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NITTEDU-KSHEMA

HANDBOOK OF COVID-19

PROTOCOLS

PREPARED BY :

KSHEMA COVID-19 Task Force

Justice KS Hegde Hospital, Derlakatte, Mangalore - 575018Tel: 0824-2204300; e-mail: [email protected]

V E R S I O N 2 . 0 ** Subject to revision

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NiiteDU-KSHEMA Handbook of COVID-19 Protocols [Version 1.4, Issue Date 17-04-2020]

NitteDU-KSHEMA Handbook of COVID-19 Protocols (Version2.0)

TABLE OF CONTENTS

VERSION HISTORY .............................................................................................................................. 1

MESSAGE FROM CHANCELLOR ......................................................................................................... 2

FOREWORD .......................................................................................................................................... 5

PREAMBLE ............................................................................................................................................ 6

OBJECTIVES OF THE PROTOCOL ...................................................................................................... 6

THE KSHEMA COVID-19 TASK FORCE ............................................................................................... 7

CONTACT NUMBERS IN CASE OF EMERGENCY ............................................................................... 8

GENERAL INSTRUCTIONS ................................................................................................................. 10

INDEX OF PROTOCOLS FOR PART 1 ................................................................................................ 13

INDEX OF ANNEXURES FOR PART 1 ................................................................................................ 13

PROTOCOL 1.1 ................................................................................................................................... 14

PROTOCOL 1.2: DEPLOYMENT OF PERSONNEL AT OPD SCREENING ANDFEVER CLINIC* ...... 16

PROTOCOL 1.3: SCREENING AT FEVER CLINIC AND TRIAGING ................................................... 17

PROTOCOL 1.4: STANDARD OPERATING PROCEDURE FOR OPD SCREENING AND FEVER

CLINIC ................................................................................................................................................. 18

PROTOCOL 1.5: TRANSPORT OF COVID-19 POSITIVE / SUSPECT CASES .................................. 20

PROTOCOL 1.6: CRITERIA FOR ADMISSION AND TRANSFER TO/FROM COVID AND NON-COVID

ICUs .................................................................................................................................................... 21

PART 2: RESPONSIBILITIES, MANAGEMENT, DECLARE OF CURE AND DISCHARGE OF COVID-

19 (SUSPECT AND POSITIVE) PATIENTS ............................................................................................ 22

INDEX OF PROTOCOLS FOR PART 2 ................................................................................................ 22

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NiiteDU-KSHEMA Handbook of COVID-19 Protocols [Version 2.0, Revision Date 01-06-2020]

INDEX OF ANNEXURES FOR PART 2 ................................................................................................ 22

PROTOCOL 2.1: GENERAL MANAGEMENT OF STABLE COVID-19 SUSPECT / POSITIVE

PATIENTS–ISOLATION WARDS ......................................................................................................... 23

PROTOCOL 2.2: GENERAL MANAGEMENT OF UNSTABLE COVID-19 SUSPECT PATIENTS –

COVID ICUs ........................................................................................................................................ 26

PROTOCOL 2.3: INVESTIGATIONS FOR COVID-19 SUSPECT / POSITIVE PATIENTS ................... 29

PROTOCOL 2.4: MEDICAL MANAGEMENT OF SICK COVID-19 SUSPECT/ POSITIVE ................... 32

PROTOCOL 2.5: GUIDELINES FOR DIALYSIS OFCOVID-19 SUSPECT / POSITIVE ....................... 44

PROTOCOL 2.6: GUIDELINES FOR COVID-19 SUSPECT / POSITIVE REQUIRING EMERGENCY

SURGERY ........................................................................................................................................... 47

PROTOCOL 2.7: PRACTICE GUIDELINES FOR NON COVID PATIENTS REQUIRING EMERGENT

OR URGENT INTERVENTION/ SURGERY ......................................................................................... 50

PROTOCOL 2.8: MANAGEMENT OF DEAD BODY AND GUIDELINES FOR AUTOPSY ................... 51

PART 3: HOSPITAL SERVICES GUIDELINES .................................................................................... 56

INDEX OF PROTOCOLS FOR PART 3 ............................................................................................... 56

INDEX OF ANNEXURES FOR PART 3 ............................................................................................... 56

PROTOCOL 3.1: LABORATORY GUIDELINES FOR HANDLING SAMPLES OF COVID-19

SUSPECTS AND CONFIRMED PATIENTS ........................................................................................ 57

PROTOCOL 3.2: GUIDELINES FOR RADIOLOGY INVESTIGATIONS FOR COVID-19 SUSPECTS/

POSITIVE ............................................................................................................................................ 60

PROTOCOL 3.3: ICMR GUIDELINES TO RECORD ICD-10 CODES DISCHARGES/ DEATHS ......... 63

PROTOCOL 3.4: HANDLING, TREATMENT AND DISPOSAL OF WASTE GENERATED DURING

DIAGNOSIS / TREATMENT / QUARANTINE OF COVID-19 SUSPECT / POSITIVE........................... 68

PROTOCOL 3.5 WORKPLACE GUIDELINES ..................................................................................... 72

PROTOCOL 3.6: COVID-19 QUARANTINE PROTOCOL .................................................................... 78

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PROTOCOL 3.7: COVID-19 POST-EXPOSURE PROPHYLAXIS ....................................................... 82

PROTOCOL 3.8: STANDARD OPERATING PROCEDURE (SOP) FOR TRANSPORTING A

SUSPECT/POSITIVE CASE OF COVID-19 ......................................................................................... 83

ANNEXURES ....................................................................................................................................... 85

ANNEXURE 1.1 - GUIDELINES ON RATIONAL USE OF PERSONAL PROTECTIVE EQUIPMENT .. 86

ANNEXURE 1.2 – OUTPATIENT TRIAGE CHECKLIST ....................................................................... 96

ANNEXURE 1.3 – CASE INFORMATION FORM FOR COVID-19 SUSPECT/ POSITIVE .................... 97

ANNEXURE 1.4: THROAT SWAB FOR COVID-19 AND ICMR RT-PCR APPLICATION ................... 100

ANNEXURE 1.5 – PAEDIATRIC FEVER CLINIC CHECKLIST ........................................................... 105

ANNEXURE 1.6 - PAEDIATRIC DRUG DOSAGE INFORMATION .................................................... 106

ANNEXURE 2.1 - CHECK LIST FOR COVID -19 ISOLATION WARD ............................................... 107

ANNEXURE 2.2 - PEDIATRIC MONITORING CHECKLIST FOR COVID -19 IN ISOLATION WARD 109

ANNEXURE 2.3 - PAEDIATRIC INVESTIGATION CHART IN COVID -19 ISOLATION WARD ......... 110

ANNEXURE 2.4 – PATIENT EDUCATION MATERIAL ....................................................................... 111

ANNEXURE 3.1 SPECIMEN COLLECTION, PACKAGING AND TRANSPORT GUIDELINES .......... 112

ANNEXURE 3.2: SELF REPORTING FORM FOR ALL TRAVELLERS ARRIVING FROM AREAS

REPORTING COVID-19 TRANSMISSION ........................................................................................ 116

ANNEXURE 3.3: LIST OF INDIVIDUALS WITH TRAVEL / CONTACT HISTORY REPORTING TO

HOSTELS .......................................................................................................................................... 119

ANNEXURE 3.4: MEDICAL FORM FOR RELEASE FROM QUARANTINE ....................................... 120

Annexure 3.5: SELF REPORTING FORM FOR ALL EMPLOYEES REPORT BACK TO THE

INSTITUTES UNDER NITTE(DU) WHO HAVE TRAVELLED OUTSIDE THE DISTRICT LIMITS OF

DAKSHINA KANNADA DURING THE COVID-19 LOCKDOWN ........................................................ 123

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VERSION HISTORY

Version Date Major revision(s)

Version 2.0 Revision date 01June 2020 Substantial revisions to entire document

Version 1.4 Revision date 17 April 2020 Additions: Protocol 3.2 – Guidelines for Radiology Investigations Protocol 3.3 – ICMR Guidelines on ICD coding Annexure 2.4 – Updated ICMR Specimen Referral Lab Form

Version 1.3 Revision date 09 April 2020 Protocol 1.5 - Throat swab collection approval and references to it deleted. Annexure 1.5 (Approval form) deleted

Version 1.2 Revision date 08 April 2020 Annexure 2.7 - Protocol Lab testing protocol for covid-19 [Government of Karnataka] added

Version 1.1 Issue date 31 March 2020

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MESSAGE FROM CHANCELLOR

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FOREWORD

Justice KS Hegde Charitable Hospital and KS Hegde Medical Academy are probably

facing the greatest challenge in their 20-year existence. Even as the threat of the COVID-

19 outbreak looms ominously over us, KSHEMA family has risen to the occasion and is

preparing itself for safeguarding its patients and employees. The faculty and staff have

acted rapidly and decisively under the leadership of the Dean Dr. PS Prakash and Medical

Superintendent Dr. S Hiremath with the support of the Management.

