key: cord-1024544-vvvo5t4h
authors: Tempe, Dr. Deepak K.; Khilnani, Dr. Gopi C.; Passey, Dr. J.C.; Sherwal, Dr. BL
title: Challenges in Preparing and managing the critical care services for a large urban area during COVID-19 outbreak: Perspective from Delhi
date: 2020-05-26
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2020.05.028
sha: 2092aff43d22beb3649e57d7df1bcfd0b8389327
doc_id: 1024544
cord_uid: vvvo5t4h

Abstract The Coronavirus disease-2019 (Covid-19) pandemic has put the healthcare services all over the world into a challenging situation. The contagious nature of the disease and the respiratory failure necessitating ventilatory care of these patients has put extra burden on the intensive care unit (ICU) services. India has been no exception and by March 2020, the number of covid-19 patients started increasing in India. This article describes the measures taken and challenges faced in creating the ICU beds to cater to the anticipated load of patients in the state of Delhi, India. The main challenges faced among others were, estimating the number of ICU beds to be created; deciding the dedicated Covid hospitals; procurement of ventilators, personal protection equipment and other related material; mobilizing the human resource and their training; and providing isolated in-house accommodation to the staff on duty. The authors acknowledge and agree that the methodology proposed in this article is, but one way of dealing with this difficulty scenario, and that there could be other, perhaps better methods of dealing with such a problem.

In December, 2019, many health care facilities in Wuhan, China reported patients with symptoms of severe acute respiratory failure, similar to those observed in 2002 with severe acute respiratory syndrome (SARS-Cov). On January 7, 2020, a novel strain of Corona virus SARS-Cov-2 was isolated, which confirmed the circulation of a new disease with respiratory illness, Coronavirus disease-2019 (Covid-19). 1 The virus rapidly spread to several other countries and at the time of writing this article (April 12, 2020) the disease has already been reported to have spread to 210 countries, with a total number of reported cases being 1,826,245 and deaths being 112, 371. 1 In India, the first case of Covid-19 was reported from the state of Kerala on 30 January, 2020, which originated from China, the number rose to 3, all were students who had returned from Wuhan, China. 2 3 The Government of India initiated several precautionary measures such as screening of the international travelers at the airport and quarantine of the suspected travelers and later on stopping the flights from China, Italy and a few other countries. Also, bans were imposed in the country on social gatherings, cinema halls, restaurants, functions, conferences, among others. On 24 th March, the Chief Minister of Delhi formulated a "Task Force committee" (Dr. SK Sarin as Chairman with DKT, GCK and other 2 members) with the responsibility to review the current status of the preparedness and to recommend urgent measures for preparedness of Delhi for the Covid-19 pandemic. At this time there were 31 Covid positive patients in Delhi. In the absence of any published data to suggest how many of the exposed get infected (Covid test positive), the committee took into account the World Health Organization (WHO) estimates and the existing published literature to arrive at a worst-case scenario in Delhi. Accordingly, it was estimated that

Delhi may have about 15% of the 20 million population exposed during the coming months, i.e. around 3 million people may get exposed to Covid-19. It is not known how many of them may get infected and suffer from the disease. It is known that of those who test positive from Covid-19, about 14% have severe disease, 5% become critical requiring intensive care unit (ICU) admission, and 2.3% require mechanical ventilation and 1.4% die. 5 It was a challenging task to estimate the numbers and after deliberating on various aspects, it was proposed that there is a need to be prepared for at least 3000 ICU beds with ventilation facility in Delhi. These numbers may not be needed at one time, and at present preparedness for 1000 ICU beds with ventilation facility should be considered. The situation would need to be reviewed from time to time. Another aspect that was taken into account was the presence of dual healthcare system in Delhi. Being the capital city, Delhi also has large hospitals run by the central government, who would share the burden of these patients. Even so, the committee decided to persist with these numbers and preferred to err on the safer side.

With this background, a comprehensive plan of requirements for all the aspects of providing care to the Covid-19 patients including among others, infrastructure, equipment, disposables, medicines, human resource and several others was planned, DKT agreed to be the nodal officer for training and supervising the facilities in the ICU services at Delhi government hospitals.

