Revised covid 19 orientation , Dedicated CoVID19 Hospital

COVID-19
Orientation of Medical Officers
and Private Hospitals
Dedicated CoVID 19 Hospitals
Dr Rishabh Kumar Rana , Assist. Prof., Deptt. of PSM, PMCH
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Topics to be Covered
Topics Facilitators
Introduction & Case Definition Dr Rishabh Kumar Rana , Assist Prof ,
MD ,PMCH
Triage and Concept of Dedicated COVID hospital Dr Rishabh Kumar Rana , Assist Prof,
MD ,PMCH
Isolation & Intensive Care Dr Rishabh Kumar Rana , Assist Prof,
MD,PMCH
Laboratory Testing Dr Rishabh Kumar Rana , Assist Prof,
MD,PMCH
Transportation of Patient Dr Rajan Barnwal , WHO
Personal Protective Equipment Hand Hygiene & use of Mask Dr Rajan Barnwal , WHO
Clinical Case management Prof Dr U K Ojha ,MD , PMCH
Practices For Environmental Cleaning in Healthcare Facilities Dr Rishabh Kumar Rana , Assist Prof,
MD ,PMCH
Guidelines on Dead Body Management Dr Rajan Barnwal , WHODr Rishabh Kumar Rana , Assist. Prof., Deptt. of PSM, PMCH
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CASE DEFINITION
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Case definitions of COVID-19
DEFINITIONS – SUSPECT / PROBABLE INFECTED PERSON
• A person with acute respiratory illness (fever and at least one
sign/symptom of respiratory disease (eg. Cough, shortness of breath) AND
history of travel to or residence in a country/area or territory reporting local
transmission of COVID-19 disease during the 14 days prior to symptom
onset
OR
• A person with any acute respiratory illness AND having being in contact
with a confirmed COVID-19 case in the last 14 days prior to onset of
symptoms
OR
• A person with severe acute respiratory infection {fever and at least one
sign/symptom of respiratory disease (eg., Cough, shortness of breath)}
AND requiring hospitalization AND with no other etiology that fully
explains the clinical presentation
OR
• A case for whom testing for COVID-19 is inconclusive.
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Case definitions of COVID-19
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Quarantine and Isolation
Quarantine:
Quarantine refers to separation of individuals who are not yet ill
but have been exposed to COVID-19 area or travel history to
affected countries / states and therefore have a potential to
become ill.
Isolation
Isolation refers to separation of individuals who are ill and
suspected or confirmed of COVID-19 will be hospitalized and
kept in isolation in a designated facility till such time they are
tested negative.
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THE CONCEPT OF DCOVID HOSPITAL
• Nearly 70% of cases affected with COVID-19 either exhibit mild or very mild symptoms.
• Such cases may not require admission to COVID-19 blocks/ dedicated COVID-19 hospitals.
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Principals to guide
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3 Types of Dedicated Centers
(1) COVID Care Center (CCC)
• 1.1. The COVID Care Centers shall offer care only for cases that have
been clinically assigned as mild or very mild cases or COVID suspect
cases.
• 1.2. The COVID Care Centers are makeshift facilities. These may be set
up in hostels, hotels, schools, stadiums, lodges etc., both public and
private. If need be, existing quarantine facilities could also be
converted into COVID Care Centers.
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(2) Dedicated COVID Health Centre (DCHC):
• 2.1. The Dedicated COVID Health Centre are hospitals that shall offer care
for all cases that have been clinically assigned as moderate.
• 2.2. These should either be a full hospital or a separate block in a hospital
with preferably separate entryexit/zoning.
• 2.3. Private hospitals may also be designated as COVID Dedicated Health
Centers.
• 2.4. Wherever a Dedicated COVID Health Center is designated for admitting
both the confirmed and the suspect cases with moderate symptoms, these
hospitals must have separate areas for suspect and confirmed cases.
Suspect and confirmed cases must not be allowed to mix under any
circumstances.
• 2.5. These hospitals would have beds with assured Oxygen support.
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(3) Dedicated COVID Hospital (DCH):
• 3.1. The Dedicated COVID Hospitals are hospitals that shall offer
comprehensive care primarily for those who have been clinically assigned
as severe.
• 3.2. The Dedicated COVID Hospitals should either be a full hospital or a
separate block in a hospital with preferably separate entryexit. Private
hospitals may also be designated as COVID Dedicated Hospitals.
• 3.4. These hospitals would have fully equipped ICUs, Ventilators and beds
with assured Oxygen support.
• 3.5. These hospitals will have separate areas for suspect and confirmed
cases. Suspect and confirmed cases should not be allowed to mix under
any circumstances.
All these facilities will follow strict infection prevention and control practices.
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TRIAGE
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Patient Flow Chart
Patient comes to the Hospital
TRIAGE AREA
 Manpower – Two Trained Staff Nurse wearing triple layer mask and gloves
 Filling up of self-declaration form by SN
 Recording of temperature using thermal scanner
 Patient with fever and / or respiratory symptoms will be segregated and
sent to Fever – RTI Special Clinic
 Patient without fever or respiratory symptoms will be diverted regular OPD
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Set up of the area during triage:
 Ensure adequate space for triage (maintain at least 1 m distance between
staff screening and the patient ). Ideally triage area should be before
entering OPD/Emergency
 Waiting room chairs for patients should be 1m apart
 Maintain a one way flow for patients and for staff. Entry to the facility is
controlled such that it is not possible for staff, visitors or patients to enter
without being triaged.
 Family members should wait outside the triage area (Only 1 attendant
allowed)
 Prevent triage area from overcrowding
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The triage or screening area requires the following
equipment:
• All triage areas should have hand washing stations, hand sanitizers,
functioning thermometers, and available triple layer mask and gloves.
• SNs / Health Worker are to be designated for Triaging in the Hospital.
• Triaging should continue 24 x7 in shifts
Screening questionnaire Infrared thermometer
Hand hygiene equipment (sanitizer, water,
soap and posters
Waste bins and access to
cleaning/disinfection
Triple layer mask Documentation papers
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Fever – RTI Special Clinic
 Manpower – Trained Medical Officer, Staff Nurse, Ward Boy, Cleaner wearing triple
layer mask and gloves
 Detail history including travel history to COVID affected area will be taken
 If the patient fulfills COVID-19 suspected case definition, then the patient will be
shifted to designated area for sample collection
 The symptomatic patient has to be shifted to Isolation ward designated for
suspected patients (yellow zone) and will be given a mask to cover his face
 The sample from the suspected case will be collected by the Trained Laboratory
Technician / Microbiologist / RRT wearing PPE
 If the sample test becomes positive, then the patient will be shifted Isolation ward
designated for confirmed patients (red zone)
 If the patient does not fulfil the case definition of COVID-19, symptomatic
treatment will be given but no sample collection done
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Contd…
Role of the fever clinic:
• Based on the suspected case definition the medical officer with take detailed
