Rapid Establishment of a Tertiary Level Makeshift COVID-19 Care Hospital in New Delhi during Second Wave of the COVID-19 Pandemic

INTRODUCTION Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the seventh human coronavirus, was discovered in Wuhan, Hubei Province, China.[1-3] The first COVID-19 case in India was reported on January 27, 2020, and the country went into nationwide lockdown on March 25, 2020. Considering the quantum of the pandemic in terms of quarantine, isolation, and treatment facilities, there was a strong felt need for the COVID-19 dedicated facilities. Armed forces were tasked to establish tertiary care hospitals dedicated to COVID-19 in major cities of the country. Similarly, paramilitary (the Central Armed Police Force) was tasked to establish a 10,000-bedded quarantine facility in Delhi. After the first wave was over, such facilities were decommissioned. During the second wave, the delta variant was the circulating strain globally,[4] resulting in severe morbidity and mortality.[5] During the second wave, the country's surge in cases started in mid-March 2021 and raised to over 400,000 new COVID-19 cases in a single day on May 1, 2021.[6] Armed Forces Medical Services was tasked to recommission the dedicated COVID-19 hospitals in New Delhi [Figure 1]. This facility was the recommissioning of a 1000-bedded COVID-19 hospital established during the first wave, which was dismantled following a significant fall in the number of COVID-19 cases. During the second wave, this dedicated facility was recommissioned with 500-bed capacity in compliance with national guidelines for COVID-19 by the Ministry of Health and Family Welfare (MoHFW).[7] A brief timeline of events is depicted in Figure 2. The magnitude of the second wave along with the response, necessitated the need to document the establishment of a dedicated makeshift tertiary care COVID-19 hospital along with the challenges faced and their resolution. The study was designed to document numerous factors and services that were essential in establishing such a facility so as to better prepare us for the future in establishing a tertiary-level facility in akin situations.Figure 1: On ground picture of functional COVID-19 facilityFigure 2: Brief timeline of COVID-19 facilityDESCRIPTION OF EVENTS This facility was rapidly commissioned within a week on April 19, 2022, and consisted of 128 intensive care unit (ICU) beds and 372 high dependency unit (HDU) beds [Figure 3]. The location of the hospital was in such a way that it was easily approachable but reasonably away from residential areas and it catered to for moderate-to-severe cases. This facility had three oxygen plants to supply the medical oxygen, which had become scarce during the second wave. There was a total of 1658 admissions in the hospital, of which there were 856 discharges (out of which 65 were discharges against medical advice) and 802 deaths. After the second wave, instead of decommissioning, the hospital has been kept in suspended animation and can be reactivated at a short notice.Figure 3: Inside view of the facilityLAYOUT OF HOSPITAL The hospital was broadly classified into two zones, namely the green zone and red zone. Red zones included the triage area, ICU, ward/HDU, donning/doffing area, kerb site (earmarked BMW site), and mortuary. The rest of the hospital constituted a green zone which included a control room, health office, administration office, kitchen, security office, help desk/documentation cell for next of kin (NOK) of deceased, and oxygen plant. Triage was established in a separate hanger connected to the ICU and HDU through a small strip of exclusive corridor to transfer the patients. For all shifts, two medical officers were posted as in-charge along with two paramedics and one squad of four ambulance assistants (AA) to transfer the patients to ICU/HDU. Triage was the first point of contact between patient and health care, where the patients were categorized as mild, moderate, and severe as per the prevailing guidelines by the Health Ministry.[8,9] Patients in the mild category were advised medication and home isolation along with details on warning signs on when to seek health care. Hospital ICU and wards were stationed in two hangars with 250-bed capacity each. Both hangers were mirror images of each other in terms of layout, rostered duties, equipment, ventilation, and all other practices. Each hangar was further divided into eight blocks named alphabetically A through H. Each block was further subdivided into two subblocks named by placing numerals after the alphabet of that block, for example, A1, A2, B1, B2, and so on till H1, H2. The D and E block of each hanger was converted into ICU as a nursing station was located between these blocks. Each hangar had 64 ICU beds in D and E blocks, with 32 beds in each, which was further divided into sub-blocks, namely D1, D2, E1, and E2, with 16 beds in each sub-block. Hence, there were a total of eight sub-blocks in both hangars, each with a capacity of 16 beds. A, B, C, F, G, and H blocks of the hospital constituted wards. Each block had a capacity of 32 beds. ICU was divided into sub-blocks for the purpose of focused clinical care, division of responsibility, and administration such as accountability, and easy referral, as each sub-block had separately rostered medical care/attendings. However, wards were subdivided for administrative purposes only, as each block was manned by the same attending/medical care. ADMISSION, DISCHARGE, AND DEATH Procedures of admission and discharge of moderate and severe cases were as per the criteria by MoHFW. The following definitions, as given by MoHFW, were adopted to maintain uniformity in the chain of referral, as these definitions were adopted by health-care facilities from primary care to tertiary care level in not only in Delhi but the entire country.