Sri Ramachandra Preparedness, Advisory And Position ... · Government Helpline : Central Helpline...

Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic

1.0 Purpose ...................................................................................................................................................................................................................................................................................... 1

2.0 Scope .............................................................................................................................................................................................................................................................................................. 3

3.0 Responsibilities............................................................................................................................................................................................................................................................. 3

4.0 Procedure ................................................................................................................................................................................................................................................................................. 3

4.1 Lobby and ER Zone Arrangement ................................................................................................................................................................................. 3

4.2 Screening Criteria (ER & Lobby) ....................................................................................................................................................................................... 3

4.3 SampleCollection..................................................................................................................................................................................................................................... 4

4.4 Infectionpreventionandcontrol(IPC)measures............................................................................................................................. 5

4.5 ImplementingIPCmeasuresforpatientswithsuspectedorconfirmed COVID-19infection................................................................................................................................................................................................................................. 6

4.6 Standardprecautionsshouldalwaysbeapplied.Additionalcontactand dropletprecautionsshouldcontinueuntilthepatientisasymptomatic............................................... 7

5.0 EnvironmentalInfectionControl.................................................................................................................................................................................................... 7

6.0 Case Management ................................................................................................................................................................................................................................................ 7

6.1 Generalsupportivemeasures............................................................................................................................................................................................. 7

6.2 Closemonitoringforworseningclinicalstatusisofparamount importance (designated team) .......................................................................................................................................................................................... 8

6.3 Dosage .......................................................................................................................................................................................................................................................................... 8

7.0 Protocol for Managing a Suspected Case ........................................................................................................................................................................ 8

8.0 PatientAdmissionPolicy............................................................................................................................................................................................................................... 9

8.1 Attenderguidelines................................................................................................................................................................................................................................ 9

8.2 Visitor policy ...................................................................................................................................................................................................................................................... 9

9.0 StaffingPlan......................................................................................................................................................................................................................................................................... 9

9.1 StaffClinic................................................................................................................................................................................................................................................................ 9

10.0ProceduresforTakingRemedialActionsagainstOccupationalExposuretoCOVID-19.................. 10

11.0PersonalProtectionManagement(PPM)Protocol........................................................................................................................................ 11

12.0 Diet protocol ...................................................................................................................................................................................................................................................................... 11

13.0 Spill Protocol .................................................................................................................................................................................................................................................................. 11

14.0BiomedicalwasteClearance.................................................................................................................................................................................................................. 12

15.0DisinfectionProtocol........................................................................................................................................................................................................................................... 12

16.0 Dialysis Protocol............................................................................................................................................................................................................................................................ 13

17.0 Deceased Handling Protocol ................................................................................................................................................................................................................. 14

18.0Annexures............................................................................................................................................................................................................................................................................... 14

INDEX

Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic SRIHER, Chennai | March 19, 2020

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Departments respOnsIBILItY

Leadership

Planningeffectiveandefficientuseofresourcesincludingmanpower.CoordinationwithALLHOCsandconsultantstocomplyCOVIDguidelines,Identifyingtheconsultantsfromeachdepartmentalongwithlistofresidentssupposedtopostedwithbackupplan,Staffclinics,ensureadequatesupplyofresourcesandinfrastructurechanges,safetyandprecautionarymeasurestakenfromallthestaffinvolvedforCOVID19,resolvebottlenecksoftheprocessflows,

NodalOfficer

PhysicianCo-ordination,Todeviseadmission&dischargecriteria,managementprotocols,identifyingtrainingrequirements,overseeimplementationofGOVTpolicies,sensitizationandconductingdailyreviews,datareportingtoGOVT,liaisingbetweenGovtandSRIHER.FurthercommunicationsaspertheGOVTguidelines.

ICOValidationofappropriatenessoftheprocesses,protocols,checklists,developmentofinfectioncontrolmeasuresandstrategicteams,conductingDRILLS,trainings,Overallcoordinationfromleadershiptogroundlevelstafffordevisingriskmitigationguidelines,

ICN

DataCollectionandReport,Counsel,educate,trainabouthandhygiene,respiratoryhygiene,coughetiquette,useoftissues,todisposetissues,contaminateditemsindustbin,monitorimplementationofareaspecificchecklisttrainings,Coordinationwithtriageareainisolatingsuspectedcases,attendingtothequeriesandgivenresponsibilities

EducationEnsuretraining&educationofthestaffsofidentifiedgroupsonCOVID-19protocol,drillevaluation,monitoringforcompliancewithareaspecificchecklists,evaluationofknowledgeandskilldemonstration&retrainingasrequired.

HR

Staffinglistdonefor–Physicians,Nurses,Admin,Supporting,technicalandcontractual.Adequatepreinductionandpostinductionwelfaremeasurestaken,riskallowance,Fittestedemployeesposted,contingencyplanforstaffing,adequateplanningforcontractworkers,Developingstrategicstaffingplan,fallbackplan,dailyreviews.

AdminIncharge

Ensureeffectiveimplementationasperthedecisionsandguidelines,monitorandensureallstafftrainedappropriatetothehandledjob,coordinateadmissionandregistrationservicesonadynamicbasis,createsmoothoperationalflowenvironment,signage’sandeducationmaterial,ensureareasarewellequippedandreadyforuse,coordinationwithsupportandancillaryservicesasneedbased,developingroutemapsforpatientflows.

