The Corona Virus (CV) pandemic is real and is in its early phases.
For many countries, it has left a devastating path with an unknown future.
But for many developing countries like Pakistan, an innovative and pragmatic approach is urgently needed.
A country like Pakistan with a population of more than 200 Million the only positive thing seen on the horizon by the government seems to be wishful thinking.
If the plan is taking kalonji, eating garlic, and drinking Joshanda while you stay away from each other and pray, then God help us. God only helps those who help themselves.
The devastation in the more affluent and technology-rich Western world has provided some valuable data, but even with such resources millions will be infected and hundreds of thousands are expected to have a bad outcome, unfortunately.
Pakistan and developing nations seem confused, unprepared and helpless. It is impossible for Pakistan to prepare for a potentially devastating corona virus healthcare crisis, by emulating the customarily expected preparation models of resource-rich nations like China or The United States. The Pakistani media and Government should stop seeing the developed resource-rich countries as the role model for their situation.
While the Coronavirus (CV) may infect and harm Pakistani populations similarly as other countries but Pakistani economic and health care system reality is entirely different and extremely subpar compared to the developed countries and that is an existential reality.
When Pakistani established government and non-government institutions in their honest attempt talk about CV and its mitigation standards, following the transcendent psychology, rhetoric, guidelines of US/China is fine, but what if the wishful thinking (summer, BCG vaccine, Kalonghi etc.) don’t work and cases start to pour into the hospital, Pakistani health care system is NOT what is in Wuhan nor New York.
So the head of Pakistani CV task force should stop talking like Dr. Fauci and Pakistani Prime Minister should stop speaking like President Trump. They should wake up to the realities of the Pakistani Healthcare system and its capacity to deal with the potential CV peak while at the same time the economic corridors should stop daydreaming about a government that can give grants and funds to get Pakistanis out of this crisis.
This document narrates a pragmatic approach to dealing with the potential realities that Pakistan and other third world countries may face and what they can do to decrease the harm and impact of past failures that are knocking on the door.
-Optimism, that weather or other factors might help Pakistan, but there should be a plan if there is an epidemic.
-Pakistan cannot fix the devastating infrastructure in the next few weeks and months, emulating the US and China in the short term is self-delusional.
-Pakistan has an extremely weak infrastructure of healthcare and an extremely weak economy, a reality that has to be accepted.
-Pakistanis need to understand the difference between “mitigation” and the capacity to deal with the acute phase and post-acute phase of CV – both from a health care capacity and economic perspective.
-Pakistan neither has the infrastructure of healthcare which will be more relevant in the acute CV surge phase nor has the economic stability that will be needed during the mid acute phase to post-acute phase of CV.
-Pakistan has to prepare for its CV impact based on Pakistan’s capacity not based on the model of the US and China. When the whole world is in crisis, banking on aid or foreign help is simply absurd.
-Pakistan has to first define its reality of the Healthcare system and compare this to the potential need, only after doing this Pakistan will be able to see with clarity the reality and prepare its health delivery to the potential surge of the sick population.
-The economic crisis preparation is a different topic and this document will start gravitating towards Health care delivery emergency planning.
There are three phases to CV.
Pre phase – The honeymoon phase where the US was in Jan/Feb 2020.
Acute Phase – That can last 12-20 weeks.
Post-acute phase – last months if not years, especially relevant to the economic crisis and its management.
CV Health crisis facts
The rate of infection cannot be predicted. There are several known and unknown factors that impact the rate and number of infections in a community. The mitigation factors even when enforced in a relatively similar cohort can have myriad results, depending on the level of execution, enforcement, adaptation level by the public, living conditions and the time of implementation.
For example in California, the Shelter in was in effect on March 19th, 2020 and by April 12th 2020there were 25,000 cases (reported) and 700 deaths, while in the State of New York shelter in place was effective on March 20th, 2020 and there are close to 200,000 cases and 10,000 deaths by April 12th, 2020. This extreme discrepancy of CV infections and death between the two States validates the poor reliability of the effectiveness of shelter in place or mass self-quarantine. Thus, the rate and number of people that can be infected with CV in Pakistan cannot be determined by any model, however, the partial closure of the Country by the PM a few weeks ago will save many lives.
