Table 1 Managing COVID-19 when resources are limited
From: Managing COVID-19 in resource-limited settings: critical care considerations
Resource limitation | Specific challenges | Optimal use of existing resources | Repurposing other resources for human medical care |
|---|---|---|---|
Infrastructure | Limited 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/testing | Limited 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) |
Treatment | Insufficient 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 equipment | Insufficient 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 |
Personnel | Insufficient 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 |
Information | Uncertainty 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 |
Transport | Insufficient transport options for patients | • Inclusion of public, commercial, and military healthcare transport vehicles | • Getting nonmedical transport services to become ambulances |