|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 3 | Page : 55-57
The second wave of COVID-19: Rapid establishment of an isolation unit at a tertiary care setup in India
Prakash K Dubey1, Krishna Gopal2, Sudhir Kumar3, Akhileshwar1
1 Department of Anesthesiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2 Department of Hospital Administration, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
3 Department of Internal Medicine, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
|Date of Submission||10-May-2021|
|Date of Decision||15-May-2021|
|Date of Acceptance||19-May-2021|
|Date of Web Publication||10-Aug-2021|
Prakash K Dubey
E¾, IGIMS Campus, Patna - 800 014, Bihar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dubey PK, Gopal K, Kumar S, Akhileshwar. The second wave of COVID-19: Rapid establishment of an isolation unit at a tertiary care setup in India. Saudi Crit Care J 2021;5:55-7
|How to cite this URL:|
Dubey PK, Gopal K, Kumar S, Akhileshwar. The second wave of COVID-19: Rapid establishment of an isolation unit at a tertiary care setup in India. Saudi Crit Care J [serial online] 2021 [cited 2022 Jan 20];5:55-7. Available from: https://www.sccj-sa.org/text.asp?2021/5/3/55/323607
A sudden surge in COVID-19 pandemic in India led to a rush for augmenting the number of hospital intensive care unit (ICU) beds to meet the growing requirement. The planning required for setting up an isolation ICU at a short notice posed unique challenges for a tertiary care university hospital that had been functioning as a non-COVID center since the beginning of the pandemic. However, there were some advantages also as most of the health-care workers were well versed with the protocols of safe practices and biomedical waste management. Presented here is an overview of our experiences in preparing an isolation ICU utilizing the available resources and logistics at a notice of 48 h.
| The Team|| |
Initially, a team comprising of hospital administrator, faculties from the department of anesthesiology, and critical care medicine and internal medicine discussed the identification of space, utilization of equipment, and workforce for setting up the facility. Discussions were held with the departments of laboratory medicine and radiodiagnosis for providing a seamless investigation backup. The nursing superintendent was advised to prepare the workforce according to the pandemic requirements. Protocol for the disposal of dead bodies was finalized.
| The Space|| |
The emergency facility at our center runs in a two storied building. It comprised of 46 ICU beds, two dialysis beds, two isolation rooms and 5 bed step down bed facility. It has also two fully equipped operation rooms. There are three entrances to the ground floor and two for the first floor facility. It facilitated dedicated passages for entry and exit of health-care workers and patients including proper donning and doffing facilities.
These features were ideally suited for turning the whole building in to an isolation ICU as it is also has a separate access away from the main hospital area. Furthermore, the surge capacity of this area was favorable in the form of additional 25 upgradable beds.
Seven beds were earmarked for triage/initial stabilization of the patients in need of intensive care that were referred from other health-care facilities of the city. Twenty-three beds were used as an isolation ICU and 15 as high-dependency unit.
| The Equipment|| |
All beds were already equipped with pendants for oxygen, suction, compressed air, and multiparameter monitors. Each floor had one portable ultrasonography machine, portable X-ray machine in addition to one fiberoptic bronchoscope and blood gas analyzer. More ventilators and Bilevel positive airway pressure (BIPAP) machines were mobilized from other ICUs and wards of the hospital. Process of acquiring new machines was also started. Sufficient number of personal protective equipment (PPE) kits, transparent plastic sheets, and disposables such as closed suction units were stocked as a preventive measure for aerosol and respiratory droplet transmission.
Isolation ICUs should have the provision of a negative pressure system to prevent airborne transmission of COVID-19. However, we proceeded with the existing system in the building as it was felt that in view of the paucity of time, the focus should be on the most essential services rather than the best.
