Preparing Intensive Care Unit in Resource-Constraint Setting Amid COVID-19 Pandemic: Our Experience and Review.

COVID-19 pandemic is an emerging, rapidly evolving public health emergency where a nation's health-care system can face a marked surge in demand for intensive care unit (ICU) beds and organ support. In regions with insufficient medical resources, it may further aggravate the existing shortage, limiting an ICU's ability to provide the normal standard of care. It can present ethically or legally demanding questions about how to prioritize the allocation of life-saving medical resources. In developing countries like India, still many hospitals are challenged by competing priorities and remain underprepared. In the wake of COVID-19 pandemic, to guide the intensive care disaster planners in regions with low resources and to ensure ICU readiness, this review shares our experience and strategies for preparing ICU with existing and alternative resources, focusing on space, equipment, and health-care workers' safety and training. Copyright:

INTRODUCTION

As of September 9, 2020, 44 lakh confirmed cases and 75,000 deaths due to COVID-19 pandemic have been reported in India (updated data available at https://www.mygov.in/covid-19). Among these circumstances, there has been a rush to augment the number of hospital ICU beds to meet the unexpected peak. The need to plan and prepare for this potentially formidable infectious outbreak has added a whole new set of challenges to the practice of intensive care medicine. The emergence of this pandemic will severely affect our capability to care for many anticipated additional COVID-19 patients with the standard intensive care practices with which we have become accustomed, posing an invincible challenge to intensivists. The efforts to augment intensive care are not adequate with the severe mismatch of patient need and life-saving medical resources. With no fair and just system in place to allocate them, the entire medical and public health response in the sloppy health-care delivery system may halt. Preparedness is essential for a successful response. This chapter provides a brief overview of our experience in planning and preparing ICU in a short period, with limited resources highlighting our strategies to alleviate the potential impact of this pandemic.

THE COVID-19 MULTIDISCIPLINARY INTENSIVE CARE UNIT TEAM

First, we constituted a special team of intensivists, anesthesiologists, infection control specialists, and hospital administration to analyze the issues that we might face and countermeasures to tackle. We then identified an isolated building which is away from our main hospital, with the capacity to incorporate a larger number of COVID-19-infected patients. Further, the work was assigned to three specific teams:[1] team for identifying designated ICU space and installation of ICU beds, ventilators, monitors, and other ICU-related equipment,[2] team for procurement of medical equipment and devices and to explore auxiliary innovative resources from local manufactures which can be utilized when stockpiles are limited,[3] and team for training health-care workers (HCWs) comprising faculty, residents, nurses, technician, hospital attendants, and sanitary workers who will be employed in the ICU.

SPACE

Our hospital is a tertiary care center with existing 14 ICUs incorporating more than 200 ICU beds, with almost 100% occupancy rate. However, in the middle of this pandemic, it is not advisable to make use of these critical care units of the main hospital due to risk of transmission to already existing patients. Furthermore, the surge capacity of these spaces is minimal and can hamper the hospital's ability to maintain a routine system of patient flow. Thus, it is advisable to make use of separate health-care setting, away from the main hospital for critical care delivery (e.g., hospital building with deployable medical facilities).[1] Hence, we decided to utilize the newly built unequipped separate building, a 250-bedded hospital block exclusively for treating COVID-19 patients, owing to the rapid global rise in the number of cases.[2] We have planned to set up a 20-bedded ICU initially on the top floor of building, with the potential to expand up to 50 beds.

EQUIPMENT

Overwhelming respiratory failure in COVID-19-positive patients and without surge planning might lead to high mortality, without the assistance of mechanical ventilation. A checklist of required numbers of ICU bed, ventilator, monitor, ultrasound machine, bronchoscope, dialysis machine, drugs, personal protection equipment (PPE), and many other related medical equipment was prepared. Ventilators are high-priced and not easy to stockpile, but contingency plans at the facility and government level (local, state, and national) should be instigated to supply for some additional ventilators and their accessories. In the course of this pandemic, with countrywide lockdown augmenting the delay in supply of medical stock, planned criteria for re-distribution or conservation of equipment may ease the execution during the surge.[3] Provision of most essential services among these circumstances would be more appropriate rather than the best clinical services.[4]

Intensive care unit ventilators and monitors

The availability of mechanical ventilation is expressed as a critical bottleneck in response to the evolving COVID-19 pandemic where the need for ventilators remarkably exceeds demand.[5] All possible measures should be initiated to increase capacity, including interhospital transfers and use of alternative equipment.[1] At first, we shifted over 20 reserve ventilators from different ICU units of our hospital. While the procured ventilators would eventually be available, there could be a time when the hospital may need to provide ventilatory support to a greater subset of COVID-19 patients than the available number of ventilators. To overcome this excess demand, (a) Y-shaped connectors with potential to split airflow and multiply the number of patients requiring respiratory support were arranged, [Figure 1] where a single ventilator can be rapidly adjusted to ventilate multiple patients at a time for a short period.[6] (b) Several portable CPAP devices were arranged from a local manufacturer. (c) If the demand exceeds further, elective operation theaters with equipped anesthesia ventilators will be utilized.

Figure 1

Y-shaped connector (a) to split airflow from a single ventilator (b)

Many unused and reserve monitors (fixed and portable) were transferred from different areas of the hospital. The local medical industry was approached to support in providing economical low-end monitors with basic monitoring features for mass use with the central monitoring system.