The Task Force formed to manage the situation has worked tirelessly and as a cohesive

unit in understanding the issues, developing detailed guidelines and standardizing

operating procedures for the functioning of the hospital. This has not been an easy task

given the constantly changing scenario and the need to collate guidelines from multiple

sources. I laud their efforts and congratulate them on a task well done.

This handbook, which provides quick access to all the important protocols and guidelines

related to hospital services during the COVID-19 outbreak, will be an essential guide for all

healthcare workers of the hospital. I urge everyone involved in the hospital services to

familiarize themselves with this document and its subsequent versions. This will prove to

be crucial for your safety as well as for the effectiveness of our patient services.

I appreciate the commitment shown by everyone during these difficult times. Your well-

being is of utmost importance to the University. Our safety is our collective responsibility

and following the guidelines and protocols described in this document is an important

action that we can take to safeguard our health. I am proud of your determination to

continue to serve the community in line with our vision and mission.

Prof. Dr. Satheesh Kumar Bhandary

Vice Chancellor, NITTE (Deemed to be University)

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PREAMBLE

Justice KS Hegde Charitable Hospital, the teaching hospital for KS Hegde Medical Academy is a unit of Nitte (Deemed to be University). The 1000 bed hospital offers health care through 13 specialty and 14 super-specialty departments / units.

With the emerging risk of COVID-19 outbreak, the Hospital has taken proactive steps to ensure efficient functioning of while ensuring safety of its employees. A Task Force has been established to monitor the situation on a continuous basis, plan for anticipated scenarios, develop protocols for critical areas of functioning and oversee the implementation of safety precautions.

The COVID-19 protocols have been developed from the relevant guidelines prescribed by World Health Organization (WHO), Indian Council of Medical Research (ICMR), Ministry of Health &Family Welfare (MoHFW), GOI, MoHFW, Government of Karnataka, and related agencies. Each hospital is unique in its operational characteristics and it is therefore important to interpret and contextualize general guidelines. These protocols have been developed collaboratively by experts with varied medical, nursing and administrative experience. It is hoped that this they will assist all hospital staff and users in facing the challenges thrown up by the global pandemic of COVID-19.

This resource is organized in three parts. Part 1 provides guidelines for screening, categorization and triaging of COVID-19 suspects. Part 2 outlines the management guidelines for COVID-19 Positive and Suspects under various circumstances and settings. Part 3 provides guidelines for general hospital services. The various protocols and relevant annexures are cross-referenced with hyperlinks and page numbers for ease of use in both print and digital versions.

Given the novel nature of COVID-19 and the rapidly growing understanding of its dynamics, these Protocols will also necessarily evolve with time and experience.

Hence this document is a living document which will see revisions and amendments over time.

OBJECTIVES OF THE PROTOCOL

1. Develop protocols for prompt identification, isolation and treatment of patients with possible COVID-19

and to care for them as part of routine operations

2. Maintain continuity of care to non-COVID patients while adhering to stringent precautionary measures

3. Communicate, train, repurpose, motivate and support the health care workers to adapt to the changed

scenario

4. Prevent the spread of COVID-19 within the hospital

5. Protect the health of the workforce, monitor and manage any healthcare personnel who might be exposed

to COVID-19

6. Implement work space etiquette in the background of pandemic

7. Build capacity to care for a potentially larger number of patients in the context of an escalating outbreak

8. Co-ordinate patient-care efforts with district health authorities and ensure mutual co-operation

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THE KSHEMA COVID-19 TASK FORCE

Name Designation Phone E-Mail

Major Dr. Shivakumar Hiremath

Medical Superintendent

9008093116 [email protected]

Dr. Sripada Mehandale Professor& HOD,

Anesthesiology


Dr. Rathika Shenoy Professor and HOD,

Pediatrics


Dr. Sumalatha Shetty Professor,

Anesthesiology


Dr. Sudheendra Rao Professor,

General Medicine


Dr. Vikram Shetty Professor,

Orthopaedics


Dr. Giridhar Belur Professor and HOD,

Respiratory Medicine


Dr. Ankeeta Menona Jacob

Assistant Professor,

Community Medicine


Dr. Amit Khelgi Assistant Professor,

Microbiology


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CONTACT NUMBERS IN CASE OF EMERGENCY

Contact Person / Unit Phone

Assistant Medical Superintendent (AMS) 9901076678

Nursing Superintendent (NS) 9945284433

Assistant Nursing Superintendent 9480532873

Infection Control Nurse (ICN) 9900282566

Biomedical Engineering 9972875299

Maintenance 9606764248

Security 9902422644

Fever Clinic 7259772233

Public Relations Officer 9740083240/9449366744

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COVID-19 DESIGNATED AREAS

Designated Service Area Location

Screening Points Outpatient Triage&

Fever Clinic

COVID-19 Suspect

Non-Critical Care

Isolation wards

IP 6th floor General Ward;

5th floor Special Ward

COVID-19 Suspect

Critical Care - Respiratory

Severe Acute Respiratory Illness (SARI) Ward

(Old post-op ward)

COVID-19 Suspect

Critical Care– Not SARI

High Dependency Unit(HDU)

COVID-19 Suspect/ Positive

Pregnant women in Labor

COVID-19 Obstetric Care

(Burns ICU)

COVID-19 Suspect / Positive

Pediatric & Neonatal Critical Care

Pediatric Intensive Care Unit (PICU)

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GENERAL INSTRUCTIONS

COVID-19 Areas

(Fever clinic / Isolation wards, COVID ICUs):

1. All health care professionals working in the COVID-19 areas should be in scrubs before the shift begins.

2. Do not bring personal stethoscope, pens, stationary, etc. in any of the areas or carry from the unit when the shift is completed. You may carry your mobile, either cling wrapped or after placing it inside a transparent cover.

3. You should be familiar with appropriate Personal Protective Equipment (PPE) for the designated area [Annexure 1.1 on page 86] and the designated spaces for Hand wash, Donning [https://youtu.be/jH8OVjeuEeM] and Doffing [https://youtu.be/9FBWkFTbtH4].

4. Once donned in PPE, do not move out of your designated areas until your shift ends. Avoid having a snack/ water or using the washroom.

5. All PPE when doffed should be disposed of appropriately; and all scrubs must be dropped in Hypochlorite tubs when you leave the hospital.

6. Remember to hand wash and sanitize between the steps of Donning and Doffing and when you leave the hospital [https://youtu.be/IisgnbMfKvI]

Scan or click to watch videos on donning PPE, doffing PPE and hand washing.

https://youtu.be/jH8OVjeuEeM

https://youtu.be/9FBWkFTbtH4

https://youtu.be/IisgnbMfKvI

https://youtu.be/jH8OVjeuEeM

https://youtu.be/9FBWkFTbtH4


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Non- COVID-19 Areas

(All other areas except mentioned above):

1. Identity card, mask, hand wash and thermal check are compulsory and is provided at the entrance near the ATM.

2. Do not wear watches, rings or threads. Use surgical mask. Put your mobile in a Ziplock or transparent plastic pouch and discard it when you leave the hospital. Do not bring laptops, personal bags, etc.

3. Make sure the OPD triage screening check list is attached to the file before seeing the patient. Ensure both the patient and attenders are wearing the surgical mask appropriately. Reduce physical contact as much as possible & maintain adequate distance between you and the patient Keep investigations to basic minimum. Encourage quick turnover at OP and Lab. Use OP EMR as much as possible.

4. Hand wash/ hand sanitize between patients.

Please Note:

Faculty and residents working in non-COVID-19 areas are NOT permitted to enter or substitute or do double duty in the COVID-19 service areas unless authorized.

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PART 1:

SCREENING, CATEGORISATION OF COVID-19 SUSPECTS AND SOP FOR SERVICE

AREAS ON ADMISSION AND TRANSFER OUT

Who is a Suspect Case?

A patient with acute respiratory illness (fever and at least one sign/ symptom of respiratory disease (e.g., cough, shortness of breath) AND a history of international travel or residence in an area or territory reporting local transmission of COVID-19disease during the 14 days prior to symptom onset

OR

A patient / Health care worker with any acute respiratory illness AND having been in contact with a confirmed COVID-19 case in the last 14 days prior to onset of symptoms

OR

A patient with severe acute respiratory infection (fever and at least one sign/symptom of respiratory disease (e.g., cough, shortness 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.

Definitions

Influenza Like Illness (ILI):

An acute respiratory infection with:

▪ history of fever or measured fever of ≥ 38 C° and cough ▪ onset within the last 10 days

Severe acute respiratory illness (SARI):

An acute respiratory infection with:

▪ history of fever or measured fever of ≥ 38 C° and cough ▪ onset within the last 10 days ▪ requiring hospitalization for intensive monitoring

Containment Areas:

Containment Zone also known as Hotspot is a well-defined “area” around the residence/premises where a COVID – positive person resides/ works and where the most intensive measures to prevent the spread of viral infection need to be implemented. The “area” remains a containment zone till no new COVID-19 case is reported within 28 days of the last positive case of that area OR less than 10 primary and secondary contacts remain under active home quarantine

Buffer Zone is a well-defined area around the containment zone which is of 5 km radius in an urban area and 7 km radius in a rural area

These areas are notified by the Honorable District Commissioner’s Office, Dakshina Kannada District, Karnataka and is important for selection of individuals for throat swabbing.

