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   Table of Contents      
SPECIAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 2-8

Challenges and Experience of Setting Up a 2000 Bed COVID-19 Care Center on an Urgent Basis at Delhi


1 Base Hospital, ITB Police, Tigri Camp, P.O. Madangir, New Delhi, India
2 Maulana Azad Medical College, New Delhi, India
3 Department of Neonatology, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi, India
4 44 BN, ITB Police, Delhi, India

Date of Submission30-Dec-2020
Date of Decision10-Feb-2021
Date of Acceptance16-Feb-2021
Date of Web Publication28-Apr-2021

Correspondence Address:
Dr. Deepak K Tempe
FRCA, Professor of Excellence and Former Dean, Maulana Azad Medical College, New Delhi, Type VI/5, MAMC Campus, New Delhi 110002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_130_20

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  Abstract 


Background: In the city of Delhi, with rapidly increasing number of COVID-19 positive patients, a need for creating a large COVID-19 care center (CCC) for mildly symptomatic patients was badly felt. This paper describes the challenges of setting up a 2000 bed facility and the experience with the first 400 patients treated in the center. Methods: The Indo-Tibetan Border Police was assigned this task, which was completed in a record time of 10 days in collaboration with several other government and nongovernment agencies. Results: All the involved agencies displayed teamwork of the highest order and completed the task. The first 400 mildly symptomatic patients were successfully treated at the center. Patient safety was the priority, and a protocol was devised for early detection of patients worsening further to moderate (oxygen saturation [SpO2] 90%–94% on room air) or severe category (SpO2 < 90% on room air), and arrange timely transfer to a COVID hospital. Twenty-six patients progressed to moderate disease and were managed with oxygen therapy in an area designated as COVID health center (200 beds) having facilities to oxygenate the patients, one patient required bilevel positive airway pressure. Thirteen patients were transferred to a COVID hospital as they worsened to severe category. All patients were discharged home; the mean hospital length of stay was 9 ± 2.3 days. Conclusions: With careful planning and team work, it is possible to commission a large CCC in a short span of time. The patients can be safely managed in such a facility.

Keywords: COVID-19, COVID care center, COVID health center


How to cite this article:
Kotnala RK, Tempe DK, Mishra P, Ramji S, Patil AP. Challenges and Experience of Setting Up a 2000 Bed COVID-19 Care Center on an Urgent Basis at Delhi. MAMC J Med Sci 2021;7:2-8

How to cite this URL:
Kotnala RK, Tempe DK, Mishra P, Ramji S, Patil AP. Challenges and Experience of Setting Up a 2000 Bed COVID-19 Care Center on an Urgent Basis at Delhi. MAMC J Med Sci [serial online] 2021 [cited 2021 Jun 12];7:2-8. Available from: https://www.mamcjms.in/text.asp?2021/7/1/2/314879




  Introduction Top


On January 7, 2020, a novel strain of coronavirus SARS-Cov-2 was isolated, which confirmed the circulation of a new disease with respiratory illness, coronavirus disease-2019 (COVID-19).[1] This disease that originated in Wuhan, China, spread rapidly around the globe and has so far infected 21,082,038 patients out of which 757,633 have died (August 14, 2020).[2]

In India, the first case of COVID-19 was reported from the state of Kerala on January 30, 2020. Despite several precautionary measures including a countrywide lockdown spanning 75 days from March 24, 2020, the number of COVID-19 positive cases kept on spiraling. In the national capital city of Delhi, at the beginning of the lockdown on March 24, there were only 31 COVID-19 positive patients. Thereafter, the number showed a steady increase, and by June 7, the total number had risen to 28,936 with daily cases averaging around 2000 per day, and in another 2 weeks was around 4000 patients per day. It was anticipated that the number would increase further rapidly, and some estimates suggested that it could be as high as 500,000 patients by June end, which would necessitate availability of about 80,000 beds by end of July.[3] Under the circumstances, the need for a large facility to accommodate mildly symptomatic patients (COVID-19 care center, CCC) was obvious. A decision was taken on June 23, by the Government of India to urgently create a CCC with a large bed capacity to the tune of 10,000 in a phased manner. The center was named as Sardar Patel COVID-19 care center (SPCCC). The task was assigned to the Indo-Tibetan Border Police (ITBP) who conceptualized the planning of commissioning the first 2000 beds within 10 days by harnessing the resources of the Delhi government, paramilitary forces, nongovernment organizations (NGOs), and civil society. This paper is an account of the challenges faced during setting up of the center (especially medical facility related) and the experience with management of first 400 patients at this center.