Nursing

Identifystaffing,equipment,medication,PPEs,essentiallistofstationaryandthingstosetupisolationareaatF7andSRHforwardandICUs,providelistofStaff,coordinatewithtrainingneeds,ensuresafetyofdeployednursesandstaffcomesundernursingservices,escalatethebottleneckswithconcernedasandwhenrequired.

Quality

ToDevelopProtocolsandprocessflows,checklistsasperevidencebasedguidelines&monitoreffectiveimplementation.CreatesurveillancemechanismandindicatorsincoordinationwithNodalofficerandICO,coordinatefordailydebriefings,andcommunicatedecisionsthroughminutesfordaytodayoperationalimplementationbyrespectivestakeholders.Evaluationofdrillsanddocumentationandreporting

House Keeping

Ensurestafftrainedoverdisinfectantprotocolsandreligiouslypractised.Counselontheirsafety,fittestedstaffsneedtobeposted,ThePPE’susedbythepatientshouldbedisposedinayellowbaglabelled&transportedinseparatetrolley.Trolleyshouldbecleanedwithbleacheverytimeafteritisbeenusedfortransporting.Liftmustbedisinfectedregularly,strictmonitorforcomplianceatallthedesignatedareasforsurfacecleaningonhourly/twohourlybasis.

SRMC/SRH-STRATEGIC TEAM COVID-19


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Departments respOnsIBILItY

Biomedical purchase

AdequatesupplyandqualityofdeliveredgoodsmaintainedwithingivenTAT,PPMandreadinessofequipment’sbeforeplacingintoF7andSRH,meetDr.RamEandtakeapprovalonworkingcondition.Ensurewrittenapprovalontheselectionanduseofresourcesprocured,aswellassupervisingitsperformancetestingandmaintenance.Forecastingupcomingdemand.

IT Digitalsupportinreportingandprocessflows;educationalSMS/throughMed.Dir.

PharmacyEnsurethatstockhastobemaintained.InvolveinprocurementanddistributionofallPPEsrequiredforthepatient.Thermalscannersneedtobeprocuredforscreeningofpatients

SecurityEnsurethatERtoF0Aliftpathwaybarricadedandmannedbysecurity.Compliancewithvisitorspolicy,escalatetoCHA/Asst.MedicalDirectorondaytodayissues.staffcounselledandnotchangedafteridentifyingthelist

1.0 purposeTo,delineatetheprocessofcareforpatientwithsuspected/positiveCOVID-19atSriRamachandraMedicalCentreandAriRamachandraHospital.

note: TheprocessofcareisbasedonrecommendationsbytheCDC,WHOandMinistryofHealth(MOH)GovernmentofIndia(GOI)

When to suspectAny patient with acute respiratory illness with:

1. Ahistoryofnationalandinternationaltraveltothesuspected/reportedcasesinthe 14 days prior to symptom onset, or

2. Closecontactwithaconfirmed/suspectedcaseofCOVID19inthe14dayspriorto symptom onset, or

3. Healthcareworkertakingcareofconfirmed/suspectedpatientsofCOVID19

Case Definition of Covid 19 Suspected Case

Patientswithacuterespiratoryinfection(suddenonsetofatleastoneofthefollowing:cough,sorethroat,shortnessofbreath)requiringhospitalizationornot

anD

Inthe14dayspriortoonsetofsymptoms,metatleastoneofthefollowingepidemiologicalcriteria:WereinclosecontactwithaconfirmedorprobablecaseofCOVID19infection;

Or

HadahistoryofinternationaltravelwithongoingcommunitytransmissionofSARSCoV-2

Or

WorkedinorattendedahealthcarefacilitywherepatientswithSARSCoV-2infectionswerebeingtreated.


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Close Contact Closecontactisdefinedas:•Healthcareassociatedexposure,visitingpatientsorstayinginthesamecloseenvironmentasaCOVID-19patient.•WorkingtogetherincloseproximityorlivinginthesamehouseholdwithaCOVID19patient.• TravellingtogetherwithaCOVID-19patientinanykindofconveyance•Theepidemiologicallinkmayhaveoccurredwithina14-dayperiodbeforeoraftertheonsetofillnessinthecase underconsideration

probable Case AsuspectedcaseforwhomtestingforCOVID-19isinconclusive(theresultofthetestreportedbythelaboratory) orforwhomtestingwaspositiveonapan-coronavirusassay

Confirmed Case ApersonwithlaboratoryconfirmationofSARSCoV-2infection,irrespectiveofclinicalsignsandsymptoms

Clinical Features TheclinicalandradiologicalmanifestationsofCOVID-19include:

•Fever(83%)•Cough(82%)•Shortnessofbreath(31%)•Sorethroat(5%)•Rhinorrhoea(4%)•Diarrhea(2%)•Bilateralpneumoniaonimaging(75%)•ARDS(10-17%ofadmittedpatients)

2.0 scopeHospitalWide(SriRamachandraMedicalCentreandSriRamachandraHospital)

3.0 ResponsibilitiesViceChancellor,DeanofFaculties,MedicalDirector,NodalOfficer,DirectorFinance,MedicalSuperintendent,InfectionControlOfficer&Committee,AssistantMedicalDirector,HQAD,DeputyMedicalSuperintendent, AllHOCS,GM-HR,NS,CHA,CQO,CSOandalltheHODs.