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INDEX OF PROTOCOLS FOR PART 1

1. Protocol 1.1: Categorization of Patients and Service Areas

2. Protocol 1.2: Deployment of Personnel at OPD Screening &Fever Clinic

3. Protocol 1.3: Screening at Fever Clinic and Triaging

4. Protocol 1.4: Standard Operating Procedure for OPD Screening and Fever Clinic

5. Protocol 1.5: Transport of Covid-19 Positive / Suspect Cases

6. Protocol 1.6: Criteria for admission and transfer to/ from COVID and non-COVID ICUs

INDEX OF ANNEXURES FOR PART 1

1. Annexure 1.1 - Guidelines on rational use of personal protective equipment

2. Annexure 1.2 – Outpatient triage checklist

3. Annexure 1.3 – Case information form for COVID-19 suspect/ positive

4. Annexure 1.4 – Throat Swab For Covid-19 And Icmr Rt-Pcr Application

5. Annexure 1.5 - Paediatric Fever Clinic Checklist

6. Annexure 1.6: Paediatric Drug Dosage Information

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PROTOCOL 1.1

1.1.1: CATEGORIZATION OF PATIENTS AND SERVICE AREAS*

*Subject to change

Criteria Category Service Area Remarks

Fever AND Respiratory symptoms: Cough, Breathlessness of 10 days duration AND H/o International or Interstate travel/ Contact with confirmed case in the last 14 days

OR

SARI requiring admission

OR

ILI from containment area

OR

Pregnant woman from containment zone within 14 days of EDD or in labor

OR

Any individual from containment area seeking health care [emergency/ in-patient / out-patient]

Category I

(COVID-19 Suspect)

Outpatient Triage &Fever Clinic

Responsibility:

Resident/ Intern posted in the areas and Faculty Supervisor

Duty Roster:

Task Force

• Emergency and Trauma

• Patients requiring casualty care (NOT Category I)

Category II Inside Casualty Responsibility &Duty Roster: Respective department

Note: Multi-disciplinary ICU (MICU) is identified as Non-COVID-19 ICU

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Not Category I or II

• Follow up patients

• Pregnant women

• Immunosuppressed (Chronic systemic illness/ cancer patients/ steroid therapy/ etc.,)

Category III# Respective OPD

(08.00am to 04.00pm)

•

Responsibility &Duty Roster: Respective department incharges.

*Subject to change

# Pregnant women, follow-up patients, those with chronic systemic illness, immunosuppressed presenting with fever and respiratory illness should be triaged in the Fever Clinic as Category I

1.1.2: Who are the High-Risk individuals for close monitoring?

High risk individuals for COVID-19 include:

▪ Persons ≥ 60 years

▪ Pregnant Women

▪ Diabetes Mellitus, Hypertension

▪ Tuberculosis

▪ Cancers

▪ Dialysis

▪ Stroke

▪ HIV Positive, Primary Immunodeficiency disorders (PID) and Other Immunocompromised

▪ Organ transplant

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PROTOCOL 1.2: DEPLOYMENT OF PERSONNEL AT OPD SCREENING ANDFEVER

CLINIC*

Personnel Working Pattern Remarks

OUTPATIENT TRIAGE

Faculty supervisor, Interns & Social workers

FEVER CLINIC

Resident -1

Nurse – 1

MNA/ FNA – 1

1-2 Shifts from 08.00am to 04.00pm

Three shifts of 8 hours each

Doctors:

6.00 am -2.00 pm

2.00 pm -10.00 pm

10.00 pm – 6.00 am

Nurses:

7.00AM to 3.00 PM

3.00 PM to 11.00PM

11.00PM to 7.00AM

Contact Task Force for any clarifications

Faculty supervisor in shifts. Contact Task Force/ General Medicine Duty Consultant at SARI/ Pediatric Duty Consultant at PICU if in doubt regarding triage/ activating protocols

*PPE appropriate for the service area is made available

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PROTOCOL 1.3: SCREENING AT FEVER CLINIC AND TRIAGING

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PROTOCOL 1.4: STANDARD OPERATING PROCEDURE FOR OPD SCREENING AND

FEVER CLINIC

1.4.1 STANDARD OPERATING PROCEDURE FOR OPD SCREENING(IP BILLING AREA)

Job Description Responsibility

• Ensure that patients & attenders wash their hands with soap and water before entering the area.

• Restricted entry

• Maintain physical distancing. Only one patient and one attender to be let in at the screening point.

Security Guard, Nurse

• Check with thermal sensor at the entry point.

• Surgical mask to be provided to the patient and attender

Nurse

• Screening with Outpatient Checklist(Annexure 1.2 on page 96); NO clinical examination

• Triage for Outpatient or Fever Clinic based on the Checklist

• Prioritize pregnant women, wheelchair bound & special clinic patients

• Direct to Registration Counter 1 if deemed non-COVID

Faculty& Nursing supervisors, Interns

• Registration to respective Outpatient department after verification of screening checklist and issue of old file/ stickers

OPD Reception staff

• Attaching OPD screening checklist to patient file and handing over to consultant

OPD nursing staff

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1.4.2: STANDARD OPERATING PROCEDURE FOR FEVER CLINIC


• Ensure that patients & attenders wash their hands with soap and water before entering the fever clinic area.

• Restrict entry. ONE attendant is permitted only for pediatric, geriatric and the physically challenged.

• Maintain physical distancing. Only one patient and one attender to be let in at the screening point.

Security Guard, Nurse

• Ask for history of fever, cough/ sore throat/ breathlessness

• Check with thermal sensor at the entry point.

• If YES, provide surgical mask to the patient especially if he is coughing

Nurse

• Examine maintaining social distance and triage. Do NOT perform throat examination. Auscultate back only. Scan or click QR code in next column to watch video (https://youtu.be/1qcxZLJ1gWc)

• Fill the Case Information Form (Annexure 1.3 on page 97)

• Pediatric vital checklist (Annexure1.4 on page 100) and Pediatric drug dosage list (Annexure 1.5 on page 105) are available for reference

• Throat swab needs to be done as per indications and procedure in Protocol 2.3. RT-PCR Application needs to be filled (Annexure 1.6 on page 106)

• Scan or click QR code in next column to watch video on throat swab collection (https://youtu.be/syXd7kgLSN8)

• For outpatient care (I-A) provide generic drugs made available at the clinic.

• Patients should NOT be sent for any investigation either to Radiology department or the Lab. The attender may be sent to the pharmacy if needed.

Resident & Nurse

• For inpatient care (I-B), three beds are made available with oxygen and monitors until baseline investigations are available

• List the investigations and medications, and coordinate with Isolation Ward Resident.

• For inpatient care (I-C), complete the admission process.

• Activate Patient Transport Protocol(Protocol 1.5 on page 20)

• Follow criteria for admission to COVID ICUs (Protocol 1.6 on page 21)

Resident alerts Nurse

Note: Code Blue (Resuscitation) not to be activated in Fever Clinic

https://youtu.be/1qcxZLJ1gWc

https://youtu.be/syXd7kgLSN8



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PROTOCOL 1.5: TRANSPORT OF COVID-19 POSITIVE / SUSPECT CASES

Jobs and responsibilities


Activation of Transport Protocol Resident alerts Nurse

Team assembly in PPE - Nurse, Lift Operator, MNA/ FNA Nurse alerts Casualty

Activation GREEN CORRIDOR

Opening of lift, clearance of corridor, opening of doors

Nurse alerts Security Guard

Nurse alerts Admission Unit

Sanitization of lift with 1% sodium hypochlorite mop and 30-min shut down after return of transport team

Lift Operator supervised by Nurse

Designated Transport Routes

Destination Route*

Fever Clinic to Isolation ward

Lab x-ray corridor → OP Lift 2 to second floor → second floor corridor → IP Lift 4 to sixth floor

Fever Clinic to SARI Ward / COVID-19 ICU Lab / X-ray corridor → OP Lift 2 → First floor

Fever Clinic to PICU Lab X-ray corridor → OP Lift 4(B) → First floor

Isolation/Quarantine to COVID-19 ICU

& vice versa

IP Lift 4 to second floor →second floor corridor → OP lift 2 to First Floor

Isolation/ Quarantine to PICU

& vice versa

IP Lift 4 to second floor → OP lift 4(B) first floor → 1st floor

COVID-19 ICU to mortuary OP Lift 2 to Lower Basement Floor (-2)

PICU to mortuary OP Lift 4(B) First Floor to Lower Basement Floor (-2)

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PROTOCOL 1.6: CRITERIA FOR ADMISSION AND TRANSFER TO/FROM COVID AND NON-