Medical care devices, personal protection equipment, and alternative innovations

Arrangement of several medical equipments such as PPE, medical face shields, and closed suction catheters, etc., is the greatest challenge due to worldwide shortage and high demand.[7] While the pandemic is growing, reacting to the acute shortage, we approached volunteers from the local engineering community, expertise in manufacturing skills to help us develop the required equipment. Local manufactures with three-dimensional printing abilities announced their willingness and initiated efforts to produce face shields and intubation boxes at free of cost for HCWs [Figures 2 and 3b]. Given the insufficient global and domestic supply of PPEs, alternative innovations from local manufactures were suggested and prepared, an initiative which helped us to overcome COVID-19-related shortages. To prevent the spread of aerosols and respiratory droplets, transparent plastic cover sheets were arranged to cover the patient [Figure 3a]. Blood gas analyzers and ACT machines were installed within the ICU premises to facilitate patient care.

Figure 2

Locally manufactured three-dimensional medical face shield (a) single (b) cluster

Figure 3

Transparent plastic sheet covering the patient to reduce spread of aerosol and droplets (a), simulation-based training with intubation box (b)

Air conditioning in intensive care unit

To prevent airborne transmission of COVID-19, ideally, ICU should be functioning with a negative pressure system.[8] There is no provision of such a system at our center. We made certain modifications in heat ventilation air conditioning system (HVAC) to minimize COVID-19 transmission in ICU:

Maximize the forward flow of air conditioning

Block the recirculation ducts with an airtight seal

Open the windows

Activate the smoke exhaust ventilation and install extra exhaust fans at the end of corridors.

Low-cost surveillance system

Literature has shown many benefits and favorable outcome with tele-ICU technology.[9] However, the cost of tele-ICU implementation is significantly high,[10] affecting its deployment in resource-constraint regions. Hence, we installed CCTV cameras with audio–visual communication at an affordable price, with 24-h surveillance of doffing and remote monitoring of ICU patients.[1112] This system has the potential to (a) provide enhanced health-care delivery from the off-site location, (b) address the increasing complexity of COVID-19 patients with less ICU staff, (c) increase access to critical care expertise, and (d) ensure HCW safety, especially during doffing [Figure 4].

Figure 4

Audio–visual surveillance of doffing process (a) and intensive care unit premises (b)

HEALTH-CARE WORKER

Three major issues pertaining to frontline HCWs of ICU, owing to COVID-19 pandemic include:

Excess demand and shortage of trained staff

Safety and well-being of HCWs.[13]

Many HCW's may be drained by the overwhelming extent of the pandemic and associated workload, together with losses by contamination, isolation, sickness, or mortality. Worldwide, a significant number of HCWs have been infected till to date. In the Asia-Pacific region till April 3, 2020, there have been 35 reported deaths and over 4000 confirmed cases among HCWs due to COVID-19.[14]

Current WHO recommendations emphasize the importance of rational and appropriate use of PPE,[15] especially in doffing procedures and hand hygiene practices. The WHO also recommends staff training based on these recommendations.[16] In the limited span of time, simulation-based training was initiated by our trained professionals in small groups, comprising demonstration of donning and doffing of PPE, hand and respiratory hygiene, sterilization techniques, and safe biomedical waste management along with routine ICU practices. Short demonstrations, PowerPoint presentations, and video clips were also used. After duty hours, provision for a stay in isolation and other necessities were arranged for HCWs. Regular yoga sessions were organized to boost mental health. Toward the end of the preparation, mock drills and dry run were carried out to make the system function effectively.

Key recommendations for ICU setup in resource-constraint hospitals among COVID-19 pandemic [Table 1]:

Table 1

Problems and suggested recommendations for intensive care unit setup amid COVID-19 pandemic in low resource setting

	Problems	Recommendations
Space	Designated space Airborne transmission of COVID-19 Nonavailability of negative pressure room	Separate hospital building for COVID-19 patients isolated from the main hospital Modification of HVAC system  Maximize forward flow  Block return ducts  Open hospital windows to outside air and installation of extra exhaust fans
Resources	Insufficient ventilators, ICU beds, monitors, PPEs, drugs, etc.	Mathematical model to predict the expected number of patients, required resources, and alternative options
HCW	Untrained staff Long duty hours and excess workload Psychological stress	Simulation-based training by experts Curtailed duty hours (6-h duty shift) Motivation and psychological support through counseling and yoga sessions

HCW=Health-care worker, HVAC=Heat ventilation air conditioning system, ICU=Intensive care unit, PPE=Personal protection equipment

A multidisciplinary team of experts (intensivist, anesthesiologist, infection control specialist, and hospital administration) must be engaged in planning for surge capacity

Develop contingency plans at the facility and government levels (local, state, and national) to provide additional ICU beds, ventilators, PPEs, and other necessary equipment

Layout plans for ICU expansion by using, high dependency units, step-down units, PACU, operation theaters, and hospital wards finally

Meticulous use of a minimum number of HCW required on ICU duty at one point of time while ensuring the best possible care for the greatest number of patients

Use 24-h audio–visual surveillance system with a remote view monitoring facility for better patient care as well as for ensuring the safety of HCW.

CONCLUSION

In the course of COVID-19 pandemic, effective augmentation of intensive care services at a hospital is a complex, challenging task for planners of the intensive care unit. No disaster response is perfect. Nevertheless, judicious planning of space, infrastructure, HCW training and safety, with the integration of planning efforts involving multiple services of the hospital, and the engagement of government and community associates will facilitate the prepared intensive care units to respond effectively for surge capacity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.