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

The 2019 coronavirus (COVID-19) pandemic has now involved numerous low-to-middle-income countries (LMICs). The healthcare systems in LMICs face serious constraints in capacity and accessibility during normal times. This would be aggravated during an outbreak, leading to worse clinical outcomes. Moreover, 69% of the global population aged 60 and above live in LMICs. These older persons are at increased risk of severe COVID-19 and mortality [1]. LMICs lack time and finances for swift uptake of new technologies (e.g., rapid test kits, vaccines, and antivirals). From a more urgent and pragmatic perspective, we believe creative use of existing resources and repurposing others for human medical care are needed (Table 1). We acknowledge that our suggestions may be perceived as controversial, and we wish to emphasize that maximization of conventional healthcare assets should always be done before turning to unconventional solutions.


Infrastructure
Anticipation of an impending outbreak helps vital preparation. Unfortunately, during the COVID-19 pandemic, there is little time to construct new infrastructure. The World Health Organization (WHO) has recommended airborne isolation, but isolation facilities are limited. Industrial exhaust fans have been used to convert existing normal pressure single rooms to negative pressure rooms to increase isolation [2]. This approach is relatively quick and may be used for creating more negative pressure intensive care unit (ICU) beds. Alternatively, confirmed cases can be cohorted in open ICUs with adequate ventilation.
Opening field hospitals in large public spaces (e.g., stadiums) allows for triaging and managing stable patients and decongest other hospitals. Local networks between smaller district hospitals and larger tertiary centers can be established to facilitate patient transfers, as smaller hospitals can be easily overwhelmed. Well patients with COVID-19, instead of being quarantined in hospitals, can be quarantined in specially designated facilities, such as a hotel. If communication systems are available, well patients could be sent home and monitored remotely.
Makeshift acute or critical care units can be set up in operating theaters and clinic spaces to cope with increasing numbers of critically ill patients. This can be achieved by reducing non-essential services such as elective surgeries and outpatient clinics.

Patient monitoring or testing
For LMICs, focused testing on symptomatic patients instead of random screening would place less strain on the healthcare system. Rapid test kits are an option to allow LMICs to perform diagnostic tests faster, but this would require international health organizations to transfer knowledge and test kits. It may be necessary to isolate an entire community for containment.
Radiological investigations and laboratory support would also be stretched beyond capacity. Physicians may need to rely mainly on bedside clinical examination. If available, bedside point-of-care ultrasonography can yield significant amounts of information. Early clinical detection and admission to the correct facility can help with right-siting before confirmatory tests are out, reducing nosocomial and community spread. Simple scoring systems, such as the qSOFA score, can be harnessed to detect deteriorating patients [3].

Treatment
Hospital ventilators will likely be in shortfall. To supplement ventilators, anesthesia units in operating theaters and transport ventilators can be used. Improvised continuous airway pressure (iCPAP) ventilation systems [4] or bubble continuous airway pressure for children [5] can be employed when there is a dire shortage. The addition of high-efficiency particulate air (HEPA) filters to the expiratory limb of the circuit can help minimize aerosolization if the ventilator does not have a closed circuit. Other creative approaches include splitting a ventilator to support several patients simultaneously by using T-tubes and pressure-cycled ventilation [6][7][8].
Proning positioning has been reported to work in critically ill COVID-19 patients with moderate-to-severe acute respiratory distress syndrome [1]. Patients who are moderately hypoxemic can be proned early to improve oxygenation if oxygen supplies are limited, presumably even if they are not invasively ventilated [9]. Other approaches to save ICU resources include using enteral vasopressors, such as midodrine for hypotensive patients, instead of intravenous formulations [10]. In states of emergencies, veterinary supplies, such as cleaning solutions, syringe pumps, and even ventilators, could be mobilized to augment hospital stocks.
Ultimately, there still needs to be fair and ethical resource stewardship [11].

Personal protective equipment (PPE)
Healthcare workers (HCWs) working on the frontlines need to be protected adequately, or they risk catching COVID-19 and even dying [12]. This is also applicable to personnel such as ambulance drivers and military troops. PPE can be reused to reduce waste [13] and preserve existing stocks. Certain types of PPE like goggles may be shared after disinfection. Deploying reusable powered air-purifying respirators is an option. Other innovative approaches include testing, validating, and assembling simple reusable elastometric respirators to replace N95 respirators [14].
If prior infection can be proven to confer immunity, other approaches to reduce PPE use can include deploying convalescent HCWs to care for confirmed COVID-19 patients and enrolling convalescent patients to volunteer in healthcare.

Personnel
To cope with healthcare demands, active recruitment and training of healthcare personnel should be done concurrently. Besides recalling HCWs on leave, recruitment and redeployment from different sectors (e.g., dentists, paramedics, medical students, military personnel) and even recalling retired personnel may be required. Laypeople, including carers, can be recruited into the hospital after training to provide basic care for patients. Interprofessional skill training should also be done among nurses and doctors. For example, surgeons can be taught simple ventilator care. Sharing simple treatment protocols will aid those who have been redeployed.

Information
In a large-scale pandemic, crucial information about the disease and workflows are constantly evolving. There is a need for information to be disseminated and assimilated rapidly on the ground to prevent delays. An agile system of information dissemination should include mobile phones via text messages or emails and paperbased mailers. Protocols and checklists will also help in standardizing medical care and reducing wastage.

Transport
Harnessing non-medical transport services, such as private-hire and public vehicles and military vehicles, can help improve accessibility to healthcare in LMICs. These vehicles can help ferry unwell patients from the suburbs to regional or central hospitals and reduce delays to medical care. A caveat would be that these transport vehicles need to be thoroughly cleaned following transport [15].