COVID ICUs

1.6.1 ADMISSION CRITERIA

SARI ICU:

• Fever and critical respiratory illness fitting the case definition of SARI

HDU:

• Unknown fever and critically ill

• Breathlessness without fever (asthma, COPD, CCF, CKD & others)

• Critically ill from containment & buffer zones (Stroke, acute coronary syndrome, acute

abdomen, trauma, & others)

MICU:

• Critically ill with NO fever/ breathlessness AND NOT from containment & buffer zones

1.6.2 TRANSFER CRITERIA OF COVID NEGATIVE AND CLINICALLY COMPATIBLE

SARI ICU:

• Isolation ward: 6th floor general ward / 5th special

HDU:

• General ward/ Special ward under parent unit

• MICU if critically ill

PLEASE NOTE THAT GENERAL WARD / SPECIAL WARD PATIENTS WHO DEVELOP ILI/ SARI AFTER ADMISSION NEED TO BE PROMPTLY SHIFTED TO COVID ICU/ ISOLATION WARDS

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PART 2: RESPONSIBILITIES, MANAGEMENT, DECLARE OF CURE AND DISCHARGE OF

COVID-19 (SUSPECT AND POSITIVE) PATIENTS


1. Protocol 2.1: General management of stable COVID-19 Suspect/ Positive patients – Isolation wards

2. Protocol 2.2: General management of unstable COVID-19 Suspect/ Positive patients – COVID ICUs

3. Protocol 2.3: Investigations for COVID-19/ Suspect/ Positive

4. Protocol 2.4: Medical management of sick COVID-19 Suspect/ Positive

a. 2.4.1: Sick adults in SARI Ward

b. 2.4.2: Sick children

c. 2.4.3: Obstetric Care

d. 2.4.4: Newborn care

5. Protocol 2.5: Guidelines for Dialysis of COVID-19 Suspect/ Positive

6. Protocol 2.6: Guidelines for COVID-19 Suspect / Positive requiring emergency surgery

7. Protocol 2.7: Practice guidelines for non-COVID patients requiring emergent or urgent intervention/ surgery

8. Protocol 2.8: Management of dead body and guidelines for autopsy


1. Annexure 2.1 - Check list for COVID -19 isolation ward

2. Annexure 2.2 - Pediatric monitoring checklist for COVID -19 in isolation ward

3. Annexure 2.3 - Pediatric investigation chart in COVID -19 isolation ward

4. Annexure 2.4 – Patient education material

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PROTOCOL 2.1: GENERAL MANAGEMENT OF STABLE COVID-19 SUSPECT / POSITIVE

PATIENTS–ISOLATION WARDS

2.1.1 Who are to be Isolated?

Category I-B: All Suspect Cases who are stable and require minimal monitoring as defined in the Fever Clinic Protocol2.1.2 Where?

IP General Ward 6th floor. This Floor is divided into four areas:

Respiratory symptoms Others

Male (C-16) Male (C-19)

Female (C-17) Female (C-6G)

2.1.3 Who are the people working?

Personnel Working Pattern Personal Protection

Remarks

Faculty Supervisor

Resident –1

Intern – 1

(working externally)

Nurse – 1

MNA/ FNA – 1

24-hour shift for medical professionals

Three shift of 8 hours each for nurses

7.00AM to 3.00 PM

3.00 PM to 11.00PM

11.00PM to 7.00AM

Improvised PPE

Report progress to General Medicine Duty Consultant at SARI/ Pediatric Duty Consultant at PICU after rounds twice a day

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2.1.4 What are the responsibilities of the Resident posted?

i. Provide all patients and permitted attender with surgical mask and instruct them to wear all the time. Educate on appropriate medical waste disposal.

ii. Document case history and examination in the Isolation Ward Monitoring Checklist (Adult/ Pediatric) twice a day.

Refer to:

Annexure 2.1 on page 107



Scan / Click to view video on examination of

COVID-19 suspect / Positive

iii. Confirm from the Fever Clinic whether the Case Information Form is filled and Throat swab is collected; follow-up the report.

iv. Ensure case sheet and treatment orders are maintained appropriately on day to day basis

v. After the rounds, coordinate with the respective SARI ward Medicine faculty on duty / parent unit for management. Review the investigations sent from Fever Clinic.

vi. If COVID-19 negative, manage as a regular patient. Shift to parent unit as authorized by the parent unit.

vii. Discharge as soon as possible when fit, with medications and advise on self-home quarantine for 14 days, hand hygiene and social distancing (Refer to Annexure 2.4 on page 111)

viii. All discharges once prepared, a copy of the summary has to be sent to the respective faculty of the concerned department and get it approved.

NOTE:

UNDER NO CIRCUMSTANCES, SHALL INDIVIDUALS WITH

PENDING COVID REPORT BE DISCHARGED.

Scan / Click to view video on Throat Swab

Collection



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2.1.5 How do I monitor?

COVID-19 throat swab report awaited/ Negative and becomes Unstable:

▪ Shift to SARI ward

▪ Activate Transport Protocol (Protocol 1.5 on page 20)

COVID-19 Negative, Stable

▪ If the patient requires further treatment shift to parent unit as authorized

▪ If the patient is shifted from SARI ward, repeat throat swab on Day 5

▪ In case of direct admission or shifted from COVID ICU, discharge as per medical condition with instructions on home quarantine for 2 weeks and to report if symptomatic

▪ Inform Mr. Hemanth (PRO) before discharge

COVID-19 Positive, Stable:

▪ All COVID-19 positive will be shifted to designated COVID hospital. The discharge of these patients will be supervised by MS/ Dr. Ankeeta / PRO Mr. Hemanth (9740083240). The discharge and transport of the patient are regulated by the Government Nodal Officer. Transport details will be intimated by PRO

▪ If the patient is to be followed up in our institution, he/ she is tobe reloacted to the Isolation ward & monitored. Throat swab is to be repeated on Day 10 of symptom onset along with repeat Chest X-ray. Patient can be discharged if throat swab is negative and he is symptom free for three days

Please note:

1. Patients should not be sent out of the ward for any reason or for any investigation to radiology/ central lab.

2. Patient Attender is not allowed in the Isolation and Quarantine wards except for children aged <12 years or in special circumstances at the discretion of Medical Superintendent. One attender will be given a place to stay in the hospital.

3. Food will be supplied by hospital. The personnel will be wearing N95 mask, plastic apron and gloves. The nursing supervisor will ensure that the personnel supplying food visits these wards only after completing all other areas of the hospital.

4. Pharmacy supplies will be arranged through online indenting. An advance has to be collected at admission.

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PROTOCOL 2.2: GENERAL MANAGEMENT OF UNSTABLE COVID-19 SUSPECT PATIENTS

– COVID ICUs

2.2.1 Admission Criteria

Category I-C: COVID-19 Suspect as defined in Protocol 1.3 on page 17 with unstable clinical condition, SpO2<90% on room air either from Fever Clinic/ Isolation in the designated ICU areas.

Pregnant women from containment zone within 14 days of EDD or obstetric concerns

2.2.2 Designated areas:

Designated Service Area Location

COVID-19 Suspect

Critical

Severe Acute Respiratory Illness (SARI) Ward

(Old post-op ward)& High Dependency Unit (HDU)

COVID-19 Suspect/ Positive

Pregnant women

COVID-19 Obstetric Care

(Burns ICU)

COVID-19 Suspect / Positive

Pediatric & Neonatal Critical Care

Pediatric Intensive Care Unit (PICU)

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2.2.3 Working arrangement

Area Personnel per shift Working Pattern

SARI ward

Faculty - 2

Residents - 2

Nurse – 2

MNA/ FNA – 2

Three shifts of 8 hours each for doctors:

6.00 am -2.00 pm

2.00 pm -10.00 pm

10.00 pm – 6.00 am

Individual ICU units will put up the roster for medical professionals and shifts based on workload

Nurses:

7.00AM to 3.00 PM

3.00 PM to 11.00PM

11.00PM to 7.00AM

Burns ICU

Faculty -1

OBG Resident – 1

Nurse – 1

FNA – 1

PICU Faculty - 1

Resident – 1/2

Nurses- 2

MNA/ FNA – 1

2.2.4 Responsibilities of the Resident

▪ Throat swab needs to be done as per Protocol 2.3 on page 29. Throat Specimen

Application(Annexure 1.6 on page 106) needs to be filled up through fever clinic and the

report promptly collected

▪ SARI Ward Medicine residents should report to Dr. Suresh G, Professor, General Medicine at 10.30 a.m. every day after rounds over the phone. A report of the patients in the format made available in the SARI ward should be filled and sent to Medical Superintendent Office by 11.00 am.

▪ The SARI ward Duty General Medicine Consultant should be contacted for all queries on patient medical management and the same should be documented on the file.

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▪ There should be continuity of patient care between shifts and on transfer out. A preliminary discharge summary should be updated on the software describing the events in the ICU, investigations done and treatment given.