  Methods Top


A large covered area available at the Radha Soami Satsang Beas (RSSB) located on the outskirts of Delhi was identified as the site for this CCC. RSSB is a nongovernment spiritual organization that has a large covered area (open from sides) for spiritual congregations. This area was large enough to accommodate 10,000 beds for the envisaged CCC, which would be used for managing only mildly symptomatic patients (except pregnant women and children). However, in view of the fact that patients with mild disease may progress to moderate disease (oxygen saturation, [SpO2] of between 90% and 95% on room air, and respiratory rate [RR] ≥24/min), 10% of the beds (200) would be equipped with facilities to offer oxygen therapy to patients, named as COVID health center (CHC). This was a huge challenge, as it entailed converting an area used for religious congregations into a makeshift hospital capable of monitoring the patients and providing oxygenation facility, if required. The various issues that were targeted in commissioning of the CCC are shown in [Table 1]; important among them were physical infrastructure alterations, human resource, medical equipment and furniture, consumables, laboratory support, dietetics, communications, hospital health management system, transport including ambulances, supply and its logistics, and biomedical waste management.
Table 1 The various issues that were targeted to commission the COVID care center

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A number of agencies (government and nongovernment) were involved in completion of this mammoth task. These mainly included among others, ITBP staff (medical and nonmedical), advisors from central and state governments, Indian Railways, Public Works Department (Electrical and Civil wings), some NGOs, corporate, and philanthropists. Many of the key personnel stayed on site, and work was carried out round the clock on a war footing and after conducting a mock drill, the first patient was admitted to the CCC on July 5, 2020 [Figure 1]a–c.
Figure 1 (a) The vacant covered area used for religious congregations that was converted into a COVID-19 care center. (b) The arrangement of hard cardboard beds in a block of 200 beds. (c) Patients in COVID care center performing Yoga exercises

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The health care workers (HCWs; doctors, nurses, paramedical staff) were mobilized from the different hospitals of ITBP and other paramilitary forces around the country. Two large tertiary care teaching hospitals from the city of Delhi were linked to the CCC for referring patients with more serious illness, if necessary. Likewise, another tertiary care hospital was identified to meet the supply logistics. Besides, laboratory facilities, mobile radiological imaging units were also deployed at the facility. Patient beds, except for those in the CHC were made of durable cardboard. Infection control oversight was provided by the National Center for Disease Control (NCDC).

Patient management protocol

The patients were divided into three categories based on the severity of illness.[4] (1) Mild disease: those who are asymptomatic or mildly symptomatic with normal oxygen saturation, and no breathing difficulty; (2) moderate disease: those with SpO2 < 94% on room air, RR ≥ 24/min, and breathing difficulty; and (3) severe disease: those with SpO2 of <90% on room air or RR > 30/min and obvious breathing difficulty.

Each bed in CHC was equipped with an oxygen concentrator to provide oxygen therapy to patients. In addition, a back-up of around 100 “B” type oxygen cylinders and 10 bilevel positive airway pressure ventilation (BiPAP) machines were arranged for providing better oxygenation in case the patient showed sudden signs of worsening. To ensure patient safety, the protocol underscored that patients worsening from moderate to severe disease should be identified early and transferred to a linked COVID-19 hospital well in time to ensure provision of care commensurate with the patient illness severity. In such situations, the COVID-19 hospital was alerted in advance and an ambulance along with an HCW was readied.

The HCWs performed a shift duty of 8 hours each; a team of one doctor and a nurse was assigned to look after 100 beds. A nursing station was created for each section of 200 beds. Specialist doctors from ITBP and Delhi government hospitals were assigned to provide telephonic/video consultations to the doctors on duty at the CCC.

The flow chart of patient movement is depicted in [Figure 2]. Briefly, only COVID-19 positive patients, who were having mild disease, were referred by the district surveillance officer to the CCC. After registering the patient at reception area, they were assessed at the triage area by a doctor who would record the baseline heart rate (HR), blood pressure (BP), temperature, RR, and SpO2. The patient was transported to the CCC in ambulance, which is about 100 meters from the triage area.
Figure 2 The flow chart of the patient movement in the COVID-19 care center

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The patients in CCC were monitored every 6 hours for temperature, HR, BP, RR, and SpO2. In case, the patient showed tendency toward decreasing SpO2, for example, SpO2 96% and RR going above 20/min, they were moved to the CHC. In the CHC, above monitoring was performed more frequently (every hour, if necessary), and the patient was administered oxygen by mask with the help of oxygen concentrator. A teleconsultation was sought by the doctor on duty, if required. The patients were monitored very carefully in this area for any worsening signs and possibility of progressing to the severe category. In case, the SpO2 decreased toward 90%, for example, consistently remaining 91% to 92%, measures for transferring the patient to a COVID-19 hospital were activated.