history of the patient along with travel or contact history.
• If the patient falls in the suspected case definition; sample will be collected and
sent to designated laboratory for confirmation.
• If the patient does not fall in the case definition; symptomatic treatment will be
given but the Medical Officer will collect the contact details for further follow
up of the patient for next 14 days at home.
• If the patient is declared positive by laboratory, patient will be immediately
transferred to the isolation unit designated for confirmed cases and contact
tracing will be done.
N.B: The fever clinic staff should have access to full PPE and hand sanitization
station in house.
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Proposed Layout
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ISOLATION AND INTENSIVE
CARE
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Setting Up Isolation Facility/Ward
 Isolation ward should not be co-located with post-surgical wards/dialysis
unit/SNCU/labour room or other general wards etc.
 District level, a minimum of 2 separate units of 20 bed isolation ward should be
established. Male & female should be segregated
 20 beds to be dedicated for suspected cases (yellow zone) and 20 beds for confirmed
cases (red zone) and should not be mixed up.
 The number of beds may be changed for both zones as per requirement.
 There should be a Separate entry/exit for both the units
 Beds should be put with a spatial separation of at least 1 meter (3 feet) from one another.
(Ideally COVID-19 patients should be housed in single rooms.)
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 The following are to be ensured for the isolation unit:
 The room should be adequately ventilated
 There should be a changing room
 Nursing station,
 Drug/consumable store area,
 Separate toilet for male and female.
 Donning area (ideally should be near entry)
 Doffing area (ideally should be near exit)
 Post signage indicating that the space is an isolation area.
 All non-essential furniture are to be removed .
 All the PPE, consumables & drugs are to be transported to the isolation ward once in a day.
Setting Up Isolation Facility/Ward
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ICU
• Should provide resuscitation and Cardio respiratory support including
Defibrillation.
• 24X7 Oxygen supply, ABG analysis Desirable.
• There can be provision for non-invasion for CPAP / NIV where intubation facility is
not available;
• There can be provision of ventilators for patients for at least 24 to 48 hrs and Non
invasive Monitoring like - SPO2, H R and rhythm (ECG), NIBP, Temperature etc.
• Should have basic clinical Lab (CBC, BS, Electrolyte, LFT and RFT), Microbiology and
Imaging back up (X-ray and USG), ECG
• Protocols and policies for ICUs are observed.
• Proper zoning is to be ensured in the ICU.
• Biomedical waste management as per guidelines.
• Dedicated HR with adequate training.
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HR for ICU
• Specialist on call / tele-medicine;
• Intensivist/Resident doctors
• Nurses,
• Dietician/Nutrition Counselor;
• Physiotherapist
• Other support staff. Like cleaning staff and Class IV.
• Ward Boy / Ward Girl;
*It is important to have a good team led by an Intensivist (who spends >50%
of his time in ICU).
[The recommended nurse: patient ratio=1:4
• Doctor:patient ratio=1:4]
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Laboratory Testing
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Current testing strategy : Revised Strategy of COVID-19
testing in India
 All symptomatic individuals who have undertaken international travel in the
last 14 days.
 All symptomatic contacts of laboratory confirmed cases.
 All symptomatic health care workers.
 All hospitalized patients with Severe Acute Respiratory Illness (fever AND
cough and/or shortness of breath).
 Asymptomatic direct and high-risk contacts of a confirmed case should be
tested once between day 5 and day 14 of coming in his/her contact.
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Samples to be Collected
• Essential samples:
- Throat swab (oropharyngeal swab).
- Nasal swab (Nasopharyngeal swab)
• Other preferred samples:
- Bronchoalveolar lavage
- Tracheal aspirate Wide mouth sterile plastic containers
- Sputum
• In lab confirmed patients:
- Blood
- Stool and urine - Wide mouth sterile plastic containers
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Collection of OP and NP swabs
• Optimal timing:
- Within 3 days of symptom onset and no later than 7 days.
- Preferably prior to initiation of antimicrobial chemoprophylaxis
or therapy.
Collection of Oropharyngeal swab:
Materials:
• Sterile Dacron/Nylon flocked swab
• Viral Transport Medium (3 ml sterile VTM)
Procedure:
• Hold the tongue out of the way with a tongue depressor.
• Use a sweeping motion to swab posterior pharyngeal wall and tonsillar
pillars
• Have the subject say “aahh” to elevate the uvula.
• Avoid swabbing soft palate and do not touch the tongue with swab tip.
• Put the swab in VTM
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Collection of Nasopharyngeal swabs
• Materials
• Sterile Dacron/Nylon flocked swab
• Viral Transport Medium (3 ml sterile VTM)
• Procedure
• Tilt patient’s head back 70 degrees
• Insert swab into nostril (Swab should reach
depth to distance from nostrils to outer
opening of the ear
• Leave swab in place in place for several
seconds to absorb secretions
• Slowly remove swab while rotating it
• Place tip of swab into VTM and snap/cut off
the applicator stick
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General Guidance for specimen Collection
• A BSL2 containment level is required to handle suspected samples.
• Consider all specimens as POTENTIALLY HAZARDOUS / INFECTIOUS.
• Personal protective equipment’s (apron, hand gloves, face shield, N95 Masks etc.) need to be used
and all biosafety precautions should be followed so as to protect individuals and the environment.
• Proper labelling (name/age/gender/specimen ID) need to be done on specimen container and other
details of sender (name/address/phone number) on the outer container by mentioning “To be tested
for 2019-nCoV”
• Do not contaminate the outside of the specimen container.
• Do not handle laboratory requisition forms with gloves.
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• Restricted entry to visitors or attendants during sample collection
• Complete the requisition form for each specimen submitted
• Proper disposal of all waste generated (yellow)
• There should be a designated vehicle for transport of sample.
• The driver and helper of the said vehicle do not require complete set of PPE (only mask and
gloves)
• For any queries, the nodal officer from the designated testing centers may be contacted.
Contact details are provided in Annexure 1
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Storage of Specimen
• Keep refrigerated (2-8 °C) if it is to be processed (or sent to a reference laboratory) within
48 hours.
• Keep frozen (-10 to -20 °C) if it is to be processed after the first 48 hours or within 7 days.
• Keep frozen (-70 °C) if it is to be processed after a week. The sample can be preserved for
extended periods.
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Transport Precautions
• Adequate cushioning materials inside the box to absorb shocks during transport
• Adequate absorbing material to absorb any spillage should it occur
• Do not stick the request form on the specimen
• Specimen request forms should be put into a separate plastic bag
• The outer container, secondary containers and specimen racks for transport should be
thoroughly cleansed and disinfected periodically (i.e. at least daily) and when contaminated.