2.2.5 Transfer out

SARI ICU:

• Isolation ward: 6th floor general ward / 5th special

• Throat swabbing date on D5 to be documented

HDU:

• General ward/ Special ward under parent unit

• MICU if critically ill

2.2.2.6 Death of a patient wherein Throat swab report is awaited or COVID-19 positive:

▪ In the event of death, death summary should be written. If throat swab result is awaited, the body should not be released.

▪ Follow Protocol 2.8on page 47

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PROTOCOL 2.3: INVESTIGATIONS FOR COVID-19 SUSPECT / POSITIVE PATIENTS

2.3.1 Indications for RT-PCR (Throat swab + Nasal Swab) for COVID-19 and categorization of samples for processing:

Type of patient Characteristics of patients Category*

Influenza Like Illness (ILI)

Individuals undertaken international travel in last 14 days A

Contact of lab confirmed case- primary and secondary contacts

Health care workers- involved in mitigation and containment of COVID-19

Patients in hospital/ MoHFW identified clusters (both containment zones and buffer zones)

Interstate returnees/migrants

Suspected COVID-19 death-swab taken within 6 hours of death

Pregnant woman B

Elderly patients (≥60 years)

Co-morbid conditions with TB, Cancer, Stroke, requiring dialysis, organ transplant recipient, Diabetes mellitus, Hypertension, other immune compromised states

Severe Acute Respiratory Illness (SARI)

Severe Acute Respiratory Illness (SARI) A

Suspected COVID-19 death with history of SARI symptoms- swab taken within 6 hours of death

Pregnant woman B

Asymptomatic Asymptomatic direct and high-risk contact of confirmed case family member

A

Asymptomatic health care worker in contact with confirmed case without adequate protection

Pregnant woman in/ near labor from containment zones B

individuals undertaken international travel in last 14 days C

Asymptomatic individuals with history of travel from a high prevalence state (Updated daily- as on 20th May 2020- Maharashtra, Tamilnadu, Gujrat, Delhi, Rajasthan, Madhya Pradesh)

*Labelling of the boxes dispatched to Government facility

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2.3.2 Throat Swab Sample Collection

Job Responsibility

1. Filling up of Case Information Form (Annexure 1.3 on page 97) as and when admission comes

Residents posted in Fever clinic & SARI ward

2. Collection of Throat swab kit from Microbiology Lab:

Resident to coordinate with Intern on duty

3. Collection of samples:

a. The throat swab kit consists of two sterile throat swabs (oropharyngeal & flexible nasopharyngeal), test tube containing Viral Transport Medium (VTM), paraffin tape, Ziplock bag, absorbent material(cotton or tissue paper), secondary container, cold gel pack, and ice box. Ensure that both the swabs are put in the same VTM test tube correctly labelled after sampling. The vial needs to be triple packed andthen transported in the ice box provided to the microbiology laboratory.

b. The SARI ward patient is sampled on receipt of the kit.

c. The sampling of Isolation ward patients is done by the Duty resident in PPE before 8.00am

d. Filling up of RT-PCR application and generation of PDF (Annexure 1.6 on page 106)

e. Packaging of nasopharyngeal and oropharyngeal swabs have to be done according to specimen transport protocol and sample collection and transportation guidelines by ICMR/ NIV Pune respectively (Annexure 3.1 on page 112)

Residents posted in Isolation ward 6th floor, SARI ward& Fever clinic

Scan / Click to view video on Throat Swab Collection

4. Transport of Throat swab kit from ICU/ Isolation Ward → Microbiology Lab.

Resident to coordinate with Intern on duty

5. Throat swab Dispatch: Transport of the kit and both the filled forms to Integrated Disease Surveillance Program (IDSP) office by 4.00 pm to GWH and on emergency basis

Samples to our lab should reach by 9.00am if it is be processed the same day

Microbiology Technician Casualty Sister

Ambulance Driver to coordinate


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NOTE:

1. All health care personnel are to familiarize with instructional video on nasopharyngeal swabbing and

the forms.

2. Ensure correctness and completeness of the forms.

2.3.2 Other investigations in Critical care areas

1. The following panels of Investigations have been created at the billing section:

a. Adult COVID-19 Panel 1: Hb, TC, DC, ESR, Platelet count, RBS, Urea, Creatinine, LFT, MPFT

b. Adult COVID-19Panel 2: Electrolytes, LDH, CRP, Blood culture

c. Adult COVID-19 Panel 3: Serum Ferritin, Trop T, D-dimer

d. Pediatric COVID-19 Panel 4: Hb, TC, DC, Platelet count, Urea, Creatinine, Sodium, Potassium, SGOT, SGPT, Blood culture

e. Pediatric COVID-19Panel 5: PT, APTT, Serum ferritin, CPK-MB

2. The nurse will request Billing Section on phone (Extension number 2702) to generate the credit bill for the required panel(s). No requisitions will be generated in the COVID-19 areas. The bill copy will be printed and sent by the billing staff of A&ER directly to the lab.

3. The ICU resident and Intern will coordinate the transport of samples to the Central Lab.

2.3.3 Radiology

1. All COVID-19 areas are provided with portable X-rays. The X-ray technician has to be provided with PPE before entry into the area.

2. It is requested that faculty group the x-rays so that this process is minimized.

3. All COVID-19 areas have Ultrasound machines and the Radiology resident/ faculty is to be provided with PPE before entry.

4. If CT/MRI is inevitable, no patient from COVID-19 area should be shifted to radiology department without authorization. Refer to Protocol 3.2 (on page 60) for investigations that require transport of patient to Radiology Department.

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PROTOCOL 2.4: MEDICAL MANAGEMENT OF SICK COVID-19 SUSPECT/ POSITIVE

PROTOCOL 2.4.1: ADULT SICK PATIENTS IN SARI WARD

Abbreviations:

SARI: Severe Acute Respiratory Distress Syndrome

ARDS: Acute Respiratory Distress syndrome

PaO2: Arterial oxygen partial pressure as in arterial blood gas analysis

FiO2: Fractional concentration of inspired oxygen (FiO2 of 1 = 100% O2)

2.4.1.1 Definitions:

A. Severe Acute Respiratory Illness (SARI)

History of fever or measured fever ≥ 38 C° AND Respiratory symptoms with onset within the last 10 days requiring admission

Mild pneumonia - Patient with pneumonia (bronchial breath sounds, crepitations, rhonchi) and no signs of severe pneumonia.

Severe pneumonia - Adolescent or adult with fever or suspected respiratory infection, plus one of the following:

▪ Respiratory Rate >30 breaths/min

▪ Severe respiratory distress

▪ SpO2 <90% on room air

B. 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.

▪ Oxygenation (adults):

o Mild ARDS - PaO2/FiO2 between 200 - 300 mmHg (with PEEP or non-ventilated)

o Moderate ARDS - PaO2/FiO2 100 -200 mmHg (with PEEP ≥5 cm H2O, or non-ventilated)

o Severe ARDS - PaO2/FiO2 ≤ 100 mmHg (with PEEP ≥5 cm H2O, or nonventilated)

▪ When PaO2 is not available, SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated patients)

C. Sepsis:

Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and serum lactate level >2 mmol/L

2.4.1.2 Early Supportive Therapy and Monitoring

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a. Supplemental oxygen therapy with (N95 in place), for patients with SARI at 5 L/min and titrate flow rates to reach target SpO2 ≥90% in non-pregnant adults and SpO2 ≥92-95% in pregnant patients. Prone position even in awake patient if possible.

b. Conservative fluid management in patients with SARI when there is no evidence of shock (2 ml/kg/h).

c. Empirical antibiotic treatment based on the clinical diagnosis (community-acquired pneumonia or health care-associated pneumonia [if infection was acquired in healthcare setting], or sepsis).

Do not routinely give systemic corticosteroids for treatment of viral pneumonia or ARDS.

Closely monitor patients with SARI for signs of clinical deterioration, such as rapidly progressive respiratory failure and sepsis, and supportive care interventions immediately.

Awake proning, is highly recommended, as results show improvement in oxygenation in critically hypoxemic patients. It is much easier to position the awake patient in prone than in a sedated and paralysed patient. Patients on ventilator also should be nursed in prone position, if adequate man power is available. For patients with severe ARDS, prone ventilation for more than 12 h is recommended.

2.4.1.3 Management of Hypoxemic Respiratory Failure and ARDS

a. Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing standard oxygen therapy (Nasal prongs or face mask).

b. Oxygen via face maskto be changed over to NRBM (Non-ReBreathing Mask, face mask with reservoir bag and flow rates of 10-15 L/min)

c. If patient does not maintain saturation >85%, poor GCS <8/15, respiratory rate <8 or >30/min, PaO2 <55 mmHg or PaCO2>55 mmHg consider Non-Invasive Ventilation (NIV)/Endotracheal intubation using precautions against airborne material

2.4.1.4 Ventilation strategies

A. Non-Invasive Ventilation (NIV): A short trial (1-2 h) of NIV with an initial setting of pressure support (PS) of 10 cmH2O and PEEP of 5-8 cmH2O with FiO2 (oxygen) of 1 (100%). Patients with hemodynamic instability, multiorgan failure, or abnormal mental status should not receive NIV. They will be managed with endotracheal intubation and mechanical ventilation.