The patients in CCC received only symptomatic treatment along with vitamin supplementations, nutritious diet, and Yoga therapy and meditation. In addition, treatment of comorbidities such as hypertension and diabetes were continued. For patients in CHC, antibiotics and steroids (dexamethasone) were added to the above treatment. Intravenous fluids were also considered, if necessary.


  Results Top


A total of 400 patients were admitted to the CCC till July 21, 2020 and are included in the analysis. There were 286 males and 114 females with a mean age of 37 ± 14.6 years. The demographic data and the baseline parameters on admission are shown in [Table 2]. The prominent comorbidities observed in these patients were, hypertension 22, diabetes 19, hypertension and diabetes 13, obesity five, and bronchial asthma two patients.
Table 2 The demographic and baseline parameters

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A total of 26 patients were moved from the CCC to the CHC, as they showed signs of worsening toward moderate disease. All were monitored closely and administered oxygen by mask, one patient required BiPAP. Seven patients showed improvement and were transferred back to the CCC, whereas, 13 patients showed worsening toward severe illness and were transferred to a COVID-19 hospital for further management. [Table 3] shows the various monitored parameters before the transfer of patients to the CHC or a COVID-19 hospital.
Table 3 The various parameters observed in patients who were moved from CCC to CHC and COVID-19 hospital

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All the patients were discharged home after recovery. The mean hospital length of stay was 9 ± 2.3 days, there were no deaths.


  Discussion Top


India has been hit hard by the COVID-19 with the number of total positive cases crossing 2 million mark. Although the mortality rate is considerably less (1.94%) as compared with the global number (3.5%) with a recovery rate of 71% (global 66.1%),[2] India faces a huge challenge in facing this pandemic.

Setting up of a 2000 bed CCC in a short span of 10 days was a herculean task. A variety of jobs as detailed in [Table 1] were accomplished by various agencies on a war footing. RKK (author) was the overall in charge of the medical facilities assisted by PM (author). They along with their staff toiled hard to streamline, structure, and implement the chain of events [Figure 1] that was required for managing the patients. There were several logistic issues involved in making the facility operational. These included among others preparing the inventory of the required items (medicines, disposables), procuring them and storing them properly; operationalizing the reception and triage area; setting up the computerization facilities to record patient data; preparing the requirement of human resource and deploying them; and arranging the training of the HCWs. The experience of RKK and PM and the ITBP team in setting up field hospitals as well as COVID-19 isolation facility for those returning to India from overseas during the start of the pandemic was extremely useful in this regard.

In 2 weeks of commissioning the CCC, 400 patients were admitted. The mean SpO2 on admission was 98.04% ± 1.12% and at the time of discharge it was 98.2% ± 0.89%. Timely transfer of 26 patients to a higher facility (CHC and COVID-19 hospital) ensured patient safety and the operational capacity of the CCC was tested. This is essential, as some patients who have mild symptoms initially may progress to precipitous clinical deterioration approximately 1 week after the onset of symptoms.[5],[6]

Earlier media reports of setting up a hospital in the Chinese city of Wuhan are available;[7] however, details regarding the performance and the challenges are not reported. We believe that this is the first report of setting up a large 2000 bed CCC for managing COVID-19 patients. The satisfactory performance of the CCC was not without difficulties and some of the major challenges that were faced are highlighted below.

Team work

A good pandemic preparedness entails effective leadership accompanied by coordination, cooperation, and understanding among a variety of players, which culminate into an effective and efficient outcome. Poor coordination among central and regional authorities, low reliance on scientific advice coupled with lack of preparedness can adversely influence the outcome of a pandemic.[8] The commissioning of the CCC in a span of mere 10 days and the efficient management of the first 400 patients highlights that a teamwork of the highest order was displayed.

Human resources

It was a major task to provide HCWs (in an already overburdened health care system) and other ancillary service personnel for a 2000 bed capacity CCC/HCC. For this purpose, doctors and nurses of ITBP, and other paramilitary services were mobilized from all parts of the country. The security was also provided by the ITBP. DKT and SR (authors) along with few other experts were the medical advisors who helped in structural designing, formalizing the treatment protocols, and training of the HCWs.

Education and training of HCWs

It was considered that junior doctors with MBBS qualification would be good enough to monitor and manage the COVID-19 patients suffering from the mild disease. Likewise, junior level nurses would suffice to be deputed to the CCC. However, all the staff was not aware of the methods of managing such patients, and it was essential not only to teach and train them for this purpose, but also to boost up their morale and confidence. Being from Forces, this was not difficult and all of them easily understood their responsibility and were trained using audiovisual aids and mannequins. The training included how to oxygenate the patients using a face mask, oxygen concentrator, and BiPAP with special emphasis on making them understand the three categories of illness (mild, moderate, and severe). It was reiterated that safety of the patients is paramount and that their responsibility is mainly to detect worsening of the patient condition in time and make arrangements to transfer the patient to an appropriate higher level facility.