4.0 Procedure

4.1 Lobby and ER Zone Arrangement Lobby Patients and their attenderswith history of travel and fever and/or respiratory symptoms shall be guided into asuspectedCOVID-patientzone;thosepatientswithregularfeverbutnoclearepidemiologicalhistoryshallbeguidedintoamixedzoneandotherbufferzonesshallbeusedbystaffandasexit. erAttendersaccompanyingthepatientswithhistoryoftravelandfeverand/orrespiratorysymptomsshallbeguidedintoasuspectedCOVID-patientzone(roomno.44);forhospitalizedpatientattenders,idbandischeckedandrestrictedtoonenumberscreenedandallowedtoinpatientareaswhenfoundtobeasymptomatic.

4.2 Screening Criteria (ER & Lobby)•Screeningshallbedoneatscreeningcounters(Historyoftravel,Fever,cold,cough)andsymptomaticpatients tobeidentified.•ScreeningCounterstobelocatedatadistanceof2metersapart.•SuspectedpatientstobeidentifiedbyAdministrationofquestionnairetopatient/attender/visitor,along withThermalscreening.•SuspectedpatientsshallbegivenamaskandshallbetransferredtoER-44.


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Government helpline : CentralHelplineNumber:+91-11-23978043 TamilNaduHelplineNumber:044-29510500

Email: [email protected]

FOR ANY QUERIES

Help Line Numbers:

Sri Ramachandra Medical Centre and Sri Ramachandra Hospital

Dr.Sudagar Singh - 9003178899 / Dr.Vidhya Krishna -9444976855/ Dr.Senthil - 9381049376 / Dr.Sowmya – 9840414834

FOR ANY QUERIESHelp Line Numbers:

Sri Ramachandra Medical Centre and Sri Ramachandra Hospital Dr.Sudagar Singh - 9003178899 Dr.Vidhya Krishna - 9444976855 Dr.Senthil - 9381049376 Dr.Sowmya - 9840414834

Government Helpline :Central Helpline Number : +91-11-2397 8043Tamil Nadu Helpline Number : 044 - 2951 0500Email: [email protected]

Laboratory Diagnosis Whom to test:

a) For persons with international travel history to the affected areas from last 2 weeks, respiratory samples (nasopharyngeal swab, oropharyngeal swab) and blood samples should be collected for all persons whether symptomaticorasymptomatic.

b) respiratory and blood samples will be collected only from symptomatic cases As per directive fromMoHFW, GovernmentofIndia,allsuspectedcasesaretobereportedtoDistrict&StateSurveillanceOfficers.Theirteam will arrange for sample collection and transport to the KING’S Institute and subsequently communicate the reports (to contact helpline number). *All suspected cases to bemandatorily reported to the District & State SurveillanceOfficers

4.3 Sample Collection General Guidelines

•UntilpermissiongrantedfromtheMOH,samplesshallbecollectedbytheGOVTrepresentativeafterinformation onadmissionofthesuspectedcases.•Trainedhealthcareprofessionalstowearappropriatepersonalprotectivewithlatexfreepurplenitrilegloveswhile collectingthesamplefromthepatient.Maintainproperbarrierwhencollectingspecimens.•Restrictedentrytovisitorsorattendersduringsamplecollection.•Specimensshouldbecollectedassoonaspossibleonceasuspectedcaseisidentifiedregardlessoftimeof symptom onset.• Itisrecommendedthattestingofmultipleclinicalspecimensfromdifferentsites,includingtwospecimen types-lowerrespiratoryandupperrespiratorymustbedone.•Labeleachspecimencontainerwiththepatient’sHIDnumber,name,ward,specimentypeandthedatethe samplewascollected.Completetherequisitionformforeachspecimensubmitted.•TransportimmediatelytocentralLab•Properdisposalofallwastegenerated.


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Specimen Type and PriorityForinitialdiagnostictestingforCOVID-19byRealTime-PCR,itisrecommendedtocollectandtest

•Upperrespiratory(nasopharyngealANDoropharyngealswabs)and

•LowerrespiratoryforpatientswithproductivecoughInductionofsputumisnotindicated.

Respiratory Specimen collection

A. Lower respiratory tract

Bronchoalveolar lavage, tracheal aspirate

•Collect2-3mLintoasterile,leak-proof,screw-capsputumcollectioncuporsteriledrycontainer.

Sputum

•Rinsethepatientsmouthwithwater,expectoratedeepcoughsputumdirectlyintoasterile,leak-proof, screw-capsputumcollectioncuporsteriledrycontainer.

