What has been the role of makeshift and mobile health care facilities across Europe during COVID-19?
Intensive care units (ICUs) and emergency rooms (ERs) across Europe are under pressure due to the increased volume of patients affected by COVID-19.
To increase their surge capacity, several countries have been making use of makeshift and mobile health care facilities to provide medical care to infected patients.
Makeshift health care facilities are temporary hospitals or treatment centres. They may include rapidly constructed modular buildings or converted existing venues, such as schools, rehabilitation centres, malls, or conference centres. Mobile health care facilities are medical tents, containers, or vehicles equipped with the necessary equipment to deliver specific care to patients. Depending on the respective needs, these facilities have been used to provide three functions during the pandemic: (i) isolation and hospital care for patients with mild to moderate COVID-19 symptoms, including patients requiring nursing care or oxygen, (ii) patient triage, and (iii) acute care for severely ill COVID-19 patients, such as those needing intensive monitoring on a ventilator. This policy snapshot outlines the role of these facilities for COVID-19 patients across Europe. Information was collected from the COVID-19 Health Systems Response Monitor (HSRM) (up to 1 February 2021).
Makeshift facilities have been used for treatment and isolation of cases alongside home isolation and medical treatment centres
Makeshift facilities can provide several benefits for isolating mild and moderate COVID-19 cases, such as the minimisation of patient-to-patient transmission (for COVID-19) and allowing for the pooling of respiratory care in a single facility. They can free up scarce resources at other health care facilities or higher-level hospitals for patients with severe COVID-19 illness and other patients requiring critical or complex care for other conditions. In addition, if these facilities are designated for non-acute care, they can provide a place to discharge patients recovering from severe disease. Figure 1 shows the WHO recommendations on how makeshift facilities can complement home isolation and medical treatment centres in COVID-19 care along the severity spectrum.
Figure 1. WHO recommendations for COVID-19 care locations
In the early stages of the pandemic, countries such as Italy, Spain, and the United Kingdom, turned existing buildings into makeshift health care facilities to serve patients infected with COVID-19. In other countries, such as Bulgaria, additional treatment facilities were used including a combination of camp beds and mobile units. As cases increased, many countries established large-scale temporary facilities with modular units, such as the Nightingale Hospitals in the United Kingdom. These facilities were mostly used for patients with mild or moderate cases.
This approach is reminiscent of ‘fever hospitals’, which had been used in the past to isolate and treat patients in times of serious infections, such as measles and scarlet fever. Later on, these fever hospitals were closed due to development in immunisations and the availability of antibiotics that made infectious diseases less common. Nevertheless, the COVID-19 outbreak awakened countries to the need to re-establish health facilities that would play a similar role as those ‘fever hospitals’.
Many makeshift and mobile facilities for isolation and treatment were hardly used and put on standby after the first wave of COVID-19 had ended in the respective country, such as most Nightingale Hospitals in the United Kingdom. However, due to the surge in COVID-19 cases in the latter half of 2020, many countries have reactivated these facilities, although not necessarily for COVID-19 patients.
Some very mild cases who self-isolate at home could be treated in makeshift facilities if their self-isolation could involve challenges in the organisation of case management, disease monitoring, timely referral to hospital care when their health deteriorates, as well as infection risk for their household members. Thus, several countries, such as Armenia, Bosnia and Herzegovina and Bulgaria, have introduced designated places of isolation for these patients, such as modified hotels. However, these were usually only for treating those who require minimal care and meet certain criteria, such as pre-existing risk factors. The feasibility of this measure highly depends on the case volume and most countries only employed it in less intense pandemic phases.
Makeshift and mobile facilities have been used to take over the triage function from hospitals
Makeshift and mobile facilities can be used for separating COVID-19 patients by the severity of their symptoms (“triage”). To undertake this role, these facilities pool patient registration, triage, and examination rooms in one space – however, the configurations vary by country. This allows triage of sick patients at community locations and rapid referral to the most appropriate facility, such as an ER.
The most basic configuration are tents for rapid triage that are set up at the entrance of hospitals – a configuration used by most countries across Europe. In addition, many countries coupled triage and first emergency care for patients with mild symptoms in these facilities. In Spain, makeshift and mobile units were activated in different locations around the country to receive COVID-19 cases – especially those self-isolating at home. Health workers carried out frequent monitoring and diagnostic tests to ensure that worsening patients were being immediately identified and transferred to an ICU or ER.
Countries with limited financial capacities also prioritised temporary triage infrastructure: Serbia set up 40 temporary triage containers and Bulgaria established “COVID-19 zones”, outpatient medical centres used for diagnostics and consultations of patients with flu-like symptoms.
Many countries, such as Sweden, Italy and Montenegro, deployed their armed forces in the setup of these triage facilities. This way, existing equipment, such as triage tents and field beds, as well as knowledge of the military in emergency triage and rapid mobile medical care were utilised.
Mobile and makeshift facilities have been used to increase ICU capacity
While hospitals should ideally be the treatment location for severely ill COVID-19 patients, many countries do not have enough beds in their ICU and ER to treat both COVID-19 patients and other acutely ill patients. To increase their capacities, many countries used makeshift facilities to treat severely ill COVID-19 patients – albeit mostly as last resort when their hospitals reached capacity limits. As a rapid response to its first surge in cases, Italy’s Department of Civil Protection set-up military camp hospitals with additional ICU or semi-ICU beds in the most severely affected areas. Similarly, in March 2020, the government of Spain increased their ICU capacity by setting up makeshift health care facilities in different cities. For example, one of its largest makeshift medical centres with over 5,000 beds, including 500 in an ICU, was set up in Madrid. This facility supported the local hospitals’ emergency services by treating COVID-19 patients with mild to severe symptoms.
Overall, these makeshift and mobile health care facilities can play an important role in protecting health care systems from reaching capacity limits. They could boost the efficiency and effectiveness of the response to the COVID-19 pandemic. However, countries could determine to have makeshift hospitals equipped and ready at all times for use in response to rapidly growing emergencies. They could be an inherent part of their emergency plans to help in the control of future public health emergencies or other events involving illness or injury on a large or rapidly growing scale.
ASPHER COVID-19 Taskforce
Costase Ndayishimiye, Tobias Weitzel, John Middleton