The bottom line is Pakistan has to prepare for the worst, but just to give some perspective, the best-case scenario for Pakistan can be a condition far worse than seen in the State of NY.
This document as mentioned earlier is not attempting to establish a model of virus spread nor should it be considered a reliable source of any assumptions. However, it does establish some idea of the potential range of the at-risk population. The modeling and assumptions are the responsibility of nation-states.
The more dense urban population base is expected to have a higher incidence of CV, though other areas with sparse populations may also be affected. If the urban population is assumed to be at higher risk due to the close-quarter living situation than a population of 100 million is at higher risk in Pakistan.
Pakistan has a population of 220 million. Pakistan’s urban and semi-urban population is more than 100 Million. There are close to 90 -100 cities that have a population close to 100,000 or more. Pakistan has 8 cities with a population that is more than one million, 59 cities with a population between 100,000 and 1 million people, and 284 cities with between 10,000 and 100,000 people. The populous belt along the great river (s) basins can be easily traced. We also know the above data is not correct and true numbers are unknown but likely more.
If the CV infects 10 % of the overall higher risk urban population (or 5% of the general population of 220 M +) then the number of infected is expected to be 10 million.
The world data at this point is suggesting a 50% symptomatic rate, thus out of 10 million about 5 million will be symptomatic. A reasonable assumption is that 40% of the CV positive infected symptomatic patients will have severe diseases that need health care services that require a hospital-level of care, which is a population of 2 million. Of the 2 million one third to one quarter, 500,000 to 650,000, are expected to have very severe disease and need ICU care and possibly ventilator support
Pakistan has 0.6 hospital beds / 1000 population while Japan 14, China 4 and US 3.
The 0.5-0.6 hospital bed in Pakistan is not the same level as the hospital bed in the US or China. (1)
According to another source, the total beds in Pakistan are – 118, 869 (2)
The only highly symptomatic people are advised to go to the hospital or need hospital care. People sick enough to go to the hospital are more likely to need critical care, and patients in critical condition are more likely to die than patients with mild symptoms.
The low number of hospital beds in Pakistan are simply not enough to handle the potential surge of two million sick CV patients.
The prevailing narrative from Pakistani media and administration is echoing a tone similar to officials in the US, such as Dr. Fauci. Pakistani officials are reflecting an undertone of strange indifference to the impending crisis. While the ground realities of health care quality and capacity are quite different between the US and Pakistan.
Pakistan cannot upgrade nor build its health care infrastructure in the next few weeks. Pakistan cannot rely on present infrastructure.
Pakistan cannot do much with more ventilators or higher-level patient care equipment. This equipment operation and maintenance require a force of highly trained individuals which is simply not available.
Pakistan cannot depend on wishful thinking nor foreign aid to meet this moment of impending crisis.
The spirit of selflessness, zeal to help, national pride and resolve to fight CV are all good but not a substitute for a needed work-force to manage the CV crisis in Pakistan.
The reality is that Pakistan’s health care system does not have the capacity to manage the CV infected sick patients that need hospitalization – possibly 2,000,000 citizens.
The majority of very sick patients (500,000- 650,000) that need intensive care services and ventilators will, unfortunately, die due to lack of not just ventilators but also due to lack of infrastructure and trained staff that operate an ICU system/units.
Pakistan has to rapidly make plans based on the countries reality to have some impact to save lives in an otherwise likely inevitable pending cv devastation.
The 2,000,000 potential patients that need hospitalization and the 25% (500,000) of this hospitalized patients mortality seen from the data of Italy and us may not be the same for Pakistan.
Pakistan due to severe lack of healthcare infrastructure may have mortality of 60-90 % of those who are infected, symptomatic that need hospitalization.