In Delhi, there is a perpetual shortage of ICU beds, therefore, the biggest challenge was to create sufficient ICU beds for an anticipated surge of Covid-19 patients during the next few weeks.

Initially, the specialists and resident doctors from all the Delhi government hospitals from the departments of Anesthesiology, Pulmonary medicine, and other specialties having an experience in working in the ICUs will be recruited for managing these ICUs. In order to meet this challenge, the following fundamental steps were suggested.

1. One or two major hospitals should be designated as exclusive Covid-19 hospitals.

2. It was appreciated that best / recommended care may not be possible, if excessive load of patients is received, and plan should be to provide an optimum care in the existing circumstances.

3. Suspension of elective work after initial curtailment in the hospitals designated to cater to the Covid-19 patients.

4. Arrangements to transfer the existing ICU patients initially to other ICUs of the given hospital to make immediate availability of some ICU beds (for Covid-19 patients), and later on to other government non-Covid hospitals. 5 . Rope in all the ICUs such as general ICU, respiratory ICU, coronary care units, Medical ICU, Surgical ICU, Postoperative wards, and any other.

6. Conversion of as many non-ICU beds that have the centralized oxygen source into a makeshift ICU bed by providing a ventilator and a monitor. 7 . Conversion of all the operation theaters (OT, barring one or two, which will be used for Covid-19 patients, if necessary) into ICU beds.

8. Urgent purchase of vital equipment such as ventilator and disposables to meet the demands of ICU beds created in the above manner.

9. The above arrangements should be made in a phased manner, as it was realized that all the ICU beds cannot be made available in one go.

10. In case the patient load is increased further, private hospitals may have to be involved in providing ICU care to the Covid-19 patients.

In the beginning (25 th March, 2020), Loknayak hospital (LNH), an 1800 bedded tertiary care teaching hospital, and Rajiv Gandhi Super-specialty hospital (RGSSH), a 450 bedded recently commissioned hospital were identified for this purpose. However, they were not declared as Exclusive Covid hospitals, but a part (block/s) of each hospital was to be used for Covid-19 patients.

On 30 th March, the situation at LNH was reviewed and 51 beds located at different floors of the Emergency block were identified, which could be converted into Covid ICUs. Some of these were non-ICU beds and were without a ventilator and some were having patients on ventilator, so a decision was taken to transfer out the patients to other areas and mobilize ventilators from some other areas to the identified ICU facility.

In this manner by the evening of 30 th March, 2020, a total of 22 ICU beds were created in the Emergency block. However, ventilators were to be arranged for some of these beds. In the mean time, nearly 80 Covid-19 suspect patients were admitted to LNH, 3 of whom were having breathing difficulty and were moved to the newly created Covid ICU for administering high-flow oxygen therapy. Thus, the efforts to create the dedicated Covid ICU were put to use. Likewise, the situation was reviewed at the RGSSH, and 19 bedded ICU on a single floor was identified and reserved for the Covid-19 patients. RGSSH also received about 100 Covid-19 suspect patients, but none of them had breathing difficulty, so did not require ICU admission.

There was a sudden surge of patients during the first week of April. In anticipation of further surge in numbers, the government decided to convert three hospitals into exclusive Covid hospitals, these were, LNH, RGSSH, and GB Pant Institute of Postgraduate Medical Education and Research (GIPMER). The other hospitals would remain as the non-Covid hospitals.

On the morning of April 4, 2020, the situation at the three designated Covid hospitals was reviewed in relation to the availability of ICU beds. The total number of ICU beds identified were; LNH: 125 beds, GIPMER: 180 beds, RGSSH: 54 beds (total of 359 beds)

On the morning of April 9, 2020, it was appreciated that GIPMER is the major super-specialty hospital of the Delhi government and by converting it into an exclusive Covid hospital, the care provided to the patients suffering from Cardiovascular, Neurological and Gastrointestinal ailments might be affected. Hence, the decision to declare GIPMER as an exclusive Covid hospital was withdrawn. Therefore, it was now decided to rope in more ICU beds from RGSSH (total of 200) as this 450-bedded hospital has oxygen points on almost all the beds. This would be done in two phases of 100 beds each.