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Labeling of Package
• Sender’s, name, address and telephone number
• Whom to contact in case of emergency with telephone number
• Receiver’s name, address and telephone number
• Proper shipping name (e.g. “BIOLOGICAL SUBSTANCE, CATEGORY B”)
• UN number e.g. 3373
• Temperature storage requirements
• Quantity of dry ice inside the container
• Arrow mark to indicate upright direction
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Responsibility of Sender and receiver
• Make advance arrangements with the carrier
-that the shipment will be accepted for appropriate transport
- that the shipment (direct transport if possible) is undertaken by the most direct routing
• Prepare necessary documentation, including permits, dispatch and shipping documents
• Notify the receiver in advance of transportation arrangements and expected date of delivery of shipment
• Acknowledge receipt of specimen
• Verify the integrity of packaging
• Box to be opened by personnel wearing adequate PPE.
• Open within Biosafety cabinet
• Check the specimens with the data sent
• Apply acceptance and rejection criteria
Receiver
Sender
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Transportation/Ambulance
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• All surfaces that may have come in contact with the patient or materials contaminated during
patient care (e.g., stretcher, rails, control panels, floors, walls and work surfaces) should be
thoroughly cleaned and disinfected using 1% Sodium Hypochlorite solution.
• Clean and disinfect reusable patient-care equipment before use on another patient with alcohol
based rub.
• Cleaning of all surfaces and equipment should be done morning, evening and after every use with
soap/detergent and water.
• All seats, seat handles, handrails, window rails, windows, doors to be cleaned after every trip.
Ventilate for 30 minutes.
• Floor of the vehicle, tyres to be cleaned twice a day.
• Body of the vehicle to be wiped everyday morning. One round of 7% Lysol spray in the evening.
Disinfection of ambulance
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Personal Protective Equipment
(PPE)
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Points to remember while using PPE
1. PPEs are not alternative to basic preventive public health measures such as hand
hygiene, respiratory etiquettes which must be followed at all times.
2. Always (if possible) maintain a distance of at least 1 meter from
contacts/suspect/confirmed COVID-19 cases.
3. Always follow the laid down protocol for disposing off PPEs as detailed in
infection prevention and control guideline available on website of MoHFW.
4. Shoes and oxygen cylinders can transmit infections very rapidly. Use of shoe
cover and oxygen cylinder disinfection is must.
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HAND HYGIENE & USE OF MASK
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Hand hygiene
i. Health care provider should perform hand hygiene using alcohol-based hand rub
(minimum 20 seconds) or by washing with soap and water (minimum 40
seconds). If hands are visibly soiled, use soap and water for hand wash.
ii. Performed before and after using bathroom, before, during and after preparing
food, before and after eating /drinking, after coughing, blowing or sneezing, after
touching garbage, after touching mask or soiled PPE.
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Mask
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Points to be remembered while using the mask
• Place mask carefully to cover mouth and nose and tie securely to minimize any gaps between
the face and the mask
• While in use, avoid touching the mask
• Remove the mask by using appropriate technique (i.e. do not touch the front but remove the lace
from behind)
• After removal or whenever you inadvertently touch a used mask, clean hands by using an
alcohol-based hand rub for 20 seconds or soap and water if visibly soiled for 40 seconds
• Replace masks with a new clean, dry mask as soon as they become damp/humid
• Do not re-use single-use masks
• Discard single-use masks after each use and dispose-off them immediately upon removal
• For N95 respirators adequate fit check must be performed after wearing. CDC recommends the
following hairstyles styles for male HCP suitable for wearing N-95 respirators
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Use of Masks
• Individuals with respiratory symptoms should wear a medical mask while waiting
in triage or waiting areas or during transportation within the facility
• Mask alone is insufficient to provide the adequate level of protection and other
equally relevant measures should be adopted- hand hygiene
• Using a mask incorrectly may hamper it’s effectiveness to reduce the risk of
transmission
Correct technique to wear a medical mask-
https://www.youtube.com/watch?v=lrvFrH_npQI
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Revised Guidelines on Clinical Management of
COVID – 19
Government of India Ministry of Health & Family Welfare Directorate
General of Health Services (EMR Division). Released on 31st March 2020
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Suspect
• All symptomatic individuals who have undertaken international travel in the last 14 days
or
• All symptomatic contacts of laboratory confirmed cases
or
• All symptomatic healthcare personnel (HCP)
or
• All hospitalized patients with severe acute respiratory illness ( SARI) (fever AND
cough and/or shortness of breath)
or
• Asymptomatic direct and high risk contacts of a confirmed case (should be tested once
between day 5 and day 14 after contact)
Symptomatic refers to fever/cough/shortness of breath.
Direct and high-risk contacts include those who live in the same household with a confirmed
case and HCP who examined a confirmed case.
Latest Case Definitions
Revised Guidelines on Clinical Management of COVID – 19; Released 31st March 2020
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Latest Case Definitions as per WHO
Probable case
A suspect case for whom testing for the COVID-19 virus is inconclusive.
a. Inconclusive being the result of the test reported by the laboratory.
OR
b. A suspect case for whom testing could not be performed for any reason.
Source: WHO interim guidance of Global Surveillance of COVID-19 dated 20/03/2020
Confirmed case
 A person with laboratory confirmation of COVID-19 infection, irrespective of
clinical signs and symptoms.
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Clinical Presentation
COVID-19 may present with
1. Mild (Those with low grade fever/cough/malaise/rhinorrhoea/sore throat
WITHOUT any shortness of breath)
2. Moderate
3. Severe: Severe pneumonia, ARDS, sepsis and septic shock.
• Timely recognition of suspected patients allows for timely initiation of IPC.
• Severe acute respiratory illness:
• ARI with history of fever or measured temperature ≥38 C° and cough;
• onset within the last ~10 days;
• and requiring hospitalization.
• the absence of fever does NOT exclude viral infection.
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Severe Pneumonia
• Adolescent or adult: fever or suspected respiratory
infection, plus any one of these
• respiratory rate >30 breaths/min,
• severe respiratory distress, or
• SpO2 <90% on room air
• Child with cough or difficulty in breathing,
plus at least one of the following:
• central cyanosis or SpO2 <90%;
• severe respiratory distress (e.g. grunting, very
severe chest indrawing);
• a general danger sign: inability to breastfeed or
drink, lethargy or unconsciousness, or
convulsions.
• The diagnosis is clinical; chest imaging can
exclude complications
• Patient with pneumonia and no
signs of severe pneumonia
• Child with non-severe
pneumonia has cough or
difficulty breathing + fast