B. Upper respiratory tract

Nasopharyngeal swab AND oropharyngeal swab (NP/OP swab)

Nasopharyngealswab:Tiltpatient’sheadback70degrees. Insertflexibleswabthroughthenaresparallel tothe palate(notupwards)untilresistanceisencounteredorthedistanceisequivalenttothatfromtheeartothenostril of thepatient.Gently, rub and roll the swab. Leave the swab in place for several seconds to absorb secretions beforeremoving

Oropharyngealswab(e.g.,throatswab):Tiltpatient’sheadback70degrees.Rubswaboverbothtonsillarpillars andposteriororopharynxandavoidtouchingthetongue,teeth,andgums.

UseonlysyntheticfiberswabswithplasticshaftsNPandOPspecimensshouldbekeptinseparatevials.

Do not use calcium alginate swabs or swabs with wooden shafts. Place swabs immediately into sterile tubes containing2-3mlofviraltransportmedia.

Combined Nasal & Throat Swab:Tiltpatientsheadback70degrees.Whilegentlyrotatingtheswab,insertswablessthanoneinchintonostril(untilresistanceismetatturbinates).

Rotatetheswabseveraltimesagainstnasalwallandrepeatinothernostrilusingthesameswab.Placetipoftheswabintosterileviraltransportmediatubeandcutofftheapplicatorstick.Forthroatswab,takeaseconddrypolyesterswab,insertintomouth,andswabtheposteriorpharynxandtonsillarareas.(avoidthetongue)Placetipofswabintothesametubeandcutofftheapplicatortip

InpatientswithconfirmedCOVID-19infection,repeatURTandLRTsamplesshouldbecollectedtodemonstrateviralclearance.Thefrequencyofspecimencollectionwillbeatleastevery4daysuntiltherearetwoconsecutivenegativeresults(bothURTandLRTsamplesifbotharecollected)inaclinicallyrecoveredpatientatleast24hoursapart.

4.4 Infection prevention and control (IPC) measuresIPCisacriticalandintegralpartofclinicalmanagementofpatientsandshouldbeinitiatedatthepointofentryofthepatienttohospital.Thesameshouldbecontinuedinthedesignatedwardforin-patientcareofsuspectedandconfirmedcases.Thefollowingareashavebeenidentifiedforthecareofsuspectedandconfirmedpatients:

a. NEWEmergencyscreening:AreaR.No44(bothpediatricandadults)

b. F7ward:7Isolationbedsand4criticalcareinclusiveof2negativepressureroomshavebeendemarkedforthe in-patientmanagementofadmittedpatients.

c. ERshallbeconvertedintoisolationwardwith12bedsforholdingsuspectedpatients.

d. RoutineemergenciesshallbeshiftedtoF0.

e. SRH:Psychiatrywardstartingwith15beds,shallbeincreasedupontheneedandavailableresources.


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SITUATION MEASURES

At Triage

• SuspectedpatientstobetriagedatthescreeningareaoftheR.No44Emergency• ThePromotionofhandhygieneandrespiratoryhygieneareessentialpreventive

measures (Appropriate signages)• Givesuspectedpatientsamedicalmask.• Instructallpatientstocovernoseandmouthduringcoughingorsneezingwith

tissueorflexedelbow.• Performhandhygieneaftercontactwithrespiratorysecretions.• Keepatleast1–2metersdistancebetweensuspectedpatients.• Adequatesuppliesincludingalcohol-basedhandrub(ABHR),tissues,notouch

receptacles for disposal, and facemasks at designated areas.• Teamofdedicatedphysiciansmanningtheareaandensuringminimumwaiting

timebeforeadmission.• Healthcareworker(HCW)touseaN95respirator/Three-layeredmedicalmask

duringworkindesignatedareas.• UsePersonalProtectiveEquipment(PPE)(N95respirator/medicalmask,eye

protection,glovesandgown)whenenteringroomandremovePPEwhenleaving.Donning/doffinghastobestrictlyadheredto.

• Usededicatedequipment(E.g.Stethoscopes,bloodpressurecuffsandthermometers).

• Equipmentshallnotbesharedamongpatients,Ifatall,cleananddisinfectbetweeneachpatientuse(onlymobileXray,Ultrasound,scopies,ECHO,ECMOetc).

• Healthcareworkersshouldrefrainfromtouchingtheireyes,noseandmouthwithpotentiallycontaminatedhands.

• Avoidcontaminatingenvironmentalsurfaces(e.g.Doorhandlesandlightswitches).

• Whenprovidingcareinclosecontact,useeyeprotection(Goggles)

TransfertodesignatedF7wardandSRH&Intra-hospitaltransferofpatients

• Usepredeterminedtransportroutes(Fblockliftno1)tominimizeexposureforstaffotherpatientsandvisitors.

• Standard,dropletandcontactprecautionsasabove.• Novisitoraccesstosuspected/positivepatients.• Provideonlydedicateddiagnosticandtherapeuticdevicesincluding

portableultrasonography,electrocardiography,mechanicalventilation,andcardiorespiratorymonitoringequipmentwithinthedesignatedpatientareas.

• Incaseofrequirementofprocedureslikecomputedtomography(CTscan)oroperativeprocedureswhichnecessitateshifting,thismaybeschedulesduringoutofroutineworkhours.

• Thehospitalpersonnelinvolvedinshiftingandmanagingthepatientoutsidedesignatedareasshouldfollowallstandardcontactanddropletprecautions.

