Strategies for managing surge capacity: increasing hospital capacity

• Converting wards typically used for other reasons into COVID-19 treatment wards
• Cancelling elective procedures and surgeries (at least 1 week prior to patient surge)
• Shifting outpatient appointments to other times or settings. This may be particularly useful for chronic disease, for example
• Community Health Workers (CHWs) distribute medication refills
• Phone or text messaging for virtual appointments instead of in-person consultation
• Consider increasing the time duration between follow up visits for stable patients; ensure they are given sufficient quantities of medications until their next visit
• Shift non-COVID-19 inpatients to alternate treatment sites, for example:
  • Malnutrition treatment to health centres or local community settings or CHW supported
  • Transition patients on long courses of antibiotics to oral antibiotics and discharge home
  • Move all routine hospital outpatient visits (e.g. antenatal care, under 5s) to primary care centres to repurpose outpatient space for inpatient or isolation beds
  • Identify alternate treatment sites for mild cases (churches, hotels, schools, etc.) with local authorities
• If several beds can be freed from each ward, wards can be combined to create an empty space for COVID-19 treatment
• These approaches require a multidisciplinary team, including physicians, nurses, midwives, CHWs, facilities managers, and hospital administration
• Allocation of advanced care services may become necessary for treatment such as oxygen therapy or ventilation. There are two key recommendations to consider:
  • Plan in advance: This is critical to ensure equity and to protect staff from making very difficult decisions without support
  • Focus on saving the most amount of lives and likelihood of survival from COVID-19: Allocation systems which incorporate factors such as age, gender, social or economic characteristics, or other illnesses may lead to inequity and be difficult to apply. In addition, some of these (e.g. age) will already impact likelihood of survival and therefore are inherently included

Sources & links

• Health Leaders Media | https://www.healthleadersmedia.com/clinical-care/5-strategies-manage-surge-coronavirus-patients
• ONA | https://www.ona.org/wp-content/uploads/mohltc_surgecapacitymanagementtoolkit2-0_200903.pdf
• NHS | Clinical guide for the management of surge during the coronavirus pandemic (below) | LINK to Original PDF

Introduction / overview

Preparations/setting up the patient room (bed station)

• Windows and doors of the room must be kept closed with a HEPA filter in operation
• Set up the room and protective equipment according to checklists (see below)
• Attach the “COVID-19 positive patient” signs to the patient room
• Restricted access in positive cases
• The cleaning service is informed by the ward management. The management of the cleaning service is responsible for the implementation of disinfection measures

Isolation room checklist

• Disinfectant gel, powder and wipes
• Two separate areas (clean and dirty zone, e.g. two trolleys)
• Laundry and waste containers with lids
• Garbage and laundry bags (yellow and red; double bag system)
• Nitrile gloves
• Overshoes (yellow; blue with defined exceptions)
• Respirator masks FFP2/FFFP3/N95/KN95, fit check; containers for storage
• Safety glasses
• Surgical caps
• Decongestant
• Waterproof pen
• Mobile equipment trolley (ejecting blood tubes etc.)
• Vital sign monitoring device (with pulse oximeter and blood pressure monitor), thermometer, stethoscope, glucometer, if necessary
• Bed linen, terry towels, blankets, nightgown, pillow, incontinence material, mesh pants, disposable towels and cloths
• Disposable toothbrush, toothpaste, spatula, mug, cotton swab, spatula, kidney cups, disposable mouthpiece
• Oxygen connection with adapter and nasal cannula if necessary
• Sharps container for used syringes, opened glass vials, and other sharp objects
• Wall clock, furniture (bedside table, table, chair)

Gather together the medical equipment you need to test and treat COVID-19 patients

The following table is a list of medical items you will need in the following hospital areas:

• Secondary screening area
• Presumptive COVID-19 area
• COVID-19 ward
• Critical care area

Introduction / overview

COVID-19 is highly infectious. Infection control and prevention are critical to protect patients and staff. Administrative controls, environmental controls and personal protection are all key elements of a safe environment. All of these controls rely on vigilance for suspected cases and safe screening, testing and isolating confirmed cases.

Initial screening

• Separate screening area outside of healthcare facility or at hospital entrance
• All patients entering healthcare facility are screened for fever, cough, SOB, known contact of COVID-19 patient, or recent travel that may place them at risk
• Screener should wear full PPE
• If initial screen positive:
  • Immediately place face mask on patient and provide patient with alcohol based hand sanitiser
  • Direct patient to triage & testing area

Triage & testing

• Secondary screening space should be separated from other patients
• Providers should don full PPE and observe contact and droplet precautions
• Follow protocols for specimen collection for laboratory testing
• Asymptomatic patients may be directed home with follow up and to self-isolate pending test results
• Symptomatic patients may be admitted to isolation area per protocol

Suspected / probable cases of COVID-19

There should be separate isolation areas for suspected or probable cases who have not yet been confirmed to have COVID-19.