breathing:
• fast breathing (in breaths/min):
• <2 months,≥60;
• 2–11 months, ≥50;
• 1–5 years, ≥40
• and no signs of severe pneumonia
Mild Pneumonia
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Acute Respiratory Distress Syndrome
• Onset: new or worsening respiratory symptoms within one week of
known clinical insult.
• Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral
opacities, not fully explained by effusions, lobar or lung collapse, or
nodules
• Origin of oedema: respiratory failure not fully explained by cardiac
failure or fluid overload. Need objective assessment (e.g.
echocardiography) to exclude hydrostatic cause of oedema if no risk
factor present.
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Indications for hospital admission* (AIIMS Guideline 27/3/20200)
Any ONE of the following five criteria:
1. Respiratory rate > 24/min
2. SpO2 < 94% on room air
3. Confusion/drowsiness
4. Systolic BP < 90 mmHg or diastolic BP < 60 mmHg
5. Those at high risk for severe disease:
a) Age > 60 years
b) Cardiovascular risk including hypertension.
c) Diabetes mellitus/other immunocompromised states.
d) Chronic lung/liver/kidney disease
• This is general guidance regarding which patients should be admitted. However, the final
decision to admit is at the discretion of the treating physician.
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Management of hospitalized cases
General Measures:
• Oxygen supplementation to maintain SpO2 > 94%
• Conservative fluid management if there is no evidence of shock
• Symptomatic treatment (e.g. anti-tussive syrup containing Dextromethorphan/levodropropizine and
paracetamol)
• Blood culture to be sent at time of admission before starting anti-microbials
• Empirical antimicrobials within 1 hour of admission in case of sepsis
• Send investigations to be sent at admission
• Systemic corticosteroids are not recommended, unless indicated for any other reason
• MDI preferred over nebulization to reduce risk of aerosolization
• Close monitoring for worsening clinical status is of paramount importanceDr Rishabh Kumar Rana , Assist. Prof., Deptt. of PSM, PMCH
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Early supportive therapy and monitoring : Oxygen Therapy
• Give supplemental oxygen therapy immediately to patients with SARI
and respiratory distress, hypoxaemia, or shock.
• Initiate oxygen therapy @ 5 L/min and titrate flow rates to reach target
SpO2 ≥90% in non-pregnant adults and SpO2 ≥92-95 % in pregnant
patients.
• Via nasal prong/Face mask (Single Use).
• In critical cases can use 10-15 L/min with face musk with reservoir bag.
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Early supportive therapy and monitoring : Oxygen Therapy
• Start in children with emergency signs
Severe respiratory distress.
Central cyanosis.
Shock, coma or convulsions
• They should receive oxygen therapy during resuscitation to target
SpO2 ≥94%; otherwise, the target SpO2 is ≥90%.
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IV Fluid Therapy
• Use conservative fluid management in patients with SARI when there is no
evidence of shock.
• IV Fluids like NS-RL-DNS can be used.
• Consider in case of Low BP, Low urine output, poor oral intake, dehydration.
• Patients with SARI should be treated cautiously with intravenous fluids, because
Aggressive fluid resuscitation may worsen oxygenation, especially in settings
where there is limited availability of mechanical ventilation.
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Empiric Antibiotics Policy
• Give empiric antimicrobials to treat all likely pathogens causing SARI.
• Although the patient may be suspected to have COVID - 19, Administer
appropriate empiric antimicrobials within ONE hour of identification of sepsis.
• Empirical antibiotic treatment should be based on
Clinical diagnosis (community-acquired pneumonia, health care-associated
pneumonia or sepsis).
Local epidemiology and susceptibility data.
Treatment guidelines.
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Which antibiotics
Empirical antibiotics
• Azithromycin (Tab/Syrup/Inj): 10 mg/kg once daily for 5 days
AND/OR
• Co-Amoxyclav (Tab/Syrup/Inj):
10 mg/kg Amoxycillin 8 hourly (For Oral Uses).
1.2 gm Inj. IV 8 hourly if weight ＞ 40 kg, Half dose for those ＜ 40 KG
For Critically ill patients with COVID-19 (ICU), antibiotics for secondary infection
use Inj. Ceftriaxone/Piperacillin Tazobactam
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Specific COVID-19 treatments and clinical research
• No current evidence from RCTs to recommend any specific treatment for
suspected or confirmed patients with COVID - 19.
• No specific anti–virals are recommended for treatment of COVID – 19 due to lack
of adequate evidence from literature.
• The use of Lopinavir/ Ritonavir in PEP regimens for HIV (4 weeks) is also
associated with significant adverse events which many a times leads to
discontinuation of therapy.
• In light of the above, Lopinavir/ Ritonavir should ONLY be used with proper
informed expressed consent on a case to case basis for severe cases.Dr Rishabh Kumar Rana , Assist. Prof., Deptt. of PSM, PMCH
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Specific therapy
• Drugs that may be considered in COVID 19 Positive cases only include:
Hydroxychloroquine
Suggested dose – 400mg BD for 1 day followed by 200mg BD for 4 days
OR
Lopinavir/Ritonavir
Suggested dose – (200/50) 2 tab BD for maximum 14 days/ 7 days after becoming
asymptomatic
• Maybe considered on case to case basis
Caution: Do NOT co-administer Lopinavir/ritonavir and Hydroxychloroquine due to drug interaction which may
cause increased Hydroxychloroquine levels and subsequent toxicity (eg. QT prolongation, hypoglycemia).
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Administration of Lopinavir/ Ritonavir
Administration of Lopinavir/ Ritonavir to be considered in Laboratory confirmed cases of COVID – 19 when
the following criteria are met:
Symptomatic patients with any of the following:
• Hypoxia,
• Hypotension,
• New onset organ dysfunction (one or more)
Increase in creatinine by 50% from baseline, GFR reduction by >25% from baseline or
urine output of <0.5 ml/kg for 6 hours.
Reduction of GCS by 2 or more.
Any other organ dysfunction
• High Risk Groups:
Age> 60 yrs.
Diabetes Mellitus, Renal Failure, Chronic Lung disease
Immuno – compromised personsDr Rishabh Kumar Rana , Assist. Prof., Deptt. of PSM, PMCH
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Dosage:
• Lopinavir/ Ritonavir (200 mg/ 50 mg) – 2 tablets twice daily
• For patients unable to take medications by mouth: Lopinavir
400mg/Ritonavir 100 mg – 5ml suspension twice daily
Duration: 14 days or for 7 days after becoming asymptomatic.
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Supportive Treatment In Critically Ill Patients
• Head end elevation
• Oral hygiene with mouthwash
• Glycemic control to maintain blood sugar below 180 mg/dl
• Ulcer prophylaxis with proton pump inhibitors
• Foley’s catheter and Ryle’s tube
• Central venous catheter
• Bedsore prevention by position change every 2 hours
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Role of Corticosteroid
• Do not routinely give systemic corticosteroids for treatment of viral
pneumonia or ARDS .
• Given lack of effectiveness and possible harm (Avascular necrosis,
psychosis, diabetes, and delayed viral clearance) , routine corticosteroids
should be avoided unless they are indicated for another reason like in
septic shock.
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Investigations
• CBC, ESR
• RBS, S. Creatinine
• SGOT,SGPT, Bilirubin
• Chest X-ray: (Portable) Need Based
• S. Electrolyte (Need Based)
• ECG: Need Based
• PF/PV, Typhi Dot, Dengue serology: Need Based.
,Dhanbad
76