B. Endotracheal intubation, only rapid sequence intubation:

▪ Give 100% oxygen with face mask, no IPPV

▪ Fentanyl 1-2 microgram/kg

▪ Induction agent as per the case scenario

▪ Muscle relaxant- Succinyl choline (1.5 mg/kg)

▪ Intubate with appropriate size endotracheal tube (male 8.0, female 7.0)

▪ Connect HME filter, and connect to ventilator, start ventilation

▪ Confirm tube in-situ using capnogram

C. Mechanical Ventilation

▪ Volume control ventilation with peak pressure less than 35 cm of H2O

▪ Low tidal volumes (start 6 ml/kg and increase up to 8 ml/kg)

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▪ Respiratory rate 20 to 25 breaths/min.

▪ FiO2 start with 100% and titrate to keep SpO2> 90-95%

▪ Sedate the patient with Fentanyl /Morphine and Midazolam/Lorazepam

▪ Muscle relaxant, if needed- Vecuronium infusion at 0.1microgram/kg/min

▪ PEEP starting from 5 cm H2O to progressive incremental increases if no hypotension/bradycardia

▪ Episodic periods of high CPAP (continuous positive airway pressure) of 30–40 cm H2O

▪ Application of prone ventilation if possible.

2.4.1.5 Management of Septic Shock

▪ Recognize septic shock in adults when infection is suspected or confirmed, if:

o Vasopressors are needed to maintain MAP (mean arterial pressure) ≥65 mmHg

o Lactate is >2 mmol/L, in the absence of hypovolemia.

▪ Give at least 30 ml/kg of NS or RL in adults in the first 3 hours.

▪ Determine need for additional fluid boluses 250-1000 ml based on clinical response and improvement of MAP (>65 mmHg), urine output (>0.5 ml/kg/h in adults), and lactate level

▪ Continue vasopressors when shock persists during or after fluid resuscitation (target MAP ≥65 mmHg)

▪ Vasopressor of choice is noradrenaline. Two ampoules diluted in 50 ml of normal saline. Start at 5 ml/h to begin with, then titrate up or down to target MAP (>65 mmHg).

2.4.1.6 Supportive Measures

A. 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). It is recommended that dose should not exceed the equivalent of methylprednisolone 1 – 2mg/kg/day. In severe and critically ill patients with pregnancy, consider termination in consultation with obstetrician and neonatologist.

B. NO SPECIFIC ANTIVIRALS have been proven to be effective as per currently available data. However, based on the available information (uncontrolled clinical trials), the following drug combination may be considered as an off – label indication in patients with severe disease and requiring ICU management:

1. Hydroxychloroquine (Dose 400mg BD – for 1 day followed by 200mg BD for 4 days)

2. Azithromycin (500 mg OD for 5 days)

These drugs should be administered under close medical supervision, with monitoring for side effects including QTc interval.

NOTE:

▪ If the patient is clinically unstable - superscript the sample collection form as “URGENT” to expedite testing process at the testing facility

▪ As per the latest guidelines, throat swab of every SARI patient needs to be sent on the day of admission, as well as the fifth and the twelfth day from the day of admission.

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▪ Discharge of such patients needs to be planned accordingly. Counsel the patient/ patient bystander that only after the receipt of an official negative result on throat swab (taken on 12th day) discharge will be allowed based on clinical stability of the patient.

2.4.1.7 CPR guidelines

▪ All Health Care Workers managing suspected or confirmed COVID-19 must use of PPE. ▪ The need to don PPE may delay CPR in patients with COVID-19 but staff safety is paramount. ▪ Restrict the number of staff in the room/area. ▪ Early identification of suspected/confirmed COVID-19 at risk of acute deterioration or cardiac

arrest is important.

▪ Recognise cardiac arrest.

▪ Look for the absence of signs of life and normal breathing. Do not listen or feel for breathing. Look for normal breathing. If absent or only gasping, consider cardiac arrest.

▪ Feel for a carotid pulse if trained to do so.

▪ When calling for defibrillator, state the risk of COVID-19.

▪ If a defibrillator is readily available, first defibrillate shockable rhythms prior to starting chest compressions.

▪ No chest compressions or airway procedures without PPE worn by all members of the resuscitation/emergency team before entering the room.

▪ Start compression-only CPR and monitor the patient’s cardiac arrest rhythm as soon as possible.

▪ Do not do mouth-to-mouth/pocket mask ventilation.

▪ If the patient is already receiving supplemental oxygen therapy using a face mask, leave the mask on the patient’s face during chest compressions as this may limit aerosol spread. If not in situ, but one is readily available, put a simple oxygen mask on the patient’s face.

▪ Airway intervention- tracheal intubation must be carried out by experienced and competent person

in this procedure.

▪ Identify and treat any reversible causes (e.g. severe hypoxemia).

▪ Discussion should be maintained throughout the resuscitation event and early planning of the post resuscitation phase undertaken.

▪ Dispose/clean all equipment used during CPR.

▪ Any work surfaces used for airway/resuscitation equipment will also need to be cleaned.

▪ Doffing PPE is only in pre-designated area. Remove PPE carefully to avoid self-contamination and dispose into designated bins.

▪ Thoroughly wash hands with soap and water; alternatively, alcohol hand rub is also effective.

▪ Post resuscitation debrief is important and should be planned

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PROTOCOL 2.4.2: SICK CHILDREN

2.4.2.1 Criteria for admission in PICU:

Any child with Severe acute respiratory illness (SARI):

SARI is defined by the presence of cough and fast breathing plus at least ONE of the following:

▪ Oxygen saturation (SpO2) <90%

▪ Severe chest indrawing and grunting

▪ Altered mental status

2.4.2.2 Precautions

ICU professionals face the risk of exposure during Aerosol generating procedures like:

▪ Coughing/sneezing

▪ Inadequate seal during NIV or HFNC

▪ Nebulization

▪ Intubation

▪ Laryngoscopy

▪ Endotracheal suction Front of neck access

▪ CPR prior to intubation

▪ Extubation

▪ Bronchoscopy

All personnel handling the patient should wear PPE

If facility available, intubate in a negative pressure room with >12 air changes per hour or 160

litres/ second / patient in areas with natural ventilation and then shift to main ICU preferably with

the same facility to minimize aerosol generation

2.4.2.3 Emergency Care:

▪ IV cannulation – two wide bore IV cannulas to be secured.

▪ Start 10ml/kg bolus if in shock (Conservative fluid management)

▪ Attach all monitors – ECG, NIBP, pulse oximeter.

▪ Start Oxygen through normal face mask with 5L/min O2 flow (Low flow device)

▪ Reassess

2.4.2.4 Management of respiratory failure

▪ Start supplemental oxygen if SpO2 <90% or in children with respiratory distress.

▪ Target Spo2 = 90%

▪ Low flow devices are preferred (less aerosol generation)

▪ Nasal prongs or cannula with 2-4 L/min flow

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▪ Cover the patients face with double layer surgical mask

▪ No nebulization

▪ MDI with face mask preferred

▪ HFNC may be used preferably over NIV

▪ NIV should be avoided as it increases aerosol spread

▪ Bubble CPAP can be used for newborns and children - the infant should be placed in an oxygen hood to reduce droplets.

▪ Patients with worsening hypercapnia, acidemia, respiratory fatigue, hemodynamic instability or those with altered mental status should be considered for early invasive mechanical ventilation.

2.4.2.5 Indications for intubation:

▪ PaO2/FiO2 ratio <300

▪ SpO2/FiO2 ratio <200

▪ Worsening respiratory distress

▪ High concentration (>60%) of oxygen on HFNC

▪ Hemodynamic instability

▪ Multiple organ dysfunction

2.4.2.6 Establishment of Airway & Ventilation Strategies

A. Pre – intubation:

• Oxygenation with 100% oxygen using appropriate size NRBM

• A tight-fitting face mask prepared with plastic cover and HME filter is placed over the patient.

• No Ambu bag ventilation

• A Bain circuit with gas inflated bag should be used

• One personnel should hold the mask tightly

• Other person should bag with Bain circuit with minimum pressure required to maintain chest rise/saturation. NO emergency intubation

• Limit number of persons at intubation site to 3: Intubator, assistant and Nurse.

• All drugs needed should be preloaded preferably outside the room.

• Adrenaline 0.1ml per kg 1 in 10,000 solution

• Atropine 0.02 mg/kg (not needed as routine, use in case of bradycardia or as antisialogogue before ketamine)

• Ketamine 1- 2mg/kg

• Vecuronium 0.1mg/kg or Rocuronium 1.2mg/kg

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B. Intubation

▪ Rapid sequence induction with fentanyl, midazolam/ketamine and vecuronium

▪ Intubation to be done only after complete paralysis

▪ Intubation to be done with appropriate size endotracheal tube and confirmed with capnography only and avoid auscultation

▪ Connected to ventilator and put on closed system with HME filters.