The training also included donning and doffing, biomedical waste disposal, role of aerosol generation in the spread of disease, importance of following the cleanliness, social distancing and hand hygiene, and soft skills. The doctors, nurses, and paramedical staff were also apprised of the cardiopulmonary resuscitation (CPR) protocol in a COVID-19 scenario with emphasis on protection of HCW during a CPR.

The training was conducted by personnel from World Health Organization, NCDC, ITBP, and a few other hospitals. The training continued even after commissioning of the facility in an area that was designated for this purpose.

Patient counseling

It is well known that COVID-19 patients are likely to suffer from psychological disturbances due to isolation and cut-off from the social contacts. In order to assist the patients, a trained counselor was deployed. In addition, a recreational facility including a library and a few indoor games (carom board, ludo, chess), and prayer was created [Figure 3]. A family block was also created to accommodate the entire family in case all the members of the family were affected so that they could live together.
Figure 3 The recreational area close to the ward showing patients playing indoor games

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Others

Isolation of the HCWs was accomplished by housing them in the nearby hotels and providing them with dedicated vehicles for transport to and from the CCC. Biomedical waste management was arranged as per the advice given by the infection control team. In addition, arranging the food supply for the patients was a big challenge, which was managed by designating a separate kitchen for this purpose. Since the CCC was created in the existing facilities meant for religious gatherings, many logistic arrangements were made to suit the requirements. For instance, the existing wash rooms/toilet facilities were around 100 meters away; therefore, mobile bio-toilets were positioned close to the CCC for those patients who were not comfortable walking 100 meters. Likewise, the closest block to the CCC was also 100 meters away, which was converted into a reception/central store/triage area. Ambulances were used to transport patients from this area to the CCC. As the CCC became operational, several minor difficulties surfaced during the initial period, which necessitated further modifications/changes in order to improve the functionality of the CCC.


  Conclusion Top


The commissioning of a CCC to accommodate a large number of patients suffering from COVID-19 may be necessary on an urgent basis to handle the pandemic. The creation of the SPCCC in a short span of 10 days demonstrates that it is feasible, and is an example of exemplary teamwork coupled with dedication and zeal of all the team members participating in the project with a focused mind. The operational capacity was tested and found to be satisfactory.

Acknowledgements

The authors would like to thank all the agencies (government and nongovernment) and their officials and workers involved in creation of the SPCCC in a short span of 10 days, but especially to Mr S.S. Deswal, Director General, ITBP; Mr S.C.L. Das, Additional Secretary, Government of India; Mr Anand Swaroop, Inspector General, ITBP; Dr B.M. Mishra, the District Magistrate, for their supervision and valuable guidance in completion of this project. Special thanks to the management and officials of the RSSB, for offering the space for this project and also providing all the necessary support in the day-to-day running of the SPCCC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Li Q, Guan X, Wu P et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-1207.  Back to cited text no. 1
    
2.
www.worldometers.info/coronavirus/. [Accessed on August 14, 2020].  Back to cited text no. 2
    
3.
Atul Mathur. Delhi could reach 5.5 lakh cases, need 80000 beds by end July, says Manish Sisodia. http://timesofindia.indiatimes.com/articleshow/76292580.cms?utm_source=contentofinterest & utm_medium=text&utm_-campaign=cppst. [Accessed December 23, 2020].  Back to cited text no. 3
    
4.
CLINICAL MANAGEMENT PROTOCOL: COVID-19 Government of India Ministry of Health and Family Welfare Directorate General of Health Services (EMR Division) Version 5 03.07.20. https://www.mohfw.gov.in/pdf/UpdatedClinicalManagementProtocolforCOVID19dated.03072020.pdf. [Accessed December 23, 2020].  Back to cited text no. 4
    
5.
Huang C, Wang Y, Li X et al. Clinical features of patients infected with2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 5
    
6.
Wu C, Chen X, Cai Y et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020;180:934-43.  Back to cited text no. 6
    
7.
https://www.bbc.com/news/world-asia-china-51245156. [Accessed on August 14, 2020].  Back to cited text no. 7
    
8.
Garcia-Basteiro A, Alvaraz-Dardet C, Arenas A et al. The need for an independent evaluation of the Covid-19 response in Spain. Lancet 2020;396:529-30. http://doi.org/10.1016/S0140-6736(20)31713-X  Back to cited text no. 8
    

This article has been published in part in the Journal of Cardiothoracic and Vascular Anesthesia 2021; https://doi.org/10.1053/j.jvca.2021.01.047


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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