key: cord-310621-wnd47uss
authors: Singh, Shalendra; Cherian Ambooken, George; Setlur, Rangraj; Paul, Shamik Kr; Kanitkar, Madhuri; Singh Bhatia, Surinder; singh Kanwar, Ratnesh
title: Challenges faced in establishing a dedicated 250 bed COVID-19 intensive care unit in a temporary structure
date: 2020-11-06
journal: nan
DOI: 10.1016/j.tacc.2020.10.006
sha: 
doc_id: 310621
cord_uid: wnd47uss

An Intensive Care Unit (ICU) is an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency. While this availability of trained manpower and specialized equipment makes it possible to care for critically ill patients, it also presents singular challenges in the form of man and material management, design concerns, budgetary concerns, and protocolization of treatment. Consequently, the establishment of an ICU requires rigorous design and planning, a process that can take months to years. However, the Coronavirus disease-19 (COVID-19) Epidemic has required the significant capacity building to accommodate the increased number of critically ill patients. At the peak of the pandemic, many countries were forced to resort to the building of temporary structures to house critically ill patients, to help tide over the crisis. This narrative review describes the challenges and lessons learned while establishing a 250 bedded ICU in a temporary structure and achieving functionality within a period of a fortnight.

Post planning and designing of the hospital, work on building the hospital commenced on 2 24 June 2020. The treatment area of the hospital consisted of four main hangars (each consisting 3 of 250 beds, with one hangar being designated the ICU/Unit/ High Dependency Unit), and a 4 triage area for reception of patients (Fig. 2, 3) . All treatment areas of the hospital were connected 5 by a concrete platform. Apart from the treatment area, the hospital also contained a doctors' 6 block, an administrative area, separate donning and doffing areas and a mortuary with the 7 capacity to store the 10 bodies. Additional facilities available also included a liquid oxygen tank, 8 a laboratory, radiology services including X-Ray and ultrasonography, and an in-house 9 pharmacy. All regions of the hospital were demarcated as 'Red' zones (requiring donning of full 10 complement personal protective equipment prior to entering), and 'Green' zones, where freedom 11 of movement was allowed.

Being a temporary set up, the frames of the hospital were made of aluminium alloy, and 14 the sheet was made from fire-resistant poly-elastic material. The cubicles and partitions were 15 made from octanorm® partitions. The description of the whole hospital including the technical 16 specifications is beyond the scope of this article, which will deal primarily with the challenges 17 faced during the operationalization of the ICU. In its 2020 guidelines on ICU planning and designing in India, the Indian Society of 22 Critical Care Medicine(ISCCM) has laid down recommendations for the setting up of an ICU, 23 including the initial planning, decisions about ICU level, number of beds, ICU design, equipment 24 provision, support system recommendations, manning plans, human resource development, and 25 environmental planning among others(8). These guidelines were developed by the ISCCM as a 26 consensus document for the standards to be aspired for the provision of safe and high-quality 27 intensive care in India and were taken as a baseline while planning the design and functionality 28 of the ICU. However, while the ISCCM guidelines do address resource limitations in the form of 29 resources, size of the institution and variability across specialties and subspecialties, the 30 J o u r n a l P r e -p r o o f designing of this ICU differed at places with these guidelines due to the restrictions in place due 1 to the disease process per se, as well as the time constraints due to the urgency of the project. In accordance with the ISCCM guidelines, the planning committee for the ICU design 4 and equipment provision included all the stakeholders -the architects, and engineers, the 5 consultant intensivist, physicians, and was coordinated by an administrator to ensure smooth 6 functioning and to ensure that everyone was on the same page. However, some difficulties were 7 faced since a consultant intensivist was not involved during the initial (first 3 days) of planning 8 of the architectural design of the hospital, leading to a few points being overlooked during the 9 initial planning, such as the integration of a shower area in the doffing zone, establishment of fire 10 safety protocols and evacuation plan, maintenance of optimal temperature of the ICU, and 11 provision of uninterruptible power supply (UPS) system and generator backup for the ICU, 12 especially the ventilators. These points were addressed subsequently, with separate shower areas 13 being built in the doffing zones, fire safety protocols and evacuation plans being formalized, 14 climate control of the ICU is optimized, and UPS and generator system is enabled. Specific 15 challenges faced concerning these points have been discussed in subsequent paragraphs. 

The first challenge in the designing of the ICU was in deciding the level of the ICU. The 20 ISCCM defines three distinct levels of ICU, with a Level II ICU being recommended for large 21 general hospitals, and a Level III ICU (the highest tier) being recommended for tertiary care hospitals [8] . It was also suggested that an ICU comprises not more than 16 beds in any setup.