The most essential point of this document is that Pakistan cannot scale-up ICU level care for the very sick -it has to be recognized and accepted that the very sick will have a bad outcome, however, Pakistan can scale mass level of simple healthcare delivery model (tailored to cv) with the fundamental mission to slow the conversion of sick population that needs hospitalization towards very severe illness status that needs ICU. If the sick patients are not given the health care services that are needed than a majority of them will convert to very sick bad outcome cases, which is presently the Pakistan trajectory.
If a plan that is cheap, simple, effective, easily implementable, requires not much expertise and no hospital nor doctors, can be scaled out at mass level, such a plan can have the potential to save the massive conversion of those sick to progress towards a status of being very sick. This is the opportunity Pakistan has today.
We are offering this plan
The COVID pandemic plan for healthcare delivery in a developing country should be based on realism instead of idealism.
This plan is not a holistic approach to provide or enhance health care delivery to the mass population of a pandemic in a certain Nation, but rather based on affecting the most critical but yet tangible aspect of the COVID19 infected patient population in an underdeveloped country.
This plan is aimed to reduce mass mortality, which if not implemented in a certain community with no other alternative, will lead to significantly higher mortality.
This model is an idea, not a healthcare management system recommendation, has no proven record and does not guarantee any outcomes or merits. Feasibility of the plan is the responsibility of implementing Organization.
What the modern world has learned is that a pandemic is not just a medical crisis but also an economic crisis.
The only thing worse than a hungry mob on the street is an infected hungry mob.
The model presented complete and ready to execute and implement.
US Physicians team can be available to the Government of Pakistan, Provincial Governments or other institutions for advice on implementing this plan.
DEFINITION OF TERMS
Coronavirus – CV
Field Hospital System – FHS
(COVID) Central Command and Control – CCC
Local Command Station – LCS
Provincial Command Station – PCS
Operation Unit – OU
General Ward – G Ward
Pulmonary Ward – P Ward
Clinical assistant – CA
Medical assistant – MA
Oxygen Technician – OT
COVID EMERGENCY FIELD HOSPITAL SYSTEM
The COVID Emergency Field Hospital System (FHS) is a novel concept that establishes an emergency temporary health care delivery model at a mass level in a community without the direct support or involvement of health care facilities and health care providers, by default, not by choice.
This is to be implemented when there is no availability of hospitals, doctors, nurses, and labs. In other words, this is the best option in comparison to no option or simply chaotic public behavior in a pandemic.
This model provides the COVID19 infected patient with a regimented treatment that is standardized for all admitted patients. The primary goal is to prevent the progression of sick COVID19 hospital patients from becoming “very sick” status that requires ICU and ventilator. essential health care delivery that can be easily erected and managed by non-medical professionals.
The regimented standard protocol is 3-5 drug therapy and oxygen supplementation via small nasal cannula /nostril tube (not CPAP and NOT ventilator) – see picture
The above standard protocol can significantly impact and retard progression and prevent advanced morbidity and mortality.
The above 5+O2 protocol can be implemented at mass-level by non-medical professionals and is the crux of the FHS model.
Pulse oximetry is a very simple way to measure blood oxygen level. This is critical in assessing the severity of COVID19 patients. The pulse oximetry (pulse ox) can be done within a few seconds by a small handheld device the size of a golf ball that is placed on the index finger. No blood is drawn, anyone can do this and needs no training at all. This test will be done at the time of screening and during the hospital stay and is an excellent, cheap, standard of care and a reliable tool to measure the severity status of COVID19 patients.
The role of testing COVID19 PCR or Antibodies is somewhat questionable under the circumstances of the Pandemic in an underserved community. The clinical symptoms are adequate to confirm the diagnosis. We do not see an absolute need for testing every patient under these circumstances. Therefore we have not included testing as part of our FHS system setup. However, if the establishing organization intends to use testing then those logistics may be added to the FHS system by the establishing organization.