• Allspecimenscollectedforlaboratoryinvestigationsshouldberegardedaspotentiallyinfectious;reinforcesafehandlingpracticesandspilldecontaminationproceduresforstafftransportingthesamples.

Applyairborneprecautionswhenperforminganaerosolgeneratingprocedures.Includesopensuctioningofrespiratorytract,intubation,bronchoscopy,cardiopulmonaryresuscitation(CPR)

• Patientcareteamperformingaerosol-generatingproceduresshouldusePPE,includinggloves,long-sleevednon-permeablegowns,eyeprotectionandN95nrespirator.

• Adequatelyventilatedsingleroomsshouldbeusedperformingaerosol-generatingprocedures.

4.5 Implementing IPC measures for patients with suspected or confirmed COVID-19 infection


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4.6 Standard precautions should always be applied. Additional contact and droplet precautions should continue until the patient is asymptomatic.StandardprecautionsshouldalwaysberoutinelyappliedinallareasofhealthcarefacilitiesincludingOPD.Standardprecautionsaresummarizedbelow:

•Handhygiene-

- Everystaffshouldperformhandhygieneusingalcohol-basedhandruborbywashingwithsoapandwaterforat least20seconds.Ifhandsarevisiblysoiled,usesoapandwaterbeforereturningtoABHR

•UseofPPEtoavoiddirectcontactwithpatients’blood,bodyfluids,secretions(includingrespiratorysecretions)andnon-intact skin.

- AnareaisdesignatedfordonninganddoffingPPEintheimmediatevicinityofthepatientareainF7inSRMCand psychiatricwardatSRH

- Gloves-Performhandhygiene,thenputonclean,non-sterileglovesuponentryintothepatientroomorcare area.Changeglovesiftheybecometornorheavilycontaminated.Removeanddiscardgloveswhenleavingthe patientroomorcarearea,andimmediatelyperformhandhygiene

- Gowns-Putonacleandisposablenon-permeablegownpriortoentryintothepatientroomorarea.Changethe gownifitbecomessoiled.Removeanddiscardthegownbeforeleavingthepatientroomorcarearea.

- RespiratoryProtection-Userespiratoryprotection,i.easfollows:

I. Three-layeredmedicalmasktobewornbypatientsatalltimes

II. AdisposableN95 respirator tobewornbyHealthCareProviders (HCPs).Disposable respirators shouldbe removedanddiscardedafterexitingthepatient’sroomorcarearea.Performhandhygieneafterdiscardingthe respirator.

5.0 Environmental Infection Control•Dedicatedmedicalequipment/singleusedisposableequipment(eg;Stethoscopes,bloodpressurecuff, thermometersetc)shallbeusedforpatientcare

•Allnon-dedicated,non-disposablemedicalequipmentusedforpatientcareshouldbecleanedanddisinfectedas routinedisinfectionprotocol(70%ethylalcohol)

•Ensurethatenvironmentalcleaninganddisinfectionproceduresarefollowedconsistentlyandcorrectly (1%SodiumHypochlorite)

•Managementoflaundry,foodserviceutensils,andmedicalwasteshouldalsobeperformedinaccordancewith routineprotocol.

•Preventionofneedle-stickorsharpsinjuryasuniversalprecautions

•Safewastemanagementasroutinehospitalprotocol

•ReinforcingtheproperuseofPPEbyhealthcareworkers/otherstaffinvolvedinpatientcare

6.0 Case Management •Themanagementwillneedtobeindividualizedaspatientmaypresentwithawidespectrumofillnessranging fromuncomplicatedillness,mildpneumonia,severepneumonia,ARDS,sepsisandsepticshock.

6.1 General supportive measures •Oxygensupplementation

•Conservativefluidmanagementifthereisnoevidenceofshock

•GiveempiricantimicrobialstotreatalllikelypathogenscausingSARS–CoV-2.Giveantimicrobialswithinonehour ofinitialpatientassessmentforpatientswithsepsis

•Ventilatormanagementasrequired

•Systemiccorticosteroidsarenotrecommended,unlessindicatedforotherreasons


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6.2 Close monitoring for worsening clinical status is of paramount importance (designated team)

NO SPECIFIC ANTIVIRALS are recommended for treatment of SARS-CoV andMERS-CoV due to lack of adequateevidence from literature. Theuseof lopnavir/ ritonavir in PEP regimens forHIV (4weeks) is also associatedwithsignificantadverseeventswhichmanyatimes leadstodiscontinuationof therapy. In lightof theabove, lopnavir/ritonavirshouldONLYbeusedwithproper informedconsentonacase-to-casebasiswithin theabove frameworkalongwith supportive treatment asperneed. The current standardsof care that are consistentwithbest clinicalpracticesandWHOguidelinesincludinginfectionpreventionandquarantineasthemainstayofmanagementforthepatientsshouldbefollowed.PregnantwomenwithsuspectedorconfirmedCOVID-19infectionshouldbetreatedwithsupportivetherapiesandmultidisciplinaryteam.