[8] The report and returns from the hospital added to national repository. Asymptomatic Suspected contact (rapid antigen test [RAT] or reverse transcriptase polymerase chain reaction [RT-PCR] negative or not available), incidentally detected (RAT or RT-PCR positive), take 6-min walk test as per details in 6-min walk test at a glance box. Mild No shortness of breath, no difficulty in breathing, respiratory rate <24/min, SpO2: ≥94% on room air, take 6-min walk test as per details in 6-min walk test at a glance box. Moderate Shortness of breath ++, difficulty in breathing ++, a respiratory rate of more than 24 but <30, SpO2: 90%–93% on room air. Severe Shortness of breath +++, difficulty in breathing +++, a respiratory rate more than 30/min, SpO2: <90% on room air except in chronic obstructive pulmonary disease patients. Occurrence of death After the occurrence of death, medical officer incharge (MO I/C) informs the Duty Officer (Officers incharge (OIC) Control Room) and Health OIC. Health workers (after ensuring personal protective equipment [PPE]) attend to the dead body and remove all tubes, catheters, and drains. Any puncture holes/wounds resulting from the removal of the catheter, drain, and tubes were disinfected with 1% hypochlorite and dressed with impermeable material. The body was then wrapped in a leak-proof plastic bag and passed to the outside of the mortuary followed by a transfer inside the mortuary. Body bags were marked outside with name, age, date of admission, and admission number for identification at the time of handing/taking. Embalming of the body was not allowed. Temperature inside the mortuary was maintained at 2°C–8°C which was daily monitored and recorded. The bodies were kept in the mortuary till the NOK/transporting staff got the appointment at the crematorium/burial ground, which was earmarked by the Delhi Government. The bodies were handed over to the NOK 2–4 h before the time of last rites. It was regularly conveyed to the transporting staff/NOK that the body, secured in a body bag, the exterior of which is decontaminated poses no additional risk. The personnel handling the body followed standard precautions. Viewing the body by unzipping the bag was discouraged. MLC CASES, SECURITY, AND SAFETY OF THE HOSPITAL Disposal of medico-legal case (MLC) cases was dealt with by informing and involving the rep of civil police and the standard protocols as per the law of the land (civil). The hospital was guarded by the security agency privately hired by the Central Government. In addition, one police representative was detailed for the hospital by Delhi Police, who was the person of contact for any unusual incidents which required assistance of the police. DOCUMENTATION CELL To aid the NOK/relatives in getting the documentation done, which included handing/taking over the certificate, medical certificate for cause of death and authority letter to NOK for carrying out cremation/burial, this cell was setup in the hospital premises closer to the main entrance (green zone). This cell functioned under the OIC mortuary, in close liaison with the Delhi Cantonment Board (the Authority for issuing Final Death Certificates under the Delhi Government) for issuing the final death certificate. PUBLIC HEALTH SERVICES Public health services were looked after by a community medicine specialist, who was appointed as officer-in-charge health. Dietary services A dedicated kitchen was established in the hospital premises in the green zone for the patients. Drill of the dietary services was moored as every day at 0600 h, 1000 h, and 1800 h. In addition, 10 diets with sustenance nutritive value were kept in each ward for each meal as a reserve for new admissions. Tea was served to the patients at 0700 h and at 1700 h. To distribute the diet and tea, 20 people from nonmedical backgrounds were detailed who were imparted special training in donning/doffing practices and were oriented to the layout of the hangars [Figure 4].Figure 4: Training in donning/doffing practicesBiomedical waste and general waste One team of conservancy staff was detailed in each hangar in each shift to dispose of the BMW at the Kerb site, which in turn was collected by the Common Bio-medical Waste Treatment Facility on a daily basis [Figure 5].Figure 5: Handling of BMW and subsequent transfer to kerb siteVector control The vector control measures were outsourced to the local agency under the supervision of OIC Health. Each day of the week was earmarked for a particular vector, namely Monday for mosquito control, Tuesday for housefly and cockroach control, Wednesday for rat and snake control, Thursday for ant control, Friday for mosquito control, and Saturday for housefly and cockroach control. Water supply As this was a makeshift facility, so water supply was obtained through the Delhi Cantonment Board. The responsibility of the disinfection of water at the source was of the Station Health Organization, Delhi Cantt. The chlorination levels in the hospital were checked daily by residents and health assistants. Conservancy staff These services were outsourced by Defence Research and Development Organization (DRDO) to an external agency on a contractual basis. More than a hundred staff were hired and given training on donning/doffing practices by the residents of community medicine as shown earlier in Figure 3. There was a separate donning/doffing area established for conservancy staff to avoid overcrowding. Laundry services Like conservancy, laundry services for bed linen, scrubs, patient dresses, and other clothing were also outsourced through DRDO to an external agency on a contractual basis for the entire duration of the functioning of the hospital. There was a separate earmarked collection site where laundry was dipped in hypochlorite solution before collection and the separate delivery site near the donning area. One senior nursing assistant (noncommissioned officer) was detailed as a rep for collection/distribution and accounting of laundry. Medical store For supplying the medicines, the Central Government had hired pharmacy services on a contractual basis locally. Laboratory and radiological services Similarly, laboratory and radiological services in terms of