Converting a British-era hospital into a state-of-the-art COVID-19 care centre

Abstract

As of 13 May 2021, the COVID-19, caused by SARSCoV-2, has affected 161 162 786 people worldwide with 3 347 577 confirmed fatalities. India is precariously placed with 23 703 665 confirmed cases and 258 351 deaths. The country is amidst a deadly second wave. Our hospital, a tertiary care super specialty centre in Western Maharashtra, caters to the serving personnel, veterans of the Indian Armed Forces and their dependents. The hospital, originally established in 1869, was at the forefront in providing medical care during the two world wars, the wars fought by the Indian Republic and during natural calamities (earthquakes at Bhuj and Latur, and the tsunami in Southern India). When the pandemic struck, we were tasked with establishing a stateoftheart COVID-19 care centre at a Britishera hospital while at the same time handling routine medical emergencies. We have written this article with a unique perspective of a doctor and a soldier. We have dwelled on the standard operating procedures (SOPs) established by our hospital during COVID-19 pandemic. The protocols described in the article were retrieved from unit ‘War Diary’, a regularly updated official record, beginning from January 2020 to March 2021. The first and the foremost job was to plan for the difficult times that lay ahead. Thus, the administrative block turned into a war room by March 2020. A nodal officer was nominated, and our infantry made its humble beginnings along with a nursing officer (NO) of the hospital infection control committee (HICC), a couple of medical officers (MOs), nursing assistants (NAs) and a single junior commissioned officer (JCO) who later on would be the manpower of the influenza clinic. Our hospital has a distinct advantage. It is spread over 105 acres of land. We first identified an outpatient department (OPD) complex, which is separate from the main hospital building, as the location of a sixbedded isolation facility. Changes were done in existing OPDs by providing screen/physical barrier between healthcare workers and patients, and arranging the seating arrangement in waiting area so as to avoid overcrowding. Certain engineering modification of existing inpatient infrastructure was done to ensure better ventilation, increased air changes and air filters. Disinfection of all surfaces was being done at required frequencies to ensure that no viral transmission occurs through fomites. Parallel defence screens were set up at the main gate which was the only designated entry and exit point to the hospital. This screening at main gate continued 24/7. The second important aspect was to establish a functional isolation ward. The following aspects were critical in planning of isolation ward and other work premises: Donning room: a separate donning and doffing room was established for wearing personal protective equipment (PPE). The PPE/clothing had to be donned prior to entry into the isolated contamination area. Performing hand hygiene with an alcoholbased hand rub was ensured. Adequate storage cabinets were made available in the donning room for storage of PPE. Doffing room: separate doffing room was established where PPE would be removed before leaving the isolated contamination area. General principles like removing the most contaminated PPE items first, performing hand hygiene immediately after removing gloves, removing the mask or particulate respirator last by grasping the ties and discarding it in a touchfree bin were all ensured. Special signage boards highlighting the procedure of donning and doffing were placed in respective rooms. Air conditioning: since the isolation ward would cater to COVID-19positive patients with mild or moderate symptoms, modification to air conditioning was done with an aim to provide comfortable environment to the patient, removal of contaminants, nonturbulent unidirectional airflow and prevention of leak of contaminated air to surrounding noninfected areas. Where the wards were not airconditioned, additional exhaust fans were installed to create dilution and removal of contaminated air, increased unidirectional air flow and negative pressure (Figure 1). The influenza clinic, a separate OPD location for screening patients with influenzalike illness and severe acute respiratory illness (SARI), with the nodal officer as its medical officer in charge, 2× MOs, 1× NA/JCO, 2× NAs and 1× ambulance assistant, was established in the erstwhile general OPD. From here on, the influenza clinic became a nodal point for handling all COVID-19 and nonCOVID-19 queries related to the hospital through three help lines. The help line rang every 5 min from civilians stuck up at various places in India during the lockdown period. Most of them were for administrative help and the MOs never said ‘no’ to any of these. To quote a couple of instances, we helped a serving JCO posted at a forward post in arranging rations for his next of kin stuck up near Chennai and provided help to a civilian ward sahayika working at a private hospital in Hyderabad from getting evicted from her rental home. A very important aspect was training the manpower and emphasising adherence to standard SOPs. A rigorous training schedule was initiated to train our warriors to better protect themselves and recruit new ones to be a strength multiplier. Members of HICC and the intensivists played an active role in training and in circulating videos on them for bettering awareness on safe healthcare practices during COVID-19, biomedical waste disposal, etc. The final step but not the last to occur in actualisation was procurement of nonexpendables and expendables, our arms and ammunition, which continued at war footing. The Department of Microbiology established their reverse transcription (RT)PCR services in April 2020. They were our sighters for the enemy and have been working 24/7 to cater for this additional load apart from the handling of routine samples of the entire hospital until this date. A separate triage intensive care unit (ICU) was set up where all critical patients and unstable SARIs were being admitted. It was a fullfledged stateoftheart Gastroenterology, Command Hospital, Pune, Maharashtra, India Hospital Administration, Armed Forces Medical College, Pune, India Commandant, Command Hospital, Pune, Maharashtra, India Ex Commandant, Command Hospital, Pune, Maharashtra, India ENT, Command Hospital, Pune, Maharashtra, India Internal Medicine, Command Hospital, Pune, Maharashtra, India