• Increase in creatinine by 50 % from baseline, GFR reduction by >25 % from baseline or urine output of <0.5ml/Kgfor6hours

•ReductionofGCSby2ormore

•Anyotherorgandysfunction

Highriskgroups

Age>60years

- Diabetesmellitus,renalfailure,chroniclungdiseaseandimmunocompromisedpersons,posttransplant/on ImmunosuppressiveDrugs

6.3 Dosage: •Lopinavir/ritonavir(200mg/50mg)-2tabletstwicedaily

•Forpatientswhoareunabletotakemedicationsbymouth,lopinavir400mg/ritonavir100mg5-mlsuspension twicedaily

Duration: 14 days or for 7 days after becoming asymptomatic

When to discharge? •IfthelaboratoryresultsforCOVID-19arenegative,dischargeistobedecidedasperdiscretionofthetreating physicianbasedonhisprovisional/confirmeddiagnosis

•IncaseofhighsuspicionofCOVID-19repeatsamplesaretobesent

•Confirmedcase-Resolutionofsymptoms,radiologicalimprovementwithadocumentedvirologicalclearancein2 samplesatleast24hoursapart

7.0 Protocol for Managing a Suspected Case

Sample Negative

stable

Discharge as per treating physician

discretion

stable

Inform Govt.

Home Quarantine

Sick

Admission as regular

Admission if bed available

Sample Positive

Suspected case- send samples for COVID-19 testing

note:ThisdocumentisdynamicandmaybemodifiedasperprogressionofthediseaseinIndiaandwhenmoredataareavailableregardingepidemiology,transmission,andtreatment.


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8.0 Patient Admission Policy•Patientsrequiringadmissionforsuspected/positiveCOVID-19shallbeadmittedinF7(Stablepatients)and (UnstablePatients)underprivilegeddoctorandstablepatientsatpsychiatricward,SRH.

•Internationaldepartment,MHC,NortheastandBangladeshshalladmitpatientswithapprovalfromMedical director.

•AllpatientsshallbeadmittedunderGeneralMedicine/Pediatricsdepartmentandshallformmultidisciplinary teamswithPulmonologyandotherspecialtiesasrequired.

•RestrictelectiveadmissionsapartfromCOVID19.

8.1 Attender guidelines •Forregularpatientadmittedinotherareasshallbeallowedwith2bystanders.

•Noattendersshallbeallowedforsuspectedandpositivepatient.

•Theattenderswhocomewithpatientwillbecounselledandinformedtogovernmentandwillbesenthomeand tobequarantined.

8.2 Visitor policy•ForsuspectedandPositivepatientshallhavenovisitor.

•Changeofvisitinghoursshallbefollowedfrom4.30pmto6.00pmbyrestrictingonevisitorperpatientand 3visitorswillbeallowedatthetimeofendoflifecare

•Restrictedvisitors,allowedonlywhenpermittedfromMedicalDirector’soffice

9.0 Staffing Plan

Allstaffstobescreenedeverydaybeforeworkandtobeescalatedifanysymptoms

Nursing TomaintainNPratio1:1forsuspectedandventilatedpatientsand1:2forpositivecaseswithadultandpediatricprivilegesbasedontheallocation.

•6Batchofstaffstobeidentified,1stbatchofstafftoworkforaweekshallstayinsidetheward.

•2ndBatchshalltakehandoversattheendoftheweeksameshallbefollowedbythe3rdbatch.

•4thbatchshallbeonbackup.Incase,ofstaffunwell/becomesymptomatic.

•TherelievingstafftobetestedforCOVIDnegativebeforehandingoverdutiestothenextbatchofstaff.

•FitnessofstaffshallbetestedandConsentshallbeobtainedfromallstaffbeforeallocation.

Physician

•3batchesofconsultants

•3batchesofresidents/medicalofficers,whoshallmanpatientcareareas.

Admin staff

•3batchesofadminstaff

Support Staff (Diet, Housekeeping, Pharmacy, Maintenance, Biomedical & Security)

•3batchesofsupportstaff

Technical Staff (Lab, Radiology, Bronchoscopy, Endoscopy, Non Invasive Cardiology, Dialysis)

•3batchesoftechnicalstaff

9.1 Staff ClinicScreenvoluntaryreporting,Fittest,Referraltoconsultantsandseeninstaffclinicitself,Quarantineguidance,Vaccinationofstaff


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10.0 Procedures for Taking Remedial Actions against Occupational Exposure to COVID-19


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ProtectionLevel ProtectiveEquipment ScopeofApplication

Level1

•Disposable surgical cap•Disposable surgical mask•Workuniform•Disposablelatexglovesor/anddisposableisolationclothingifnecessary

•Pre-examinationtriage,outpatientdepartment

Level2

•Disposable surgical cap•Medicalprotectivemask(N95)•Workuniform•Disposablemedicalprotectiveuniform•Disposablelatexgloves•Goggles

•Feveroutpatientdepartment• Isolationwardarea(includingisolatedintensiveICU)

•Non-respiratoryspecimenexaminationofsuspected/confirmedpatients

• Imagingexaminationofsuspected/confirmedpatients

•Cleaningofsurgicalinstrumentsusedwithsuspected/confirmedpatients

Level3

•Disposable surgical cap•Medicalprotectivemask(N95)•Workuniform•Disposablemedicalprotectiveuniform•Disposablelatexgloves•Full-facerespiratoryprotectivedevicesorpoweredair-purifyingrespirator

•Whenthestaffperformsoperationssuchastrachealintubation,tracheotomy,bronchofibroscope,gastroenterologicalendoscope,etc.,duringwhich,thesuspected/confirmedpatientsmaysprayorsplashrespiratorysecretionsorbodyfluids/blood

•Whenthestaffperformssurgeryandautopsyforconfirmed/suspectedpatients

•WhenthestaffcarriesoutNATforCOVID-19(Labstaff)

11.0 Personal Protection Management (PPM) Protocol

12.0 Diet protocol

Alldietsshallbesuppliedbythedietkitchenbasedonthenutritionalneeds.