Monitoring (To be documented)
• Temperature chart: 8 hourly/SOS
• GCS: Once daily and SOS
• Pulse Oximetry: 8 hourly and SOS
• Blood Pressure: Once daily and SOS
• Respiratory rate: Twice daily and SOS
• Chest Auscultation: Once daily and SOS
• Input Output Charting
,Dhanbad
77

• Increasing breathlessness
• SpO2 is ＜92% with O2 flow 5 L or more/min.
• Requiring mechanical ventilation
• Hypotension requiring vasopressor support
• Worsening mental status
• Multi-organ dysfunction syndrome
Criteria for ICU admission:
,Dhanbad
78

Management of hypoxemic respiratory failure and ARDS
• Recognize severe hypoxemic respiratory failure when a patient with
respiratory distress is failing standard oxygen therapy.
• Increased work of breathing or hypoxemia even when oxygen is
delivered via a face mask with reservoir bag (flow rates of 10-15 L/min).
• Hypoxemic respiratory failure in ARDS commonly results from
intrapulmonary ventilation-perfusion mismatch or shunt and usually
requires mechanical ventilation.
,Dhanbad
79

High – flow nasal catheter oxygenation or Non – invasive
mechanical ventilation (NIV):
• When respiratory distress and/or hypoxemia of the patient cannot be alleviated
after receiving standard oxygen therapy
 High – flow nasal cannula oxygen therapy or
 Non – invasive ventilation can be considered (NIV).
• If conditions do not improve or even get worse within a short time (1 – 2 hours),
tracheal intubation and invasive mechanical ventilation should be used in a
timely manner
,Dhanbad
80

• Compared to standard oxygen therapy, HFNO reduces the need for
intubation.
• Patients with hypercapnia (exacerbation of obstructive lung disease,
cardiogenic pulmonary oedema), hemodynamic instability, multi-organ
failure, or abnormal mental status should generally not receive HFNO.
• Although emerging data suggest that HFNO may be safe in patients with mild-
moderate and non-worsening hypercapnia .
• Patients receiving HFNO should be in a ICU setting, cared for by experienced
personnel capable of endotracheal intubation in case the patient acutely
deteriorates or does not improve after a short trial (about 1 hr).Dr Rishabh Kumar Rana , Assist. Prof., Deptt. of PSM, PMCH
,Dhanbad
81