However, the fact that the structure was meant to be temporary, in addition to the urgency due to 24 the rapid spread of the pandemic precluded such a design. The ICU was consequently divided ventilators assembled in the ICU (Fig. 4) . Another challenge that we faced was that, even with 2 robust manufacturer support, the haste at which the whole project had to be completed resulted in 3 a few equipment glitches and faulty equipment (approximately 5%) being delivered. The faulty 4 equipment was repaired post-inauguration but did not affect the functionality of the hospital 5 since the initial days were covered by the functional equipment already available. Perhaps the most specialized and maintenance reliant equipment in the hospital was to be 9 established in the laboratory. It was realized that for organizations with a dearth of experience in 10 laboratory design, the task of setting up a laboratory in a fortnight could prove complicated.

However, an in-house laboratory with the facilities to run all basic investigations was considered 12 essential for patient management. Consequently, a private diagnostics firm was given the 13 contract to establish a laboratory with all the basic investigations within the hospital premises.

14 Additionally, the liaison was maintained with a local diagnostics facility to conduct specialized 15 tests. The quality control for the laboratory was done by specialists who were part of the duty 16 contingent.

The indenting procedures for drugs and other consumables in the ICU also required fine-tuning 19 and proved surprisingly difficult. The hospital had given the contract for the provision of all 20 required consumables to a private pharmacy which, apart from maintaining an on-site pharmacy, 21 would also liaise locally for any extra requirements should the need arise. However, the private 22 pharmacy company did not have the requisite licenses to provide 'Schedule X' drugs (strongly 23 habit forming drugs, which have the potential to be abused -predominantly opioids); these had to 24 be locally sourced from a sister hospital. Additionally, the lack of universal nomenclature for 25 many commonly used ICU consumables resulted in erroneous materials being initially provided, 26 which had to then be returned. However, most issues could be ironed out within the building 27 period and did not significantly hamper ICU functionality. 

With the project having to be completed in under a fortnight, difficulty was encountered in 1 ensuring adequate electric supply and climate control for the hospital. Electric supply was 2 provided with a generator capable of providing 5.5 MW power. Due to an oversight, the initial 3 electrical design of the ICU had only catered for three plug points per patient bed, which was 4 inadequate and had to consequently be augmented to eight per bed. Also, with the indented 5 equipment arriving and being calibrated only three days prior to the inauguration of the hospital, 6 load testing could not be conducted until two days prior to commencement of operation. Load However, the same could not be catered due to the design and space constraints within the ICU, 1 and only two washbasins could be provided per ICU partition of 25 beds. It is well recognized that nutritional support is a cornerstone of good critical care [14] . 5 However, the catering services for the hospital had been outsourced to catering with limited 6 experience in hospital diets. Specific diet charts were provided to the firm, along with 7 instructions, to ensure adequate nutrition of the admitted patients. Apart from the monitoring of 8 the nutritional value of the diets, regular patient feedback was also sought to assess the 9 palatability of the hospital food, as this was deemed to be a significant determinant in overall 10 patient satisfaction. 

The disinfection and disposal of biomedical waste (BMW) also proved to be a challenge, 14 with extra caution needed to be exercised since improper handling of the waste could also lead to 17 The ICU was designed in such a way that it was connected to all the wards of the hospital 18 by a common alleyway, and was easily accessible from any of these wards. This was considered 19 essential to expedite the transfer of any patient who would deteriorate in the ward. Specific Logistical support remained a significant challenge, with considerable effort being 8 needed to fine-tune the system to attain maximal efficiency. Issues such as apparel size for the 9 duty personnel, catering demands of the patient population, Wi-Fi connectivity issues and user 10 unfamiliarity with the online database, all surfaced after the commencement of the functioning of 11 the hospital. It was also found that despite extensive training and mock drills being carried out 12 prior to accepting patients, there arose considerable confusion in certain facets relating to 13 logistical support, and had to be proactively corrected by the administrative teams. requirements of the other collaborators. One valuable lesson learnt from the establishment of this 6 ICU was the importance of including the intensivist at the very beginning of the planning and 7 designing process as the intensivist provides a unique viewpoint, which is often overlooked by 8 administrators. The involvement of ground-level workers during the designing process could also 9 help reap rewards, as they are often best placed to provide an insight into the patient perspective. The initial trends from the ICU also showed that while concerns over the effectiveness of 21 makeshift hospitals do still exist, when executed well, they have the potential to significantly 22 augment the healthcare facilities in the event of an epidemic. However, there is a need for a more 23 defined protocol for the establishment of a large-scale ICU, which would aid significantly in the 24 disaster response to future medical emergencies. 

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