13.0 Spill ProtocolFor spills of a small volume (< 10 ml) of blood/bodily fluids:

Option1:Thespills shouldbecoveredwithchlorine-containingdisinfectingwipes (containing5000mg/Leffectivechlorine) and carefully removed, then the surfaces of the object should bewiped twicewith chlorine-containingdisinfectingwipes(containing500mg/Leffectivechlorine);

Option2:Carefullyremovethespillswithdisposableabsorbentmaterialssuchasgauze,wipes,etc.,whichhavebeensoakedin5000mg/Lchlorine-containingdisinfectingsolution.

For spills of a large volume (> 10 ml) of blood and bodily fluids:

(1)First,placesignstoindicatethepresenceofaspill;

(2)PerformdisposalproceduresaccordingtoOption1or2describedbelow:

Option1:Absorbthespilledfluidsfor30minuteswithacleanabsorbenttowelandthencleanthecontaminatedareaafterremovingthepollutants.

Option2:Completelycoverthespillwithdisinfectantpowderorbleachpowdercontainingwater-absorbingingredientsorcompletelycoveritwithdisposablewater-absorbingmaterialsandthenpourasufficientamountof10,000mg/Lchlorine-containingdisinfectantontothewater-absorbingmaterial(orcoverwithadrytowelwhichwillbesubjectedtohigh-leveldisinfection).Leaveforatleast30minutesbeforecarefullyremovingthespill.


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(2)Fecalmatter,secretions,vomit,etc.frompatientsshallbecollectedintospecialcontainersanddisinfectedfor2 hoursbya20,000mg/Lchlorine-containingdisinfectantataspill-to-disinfectantratioof1:2.

(3)Afterremovingthespills,disinfectthesurfacesofthepollutedenvironmentorobjects.

(4)Thecontainersthatholdthecontaminantscanbesoakedanddisinfectedwith5,000mg/Lactivechlorine- containingdisinfectantfor30minutesandthencleaned.

(5)Thecollectedpollutantsshouldbedisposedofasmedicalwaste.

(6)Theuseditemsshouldbeputintodouble-layermedicalwastebagsanddisposedofasmedicalwaste.

14.0 Biomedical waste Clearance•2hourlyclearanceofbins/linenwithappropriatelabellingtobedone

•Transported in a demarked bin to laundry.

15.0 Disinfection Protocol•Allsurfacesincontactbypatientsatscreeningcounter,admissioncounter,ER-44,F7,psychiatricwardtobe disinfectedontwohourlybasisoraswhencontaminationissuspected.

•Alldevices,equipmentsusedforsuspected/positivepatientstobedisinfectedaftereveryuseforapatient.

•Patientforms,casesheetstobehandledasperhandlingcontaminationmedicalrecordspolicy.

•Wheelchair,trolleytobedisinfectedatdesignatedareasaftershiftingsuspected/positiveCOVID-19patientsand beforere-enteringlift.Theliftsurfacestobedisinfectedafterpatienttransfer.

2.1 Disinfection for Floor and Walls(1) Visiblepollutantsshallbecompletelyremovedbeforedisinfectionandhandledinaccordancewithdisposal proceduresofbloodandbodilyfluidspills;

(2) Disinfectthefloorandwallswith1000mg/Lchlorine-containingdisinfectantthroughfloormopping,sprayingor wiping;

(3) Makesurethatdisinfectionisconductedforatleast10minutes;

(4) Carryoutdisinfectionthreetimesadayandrepeattheprocedureatanytimewhenthereiscontamination.

2.2 Disinfection of Object Surfaces(1) Visiblepollutantsshouldbecompletelyremovedbeforedisinfectionandhandledinaccordancewithdisposal proceduresofbloodandbodilyfluidspills;

(2) Wipethesurfacesofobjectswith1000mg/Lchlorine-containingdisinfectantorwipeswitheffectivechlorine; waitfor30minutesandthenrinsewithcleanwater.Performdisinfectionprocedurethreetimesaday(repeatat anytimewhencontaminationissuspected);

(3) Wipecleanerregionsfirst,thenmorecontaminatedregions:firstwipetheobjectsurfacesthatarenot frequentlytouched,andthenwipetheobjectsurfacesthatarefrequentlytouched.(Onceanobjectsurfaceis wipedclean,replacetheusedwipewithanewone).