equipment and workforce were also hired on a contractual basis locally by the Central Government. DUTY (CONTROL) ROOM One medical officer and one dental officer were posted to the control room on the rostered basis with 8 h shift to coordinate between ICU/HDU (red zone) and supportive services (green zone). All the administrative matters and impromptu issues related to the functioning of the hospital were first reported to the duty room which was further informed to the respective stakeholders to resolve those issues. Rosters of all duties, namely ICU, HDU, triage, control room, health office, and so on were prepared by the OIC control room. The duty room provided necessary relief to all health-care workers facing difficulty while on/off duty. QUICK RESPONSE TEAM OF FIREMEN One team of firemen used to remain in the hospital all the time for quick action in case of fire. All firemen received training in donning/doffing of PPE. One fireman on a daily basis used to visit the red zone for inspection and any proactive cautionary action. PATIENT INFORMATION SYSTEM Helpline center There were four helpline numbers in the hospital, manned by four personnel in a shift under the supervision of a dental officer which was functional 24 × 7. All the staff in the center was on 6-h rotational duty. This center was one of the nodal points of contact with the NOK of patient. All the NOKs were contacted at least once a day to update the health status of the patient and also to inform in case of the death of the patient. Video calling facility e-Tablets were provided inside the ICU as well as HDU for video calling of the patients and their relatives and additional personnel were detailed for assisting the patients for the same. Liquid crystal display display of patient information In addition, live updates of the patient vitals and the condition were also updated on multiple liquid crystal displays displayed at the entrance of the hospital for ease of the NOK. Linkage of NOK mobile number to dashboard In the later stages, a new interface in the patient registration software was added, which led to sending an SMS to the patient NOK mobile number about the patient's admission, discharge, and status of the patient. Dedicated data entry operators were employed to update the patient condition twice on the software. DISCUSSION Globally, all countries established rapid facilities to handle the pandemic,[1] but the crucial bottleneck were resources such as health-care workers, oxygen supply, ventilators, and other medical equipment and last but not the least the correct information and knowledge about the disease not only to the medical fraternity but also to the public to prevent the panic and stigma during the active wave. The knowledge of quarantine, isolation, and management employed during earlier pandemics such as SARS and MERS was applied successfully during the COVID-19 pandemic in various countries.[10] Such countries had beforehand experience of pandemic, but most of the countries struggled to manage the present pandemic. India is such an example which was affected by the swine flu pandemic, but because of stringent measures, it was effectively controlled without having to establish additional dedicated facilities for pandemic management.[11] However, the present pandemic was able to overwhelm existing resources and many government agencies, including armed forces, also had to chip in the management of the pandemic. In a similar study in South Korea, the reallocation of health-care capacity and the repurposing of hospitals was done to tackle the COVID-19 pandemic as was done in earlier MERS pandemic in South Korea.[12] Another study in Iraq depicted successful strategies and innovations for tackling the pandemic despite 40 years of war, sanctions, sectarian violence, and foreign invasions.[13] There were numerous challenges faced by administrators during the opening and daily running of the makeshift hospital. However, with the passage of time and the active intervention of various personnels, these challenges were overcome. For example, segregation of biomedical waste at the point of generation was a major challenge. To tackle this issue, OIC health regularly briefed all the health-care staff before the shifts in the donning area on BMW guidelines and the importance of proper segregation and disposal. This intervention proved very effective and it was found that health-care workers were more receptive before entering the red zone (for duty). Provision of timely dietary services in such a facility was another challenge that was tackled meticulously by a pro-active approach, i.e. a nursing officer from the respective hangar would call OIC dietary services at least 2 h before the distribution to inform regarding the strength of patients, new admissions, discharges, deaths, and prudent diets (diabetic, renal, salt restricted, salt-free, and liquid) so that the timely distribution of diet can be done. On a daily or reoccurring basis, PPE training of nonmedical supportive staff, isolation and quarantine of hospital staff and their adequate relief of duty, round-the-clock IT support, proper drill for disinfection of dead body, and handing taking of dead body with NoK were the crucial points which posed a specific challenge in the sense that they cannot be compromised at any cost and require constant attention and supervision. CONCLUSION AND WAY FORWARD These prototype and novel versions of the COVID-19 care hospital have ultimately catered to the needs of the citizens and have been replicated in cities such as Patna, Varanasi, Ahmedabad and can be used and modified in the future as per the exigency. Such facilities should not be decommissioned with the reduction in cases and should be kept in a dormant state in such a way, that they can be reactivated in a short time till the existing pandemic is over. Keeping in view of the same, this makeshift hospital has been kept in suspended animation and can be reactivated at short notice. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.