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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
| Page1
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
Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic SRIHER, Chennai | March 19, 2020
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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.
Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic SRIHER, Chennai | March 19, 2020
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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.
Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic SRIHER, Chennai | March 19, 2020
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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.
Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic SRIHER, Chennai | March 19, 2020
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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.
Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic SRIHER, Chennai | March 19, 2020
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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
Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic SRIHER, Chennai | March 19, 2020
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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
Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic SRIHER, Chennai | March 19, 2020
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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.
Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic SRIHER, Chennai | March 19, 2020
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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
Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic SRIHER, Chennai | March 19, 2020
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10.0 Procedures for Taking Remedial Actions against Occupational Exposure to COVID-19
Sri Ramachandra Preparedness, Advisory And Position Statement For Handling SARS CoV-2 Pandemic SRIHER, Chennai | March 19, 2020
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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