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Table 1 Managing COVID-19 when resources are limited

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

Resource limitationSpecific challengesOptimal use of existing resourcesRepurposing other resources for human medical care
InfrastructureLimited number of isolation beds (negative pressure and normal pressure) for suspected and confirmed COVID-19 patients• Central monitoring of bed numbers for better visibility and allocation
• Inclusion of private hospitals and military hospitals in total bed count
• Transforming clinics into inpatient care units
• Home as hospital concept with HCW monitoring less ill patients in the community using telemedicine
• Mounting fever tents outside emergency departments to better triage and segregate symptomatic patients
• Utilize military hospital assets (land-based units; hospital ships)
• Use diesel-based electrical generators to cope with energy demands
• Early engagement of community leaders
• Isolating communities instead of individuals in case of local outbreaks
• Opening field hospitals by converting public facilities (e.g., sports facilities, stadiums, soccer fields) and building open tents to house non-critically ill patients and those who cannot stay at home. Use of industrial fans in these spaces to ensure good ventilation
• Tap on portable power and solar generators for electricity to run medical equipment
• Conversion of public and commercial facilities (e.g., hotel rooms, chalets, hostels) into quarantine facilities for well patients
• Mobilizing the community and restaurants to help prepare and deliver food for HCWs and patients in quarantine facilities
• Use of industrial exhaust fans to convert single rooms with normal pressure to negative pressure rooms for isolation in hospitals, especially for ICU
• Conversion of veterinary hospitals and deploying medical personnel to accept non-critically ill patients
• Cohort all confirmed cases in well-ventilated open cubicles to free-up isolation beds for suspected cases
Monitoring/testingLimited number of accredited test labs/sites, especially in suburbs and regional hospitals
Lack of point-of-care-certified test kits at the frontlines and community
Lack of sufficient mobile test sites/clinics
• International health organizations should coordinate rapid technology transfer to LMICs. Allowance and early acceptance of rapid test kits
• Provide 1 low-cost thermometer per family unit for self-monitoring of temperature
• Rely on clinical parameters and examination rather than blood tests to preserve lab capacity (e.g., capillary refill time instead of lactate, qSOFA score to predict deterioration)
• Noninvasive manual methods, e.g., manual BP rather than IA lines; SpO2 rather than ABG
• Point-of-care ultrasound rather than X-rays/CT scans
• Usage of veterinary facilities including animal devices used for patient monitoring and animal ultrasound devices
• Mobilize military forces, community partners, schools, and volunteers to help establish mobile test sites for symptomatic patients. These patients can be issued a stay-home notice after the test. Establish a call-center to rapidly inform patients of results and follow-up action (e.g., contact-tracing)
TreatmentInsufficient ICU ventilators
Insufficient oxygen supply
Insufficient medications
• Use transport ventilators and anesthesia units
• Splitting ventilators (i.e., attaching up to 4 COVID-19 patients to the same ventilator), using pressure cycling rather than volume cycling, and with continuous mandatory ventilation
• Improvised CPAP (iCPAP) to replace invasive ventilation
• Using bag-valve-ETT with PEEP valves
• Use portable oxygen concentrators rather than tanks, especially in field hospitals
• Early use of prone positioning if oxygenation needs exceed available inspired oxygen supply, even in patients who are not on invasive mechanical ventilation
• Enteral hydration, vasopressors (e.g., NG midodrine), antimicrobials rather than using intravenous formulations
• Avoid expending resources on experimental therapies
• Non-medical factories or production lines to manufacture medical equipment like face masks, ventilators, monitoring devices, and intravenous fluids
• Usage of suitable veterinary equipment, e.g., ventilators, IV pumps, and approved drugs, e.g., analgesics, antibiotics, and consumables for wound care
Personal protective equipmentInsufficient PPE• Re-use surgical masks and goggles
• Sharing of certain types of PPE like googles after disinfection
• Ultraviolet light decontamination of medical equipment, re-used surgical masks and goggles
• Use washable gowns and gloves
• Use alcohol-based rubs and spirits rather than clean water, which may be in short supply
• Assemble reusable elastometric respirators to replace N95 respirators
• Use protective face masks, respirators, and gowns from other industries, e.g., food industries, manufacturing plants, construction, and mining
• Getting factories and production lines to manufacture PPE
PersonnelInsufficient staff• Enrolling of dentists, paramedical personnel, village health attendants
• Enrolling of military medical personnel
• Enrolling of medical, nursing, and allied health students to help with pandemic medical treatment
• Designate convalescent HCW to provide care for confirmed COVID-19 patients
• Enroll convalescent patients to volunteer at as health attendants
• Enrolling veterinary HCWs and medical students by providing them with crash courses to help stem manpower shortages in hospitals
• Enrolling non-medical personnel to act as health attendants, e.g., to do temperature taking and man screening stations. This will relieve workload of existing healthcare personnel
InformationUncertainty and confusion over testing, triage, and treatment• Setting up protocols and checklists to standardized medical care that are simple, easy to teach. Avoid overuse of non-EBM methods
• Promotion of simplified EBM scores for risk stratification, e.g., qSOFA for LMICs
• Encourage uptake of teleconferencing platforms to discuss and learn about new updates from international medicine communities
• Use mobile/SMS technology to provide simple policy and health updates to HCWs/public, besides emails and paper-based mailers
TransportInsufficient transport options for patients• Inclusion of public, commercial, and military healthcare transport vehicles• Getting nonmedical transport services to become ambulances
  1. CT computed tomography, ETT endotracheal tube, HCW healthcare worker, LMIC low-to-middle-income country, PEEP positive end expiratory pressure, PPE personal protective equipment