The value of Antibody testing will be in the Post-Acute phase while the FHS system primarily addresses the Acute phase management of the epidemic.
Patients will be easily screened by a triage room by asking 3 questions and pulse ox + temperature and if 2 / 3 questions are positive with low pulse ox that patient is a candidate for admission.
Establishing a triage to access hospital admission for COVID19 patients is actually and surprisingly a standard and easily implementable process that does not require a qualified healthcare professional.
After accessing and admitting patients our 3-5 drug standard protocol is the same for all admitted patients. These protocols are for moderate to severe sick patients only and highly effective being widely used in developed countries. These 3-5 drugs are cheap generic drugs and readily available.
The treatment of COVID19 that the public is aware of is mostly talking about very sick patients. These include plasma transfusion, anti-virals, interleukin 6 inhibitors as well as other advanced medicines. These are neither needed nor applicable to the vast majority of patients that are moderately sick and come to the hospital.
However, if these moderate sick patients who need a simple treatment do not get this simple treatment at the time needed, this may lead to a disasterous outcome and patients will progress and need higher levels of care which are simply not possible to scale in Pakistan under present infrastructure and circumstances.
It is essential to break the FHS 500 unit bed hospital in multiple small operational units or OU to manage staffing and logistics for the best possible patient care especially by non-medical providers. Each OU is made up of staff and logistics that provide care to 25 patients/beds. Each OU will have its own team that works in 12 hours shifts and will be discussed later.
This model does not undermine the whatever existing health care model in a country or city, but rather provides a long term triage and management protocol with the capacity to channel the only very sick to the hospital, whereas without this model the hospitals are simply unlikely to manage these cases due to poor capacity and infrastructure. This model can significantly take the load off the existing health care system. Having this parallel model also provides comfort to the mass infected population of a pandemic and their families who otherwise may edge towards social collapse and rioting to demand healthcare.
The system is called FHS and has an input and output.
CENTRAL COMMAND STATION
The CCC is the brain of the COVID FHS countrywide system
The CCC is monitoring the activities of Provisional Command (PCS) Stations and Local command stations (LCS).
The primary job of CCC is to monitor the logistics and activity of PCS/LCS
CCC also directly intervenes when needed.
There should be at least 5-10 CCC members.
This is not a task force and is not involved in any other activity except COVID FHS system set-up management and operation supervision.
PROVINCIAL COMMAND STATION
LOCAL COMMAND STATION.
The PCS is the primary operational Head for set-up, management, logistics and operation of the FHS system in the respective province.
In provinces and territories with less than 25 FHS units, the PCS operates as LCS.
In Sindh and Punjab where the number of FHS units are in large numbers, there will be a need to set up LCS. Each LCS will manage no more than 20-25 FHS units.
Recommended FHS in Pakistan in the first phase, if needed more FHS can be established.
PCS Punjab – 5 LCS for 125 FHS (500 x 125 = 62,500 bed FHS system)
PCS Sindh – 3 LCS for 75 FHS (500 x 75 = 37,500 bed FHS system)
PCS KP – 1 LCS for 30 FHS (500 x 30 = 15,000 bed FHS system)
PCS Baloch – 1 PCS for 10 FHS (500 x 10 + 5,000 bed FHS system)
PCS ISL/GB/AJK – 1 PCS for 10 FHS (500 x 10 = 5,000 bed FHS system)
TOTAL FHS system recommended 250
The primary job of PCS/LCS is to establish supply chain and logistics in the set-up phase and operation management phase.
The PCS and LCS are not involved in direct patient care which will be at the FHS level.
TEAMS NEEDED FOR BUILDING LOGISTICS/ SUPPLY / CHAIN FOR FHS SETUP.