Mechanical Ventilation
• Endotracheal intubation should be performed by a trained and experienced
provider using airborne precautions.
• Patients with ARDS, especially young children or those who are obese or
pregnant, may de-saturate quickly during intubation.
• Pre-oxygenate with 100% FiO2 for 5 minutes, via a face mask with reservoir
bag, bag-valve mask, HFNO, or NIV.
• Rapid sequence intubation is appropriate after an airway assessment that
identifies no signs of difficult intubation.
,Dhanbad
82

• Start mechanical ventilation using lower tidal volumes (4–8 ml/kg predicted body
weight, PBW) and lower inspiratory pressures (plateau pressure <30 cmH2O).
• This is a strong recommendation from a clinical guideline for patients with
ARDS, and is suggested for patients with sepsis-induced respiratory failure.
• The initial tidal volume is 6 ml/kg PBW; tidal volume up to 8 ml/kg PBW is allowed
if undesirable side effects occur (e.g. desynchrony, pH <7.15).
• Hypercapnia is permitted if meeting the pH goal of 7.30- 7.45.
• Ventilator protocols are available. The use of deep sedation may be required to
control respiratory drive and achieve tidal volume targets.
Mechanical Ventilation Contd..
,Dhanbad
83

Mechanical Ventilation Contd..
• Mode of ventilation: Assisted Control Ventilation (volume/Pressure Controlled)
• Tidal Volume: 4-6 ml/kg of predicted body weight
• Respiratory rate: 15-18/min
• I:R ratio: 1:2 to 1:3
• PEEP: Start with 5 gradually increase up to 20
• FiO2: Initially FiO2 100% then gradually decrease according to SpO2 level. Keep
SpO2 ≥92 % in adult .
,Dhanbad
84

When to Wean
• If the patient recovered from COVID-19.
• Hemodynamically stable
• FiO2 requirement is ＜50%
• PEEP requirement is ＜7 cm H2O
,Dhanbad
85

• Fresh ventilator circuit to be used for every new patient
• Tubing and HME (Heat and Moisture Exchangers) to be changed every 48 hours
or when visibly soiled.
• Used closed suctioning technique and avoid routine suctioning
• Sedation and muscle relaxants may be used in difficult to ventilation patients.
• Inj Midazolam (2-3 mg) on SOS basis.
Care of ventilated patient
,Dhanbad
86

• In patients with severe ARDS, prone ventilation for >12 hours per day is
recommended.
• Application of prone ventilation is strongly recommended for adult and
paediatric patients with severe ARDS but requires sufficient human
resources and expertise to be performed safely.
• Use a conservative fluid management strategy for ARDS patients
without tissue hypoperfusion.
,Dhanbad
87

Management of septic shock
• Recognize septic shock in adults when infection is suspected or
confirmed.
• Vasopressors are needed to maintain mean arterial pressure (MAP)
≥65 mmHg AND lactate is < 2 mmol/L, in absence of hypovolemia.
In the absence of a lactate measurement, use MAP and clinical signs of perfusion to define shock.
Mean Arterial Pressure (MAP)= 1/3rd of Pulse Pressure (SBP-DBP)+DBP
,Dhanbad
88

Septic Shock
• Recognize septic shock in children with any hypotension ( SBP <5th centile or >2 SD
below normal for age)
OR
• 2-3 of the following:
1. Altered mental state.
2. Tachycardia or bradycardia (HR <90 bpm or >160 bpm in infants and HR <70 bpm or
>150 bpm in children).
3. Prolonged capillary refill (>2 sec) or
4. Warm vasodilation with bounding pulses; tachypnoea; mottled skin or petechial or
purpuric rash.
5. Increased lactate.
6. Oliguria.
7. Hyperthermia or hypothermia.
,Dhanbad
89

• Standard care includes early recognition and the following treatments
within 1 hour of recognition:
1. Antimicrobial therapy and fluid loading and vasopressors for
hypotension.
2. The use of central venous and arterial catheters should be based on
resource availability and individual patient needs.
,Dhanbad
90

• In resuscitation from septic shock in adults, give at least 30 ml/kg of
isotonic crystalloid (NS/RL)in adults in the first 3 hours.
• In children : Give 20 ml/kg as a rapid bolus and up to 40-60 ml/kg in
the first 1 hr.
• Do not use hypotonic crystalloids, starches, or gelatins for
resuscitation.
,Dhanbad
91

• Fluid resuscitation may lead to volume overload, including respiratory failure.
• If there is no response to fluid loading and signs of volume overload appear
then reduce or discontinue fluid administration. For example:
1. Jugular venous distension.
2. Crackles on lung auscultation.
3. Pulmonary oedema on imaging, or hepatomegaly in children)
• This step is particularly important where mechanical ventilation is not
available.
,Dhanbad
92

• Determine need for additional fluid boluses (250-1000 ml in adults or
10-20 ml/kg in children) based on clinical response and improvement of
perfusion targets.
• Perfusion targets include
1. MAP (>65 mmHg or age-appropriate targets in children).
2. Urine output (>0.5 ml/kg/hr in adults, 1 ml/kg/hr in children)
3. Improvement of skin mottling, capillary refill, level of consciousness, and
lactate.
,Dhanbad
93

• Administer vasopressors when shock persists during or after fluid
resuscitation.
• The initial blood pressure target is MAP ≥65 mmHg in adults and age-
appropriate targets in children.
,Dhanbad
94