Thus, on the morning of April 10, 2020, the situation of identified ICU beds was; LNH: 125 beds, RGSSH 200 beds, (total of 325 beds). Admission to the ICU would be determined by the severity of disease as defined by the government of India (GOI) on 7 th April 2020. Only those with severe symptoms (respiratory rate >30/ min, arterial oxygen saturation (SpO 2 ) <90% on room air) would be admitted to the ICU; those with moderate symptoms (respiratory rate 15-30/min, SpO 2 90-94%) would be admitted to dedicated Covid Health centers for oxygenation and monitoring. 6 The timeline of various important events is depicted in figure 1.

In this crisis situation, in order to commission as many ICU beds as possible, minimum equipment required to make a bed functional as an ICU bed was identified. This would entail judicious distribution of available resources and minimizing the requirement of urgent procurement of additional equipment (which was available with difficulty due to shortage) to overcome the deficit of equipment. In this background, it was considered that each ICU bed will mandatorily have the (table 1) . This would be beneficial to strengthen each ICU bed in the coming days as and when the procurement fructifies.

The Covid-19 patients are likely to suffer from acute respiratory distress syndrome (ARDS). It was considered that as a first preference, ICU ventilator with the standard modes of ventilation inclusive of airway pressure release ventilation (APRV) mode should be preferred. However, in view of the shortage of ventilators in the market, it was suggested to consider even lower-end ICU ventilators including even the transport ventilators which would be used as a backup in a situation when the standard ventilator is not available for the patient. In addition, the patients in the OT should be ventilated with anesthesia ventilators installed on the work station / anesthesia machines.

In extreme circumstances, a bed without an oxygen source would be used as an ICU bed with the help of a turbine-based transport ventilator that can ventilate with air. Bilevel positive pressure ventilation (BIPAP) and high-flow oxygen therapy would also be a consideration. Furthermore, split ventilation was also considered, but would be used in exceptional pressing situations with the consent from the patient / relative. As a general principle, it was considered that salvageable patients should receive a better ventilator as compared to those who are considered difficult to salvage. However, the final decision would be left to the concerned consultant of a particular ICU.

Some agencies came forward with the offers to donate ventilators from their resources, which would be helpful to compensate the deficiency in part. As on date (April 12, 2020), the approximate additional requirement of ICU ventilators is estimated to be approximately 150 to activate the proposed 325 ICU beds. An equal number of multi-parameter monitors was also proposed to be purchased.

An inventory of various disposables / small equipment that is required to run the ICU was prepared (table 2). The list of medicines required to run the various ICUs was also prepared (table 3 ).

In addition, blood banks to be in readiness to fulfill the demand of blood and blood products. A Core committee consisting of 5 senior doctors was formed for each hospital to look into the above requirements and prepare the demand that can be submitted to the concerned authorities for urgent procurement.

It was appreciated by the committee that the staff will get fatigued quickly while working with the bulky PPE. Hence, it was planned to make a 6-hourly shift for the staff members. (some countries have preferred to make a 4-hourly shift). It was proposed to constitute a team of staff to look after a 12-15 bedded ICU. Each team will work for a period of one week. The team will be divided into 4 sub-teams to work in 4 shifts of 8 am to 2 pm, 2 pm to 8 pm, 8 pm to 2 am, and 2 am to 8 am. After one week, the team will be replaced by another team. The first team will be quarantined for a period of two weeks before it can be put to work again, if necessary. Thus, each team will work for a period of one week and then rested for a period of 2 weeks. 7 In the beginning, three teams should be identified for each 10-15 bedded ICU so that arrangements are made for the initial 3 weeks. The constitution of each team and the requirement of staff for a period of 3 weeks, if 100 ICU patients are admitted is shown in table 4. The testing protocol for Health care professionals (HCPs) would be symptom driven, except before termination of the quarantine period, when it would be mandatory.

It was emphasized that the safety of Health care professionals (HCPs) is paramount and therefore, good quality PPEs must be provided to each of the HCP. In addition, N/95 face masks and sufficient hand scrub antiseptic solution should be readily available to all the staff members. A full complement of PPE inclusive of goggles, face shield, mask, gloves, coverall/gowns (with or without apron), head cover and shoe cover as defined by the GOI should be used by the staff working in the ICU. 8

It was also appreciated that all the HCPs will have to be in isolation after they finish their shift duty. Hence, adequate accommodation to the HCPs was arranged at the hospital premises. For LNH, accommodation was arranged at the adjacent GIPMER by vacating three floors of a special ward, which have separate rooms with attached bath. In addition, rooms were arranged in a nearby hotel.

