Summary
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), which contains the world's largest diarrheal disease hospital, established a service centre, including testing facilities, isolation unit, out-patient department, in-patient ward, and intensive care unit during COVID-19 pandemic. When the management of COVID-19 was challenging nationwide, icddr,b established this facility with the goal to provide COVID-related services to the staff and their relatives amidst the pandemic. Data related to this analysis were collected from April 2020 to December 2021. 1399 patients received treatment under this facility. Among them, 351 patients were treated at the out-patient facility, 98 at the isolation, and 197 at the in-patient ward. Among the admitted patients, survival was 86.29% (n = 170/197). Among the suspected patients, 17% (n = 103/606) were COVID-positive. Setting up an immediate COVID-19 management facility during the pandemic was challenging. It can be an example of how an organisation can adapt to any emergency and act accordingly.
Keywords: COVID-19, Out patient department, Intensive care unit, Suspected COVID patient
Introduction
Across the globe, healthcare systems were not designed to deal with the unpredictable, large-scale health challenge exerted by COVID-19 pandemic. The first case of COVID-19 was reported from Bangladesh on March 07, 2020.1 Although Bangladesh followed aggressive measures like other countries, it faced challenges due to limited internal resources. Although the government procured equipment to strengthen the supply chain in the public hospitals in Bangladesh, the supply of adequately functioning equipment was suboptimal, which proved to be catastrophic, comparable to scenarios in other low-income and middle-income countries (LMICs). It was very challenging for the government to maintain social distancing rules effectively, particularly in the capital city, Dhaka being the fourth most-populous megacity in the world. In addition to a lack of proper management setup, the country's testing capacity for detecting COVID-19 cases—especially in peri-urban and rural areas—was also minimal for initial few months of pandemic. However, it is also important to note that testing capacity of diagnostic centres significantly improved in the later months with the help and support of the Bangladesh government.2 The country's efforts to reduce the transmission of the virus suffered due to the deficit in harmonisation between public and private authorities and groups.3 The first lockdown that was imposed nationwide started on March 26, 2020.4 On two occasions, the country announced extensions of this lockdown until May 16, 2020.3,4 Medical facilities and services, such as beds, intensive care units, ventilators, and expert nurses, were less than the required amount in government and private hospitals. International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), is a research organisation with nearly 4000 employees, including 100 scientists who conduct research on public health, epidemiology, and allied sciences, and it runs the world's largest diarrhoeal disease hospital treating approximately 200,000 diarrhoeal patients per year. The COVID-19 pandemic caught Bangladesh off-guard, leaving the healthcare sector, including icddr,b panic-stricken and perplexed. Managing the admission of an exponentially increasing number of patients, as well as the search for the right treatment regime, posed a great challenge to the healthcare professionals of the country. The icddr,b management explored to find out the best way to support the staff and their dependents and quickly set up a COVID-19 management establishment multi-pronged unit, which included laboratory diagnosis of SARS-CoV-2 virus, isolation and treatment centre on its campus in April 2020. Doctors who had been working in the diarrhoea hospital started to practice evidence-based COVID-19 treatment protocols using appropriate supplies and quality equipment. This viewpoint is focused on the establishment process, challenges, reactions of staff, and success and failures of this COVID-19 facility of icddr,b and the story of continuation of full time services to the diarrhoeal patients amidst the challenges of the pandemic and triaging the COVID-19 patients out from the routine care seekers to ensure immediate resuscitation and proper referral system.
Sixty years ago, the then South East Asian Treaty Organization (SEATO) established a small laboratory in Dhaka named Cholera Research Laboratory supported by the National Institutes of Health (NIH), USA, with the start of a severe cholera pandemic. Later in 1978, this turned into the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) through a Government Ordinance followed by a WHO meeting in Geneva in 1979.