• If central venous catheters are not available, vasopressors can be given
through a peripheral IV, but use a large vein and closely monitor for
signs of extravasation and local tissue necrosis.
• If extravasation occurs, stop infusion.
• Vasopressors can also be administered through intraosseous needles.
1. Dobutamine: 2 ampoules in 500 ml NS @6-10 drops/min (Adjust
according to the response).
2. Noradrenaline: 2 ampoules in 500 ml NS @6-10 drops/min (Adjust
according to the response).
,Dhanbad
95

Other Therapeutic Measures:
• For patients with progressive deterioration of oxygenation indicators, rapid
worsening on imaging and excessive activation of the body’s inflammatory
response, glucocorticoids can be used for a short period of time (3 to 5 days).
• Dose should not exceed the equivalent of methylprednisolone 1 –
2mg/kg/day.
• Note that a larger dose of glucocorticoid will delay the removal of coronavirus
due to immunosuppressive effects.
• Don’t use Inj Hydrocortisone in COVID-19.
,Dhanbad
96

Guidelines on Clinical Management of COVID – 19
For patients with:
 Progressive deterioration of
oxygenation indicators,
 Rapid worsening on
imaging
 Excessive activation of the
body’s inflammatory
response
Glucocorticoid:
Dose*: Glucocorticoid equivalent to Methylprednisolone (1-2mg/kg/day)
Period: 3-5 days
*Large doses of glucocorticoid delays removal of Corona virus due to immunosuppressive effect
For severe and critical cases with pregnancy – Pregnancy should be terminated
Psychological counselling – to mitigate fear and anxiety
Specific Therapy:  No specific antiviral has been proven to be effective as per currently available data
 In patients with severe disease and requiring ICU management*:
Hydroxychloroquine:
Day 1 – 400 mg BID
Day 2-5 – 200mg BID
+
Azithromycin (500mg Tab)
Day 1 – 5: 1 Tab OD
*Close monitoring of QTc interval (<500)
Not recommended:
Children < 12 Yrs
Pregnant & Lactating women
,Dhanbad
97

• For pregnant woman with severe and critical cases, pregnancy should
be preferably terminated.
• Consultations with obstetric, neonatal, and intensive care specialists
(depending on the condition of the mother) are essential.
• Patients often suffer from anxiety and fear and they should be
supported by psychological counselling.
,Dhanbad
98

Guidelines on Clinical Management of COVID – 19
• Prophylaxis: Although there is no proven prophylaxis from COVID-19, few
• literatures have suggested for Hydroxychloroquine. Best way to practice the
Airborne infection control measures as per the Govt. of India guidelines.
• For Health Care workers:
• Tab. Hydroxychloroquine (400mg) – One tablets BID on day one, followed by
one tab on weekly for seven weeks
• For close contacts of COVID-19 suspects/ diagnosed persons:
• Tab. Hydroxychloroquine (400mg) – One tablets BID on day one, followed by
one tab on weekly for four weeks
,Dhanbad
99

Human Resource
• Each team planned for 8 hours duty. Three teams for each hospital each
day will do duty for 1 week
• One team will work for 7 days and go for Quarantine for 2 weeks. The team
will re-join after 2 weeks
• The hospital will need 15 Doctors, 15 Nurses and 15 para-medical staff
each week.
• A total of 45 (15 x 3 weeks) Doctors, 45 (15 x 3 weeks) Nurses and 45 (12 x
3 weeks) paramedical staff will be needed.
• The Reserve team will have 6 Doctors, 6 Nurses and 6 paramedical staff. So
1 unit along with reserve team will have 51 Doctors, 51 Nurses and 51
para-medical staffs.
,Dhanbad
100

PRACTICES FOR ENVIRONMENTAL
CLEANING IN HEALTHCARE
FACILITIES
,Dhanbad
101

General principles
• The interiors and external areas and premises of the hospital should be kept clean and
odour free.
• Solid waste and garbage should be removed and disposed of hygienically.
• A hospital cleaning manual should be developed to provide detailed guidelines for
procedures and practices.
• There should be a cleaning schedule for daily, weekly and terminal cleaning. The
cleaning process, be it for a single room, or ward, must be coordinated with the nurse
in-charge.
,Dhanbad
102

PPE to wear while carrying out cleaning and disinfection works
1. Wear heavy duty/disposable gloves, disposable long-sleeved gowns, eye goggles
or a face shield, and a medical mask
2. Avoid touching the nose and mouth (goggles may help as they will prevent hands
from touching eyes)
3. Disposable gloves should be removed and discarded if they become soiled or
damaged, and a new pair worn
,Dhanbad
103

Cleaning agents and disinfectants
1. 1% Sodium Hypochlorite can be used as a disinfectant for cleaning and disinfection.
2. The solution should be prepared fresh.
3. Leaving the solution for a contact time of at least 10 minutes is recommended.
4. Alcohol (e.g. isopropyl 70% or ethyl alcohol 70%) can be used to wipe down surfaces
where the use of bleach is not suitable, e.g. metals.
,Dhanbad
104

•Telephone
•Mobile phone/pager
•Door knobs / handles
•Lift/elevator buttons
•Keypad & Mouse
•Chair arms (including wheel chairs)
•Hand rails
•Side rails of stretchers
High frequency touch surfaces :
 should be cleaned twice
daily by mopping with a
linen/absorbable cloth soaked
in 1% sodium hypochlorite.
,Dhanbad
105

Cleaning Protocol : Indoor /Isolation /ICU
• Sweeping and mopping thrice daily (morning and evening) and Night .
• Cleaning of the hand rails of the stairs cases, grill, window sills - Thrice daily.
• Lifts to be wiped on all sides including the floor- thrice daily
• Horizontal surfaces, ledges, window frames & curtain tracks, taps, etc constitute the
general equipment &should be. cleaned-Thrice daily
• Main doors, door handles, light switches knobs to be cleaned every hours.
• Mattress , over bed table, Bed rails, patient locker to be clean thrice daily.
• Toilet pan to be clean thrice daily and whenever used by the patient.
•
• Hand sanitizing stations should be installed especially at the entry and near high contact
surfaces.
All areas such as entrance lobbies, corridors and staircases,
escalators, elevators, security guard booths, office rooms,
meeting rooms, cafeteria should be mopped with a disinfectant
with freshly prepared 1% sodium hypochlorite solution
,Dhanbad
106