▪ In-line closed suctioning to be used

▪ In-line closed nebulization to be used

▪ During any disconnection from ventilator, endotracheal (ET) tube needs to be clamped and/or viral filter attached to the ET tube.

▪ Central line placed if indicated

▪ Clean room 20 minutes after aerosol generating procedure or intubation done.

C. Mechanical Ventilation:

▪ Low tidal volume strategy (4-8mL/kg)

▪ Limiting plateau pressures to < 30 cmH2O

▪ Higher PEEP (>10 mm Hg)

▪ Permissive hypercapnia is well tolerated and may reduce volu-trauma.

▪ Viral filters should be utilized, and circuits should be maintained for as long as allowable (as opposed to routine changes)

▪ Use paralytics liberally

D. Extubation protocol:

▪ A designated tray is used for placing the used ET tube, laryngoscope and suction catheter

▪ As we remove the endotracheal tube, face mask is placed immediately on the patient. Face mask to be covered with plastic cover beforehand.

▪ Use a transparent large plastic sheet over the face and chest to capture droplets from coughing and suctioning.

▪ Post-extubation, the need for HFNC or NIV can be assessed while reducing monitoring

▪ Patient is switched to N95 mask if stable.

▪ All the contents like endotracheal tube, suction, gloves should be immediately discarded in to appropriate bin.

▪ All the PPE used by the transport staff should be discarded after transporting the patient.

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PROTOCOL 2.4.3: OBSTETRIC CARE

Note: All pregnant women within 14 days of EDD from containment zone need to be

considered as COVID Suspect and throat swabbed

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2.4.3.1 General guidelines/ information for COVID-19 Suspect pregnant patients

1. Maternal disease does not get aggravated by pregnancy unless there are co-morbidities.

2. Swab collection approval form and swab collection form is same as for other patients

3. Labor and delivery/ Caesarian section to be managed in the Burns ICU complex

4. Isolation / Quarantine is the same for pregnant patients as in general population.

5. Await swab results before spontaneous vaginal delivery / caesarean section as far as possible

6. Consider caesarean section instead of trial of spontaneous vaginal delivery.

7. Minimize involved personnel.

8. Steroids are recommended for enhancing fetal lung maturity in situations where preterm delivery is likely between 24 to 34 weeks of gestation.

9. The main risk for infants of breastfeeding is the close contact with the mother, who is also likely to share infective airborne droplets. If mother is confirmed positive, expressed breast milk to be given.

10. Postnatal care and advise to the mother infected with covid-19 should follow routine practice. If the woman is isolated from the neonate, she should be offered psychological assessment and support.

11. Handling and disposal of placenta and membranes will be according to routine hospital waste management policy.

12. Any pregnant woman (irrespective of symptoms) coming from containment areas with less than five days from expected date of delivery or in labor- throat swab must be sent for COVID-19 testing-

NOTE: Throat swabs of the above individuals presenting should be superscripted as “URGENT” to expedite the testing process for COVID-19

2.4.3.2 Intrapartum Care Protocol

A. Caesarean section:

1. Designated OT (Burns OT)

2. Minimize persons in OT (maximum 7)

3. PPE must

4. Plan ahead, minimize the movement of the team in and out of OT during the procedure

5. Anesthesia-regional is preferred. If GA is needed then ensure negative pressures in the OT throughout the procedure and at extubation.

6. Antibiotics prophylaxis is recommended.

B. Labor management:

1. Minimize persons in the room (max 5)

2. Healthcare team to be in PPE

3. Routine monitoring protocol for high risk pregnancy.

4. Hourly vitals, intake output charting.

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5. Fetal monitoring as per protocol.

6. Minimize interventions.

7. Cut short second stage if mother is getting exhausted.

8. Early cord clamping.

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PROTOCOL 2.4.4: NEWBORN CARE

2.4.4.1 Description of Areas

Predesignated areas for conducting delivery

• Suspect/ Definite COVID 19 Mother- BURNS ICU

Predesignated areas for management of Neonate

• COVID NICU- Neonatal care area identified within PICU 2 OR Rooming in with mother

2.4.4.2 Criteria for admission

Definition in Mother

• Suspect COVID19: Symptomatic mother in perinatal period with history of travel to affected countries or affected states / places in India or history of contact with persons travelled to affected countries or affected states / places in India during the 14 days prior to onset of symptoms OR symptomatic antenatal mother when no other etiology explains her clinical presentation

• Definite COVID19: Mother with positive RT-PCR for COVID-19 irrespective of clinical signs and symptoms.

2.4.4.3 Management

Delivery room practices (Burns ICU/OT)

▪ PPE

▪ No delayed cord clamping

▪ Immediate bathing of the baby if stable

▪ No mother-baby contact until mother’s report is available

▪ Resuscitation to be carried out as per NRP guidelines

Postnatal management

A. Situation 1 - Well Neonate

▪ Baby to be shifted into PICU 2 on a warmer bed

▪ Lab tests to be done: CBC, CRP and throat swab for RT-PCR COVID-19; Sample for throat swab to be taken as per protocol.

▪ While RT-PCR reports awaited vitals to be monitored 4 hourly with PPE precautions

▪ Mother is COVID-19 negative and she is stable and Newborn is also COVID-19 negative: Both neonate and mother can be roomed-in with contact precautions and hand hygiene education for mother.

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▪ Mother is COVID-19 positive and Newborn is COVID-19 negative: Isolate neonate from mother till her COVID-19 status is negative (two consecutive samples 24 hours apart on D14 and D15). Mothers own milk (MOM) can be given by expression or formula feeds. Throat swab of the newborn should be sent on Day 12 for confirming the status

▪ Mother is COVID-19 positive and Newborn is COVID-19 positive: Isolate neonate from mother till her COVID-19 status is negative (two consecutive samples 24 hours apart on D14 and D15). Mothers own milk (MOM) can be given by expression or formula feeds. Apply discharge criteria for the baby

B. Situation 2- Sick neonate (not requiring respiratory support)

▪ Shift to PICU 2 on a warmer bed

▪ Infant incubator if free can be used to prevent aerosol spread.

▪ Starting of IV antibiotics for sepsis and other management is as per hospital policy or consultant discretion.

▪ Lab tests to be done: CBC, CRP, throat swab RT-PCR for COVID-19, LFT, RFT, Chest X-ray.

▪ MoM can be given by expression or formula feeds can be given initially till her recovery after obtaining consent from attendants.

▪ When stable, further management will depend on the COVID-19 status of the mother and baby as above.

C. Situation 3- Sick neonate (requiring respiratory support)

▪ Initiate delivery room CPAP/Intubation as per NRP.

▪ Initiate oxygen therapy

▪ Apply air-borne precautions for all health care personnel nurses and doctors while transporting and caring for such infant.

▪ Sick neonates requiring respiratory support should be tried primarily using non-invasive respiratory support as high flow nasal cannula or CPAP. In case of failed CPAP, mechanical ventilation should be attempted.

▪ Conventional ventilation, high frequency ventilation, inhaled nitric oxide, inotropes and other management can be done as clinically indicated and at decision of attending physician.

▪ When stable, further management will depend on the COVID-19 status of the mother and baby as above.

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PROTOCOL 2.5: GUIDELINES FOR DIALYSIS OFCOVID-19 SUSPECT / POSITIVE

2.5.1 Introduction

COVID-19, produces high morbidity in patients with associated comorbidities. Chronic kidney disease stage-5 (CKD-5) patients on dialysis [maintenance hemodialysis (MHD) or continuous ambulatory peritoneal dialysis (CAPD)] are a vulnerable group because of their existing comorbidities, repeated unavoidable exposure to hospital environment and immunosuppressed state due to CKD-5. These patients are therefore not only more prone to acquire infection but also develop severe diseases as compared to general population.

Patients on regular dialysis should adhere to prescribed schedule and not miss their dialysis sessions to avoid any emergency dialysis.

2.5.2 General guidelines for dialysis unit

▪ Patients will be screened in the Fever Clinic and further a sign board will be posted prominently in the local understandable language asking patients to report any fever, coughing or breathing problem in dialysis unit and waiting area.

▪ All universal precautions will be strictly followed.

▪ Dialysis unit schedule has been reorganized to decrease the work load of healthcare workers

▪ Dialysis unit staff has been trained for donning and doffing of Personal Protective Equipment (PPE).

▪ All staff have been trained for cough etiquette, hand hygiene and proper use and disposal of mask, gown and eye glasses and the need to protect themselves.