• When a patient comes to a facility with symptoms consistent with COVID-19, known contact with COVID-19, or a history of travel, it is important that IPAC is adhered to. There are two levels of isolation:
  • Asymptomatic suspected/probable cases: Known contact or travel history, but no symptoms. Once tested asymptomatic suspected cases may return home with close follow up and instructions to self-isolate pending test results
  • Symptomatic suspected/probable cases: Should be evaluated clinically for admission and separated from asymptomatic patients pending the test result
• Presumptive case areas for suspected or probable cases should be separated into low and high risk areas depending on clinical suspicion

Isolation for confirmed positive patients OR highly symptomatic suspected / probable cases

These patients should be moved immediately to the isolation unit.

General practices and procedures

• Providers should move from asymptomatic to symptomatic and finally to confirmed patients
• Limit transport and movement of patients. When transport is necessary don clean PPE, place face mask on patient, and follow respiratory/hygiene etiquette
• The isolation area must be a separate enclosed space removed from other patients
• Equipment (stethoscope, BP cuff, pulse oximeter) must remain in the room and must be cleaned and disinfected between each patient (e.g., by using ethyl alcohol 70%)
• No visitors for suspected or confirmed patients (see exceptions below) as a strategy to help conserve PPE. All parents must wear PPE and can remain with a child as a caregiver
• Once patient is in the isolation area they cannot leave except to a dedicated bathroom for isolated patients, movement within the hospital per healthcare provider, or discharge
• Maintain a record of all persons entering a patient’s room or isolation space, including all staff and visitors

Covid-19 triage & screening flowcharts

Cohort areas

If a single/isolation room is not available, cohort possible or confirmed respiratory infected patients with other patients with suspected/probable or confirmed COVID-19. Use privacy curtains between the beds to minimise opportunities for close contact. Where possible, a designated self-contained area or wing of the healthcare facility should be used for the treatment and care of patients with COVID-19. This area should:

• Include a reception area that is separate from the rest of the facility and should, if feasible, have a separate entrance/exit from the rest of the building
• Not be used as a thoroughfare by other patients, visitors or staff, including patients being transferred, staff going for meal breaks, and staff and visitors entering and exiting the building
• Be separated from non-segregated areas by closed doors
• Have signage displayed warning of the segregated area to control entry

Hospitals should consider creating cohort areas which differentiate the level of care required. It may also be prudent to consider:

• The need for cohorting in single/mixed sex wards/bays
• Underlying patient conditions (e.g., immunocompromised)
• Age groups when cohorting children
• Routine childhood vaccination status when cohorting children

 Staff cohorting

Assigning a dedicated team of staff to care for patients in isolation/cohort rooms/areas is an additional infection control measure. This should be implemented whenever there are sufficient levels of staff available (so as not to have a negative impact on unaffected patients’ care).

Maintain consistency in staff allocation where possible and reduce movement of staff and the cross over of care pathways where feasible between planned and elective care pathways and urgent and emergency care pathways. Wherever possible, reduce staff movement between different areas.

Staff who have had confirmed COVID-19 and have recovered should continue to follow the infection control precautions, including personal protective equipment (PPE).

Sources & links

• The UK Government | https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/reducing-the-risk-of-transmission-of-covid-19-in-the-hospital-setting
• New Jersey Department of Health | Considerations for cohorting COVID-19 patients in post-acute care facilities | Link

Managing COVID-19 in resource limited settings: critical care considerations

The coronavirus (COVID-19) pandemic has now involved numerous low and middle income countries (LMICs). The healthcare systems in LMICs face serious constraints in capacity and accessibility during normal times. This would be aggravated during an outbreak, leading to worse clinical outcomes. Moreover, 69% of the global population aged 60 and above live in LMICs. These older persons are at increased risk of severe COVID-19 and mortality.

LMICs may lack time and resources for swift uptake of new technologies (e.g., rapid test kits, vaccines, and antivirals). From a more urgent and pragmatic perspective, we believe creative use of existing resources and repurposing others for humane medical care are needed (see tables below). We acknowledge that our suggestions may be perceived as controversial, and we wish to emphasize that maximisation of conventional healthcare assets should always be done before turning to unconventional solutions.

Infrastructure

Anticipation of an impending outbreak helps with vital preparation. Unfortunately, during the COVID-19 pandemic, there is little time to construct new infrastructure. The World Health Organization (WHO) has recommended airborne isolation, but isolation facilities are limited. Industrial exhaust fans have been used to convert existing normal pressure single rooms to negative pressure rooms to increase isolation [2]. This approach is relatively quick and may be used for creating more negative pressure intensive care unit (ICU) beds. Alternatively, confirmed cases can be cohorted in open ICUs with adequate ventilation.

