#Title

At maximum capacity

What strategies should hospitals use to deal with the overflow of Covid-19 patients?
Ayesha Sania, Taufique Joarder, Mohib Nirob, Ahmed Sami Al Hasan and Shara Khan
The Covid-19 pandemic is spreading at an exponential rate and policymakers are racing against time to find effective solutions. Right now, hospital capacity to treat Covid-19 patients across the country is reaching a maximum. The situation is so critical that only patients with respiratory distress (with oxygen saturation below 90 percent) are being offered to be hospitalised at the designated Covid-19 hospitals. Most critically ill Covid-19 patients require oxygen support from a central oxygen supply. Of all the government run hospitals, Dhaka Medical College and Hospital’s Burn Unit and Mugda General Hospital are the only known facilities to provide a central oxygen supply to patients. Other government run hospitals do not have access to a central oxygen supply and very few places are able to provide the positive pressure oxygen that is required by Covid-19 patients. There is an urgent need for strategies to deal with the hospitalisation and management of Covid-19 patients in both urban and rural areas.
Epidemiological considerations to be remembered before delving into the strategies are that 80 percent of coronavirus patients present mild symptoms not requiring any hospitalisation, 20 percent present have severe symptoms requiring hospitalisation and 5 percent are critical, needing ICU admission and ventilation support. Due to limitations in the current testing criteria and capacity, most diagnosed patients fall under the “hospitalisation required” category. To provide the best service to these hospitalised patients and to keep the mortality as low as possible, a few steps can be adopted by healthcare facilities.
In urban areas such as Dhaka, Narayanganj, Mymensingh and Chattogram, the urban poor living in slums with mild symptoms who are unable to self-isolate may be quarantined in makeshift isolation centres, like local schools, colleges, community centres etc, where physical distancing can be maintained. To cater to patients with severe symptoms requiring hospitalisation and oxygen supply, increasing the number of hospitals (designated for Covid-19 treatment) and building central oxygen supplies are necessary. A quick and cost effective solution is to build partnerships with private hospitals with access to central oxygen supply. Also, empty cabins at these private facilities can be used to isolate and treat patients awaiting Covid-19 test results.
A huge surge in the number of Covid-19 positive patients in rural areas is expected in the upcoming weeks because of Eid travel and therefore, having plans in place to manage the surge is imperative. All patients with Covid-19 like symptoms should be tested at upazila health complexes, and to prevent community transmission, they should be quarantined in local hospitals until maximum capacity is reached. Makeshift isolation facilities such as schools and community centres, may be used to quarantine patients after full capacity is reached in hospitals. This is a crucial step in preventing community transmission. Patients with mild respiratory distress can be treated with portable oxygen cylinders at upazila health complexes and patients presenting with severe symptoms should be transferred to the nearby local Covid-19 designated hospitals.
It is recommended that each district assigns a designated Covid-19 hospital, or a few adjacent districts together assign a designated Covid-19 hospital depending on the population size and the number of expected cases. And as with urban areas, building partnerships with local private hospitals will give access to central oxygen supply and ICU facilities. At the same time, nurses need to be trained to work in these two units. Since the number of expert/trained nurses is inadequate, online courses can be offered to meet the required number of nurses.
There also needs to be in place some strategies to safely manage Covid-19 and non-Covid-19 patients simultaneously in healthcare facilities, across all districts. Grouping patients based on the severity of the disease and the urgency of the treatment needed is known as “triage” in the medical field. Setting up triage in healthcare facilities is crucial in managing this Covid-19 pandemic.
Urban hospitals can construct designated spaces for triage and upazila health complexes can utilise the open spaces available at the entrances. Low cost tents or light structures built with locally sourced construction materials can be used to set up the triage with the help of law enforcing agencies. Ideally, the entire hospital and all its divisions need to be divided into Covid-19 sections and non-Covid-19 sections with a cardboard or glass wall separating the two.
In the triage space, patients will be evaluated and prioritised according to the symptoms and severity of illness. Patients requiring urgent hospitalisation, resuscitation or at a high risk of deterioration should be immediately transferred to the emergency unit, but should be kept separated from Covid-19 positive patients while waiting for test results.
Other patients should be further evaluated for Covid-19 clinical symptoms (fever, cough, shortness of breath) and grouped as high, medium and low risk groups. Low risk patients can self-isolate at home or at isolation facilities. The medium and high risk groups should receive appropriate treatment according to World Health Organization (WHO) guidelines.
All hospitals should have specific guidelines for healthcare practitioners and other associated personnel. They should be supplied with infection prevention and control materials and trained on how to use them. In addition, they should have access to changing rooms and disposal facilities. There should also be clear and visible awareness raising materials, such as sign boards, posters etc, for patients.
The exponential growth in the number of Covid-19 patients is straining our already burdened healthcare system and healthcare practitioners are struggling to cope with this challenge. Therefore, volunteers and other professionals can be welcomed to share the burden by managing tasks not directly involved with patient care.
The healthcare budget should also be optimised keeping the disease epidemiology in mind. It is imperative to remember that 20 percent of coronavirus patients require hospitalisation and only five percent require ventilation. To reduce mortality rates and to cater to the majority of patients requiring hospitalisation, adequate supply of oxygen and devices to measure oxygen levels (pulse oximeter) needs to be ensured. Another important thing to keep in mind while budgeting is that increasing testing for Covid-19 can not only increase our improved patient outcome but also helps reduce community spread.
At this point, collaboration between public and private hospitals is necessary. To bring this collaboration to life, each district should form a committee with the Deputy Commissioner in charge of overall supervision, a Civil Surgeon spearheading the committee and the Police super assisting the committee. The goal of this committee will be to establish collaboration between selected public and private hospitals in the least amount of time. The Civil Surgeon will look after the technical and management aspects of the merger while the Deputy Commissioner will handle the bureaucratic facets. The Police Super will ensure safety and if necessary, take legal actions against unrest and chaos. At upazila levels, committees will have an Associate Civil Surgeon, Upazila Executive Officer and circle Deputy Police Super who will directly report to the district committees or their respective superiors, depending on the need.
The Covid-19 pandemic will most likely be the worst health crisis ever faced in the history of Bangladesh. To successfully overcome this, the country must fully utilise its limited resources with utmost efficiency.
Ayesha Sania is Research Scientist (epidemiologist) at Columbia University, USA; Taufique Joarder is Executive Director at Public Health Foundation, Bangladesh; Mohib Nirob is Founder of Platform, Bangladesh; Ahmed Sami Al Hasan is Assistant Professor (surgery) at Kurmitola General Hospital, Bangladesh and Shara Khan is at the University of Alberta (assisted in content writing and editing).
PHOTO:
ANISUR RAHMAN