In its in-patient and out-patient facilities, Dhaka Hospital serves children and adults with diarrhoeal illnesses. Diarrhoea (passage of three or more loose stools in 24 h), with or without associated complications or comorbidities, is the criteria for admission into the hospital. The hospital does not restrict the number of entries, even during epidemic surges. Dhaka Hospital has a regular capacity of 350 beds, which is expanded to about 450 beds using additional mobile cholera cots, and even higher by constructing temporary tents if required. Interventions provided in the hospital for diarrhoea include close monitoring of hydration status and administration of oral rehydration solution (ORS), intravenous fluid, and antibiotics in selected cases. Patients with different comorbidities and complications of diarrhoea, such as pneumonia, sepsis, malnutrition, and dyselectrolytaemia. Comprehensive medical care, including laboratory investigations, medications, lodging, and food for both patients and their attendants, are provided free of cost.
Our research institute, which contains the world's largest diarrhoeal disease hospital, established a COVID-19 service delivery centre for its staff and family members, including testing facilities, isolation centre, out-patient department (OPD), in-patient facility and a makeshift intensive care unit (ICU). Due to persistent active screening facility for the staff and family members, we found 43% (1856/4295) test positivity from March 2020 to April 2021 among the test performed in this institution.5 The hospital segregated suspected COVID-19 cases through a rigorous triaging system from its diarrhoeal mass. icddr,b set up temporary tents with optimum infection control measures and ventilation systems. Relevant data were collected from April 2020 to December 2021 for all COVID adult patients. Ethical approval was obtained from the Institutional Review Board (IRB) of icddr,b [(IRB comprises the Research Review Committee (RRC) and the Ethical Review Committee (ERC)]. Moreover, in this research data sets were analysed anonymously.
A conceptual framework for COVID-19 management system, icddr,b
By the end of March 20, 2020, there were widespread media reports that the preparation of the health systems to combat COVID-19 was inadequate. The health sector leaders faced the greatest challenge of transforming a resource-constrained healthcare system into a sustainable system capable of handling the health crisis of COVID-19. The icddr,b management reorganised its health care system with Plan A and Plan B based on the availability and supply of oxygen.
Plan A
Initial plan was to have ten beds supplied with oxygen availability for 24 h and only to provide supportive oxygen therapy before referring the patients to other COVID-19-dedicated hospitals within 24 h. For this purpose, we would have to ensure an uninterrupted oxygen supply from commercial sources so that there would be no crisis at any time.
Plan B
When the commercial oxygen delivery system failed, we prepared for the alternative step. Our staff was trained for Advanced life support and Basic life support. We acquired Biphasic Positive Airway Pressure (BiPAP) machines. We followed new COVID-19 treatment guidelines formulated by the government and antimicrobial treatment based on local sensitivity for pneumonia organisms.
icddr,b immediately set up the physical infrastructure of the COVID-19 unit at the Dhaka hospital premises with tents in front of the hospital's emergency area, converting the daycare centre into a COVID-19 isolation ward.
Health service delivery system of icddr,b COVID-19 unit
Our hospital healthcare staff, specialised in treating diarrhoea and malnutrition, immediately oriented themselves to treat COVID-19 and its complications that could affect multiple organ systems of the body. As a part of the COVID-19 response, the organisation gradually extended its services from simple screening/triaging to the management of severe cases (Fig. 1). The diagram shows the gradual transformation and upgradation of services performed by icddr,b management.
Fig. 1.
Flow chart of the activities of make shift COVID-19 unit in Dhaka Hospital of icddr,b.
Definitions
Staff eligible for COVID-19 management
Those who are currently working at icddr,b. Later, it also included retired staff who failed to get admitted to any COVID-dedicated hospital.
Relatives
The persons who stay in the same household with the staff.
COVID-inpatient ward
The tents (initial setup) and cafeteria (established later).
Stage 1: establishment of preliminary treatment facility for COVID-19 in icddr,b
We started COVID-19 testing for staff of icddr,b, which was later extended for the relatives of staff residing in the same house.
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1.