PCS/LCS LEVEL (these team will serve the LCS work)
- FHS set-up team / FHS maintenance team
- Finance team
- Healthcare team (training team)
- IT team (though the FHS is not based on any computer system)
- Purchasing team
- Recruitment team
- Marketing and Media team
- Supplies coordination team
- Acute problem-solving team
- General FHS coordinating team
FHS Level (these teams will serve the FHS)
FHS admin local team
Supplies coordination team
EMT / Ambulance Transportation team
Hospital transfer team-coordinator to local hospitals.
Local media team
Morgue and burial team
UNDERSTANDING FHS SYSTEM
The FHS is a 500 bed autonomous Covid19 patient care field hospital that manages patients that are sick and need hospital-level care which is not available.
While there is NO obstruction to allowing healthcare professionals to be operators and managers of FHS but it’s deliberately designed in a way to accommodate the absence of all and any health care professionals.
The primary goal of FHS is to provide 5-10 days of hospital alternative care for CV patients with the goal to prevent progression with these interventions, without these bare minimum medical interventions these patients are most likely in majority to progress to severe cases and significantly increase bad outcomes.
The FHS does not provide tailored treatment as much that is superior and standard of care. It has to be acknowledged that under the circumstances the FHS can only provide a single protocol of care with ease of implementation.
The best location for FHS set-up are large structures like local schools, large mosques or makeshift tents. With summer approaching the tents may get too hot, buildings may not have elevators.
The FHS has TWO teams
OU (clinical) Team
There are 20 Operational UNITS OU in a FHS. Each OU manages 25 patients thus 20 OU will manage 500 patients. Each OU has a team which will be discussed in detail with their job duties and description. They are managed by an admin team dedicated to that specific FHS. The Admin team works under the supervision and guidance of LCS.
ADMIN TEAM OF a single FHS (all full time 12 hours shifts x 2-3 months or more)
- Manager FHS
- Assistant manager FHS x 2
- Admitting / triage coordinator – 2-4 staff am shift + 1-2 staff night shift (they will triage any patient that may come and decide to admit based on criteria of admission – will be provided later.
- Discharge coordinator – 2-4 staff am and 1 staff pm – The patient will have three outcomes after he /she is admitted. They will improve and will be discharged home, they will worsen and may need to be transferred to a local hospital and the third option is they will die. The discharge coordinator does this planning and execution of three possible activities.
- HR staff – 2 staff full time.
- Supply and pharmaceutical manager x 1
- Supply and pharmaceutical assistant manager x 1
- Sweepers and bathroom cleaners x 4
- Security – what the LCS feels is feasible.
- Kitchen staff as per local admin
NO outside food should be allowed.
Visitors only 30 minutes once / day and one OU unit visitors at a time.
No outside medications. However, essential or life-saving medications that patients were taking before CV can be continued.
No IV and no Drips (if the admin can arrange that the FHS does not object but the
Administration has to be responsible for the logistics, staff training etc.)
The FHS model does not have labs, Xray or any testing.
If that is available certainly that is very valuable and can be included in the FHS system with appropriate staffing.
No computer needed and no programmers needed.
All documents will be paper with carbon copy x 2
OU STAFF TEAM
Operational unit staff or OU staff are the non-medical professional people who can relatively quickly be trained to do the work of patient care. There is NO need for any prior medical background needed, nor a higher level of education for such individuals.
The role of OU team means there is a dedicated team per OU that manages 25 patients 24 hours per day in two 12 hours shifts.
The three major categories of FHS ( CA MA and OT – details see below) non-medical staff working and conducting medical activity of patient care are based on simple chores. These are redundant chores or activities that anyone can do such as *Giving medication to a patient on a certain time, changing beds, helping with the use of bathroom, etc.
The only activity that can be constituted as somewhat medical is taking blood pressure, taking temperature, checking pulse ox, ensuring the nasal tube is in the nostril, connecting nasal tube to oxygen tank etc. which are not substantially incumbent medical actions that an adult of sound mind can be trained with 1-2 hours of sessions.
The prescription for Covid19 patients are the same and likely to be the same doses for nearly all patients.