Disposal PPE
• Remove PPE , discard disposable PPE in a Yellow Disposable bag and wash hands
with Soap Water.
• Thereafter, immediately to be incinerated or Deep buried.
• Hands should be washed with soap and water immediately after each piece of
PPE is removed, following completion of cleaning.
• Masks are effective if worn according to instructions and properly fitted. Masks
should be discarded and changed if they become physically damaged or soaked.
,Dhanbad
107

Guidelines for Cleaning Medical Gas Cylinders
 For initial cleaning hot potable water with detergents not exceeding temp of 50
degree Celsius should be used for cleaning cylinder. Valves should be covered so
that water doesn’t go inside the cylinders. Under NO circumstance medical gas
cylinder should be immersed in water.
 After cleaning with water, cylinders should be cleaned with isopropyl alcohol.
 Till COVID -19 ends all empty cylinders should be quarantined unless they are
cleaned. Medical gas should be filled only after they are cleaned.
 Wash hands properly suing soap & water & with 60% alcohol based sanitizer.
 Cleaning should be performed at end user premises because that is the site where
the infection starts. Dr Rishabh Kumar Rana , Assist. Prof., Deptt. of PSM, PMCH
,Dhanbad
108

COVID-19
GUIDELINES ON DEAD BODY
MANAGEMENT
,Dhanbad
109

Standard Precautions to be followed by Health Care
Workers while handling dead bodies of COVID
Standard infection prevention control practices should be followed at all times.
• Hand hygiene.
• Use of personal protective equipment (e.g., water resistant apron, gloves,
masks, eyewear).
• Safe handling of sharps.
• Disinfect bag housing dead body; instruments and devices used on the patient.
• Disinfect linen - freshly prepared 1% bleach (30 mins)
• Clean and disinfect environmental surfaces - Environmental surfaces or objects
contaminated with blood, other body fluids, secretions or excretions should be
cleaned and disinfected using standard hospital detergents and disinfectants e.g.
freshly prepared 1% Sodium Hypochlorite or 5% Lysol (30 mins).Dr Rishabh Kumar Rana , Assist. Prof., Deptt. of PSM, PMCH
,Dhanbad
110

Removal of body from isolation area or room
• The health worker attending to the dead body should perform hand
hygiene, ensure proper use of PPE (water resistant apron, goggles,
N95 mask, gloves).
• PPE includes shoe cover, gown, mask, eye protection & gloves.
• Shoe cover should always be worn before entering the patient care
area (Isolation ward etc.).
• If gowns are not fluid resistant, use a waterproof apron for
procedures with expected high fluid volumes that might penetrate
the gown.
,Dhanbad
111

• All tubes, drains and catheters on the dead body should be removed.
• Any puncture holes or wounds (resulting from removal of catheter,
drains, tubes, or otherwise) should be disinfected with 1%
hypochlorite and dressed with impermeable material.
• Apply caution while handling sharps such as intravenous catheters
and other sharp devices. They should be disposed into a sharps
container.
• Plug Oral, nasal orifices of the dead body to prevent leakage of body
fluids.
,Dhanbad
112

• If the family of the patient wishes to view the body at the time of
removal from the isolation room or area, they may be allowed to do
so with the application of Standard Precautions.
• Place the dead body in leak-proof plastic body bag. The exterior of
the body bag can be decontaminated by spraying 1% hypochlorite (30
mins). The body bag can be wrapped with a mortuary sheet or sheet
provided by the family members.
• The body bag should be clearly and permanently labelled as
containing COVID 19, such as: “COVID-19 – Handle with care”.
,Dhanbad
113

Handling of Dead Body in Mortuary
• Mortuary staff handling COVID dead body should observe standard precautions.
• Dead bodies should be stored in cold chambers maintained at approximately 4°C.
• The mortuary must be kept clean. Environmental surfaces, instruments and
transport trolleys should be properly disinfected with 1% Hypochlorite solution.
• After removing the body, the chamber door, handles and floor should be cleaned
with sodium hypochlorite 1% solution .
• Embalming of dead body should not be allowed.
• Autopsies should be avoided
,Dhanbad
114

Transportation
• The body, secured in a body bag, exterior of which is decontaminated
poses no additional risk to the staff transporting the dead body.
• Limited number of persons wearing PPE should handle the body. The
driver of the vehicle transporting the dead body should also gloves and
mask and should not touch the body
• The vehicle, after the transfer of the body to cremation/ burial place,
must be decontaminated with 1% Sodium Hypochlorite.
,Dhanbad
115

Cremation / Burial
• The cremation ground for cremating the infected body must be
demarcated separately in a corner area and should not be accessible
to general people
• The Crematorium/ burial Ground staff should be sensitized that
COVID 19 does not pose additional risk.
• The staff will practice standard precautions of hand hygiene, use of
masks and gloves.
• Viewing of the dead body by unzipping the face end of the body bag
(by the staff using standard precautions) may be allowed, for the
relatives to see the body for one last time, but from 1 meter distance
and no physical touching is allowed.
,Dhanbad
116

Cremation / Burial
• Religious rituals such as reading from religious scripts, sprinkling holy
water and any other last rites that does not require touching of the body
can be allowed.
• Bathing, kissing, hugging, etc. of the dead body should not be allowed.
• The burial grave should be 8 feet deep (not usual 6 feet).
• The funeral/ burial staff and family members should perform hand
hygiene after cremation/ burial.
• The ash does not pose any risk and can be collected to perform the last
rites.
• Large gathering at the crematorium/ burial ground should be avoided as
a social distancing measure as it is possible that close family contacts
may be symptomatic and/ or shedding the virus.
,Dhanbad
117

Revised covid 19 orientation , Dedicated CoVID19 Hospital

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