Tent for COVID-19 or Suspected COVID: COVID-19 inpatient ward was established in a makeshift structure, with specialised tents focusing on ensuring adequate oxygen supply. We had only 12 cylinders to supply oxygen through the central oxygen supply line. As the COVID-19 patients developed severe respiratory symptoms, we anticipated a maximum supply of oxygen of 15 L/min for a person for 24 h that could be provided through the existing supply line. Ten beds were established inside the tent to accommodate the emergency COVID-19 patients before referring them to facilities with better facility or management services. We had no high-flow nasal cannula machines until June 2020. We procured two mechanical ventilators urgently to face an unforeseen catastrophe involving the sudden deterioration of critically ill patients before referral. A hospital ambulance was used for referrals with adequate disinfection before and after.
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2.
Triage tent: Apart from COVID-19 management, we continued our diarrhoeal disease management without any dents. The hospital triage was relocated in a separate tent near the roadside main entrance, out of the main hospital building, so that suspected COVID-19 patients with diarrhoea may be segregated before admission into the main diarrhoea wards inside the hospital. During triage, doctors and nurses had to send the suspected COVID-19 cases with moderate to severe diarrhoea to the suspected COVID-19 tent. After hydration, symptomatic management, and COVID-19 testing, we referred them to any designated COVID-19 facility for further evaluation and management.
Stage 2: expansion of COVID-19 setup at icddr,b
As the pandemic intensified, the detection of cases increased among staff and their relatives. Bed crisis in COVID-19 dedicated hospitals and the scarcity of ICU beds escalated fear. We expanded our setup and services with the available resources.
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1.
The Day Care Centre of icddr,b was converted into an Isolation Unit. The cafeteria was converted into an improvised ICU with a central oxygen supply, equipped with high-flow oxygen, mechanical ventilators, and all other necessary intensive-care medical equipments. We purchased two Bi-PAP machines and one high-flow nasal cannula machine and received two high-flow nasal cannula machines as a donation. For the mild cases who had the facility to maintain isolation at home, we provided OPD services. In the tent, we had ten beds to treat suspected COVID-19 cases, irrespective of whether they were staff or not. In the isolation facility, we had three beds for females and seven beds for males. In the cafeteria (in-patient) turned COVID-19 ICU, we had eleven beds to treat moderate to severe cases. We operated round-the-clock to provide in-patient and out-patient services.
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2.
While the patients were examined by the physicians, the nurses recorded the observations. Necessary lab or radiologic tests were also performed. Patients were advised to continue treatment at home and come to the hospital in case of any discomfort. We regularly updated them about the lab reports over the phone and followed up to monitor the course of the disease. After admission to the isolation centre, patients were regularly monitored by doctors and nurses thrice a day. Relevant investigations were performed as and when required. The hospital diet section regularly supplied food for the patients. Moderate to severe cases were admitted to the cafeteria turned COVID-19 ICU. The ICU was well furnished with all essential medical supplies, including central oxygen lines, three high-flow nasal cannulas, and two ventilators.
icddr,b has its own power generating plant to maintain an uninterrupted power supply. We ensured the same to our makeshift COVID-19 facilities. We had regular training sessions on infection prevention and control, focusing on the COVID perspective. All healthcare professionals were trained on donning and doffing Personal Protective Equipment (PPE), one-way flow of movement for all healthcare professionals, precautions for biological sample collection, disposal of materials, etc.
Stage 3: beginning of a new normal
The novel initiative of providing COVID-19 treatment within the centre instilled confidence and reassurance in employees when media reports were carrying stories of ambulances refusing to carry patients with COVID-19 symptoms and many healthcare facilities either not complying with services for COVID-19 patients or even shutting down their services. The number of patients grew alarmingly with time, with a proportionate rise in the number of critical patients. Therefore, we gradually started to adapt to the new way of life and delivery of patient care services. Alongside the vigorous screening and triaging of patients, we continued our diarrhoeal patient management services throughout the pandemic period without any compromise.
Experiences of COVID-unit
The clinical response team of icddr,b worked hard to provide treatment to their staff and their families for COVID-19. As of December 31, 2021, more than 1000 individuals tested COVID-19 positive, and all of them received treatment irrespective of their type of service contract. The treatment ranged from telemedicine to intensive in-patient treatment in the COVID-19 ICU.