The safety of health-care workers is of paramount importance in an isolation ICU, especially during doffing. CCTV camera with audio-visual communication allows 24-h surveillance of doffing. As all our health-care workers were already well versed in this area, we took help of posters along with supervised during donning and doffing.
| The Healthcare Workers|| |
Availability of trained workforce for smooth functioning is as important as their safety and well-being during the work period. Paramedical staff constitute the most important part of the functioning of a facility and loss of this workforce due to sickness and mortality during the pandemic had been of concern elsewhere. In addition to sterilization and safe biomedical waste management practices, they were also trained in judicious use of oxygen, keeping in view the evolving issues in the pandemic. Provision for stay in isolation, food, and entertainment were made for all workers in a separate building.
| The Communication|| |
Effective bedside communication skill is a key to effective critical care management. In addition, we have an emotional dimension to look at by catering to the fears of the patient's family members. The visitors are allowed limited access to their patients. They expect all the answers, all the time from the care providers. Dedicated smartphone was provided to the team to disseminate rapid information to other departments and patients' relatives.
A patient information chart was prepared to record the brief details of illness and treatment provided. This was quite useful for providing updates to other team members. Relevant portions of this chart were used to update the patients' family members also. This chart also helped in storing a robust database for future reference.
Apart from-personal details and demographic profile, this chart included the following information:
- Initial symptoms, for example, respiratory/gastrointestinal/others
- Severity at admission-moderate/severe
- Comorbidities, if any
- Mode of oxygenation-cannula/mask/non-rebreather mask/noninvasive ventilation/invasive ventilation
- FiO2/flow rate
- Heart rate, blood pressure, respiratory rate, and SpO2
- Other medication
- ABG (pH, O2, CO2, lactate, and base excess)
- Ventilator settings
- C-reactive protein, D-Dimer, Ferritin, interleukin-6, and high-resolution computed tomography
- Nutrition/tracheostomy/any C/S.
Standard treatment protocol consisted of broad-spectrum antibiotics, steroids anticoagulation, and previous medication for comorbidity. Oxygen therapy protocol escalated from simple mask/prongs to mask with reservoir bag to noninvasive ventilation followed by invasive one.
The surge strategies: Guidelines have been published for putting a surge response strategy in place for the pandemic. It involves planning a surge response enhancement in the number of isolation beds, trained workforce, mobilization of equipment, and logistics such as PPE, drugs, and disposables. In India, a study was conducted to assess the capacity and tipping points of Indian health system to absorb surges in the number of people that will need hospitalization and critical care because of COVID-19 based on varying scenarios. The analysis indicated the paucity of resources to handle surge in need during the peak time for both mild infections and severe cases. The preparatory steps undertaken include home quarantine in mild cases, involvement of private sector in COVID patient management, increase in the production of equipment and disposables, ramping up production/distribution of oxygen supply, scaling up of health workforce capacity (involvement of medical/nursing students, retired physicians, armed forces logistics, and workforce), and mass vaccination drive at the government level. At the institutional level, discontinuation of nonemergent services to conserve workforce, supply and oxygen usage, and mobilization of equipment to prepare more ICU beds were employed. Training of health-care workers was also emphasized.
During the pandemic, the maintenance of isolation ICU is a dynamic process. Problems will keep on cropping up. However, the core area of management revolves around judicious planning for utilization of resources and safety of the workforce.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Phua J, Weng L, Ling L, Egi M, Lim CM, Divatia JV, et al.
Intensive care management of coronavirus disease 2019 (COVID-19): Challenges and recommendations. Lancet Respir Med 2020;8:506-17.
Kajal K, Naik BN, Singh A, Soni SL, Hazarika A, Saini K, et al.
Preparing intensive care unit in resource-constraint setting amid COVID-19 pandemic: Our experience and review. Anesth Essays Res 2020;14:366-9. [Full text]
Naik BN, Gupta R, Singh A, Soni SLs, Puri GD. Real-time smart patient monitoring and assessment amid COVID-19 pandemic – An alternative approach to remote monitoring. J Med Syst 2020;44:131.
Kain T, Fowler R. Preparing intensive care for the next pandemic influenza. Crit Care 2019;23:337.
Aziz S, Arabi YM, Alhazzani W, Evans L, Citerio G, Fischkoff K, et al.
Managing ICU surge during the COVID-19 crisis: Rapid guidelines. Intensive Care Med 2020;46:1303-25.
Verma VR, Saini A, Gandhi S, Dash U, Koya SF. Capacity-need gap in hospital resources for varying mitigation and containment strategies in India in the face of COVID-19 pandemic. Infect Dis Model 2020;5:608-21.