Sure anyone can rightfully argue issues of complication of medications or several other issues that may arise that require health professionals but one has to accept the realities of this moment and let not perfection be the enemy of the necessary.
The OU teams are NOT health professionals but are volunteers or those who volunteer to be part of OU team and should be paid a premium salary. OU team will be trained rather remarkably quickly by Video. A brief 1-2 hours training session so they can conduct a very redundant but important job.
The safety of OU staff and their personal protective equipment (PPE) will be necessary.
Some training for self-protection for OU staff will also be necessary.
Out of 20 OU units (25 bed per OU)
10 OU General ward
10 OU Pulmonary ward
60 % Male only ward
40 % Female only ward
It is very important to note that the highly symptomatic people that need hospital care are sick patients and though may not need critical care services while they are very close to the state of needing critical care. Therefore, monitoring these patients in FHS with no certified medical staff is a challenge and yet a great opportunity to help. Undermining the OU set-up is strongly not advised.
EACH OU HAS A 12 HOURS SHIFT
CA – Clinical assistant
Situating patient at admission
Making beds and changing patients
Bathroom help (majority may need bedside bathroom help)
Bringing food from FHS kitchen and helping feed patients
Communicating with family.
Will round on patients 2 times and document a CA clinical sheet
MA – Medical assistant
Giving medications to patients 2-3 times/day or more
Dispensing prn (as needed medications)
Taking Vitals multiple times per day
Documenting daily medical sheet
Assessing renal functions based on (input and output- fluids)
Evaluating status for upgrade to pulmonary ward or downgrade to discharge
OT – Oxygen therapist
Checking pulse ox on general ward patients multiple times/day
Checking pulse ox on pulmonary wards patient multiple times/day
Giving intermittent oxygen to general ward patients
Monitoring continuous oxygen to pulmonary ward patients
Lung exercises for both ward patients
2 lead MA general ward and 2 lead MA pulmonary ward – am shift
1 lead MA general ward and 1 lead MA pulmonary ward – pm shift
The lead MA will not be assigned any patients but will be responsible for maintaining census, bed allocation, sign transfers and make final decisions for patient.
If there is one place a doctor or nurse can be placed in FHS system this would be the place.
If there is one place a doctor or nurse can be placed in FHS system this would be the place of Lead MA or a nurse can be the lead MA. There can be doctors plug in this system, for-example one doctor in-charge for General ward and one doctor in-charge for Pulmonary Ward.
STEPS TO ESTABLISH THE FHS
Establish a Central Command Station – CCC
Identify the highest level of CCC team
Identify PCS and LCS
Identify geographic areas for FHS
Identify locations for FHS
Develop the team needed for building logistics/supply/chain for set-up.
Develop team leaders
Recruit the needed staffing at all level
Secure the equipment (beds, blankets etc.) medications and medical equipment (pulse ox, blood pressure equipment etc.).
Training of staff
Develop the operational SOP
The process of setting this up should not be more than 2-3 weeks.
DOCUMENTS FOR CLINICAL CRITERIA CAN BE PROVIDED UPON REQUEST
CRITERIA FOR SCREENING AND ADMITTING
CRITERIA FOR DISCHARGE
CRITERIA FOR TRANSFER
CRITERIA FOR UPGRADING FROM GENERAL WARD TO PULMONARY WARD
PATIENT MEDICAL RECORD NUMBER SYSTEM
PATIENT DAILY CHARTING NOTES BASIC DOCUMENT
PATIENT VITAL MONITORING DOCUMENT
MA job duties
CA job duties
OT job duties
Lead MA job duties.
DOCUMENTS FOR OPERATIONS CAN BE PROVIDED UPON REQUEST
SOP FOR DAILY CENSUS AND ITS DOCUMENT
SOP FOR SUPPLIES AND ITS DOCUMENT
SOP FOR PHARMACY AND OXYGEN
SOP for HR
SOP FOR DAILY INVENTORY OF SUPPLIED AND ITS DOCUMENTATION
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