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Be Prepared

I was in Nepal with the EMMS Director of Finance when the World Health Organisation declared on 12th March that there was now a global pandemic of COVID-19. We were in Pokhara, where EMMS is working with INF and its Green Pastures Hospital to build and run a new palliative care unit. We had planned to go to India after Nepal, but India cancelled all visas. So we extended our stay in Nepal by just enough to finish the proposal we were working on, and then hurried home – home to Europe that was by now showing signs of becoming the new epicentre of the pandemic. The woman in front of us on the plane cried for most of the flight, perhaps leaving loved ones behind in Nepal while repatriating to her home country. We arrived home on 18th March, Nepal announced its lockdown on 24th March, and the friends we had left in Pokhara told us that they now could not leave Nepal, even if they wanted to – which they didn’t.

INF sends weekly updates of its coronavirus work with local and national authorities, including the transport of COVID patients and distribution of food packages. At Green Pastures Hospital, they are screening entrants with infrared thermometers, gearing up to test patients suspected of having COVID-19, having inpatients wear face masks, making PPE, and preparing to visit patients at home as lockdown prevents them from coming to the hospital. When we asked what we could do to help, INF gave us a list of supplies for home visits, PPE, oxygen cylinders. Additionally, they need money to fund treatment of the increasingly impoverished population and to keep the hospital fully staffed as its income from patients’ fees plummeted.

The number of confirmed cases of COVID-19 in Nepal keeps climbing. Widespread poverty makes prevention measures difficult for households, and Nepali migrants continue to arrive home from abroad. By May it was clear that COVID-19 must dramatically affect palliative care plans at Green Pastures Hospital. The hospital might have to cope with over a year of caring for end-of-life patients who need accommodation in an isolation area. Hospital management decided to use their spinal cord injury ward first for this, and then to transfer these anticipated COVID-19 palliative patients to the new palliative care building from November, once the new building is ready. The new building will, therefore, almost certainly have to operate as an isolated clinical area for some time.

But could the new building be completed anyway, in lockdown? We had seen it nearly complete as we left, with inside works progressing, and just needing utilities, fittings and landscaping. The government had instituted a new rule that 20% of project budgets should be used for COVID-19 efforts. With the palliative care unit now designated for COVID-19 patients, its completion counted as part of the hospital’s COVID-19 efforts. And so building continues, with social distancing and hygiene precautions for builders, fitters, landscapers and engineers.

Looking at the increasing demand for palliative care due to COVID-19, as well as this unexpected temporary use of the new building as a COVID-19 isolation area, the engineers revised their building budget. INF had been their usual prudent selves in managing our funds. The Nepali design contractor had submitted a conservative budget, the winning construction tenderer had offered a competitive price, and the hospital’s excellent team of engineers had overseen all construction closely from their on-site office, sharing supervision with the design company. They had made savings. They asked us if they could add a 4-room annexe within the budget, which could serve as a non-isolation area in which to continue to develop palliative care. We quickly agreed, as did the McClay Foundation, which is funding the building.

The efficiency with which INF stuck to its building timetable before lockdown has enabled them to cope well with these unexpected changes. INF still expects to complete the building by October, even including the additional annexe. They intend to open the new palliative care unit on World Hospice and Palliative Care Day, 10th October 2020. The facility has rooms for ten adult beds, four children’s beds, and clinics for day therapy, community services and outpatients. The newly approved annexe will have a small clinical meeting room which will also host day therapy and carers’ meetings, a palliative care office, a private counselling room, and a telemedicine room. It will give extra space that is not in an isolation area and rooms to keep developing palliative care activities such as day therapy, even during COVID-19’s most intense impacts. The unit is a magnificent building, and both the unit and annexe will have a backdrop of mountain tops of Annapurna’s Machapuchare peak, the “Fishtail”. This range was on full display during our visit, in glorious weather, and this is the view that patients, families and staff will get on clear days.

We are grateful that this has worked out so well, with the original new building soon able to help the hospital cope with COVID-19. The hospital’s palliative care team will continue to develop its expert services and demonstrate high-quality palliative care both with COVID-19 patients in the palliative care unit and with other palliative care patients in the new annexe. INF was well prepared for these changes as it kept ahead of its building timetable. But in building this new unit and developing palliative care, it was also unknowingly preparing for a crisis that it could not foresee.

The long-term counselling needs brought by COVID-19 will be significant, and the annexe provides a private area for creative interventions like art therapy, while its dedicated telemedicine room will enable rapid expansion of the hospital’s telemedicine, both for community outreach and to mentor healthcare workers living far from Pokhara. The hard work that INF’s palliative care team has put in over the years to create this new palliative care unit has paid off, and it has uses that they could never have imagined when they first mooted the idea of a brand new palliative care unit. No one could have known then that they were preparing their hospital to cope with a global pandemic.


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