The healthcare coverage was extended to all who had an employment contract with icddr,b irrespective of the type of contract, including the outsourced personnel. According to the Annual Report of icddr,b 2021, a total of 5190 tests for COVID-19 were carried out between March 19, 2020, and April 15, 2021. The testing was helpful and 947 staff and 1174 family members were found to be COVID-positive. From March 19, 2020, to December 31, 2021, 1399 patients were treated by the COVID-19 response team. Among them, 351 were treated at the out-patient unit (Supplementary Fig. S1), 98 received treatment at the isolation centre, and 197 were treated in the in-patient ward (Supplementary Fig. S2). In the tent with suspected cases, 753 patients received treatment. Among the suspected cases from the hospital, 180 patients were found to be COVID-positive (Fig. 2). Ten patients in the tent with suspected cases, declined COVID testing (RT-PCR). Among 197 in-patient COVID-19 cases, 27 expired.
Fig. 2.
Number of deaths among patients treated in the tent with suspected COVID-19 cases.
Moments of emotion
“Please put me under artificial ventilation; I can't bear the suffocation anymore,” the urge of a young COVID-19 patient emotionally affected the physicians. The patient was admitted to the COVID-19 in-patient ward and was on treatment for severe pneumonia. He gradually became more hypoxic and developed severe acute respiratory distress syndrome (ARDS). At last, he was provided mechanical ventilation but unfortunately died after a few hours, with his brother beside him. Heart-wrenching painful stories like this evolved during our journey with COVID-19 patients. A mother was suffering from COVID-19 at her advanced stage of pregnancy. Despite all our efforts and applying the best of our knowledge, skills, and dedication, we lost two lives at the same time.
Although the deaths of patients were mentally distressing, gratitude from COVID-19 survivors (greetings and written notes) positively motivated the icddr,b staff. We had the opportunity to treat another pregnant mother in the early days of COVID-19 pandemic, who was successfully managed in our facility and later gave birth in a different government hospital. The COVID-19-dedicated government hospital was not prepared to tackle cases at the very beginning. Hence, we shifted the mother to our COVID-19 tent, and she was discharged after becoming COVID-negative. We have numerous successful cases like this one in our fight against this dreadful disease (survival 86.29%, 170/197).
Discussion
Key challenges and solutions for the healthcare delivery system of icddr,b
Fund
Being a research organisation, icddr,b's operating cost is dependent on its core donor's support and project funds. Within financial limitations like this, it was nearly impossible to set up and maintain a COVID-19 treatment facility, where the cost of treatment and the course of the disease are both unpredictable. The centre stepped into this challenging venture and gave a call to philanthropists and donors to contribute to the Hospital COVID-19 Appeal Fund. We appreciate different sponsors who came forward to raise funds and stood beside icddr,b, to help our hospital to save lives. But multiple comorbidities, severity, and extended duration of stay escalated the cost. To mitigate this, we requested the caregivers to bear the cost of medicine for the patients and, if possible, investigation cost too. For those who were unable to do so, the hospital provided full support.
Oxygen supply
In our hospital, we used cylinders and a central oxygen supply for a few beds in the ICU. Supplying oxygen through cylinders being inadequate for COVID-19 patients, we extended the central oxygen supply line to the makeshift COVID-19 ICU. When the patient number increased, the cafeteria was converted to an improvised ICU with a central oxygen supply and additional cylinders so that a steady reserve was kept for any contingency. We also received some oxygen concentrators from donors. Based on the patient's requirement, either a concentrator or cylinder was used in moderate to severe cases.
Workforce
The number of hospital staff was not enough to manage critical COVID patients; therefore, healthcare professionals were drafted in from different research projects which were being conducted under icddr,b in order to strengthen the workforce. It was also very challenging for hospital doctors to treat seriously ill patients requiring critical care management. Hospital doctors attended different webinars on COVID-19 management, consulted with external specialists, and provided treatment accordingly. The hospital management engaged a critical care consultant who trained the doctors, regularly monitored their activities, and supported them whenever required.