Opening field hospitals in large public spaces (e.g., stadiums) allows for triaging and managing stable patients and decongesting other hospitals. Local networks between smaller district hospitals and larger tertiary centres can be established to facilitate patient transfers, as smaller hospitals can be easily overwhelmed. Well patients with COVID-19, instead of being quarantined in hospitals, can be quarantined in specially designated facilities, such as a hotel. If communication systems are available, well patients could be sent home and monitored remotely.

Makeshift acute or critical care units can be set up in operating theatres and clinic spaces to cope with increasing numbers of critically ill patients. This can be achieved by reducing non-essential services such as elective surgeries and outpatient clinics.

Patient monitoring or testing

For LMICs, focused testing on symptomatic patients instead of random screening would place less strain on the healthcare system. Rapid test kits are an option to allow LMICs to perform diagnostic tests faster, but this would require international health organizations to transfer knowledge and test kits. It may be necessary to isolate an entire community for containment.

Radiological investigations and laboratory support would also be stretched beyond capacity. Physicians may need to rely mainly on bedside clinical examination. If available, bedside point-of-care ultrasonography can yield significant amounts of information. Early clinical detection and admission to the correct facility can help with right-siting before confirmatory tests are out, reducing nosocomial and community spread. Simple scoring systems, such as the qSOFA score, can be harnessed to detect deteriorating patients [3].

Treatment

Hospital ventilators will likely be in shortfall. To supplement ventilators, anesthesia units in operating theatres and transport ventilators can be used. Improvised continuous airway pressure (iCPAP) ventilation systems [4] or bubble continuous airway pressure for children [5] can be employed when there is a dire shortage. The addition of high-efficiency particulate air (HEPA) filters to the expiratory limb of the circuit can help minimize aerosolisation if the ventilator does not have a closed circuit. Other creative approaches include splitting a ventilator to support several patients simultaneously by using T-tubes and pressure-cycled ventilation [6,7,8].

Proning positioning has been reported to work in critically ill COVID-19 patients with moderate-to-severe acute respiratory distress syndrome [1]. Patients who are moderately hypoxaemic can be proned early to improve oxygenation if oxygen supplies are limited, presumably even if they are not invasively ventilated [9]. Other approaches to save ICU resources include using enteral vasopressors, such as midodrine for hypotensive patients, instead of intravenous formulations [10]. In states of emergencies, veterinary supplies, such as cleaning solutions, syringe pumps, and even ventilators, could be mobilised to augment hospital stocks.

Ultimately, there still needs to be fair and ethical resource stewardship [11].

Personal protective equipment (PPE)

HCWs working on the frontlines need to be protected adequately, or they risk being infected with COVID-19 and even dying [12]. This is also applicable to personnel such as ambulance drivers and military troops. PPE can be reused to reduce waste [13] and preserve existing stocks. Certain types of PPE like goggles may be shared after disinfection. Deploying reusable powered air-purifying respirators is an option. Other innovative approaches include testing, validating, and assembling simple reusable elastometric respirators to replace N95 respirators [14].

If prior infection can be proven to confer immunity, other approaches to reduce PPE use can include deploying convalescent HCWs to care for confirmed COVID-19 patients and enrolling convalescent patients to volunteer in healthcare.

Personnel

To cope with healthcare demands, active recruitment and training of healthcare personnel should be done concurrently. Besides recalling HCWs on leave, recruitment and redeployment from different sectors (e.g., dentists, paramedics, medical students, military personnel) and even recalling retired personnel may be required. Laypeople, including carers, can be recruited into the hospital after training to provide basic care for patients. Task shifting should also be considered among nurses and doctors; for example, surgeons can be taught simple ventilator care. Sharing simple treatment protocols will aid those who have been redeployed.

Information

In a large-scale pandemic, crucial information about the disease and workflows are constantly evolving. There is a need for information to be disseminated and assimilated rapidly on the ground to prevent delays. An agile system of information dissemination should include mobile phones via text messages or emails and paper-based mailers. Protocols and checklists will also help in standardizing medical care and reducing wastage.

Transport

Harnessing non-medical transport services, such as private-hire and public vehicles and military vehicles, can help improve accessibility to healthcare in LMICs. These vehicles can help ferry unwell patients from the suburbs to regional or central hospitals and reduce delays to medical care. A caveat would be that these transport vehicles need to be thoroughly cleaned following transport [15].

Sources & links

• Critical Care | https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-02890-x

Table Data | Link

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