For RGSSH, the newly constructed resident doctor's hostel was proposed to be used as accommodation for the staff members. Adequate arrangements for serving food to these staff members was also worked out. 

In the absence of any definite data, and not knowing how effective the complete lock-down would be, it was very difficult to estimate even the probable number of ICU beds that are likely to be required during next 4-8 weeks. The authors believed that it is safer to assume the worst scenario and err on the safer (higher) side for this purpose. The committee projected to create 1000 ICU beds, but in the first phase has been able to identify only 325 beds that could be converted into ICU beds. One hundred more beds can be created at RGSSH in the next phase and for further increase in the beds, the ICUs of the private hospitals will have to be roped in. Since, the situation is dynamic, evaluation will be necessary at regular intervals.

It is crucial to identify dedicated Covid hospitals exclusively for the Covid-19 patients. In the initial phase, when the number is small, it may be possible to manage Covid-19 patients in an These of course, will vary from place to place and individualization will be necessary

Due to a sudden increase in the demand of equipment and other disposable materials for managing the Covid-19 patients all around the world and also due to stoppage of import and export of material, there was an acute shortage of these items in the country. Although, the government wanted to make bulk purchases of these items, there were not enough supplies to meet the demands. However, efforts on war footing are going on and sufficient supplies are expected soon.

On 19 th April, a 3-plier surgical mask making machine was set up by the Delhi government. The machine has a capability to produce 100,000 masks per day. Likewise, the domestic manufacturing of PPE and medical equipment was ramped up to meet the increasing demand. The Defense

Research and Development Organization has taken a lead in this matter. 9 In addition, substantial material and equipment supplies is expected from the central government, which will be shared amongst all the states of India. These will be utilized to equip each of the ICU beds that has been identified in the two hospitals.

Due to sudden increase in the number of ICU beds, 6 hourly duty roster and a mandatory break of 2 weeks (quarantine period), acute shortage of trained staff should be anticipated. Hence, deployment of additional staff who can work in an ICU from other hospitals will be necessary. It was suggested that a pool of staff should be created as soon as possible so that as and when the situation worsens, the identified staff is readily available for providing necessary care.

It was decided to arrange to provide training to all levels of staff on various aspects related to the management of Covid-19 patients. In particular, the measures and precautions to be taken to avoid the contact and spread of the disease were taken into account. The other training provided 

The other challenges included creation of facilities to meet the logistic requirements such as signages, partitioning; arranging in-house accommodation for the staff; encouraging and motivating the staff to keep up the morale; arranging to transport patients to and from the Covid hospitals, and so on.

The Covid-19 endemic has posed several challenges. In essence, it is a fight against a common enemy with unknown transmission pattern with no treatment or vaccine available. The Delhi has been relatively slow as compared with other nations. 10 We pray and hope that the strict measures taken and implemented by the government by way of social (physical) distancing and the complete lockdown will show positive results and the preparations will not be actually put to test, however, if they are, it is expected that they will fulfill the requirements. The authors acknowledge and agree that the model proposed in this article is, but one method of dealing with such a difficulty, and there could be other, perhaps better methods of dealing with the problem. Also, local circumstances and existing facilities will vary from place to place and have to be taken into account before such plans are prepared elsewhere.

Conflict of Interest: DKT is on the Editorial Board of the JCVA

The authors acknowledge the support provided by the political leaders, the administrators, ICU Team (for 12-15 beds) : Faculty / Consultant-1, Senior resident-6, Junior resident-6, Nurses 24, Technicians -6, Housekeeping-12, Sanitation workers -5.

There will be 4 shifts : 8 am to 2 pm, 2pm to 8 pm, 8 pm to 2 am, 2 am to 8 am. Each team works for 6 hr/day for 1 week, then quarantined for 2 weeks; 2 nd team replaces the first team at the end of the first week. 

CNBC breaking news

Kerala defeats coronvirs

India's three COVID-19 patients successfully recover

Clinical characteristics of Coronvirus disease 2019 in Chine

Preparing for COVID-19: early experience from an intensive care unit in Singapore