Medicine and equipment
Acquisition of different novel drugs and medicine for COVID-19 management was another challenging task because of unavailability and unusual demand. The initial procurement of two mechanical ventilators was a big morale boost for the team. The management tried its best to cover up the shortage of equipment with the money received from benevolent people and organisations.
Investigations
icddr,b did not have the facility to perform advanced lab investigations like IL-6 quantification, CT scan, MRI, etc. Therefore, samples had to be sent to external diagnostic labs, and for imaging needs, patients were transported to respective facilities in our ambulance. We had to rent a second ambulance to accelerate the referral process.
Protection of health workers
Although the pandemic posed a severe threat to frontline health workers, healthcare professionals showed undaunting courage and commitment to their profession and used proper PPE while exposed personnel-maintained quarantine as per standard protocol. The centre provided health insurance and risk allowance for those who had direct contact with the patients. It was challenging to provide treatment to all staff as well as their dependents, including the retired staff, whoever was affected by this hitherto unknown disease. The COVID-19 response team of the centre worked tirelessly and provided the best support they could give to the ailing community.
However, we could not include the outcome of all our staff and relatives those treated outside the COVID-19 unit of our hospital, although receipt of treatment from outside facilities by our staff was rare due to lack of availability of ICU facilities for severe COVID-19 patients. We were also unable to follow-up the fate of a few suspected cases who were referred to other hospitals.
Preparing for the future
Leadership played a vital role in activating the hospital's response to this unique emergency and adjusting the hospital to deliver COVID services. COVID-19 may be a ‘rehearsal’ if we look at the rising evidence of a link between climate change and health issues, including infectious diseases. The organisation has rapidly adapted itself to respond to the unusual epidemic. This transformation may further be needed to provide optimal care to COVID-19 patients while the pandemic continues to evolve. Whether the event falls under a natural disaster or a pandemic, healthcare delivery organisations will face the challenge of readjusting suddenly, redesigning care, minimising financial loss, and revamping the logistic and administrative support. The pandemic was an eye-opener for us which underlined the importance of capacity building and reform to cope with future events of similar nature.
Conclusion
The whole world was taken by surprise by COVID-19 and plunged into a fear of uncertainty. The management of icddr,b came forward with structural and policy-level decisions which played an important role in fighting the pandemic. Without prior experience, our organisation established an organised COVID-19 facility with limited resources, which was an unprecedented welfare act for the staff and families in the history of the organisation, making it a role model for others to learn how an organisation can support its staff in such a unique health emergency.
Contributors
SN: data curation, formal analysis, investigation, methodology, literature search, project administration, software, validation, writing - original draft, verified data; FA: data curation, formal analysis, investigation, methodology, software, writing - original draft, verified data; MRI: investigation, formal analysis, methodology, supervision, visualisation, manuscript review; AIK: project administration, formal analysis, investigation, methodology, software, manuscript review; BA: formal analysis, investigation, methodology, project administration, manuscript review; MJC: investigation, formal analysis, methodology, project administration, supervision, visualization, verified data, validation, manuscript review; TA: conceptualisation, formal analysis, methodology, project administration, supervision, manuscript review.
Data sharing statement
De-identified data related to this manuscript are available upon request to Shiblee Sayeed (shiblee_s@icddrb.org) Research Administration of icddr,b (http://www.icddrb.org/).
Declaration of interests
None. Authors received funding from International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b; grant no Gr-00233) and its donors.
Acknowledgements
Authors thank funding from core donors which provide unrestricted support to icddr,b for its operations and research. Current donors providing unrestricted support include: Government of the People’s Republic of Bangladesh; Global Affairs Canada (GAC); Swedish International Development Cooperation Agency (Sida) and the Department for International Development (UK Aid). We gratefully acknowledge these donors for their support and commitment to icddr, b's research efforts.
Footnotes
Supplementary data related to this article can be found at https://doi.org/10.1016/j.lansea.2023.100344.
Appendix A. Supplementary data
Supplementary Figure S1.
Supplementary Figure S2.
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