if you have a negative COVID test result but still have mild symptoms or were in close contact with a positive patient, using this app will help you monitor your status and raise a flag when something is not okay and when you need to consult a doctor or get to a health facility.
5. If the person is at the Red stage, can the person be really saved in a rural setting?
There are high chances of saving a person who is at the Red stage if they have access to transport facilities.
6. Shwaas App is not available in my language. What should I do?
We are adding translated versions as and when there is a demand for it in other regions or find volunteers who would like to help translate it. If the app is not in your language already and you think it will be useful, please send an email to us at shwaas-feedback@samanvayfoundation.org. If you are interested in volunteering to translate, please let us know that too. If you know the language, translating Shwaas is a cakewalk!
7. Can you customise the app for our needs?
Drop us an email with your use case and we will see how we can accommodate. If we disagree on the changes, or cannot accommodate, you can modify and release a version of the app yourself. We are open source. Have a developer start out with the source code at https://github.com/SamanvayOrg/PneumoniaApp.
8. Has the app been approved by health experts?
The app has been conceived, lab tested, and field tested by clinical and public health practitioners at Jan Swasthya Sahyog. Jan Swasthya Sahyog has been working in curative and preventive healthcare in hospital and community settings for the last 21 years. For more details, visit- www.jssbilaspur.org.
9. Is the app available on iOS?
No, we have not created an iOS version of the app yet given the current user device pattern. But it’s not very difficult for us to create one. If you have a compelling reason for why we should do it, shoot an email at us with your reason.
10. How frequently is the app updated?
We are conscious that everyday there is something new the whole world is learning in this COVID-19 situation. We are committed to continuously keep the app updated based on feedback from experts and usage on the field.
11. Does this app store patient records?
Deliberately, we have designed the app to not save sensitive patient data. All questions and answers that were completed are listed on the recommendation screen under the recommendations. You can simply take screenshots and store them in your phone gallery for future reference as well as share them on whatsApp, email or any other communication platform for teleconsultation.
12. How do I provide feedback?
On the start screen of the app, a feedback button is provided for feedback/ queries. The button will direct you to your phone email app and you can drop an email to us. You can also directly write to us at shwaas-feedback@samanvayfoundation.org. We would be happy to get suggestions to improve the app 🙂
13. From where can I download the App?
Google playstore.
Link: https://play.google.com/store/apps/details?id=com.pneumoniaapp
14. Do I need to learn certain skills for using the app?
Yes, for using the app, you will need to learn to count respiratory rate and to do pulse oximetry. These are easy to learn. We recommend you definitely watch this training video on important medical skills available in Hindi (skills for respiratory rate and pulse oximetry are mandatory for app usage, please watch this video from the 37-minute mark onwards before using the app)
Link: https://youtu.be/yaKIMRvzgE0
Screenshots:
