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Friday, June 05, 2020

From Nightingale wards to paediatric ICUs: making of a COVID hospital in Goa

Till date, the ESI facility has treated and discharged seven COVID patients. Since April 19, when the last patient was discharged, surprise drills and training schedules have been keeping the doctors and nurses motivated as they prepare for the next wave of patients, which is expected when the international borders open.

Written by Smita Nair | Margao | Updated: May 6, 2020 10:21:05 am
From Nightingale wards to paediatric ICUs: making of a COVID hospital Nodal officer Dr Deepa Correia-Afonso (left), medical superintendent Dr Ira Almeida (centre) with other medical staff at ESI hospital in Margao. (Express photo by Smita Nair)

From stocking portable air filters to realigning beds according to the Nightingale ward philosophy and implementing epidemic SOPs reviewed by a microbiologist, all this was part of the process of bringing a COVID-19 hospital to life.

Dr Ira Almeida, medical superintendent of Hospicio hospital in Margao, recalls a disaster drill on March 22, the day of Janta Curfew. But this drill was different. “It was specific… it was for an incoming pandemic,” she says. “Not the regular trauma drills we conduct where a bus falls into a steep valley.”

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This meant visits to public hospitals and taking stock of positions, “especially of ventilators”. Soon, ESI hospital in Margao — a 56-bed facility away from the population — was identified, taken over under the epidemic Act and designated as Goa’s dedicated COVID-19 facility. Almeida of Hospicio— a hospital with a legacy of being built by alms collected by a priest, Fr Antonio Joao de Miranda, in 1867 to treat smallpox patients — was directed to take charge before a team of doctors and patients arrived.

Till date, the ESI facility has treated and discharged seven COVID patients. Since April 19, when the last patient was discharged, surprise drills and training schedules have been keeping the doctors and nurses motivated as they prepare for the next wave of patients, which is expected when the international borders open.

Inside ESI, a daily debriefing takes stock of “pandemic functions”. Every procedure is repeated, reminding health workers to disinfect at every stage, from sample collection to autopsy procedures “if the situation arises”, including usage of round-ended scissors to reduce aerosol generation due to prick injuries during autopsy. And how to engage with children who test positive, or delivery by a COVID-positive patient.

“We kept learning, we had examples from other countries. The first detail was that centralised air conditioners had to be shut. All we knew then was that the virus transmits through droplets. The hospital needed filters with High Efficiency Particulate Air (HEPA) rating, which was also recommended during SARS outbreak,” says Almeida. Portable standing HEPA filters have now been ferried from New Delhi.

The epidemic SOPs now designed — “with many steps introduced by nurses who spend the most time in the wards” — include rational use of gloves and masks, donning and doffing procedure, cough etiquette, treatment of high touch surfaces, lift, mobile and laptop infection controls, ending with “after death infection control”.

The first expert visit was that of a senior anaesthetist from Goa Medical College, who examined the ventilator facilities. With SARS CoV-2 “going for the lungs”, processes for 40 ventilators were strengthened. This is also the pandemic’s “biggest risk room” for health care providers, as the procedure of intubation releases a spray of particles directly from an infected patient’s lungs, which Almeida says has proven to be the deadliest. “The training here was twofold — with emphasis on PPEs specific to this room, and getting doctors used to working under them,” she adds.

“One of the patients went back home to a small child, and it got us thinking. With the lockdown opening, we couldn’t ignore a paediatric emergency. So now we have two ICUs, one paediatric,” she adds.

A hundred beds were counted and divided between four floors, following the Nightingale ward alignment — where the British nurse devised a linear design to treat soldiers during the Crimean War, with a metre’s distance between the beds.

SOPs on housekeeping policies and disinfectant protocols list items on PPE to be donned by health workers — with decontamination instructions using the eight stroke technique of mopping and directions like “never shake mops”, “do not use brooms” drilled into the system. The entire month has gone in perfecting a protocol where an area of 120 square feet is mopped before re-dipping the mop in chemical solutions, and changing the solutions after every 240 square feet. “There are different shifts for different surfaces and a team ensures strict inspection,” adds Almeida. “This drill based on contact, droplet and airborne transmission alone is a science in progress.”

Every ward has a room at the entrance for donning and doffing PPEs — life shields for medical practitioners to go prepared. “They make the doctors and nurses feel protected, and give them the confidence to treat patients,” adds Almeida.

An expert on PPEs and one who assists a pharmaceutical giant in their US supplies was made to visit the hospital facility and train nurses and doctors regarding PPEs. The new normal is doctors and nurses placing a respirator in a hot air oven at 70 degrees for 30 minutes — as they sterilise N95 masks. “We do not overuse or underuse our PPEs. We cannot afford to deplete our stocks,” Almeida says. “In Europe, a study showed frontline deaths were more in low-risk situation, proving lack of understanding and preparedness in using PPEs.”

“This regime will continue even after lockdown is lifted as we cannot let down our guard. At Hospicio — which is not a COVID hospital — we have also designed booths for swab collection looking at hospitals abroad,” she adds. “Now, the next set of SOPs are being worked on treating patients post-lockdown.”

The state’s treatment strategy is that all high-risk and symptomatic patients are to be treated at the COVID-19 hospital, while a still-to-be inaugurated district hospital at Margao is being readied for asymptomatic patients.

She adds that going into the future — with at least a vaccine in place — hospitals will have to function differently. “Every decision will need a thought that an epidemic still looms large. These practices will slowly flow into regular hospitals. We will have to treat every patient imagining he could turn COVID-19 someday. We cannot afford to turn anyone back,” she says.

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