PROTOCOL FOR DISINFECTION OF SCOPES1 Procedure Room - Wipethescopewithgauzepiece. - Suckinplainwatertoremovesecretionsfrominnerchannels. - Perform2–3timestoensurenosecretionsremaining.2 Wash Room - Removethesuctionbuttonandbiopsyvalve,washwithenzymaticwaterandirrigatetheinnerchannelswith enzymaticdetergents.(8ml/Litre) - Cleanthechannelsbyusingbrush. - Toinsurethereisnobloodclotortissuedebris. - Visuallyinspectthedevicetomakesureitisfreefromdebris.


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3 Wash all parts of the scope with plain water, flush and suck with plain water and then dry the scope with gauze.

4 Keep the scope in OPAHYDE fully immersed for 12 minutes.

Manualprocessing:Immersedevicecompletely,fillingalllumensandeliminatingairpockets,inOPAHYDEsolution foraminimumof12minutestodestroyallpathogenicmicroorganisms.Removedevicefromthesolutionand rinsethoroughlyfollowingtherinsinginstructionsbelow.(aspermanufactureinstructions)

5FollowingremovalfromOPAHYDEsolutions,thoroughlyrinsethemedicaldevicebyimmersingitcompletelyina largevolume(e.g.2gallons)ofwater.Potablewaterisusedwhichisbeingmonitoredbymicrobiologicaltesting. (Incaseofanyissuewithpotablewaterprovisionforsterilewatertobemade)

•Keepthedevicetotallyimmersedforaminimumof1minuteinduration,unlessalongertimeisspecifiedbythe reusabledevicemanufacture.

•Manuallyflushalllumenwithlargevolumes(notlessthan100ml)ofrinsewaterunlessotherwisenotedbythe devicemanufacture.

•Removethedeviceanddiscardtherinsewater.Alwaysusefreshvolumesofwaterforeachrinse.Donotreusethe waterforrinsingoranyotherpurpose.

•RepeattherinsingprocedureforatotalofTHREE(3)RINSES,withlargevolumesoffreshwaterorremove OPAHYDEsolutionresidue.

Residuesmaycauseserioussideeffects.SEEWARNINGS,THREE(3)SEPARATE,LARGEVOLUMEWATERIMMERSIONRINSESAREREQUIRED.

•OPAHYDEisverifiedwithOPAHYDEstripsperiodically.

•Theentireprocesstakesapproximately27minutes.

•Asanalternativetomanualcleaning,endoscopicprocessorisused

note:

•Watersuppliedtowashingareaisfilteredpriortouse.

•Qualityofpotablewaterisbeingassuredthroughperiodicmicrobiologicaltesting.

•Discussionwasdonewithwaterworkinchargeanditwasnotedthatprovisionforlargevolumeofsterilewater wasnotfeasible.Thereforeitwasdecidedthatpotablewaterbeusedinstep5.

•Manufactureinstructionidsenclosed.

ENDOCLENS Washing Protocol

1 (Procedure room) Suckinplainwatertoremovesecretionsfrominnerchannels.

- Wipethescopewithgauzepiece.

- Performthisprocedure2–3timestoensurenosecretionsareremaining.

2 (Wash room)

- Scopeisplacedinendoclensmachine.

- Removethesuctionbutton,airbuttonandbiopsyvalveplacetheminasmallcontainerbox.

- Connectthetubingsandstarttheprogramme(18minutescleaningcycleforwashing,disinfectionandrinsing).

- Removethescopeandplaceitinstoragearea.

16.0 Dialysis Protocol

•COVID19positivepatientsshallnotbeallowedfordialysisonOPDbasis


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17.0 Deceased Handling Protocol

•StaffPPE: The staffmustmake sure they are fully protectedbywearingwork clothes, disposable surgical caps, disposable gloves and thick rubber gloves with long sleeves, medical disposable protective clothing, medical protectivemasks(N95)orpoweredairpurifyingrespirators(PAPRs),protectivefaceshields,workshoesorrubber boots,waterproofbootcovers,waterproofapronsorwaterproofisolationgowns,etc.

•Deceasedcare:Fillallopeningsorwoundsthepatientmayhave,suchasmouth,nose,ears,anusandtracheotomy openings,byusingcottonballsorgauzedippedin3000-5000mg/Lchlorine-containingdisinfectant.

•Wrapping: Wrap the deceased with a double-layer cloth sheet soaked with disinfectant, and pack it into a double-layer,sealed,leak-proofcorpsewrappingsheetsoakedwithchlorinecontainingdisinfectant.

•Thedeceasedshallbetransferredbythestaffinthe isolationwardofthehospitalviathecontaminatedareato thespecialelevator,outofthewardandthendirectlytransportedtoaspecifiedlocationforcremationbyaspecial vehicleassoonaspossible.

•Finaldisinfection:Performfinaldisinfectionofthewardandtheelevator.

18.0 Annexures

•ProcessflowforCOVID-19

•Areaspecificprocessflow(ER,Lobby,OtherareasofEntry)forCOVID-19

•Admittingsuspected/positivepatientswithCOVID-19

•AreaspecificchecklistforCOVID-19

• Imaging

•Bronchoscopy

•CodeBlue

•Handlingcontaminatedmedicalrecords

•Others

note: Thisdocumentisdynamicandmaybemodifiedasperprogressionofthediseaseinindiaandwhenmoredataareavailableregardingepidemiology,transmission,andtreatment

Date post:	22-Jul-2020
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