2.5.3 Regular patients requiring Dialysis:

There will be two situations of patients who require dialysis:

▪ Patients on regular maintenance dialysis (Twice weekly or thrice weekly)

▪ Patients requiring dialysis for acute kidney injury (AKI) including Sustained low-efficiency dialysis (SLED) and Continuous renal replacement therapy (CRRT)

2.5.4 Guidelines for Hemodialysis

A. For non-COVID-19 patients

Before Arrival to Dialysis Unit

▪ All patients have been educated to recognize early symptoms of COVID-19 (recent onset fever, Sore throat, Cough, recent Shortness of breath/dyspnea, without major inter- dialytic weight gain, rhinorrhea, myalgia/body ache, fatigue and diarrhea) and contact dialysis staff before coming to dialysis center.

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▪ Patients, who are stable on MHD have be encouraged to come to the unit alone without any attendant

Screening Area

▪ The screening area for our hospital is at casualty entrance and any symptomatic patient will be asked to wear a face mask and will be referred to fever clinic if necessary (Protocol 1.3 on page 17)

Inside Dialysis Unit

▪ All Patients will wash hands with soap and water for at least 20 seconds or sanitizer, using proper method of hand washing.

▪ Patients are educated to follow cough etiquettes, like coughing or sneezing using the inside of the elbow or using tissue paper.

B. For COVID-19 Suspected/ Positive

▪ Suspected or positive COVID-19 patients will be asked to wear disposable three-layer surgical mask throughout dialysis duration.

▪ Suspected/ Positive COVID 19 patients will be dialysed only in SARI/ HDU

2.5.5 Guidelines for Dialysis of patients with AKI

A small proportion of patients (~5%) of COVID – 19 develops AKI. The disease is usually mild, but a small number may require RRT (Renal Replacement Therapy). In addition, even smaller proportion of patients with secondary bacterial infection will have septic shock, drug nephrotoxicity or worsening of existing CKD severe enough to require RRT (Renal Replacement Therapy).

▪ All modalities of RRT may be used for patients with AKI depending on their clinicalstatus (SLED and CRRT)

▪ Dialysis will be carried out within the designated ICU areas for COVID-19.

▪ In such situation portable reverse osmosis water in a tank will serve the purpose for the dialysis.

2.5.6 Guidelines for Dialysis Staff

▪ All dialysis staff are encouraged to use surgical mask with frequent hand washing.

▪ Any dialysis staff taking care of suspected or proven COVID -19 patients will be provided adequate personal protective equipment (PPE) [Annexure I on page 86 ]. This includes N95 mask, nitrile double gloves, eye shield, surgical cap, gown and shoe covers

▪ Staff caring for suspected or proved cases will not look after other patients during the same shift.

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▪ Separating equipment between patients with appropriate cleaning and disinfection should be done in between shifts.

2.5.7 Disinfection and Disposal Practices in Dialysis Unit

▪ Bed linen will be changed between shifts and used linen and gowns be placed in a dedicated container for waste or linen before leaving the dialysis station.

▪ Inside dialysis unit, frequently touched surfaces will be disinfected regularly.

▪ The solutions for disinfection will be composed either of hypochlorite or formaldehyde or glutaraldehyde.

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PROTOCOL 2.6: GUIDELINES FOR COVID-19 SUSPECT / POSITIVE REQUIRING

EMERGENCY SURGERY

Designated OT: Burns ICU

This protocol will apply for all emergency surgeries required for COVID-19 suspects (PART 1 on page 12) whose throat swab reports are awaited and COVID-19 positive. The surgical team should be in complete PPE. If the duration of the surgery gets extended a second surgical team needs to be in place. The anesthetic and surgical teams should be kept to the minimum number possible.

Preparation of Operation Theatre (Old OT complex: OT 7 & OT8):

▪ Pre-anesthetic check up to be done inside the OT, if not already performed. Documentation shall include routine preoperative details and history of exposure, contact or travel.

▪ Restrict the staff inside the OT to

• Anaesthesiologist-1

• Anesthesiology Resident-1

• Anesthesia Technician-1

• Surgical team to a maximum of three including resident

• Staff nurses-2 (1-scrub nurse, 1-floor nurse)

• MNA /FNA-1

▪ Things to be kept inside the OT (before the patient is shifted):

• Boyles machine checked and draped in transparent plastic covers.

• OT lights draped in transparent plastic covers.

• Suction apparatus draped in transparent plastic covers.

• Monitor draped in transparent plastic covers (NIBP, ECG, SpO2 Capnography, temperature probe).

• Designated tray for airway equipment-appropriate size endotracheal tubes, laryngoscopes, suction catheters and other airway equipment - checked and kept ready inside the OT.

• Prepared face mask: Face mask with transparent plastic drape fixed the retaining hooks to prevent aerosol spread, as well as HME filter to the orifice or angle piece.

• Emergency drugs.

• All other equipment and drugs including crash cart to be kept outside the OT.

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Transporting suspect or COVID-19 positive patient operation theatre

▪ Clear corridor (keep all commuters off the corridor) from SARI ward (presently 1st postoperative ward) or isolation ward (presently 6th floor) to OT.

▪ Use designated lift from isolation ward (presently 6th floor) to the designated OT directly

▪ Transport of the patient to begin only after the operation theatre is fully ready with requisite equipment along with personnel donning appropriate PPE

▪ Patient to be shifted with N95 mask on with face mask and oxygen if maintains saturation >93% or with endotracheal tube insitu with transport ventilator and oxygen cylinder.

▪ If using AMBU bag, use with HME filter insitu

▪ Patient to be received directly to operation theatre, without being shifted to preoperative ward.

Anesthetic procedure:

Plan of anesthesia: Regional anesthesia is preferred whenever possible

General anesthesia, if used: Endotracheal intubation and controlled ventilation with closed system only. Avoid assisted ventilation with Bains circuit as it leads to aerosol production

▪ IV cannulation – two wide bore IV cannulas to be secured.

▪ Attach pre-induction monitors – ECG, NIBP, pulse oximeter.

▪ Cover the patient with the plastic drape to which the face mask is fixed.

▪ Carefully remove the N95 mask under the transparent plastic drapes and immediately place the face mask with HME filter for oxygenation with 100% oxygen.

▪ Place central line, if indicated.

▪ Follow rapid sequence induction with fentanyl, induction agent and succinyl choline.

▪ Intubate with appropriate size endotracheal tube and connect it immediately to closed breathing system.

▪ Confirm proper position of endotracheal tube with capnography and chest raise ONLY. Auscultation to be strictly avoided.

▪ Administer antiemetic before extubation.

▪ Plan for a smooth extubation through the prepared facemask, without any coughing or straining to prevent aerosol. This could be achieved with small dose of propofol/ Fentanyl/ esmolol/ dexmedetomidine/ continuing nitrous oxide until extubation

▪ Extubation may be performed through the facemask, to minimise dispersion of aerosol.

▪ Place the used ET tube, laryngoscope and suction catheter in a designated tray.

▪ Deliver 100% oxygen.

▪ After extubation, shift the patient with N95 mask in place.

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▪ After extubation all the contents like endotracheal tube, suction, gloves should be immediately discarded into appropriate bin.

▪ Shift the patient to SARI ward or COVID-19 ICU as per Transport Protocol

▪ If unable to extubate, patient is transported back to SARI ward or COVID-19 ICU using AMBU bag with HME filter

▪ Complete the doffing procedure within the operation theatre used for the procedure.

▪ While doffing, ensure that the outer glove is removed first, then gown inside out (like peeling) followed by other PPE. Dispose them in closed container/plastic bag by double bagging

▪ Use sanitizer at every stage.

▪ All instruments and the OT needs to be sanitized after the procedure. Seal and fumigate the operation theatre immediately.

Post-operative care:

▪ Monitoring of the patient will be done by the personnel posted in respective wards in consultation with concerned anesthesiologist and surgeon

▪ Once the patient is fit to be shifted to ward, transport protocol is activated and shifted to 6th floor general ward/ isolation area

For all Transport – Refer Protocol 1.5 on page 20)

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PROTOCOL 2.7: PRACTICE GUIDELINES FOR NON COVID PATIENTS REQUIRING

EMERGENT OR URGENT INTERVENTION/ SURGERY

• The five theatres in the New OT complex with HEPA filter and desired air cycles to be used for all

surgical procedures with aerosol generation risk. This includes general anesthesia, use of power

drill and saw, laparoscopy, endoscopy without irrigation, and cautery

• All surgeries under regional anesthesia and not requiring power drill and saw will be scheduled in

the Old OT complex

• The scheduling will be done by the Department of Anesthesia according to the nature of

emergency/ urgency, surgical procedure, co-morbidities, and other considerations based on the

request received from the departments in the prescribed format and evaluation of the patient

• The anesthetic and operating teams should be kept to the minimum. The patient is to be shifted to

pre-op only on information from OT manager. During induction of GA, only the anesthetic team

should be in place. A time period of 21 min is recommended post induction if the surgical team is

not in PPE. If PPE is desired by the operating team, a second surgical team should be available

on call for major cases. On recovery and when stable, post-op monitoring is to be continued in the

surgical wards.

• The following good practices are desirable:

o Re-check address proof and travel history

o Posting for surgery at least 5 days after admission to observe for symptoms and signs of

COVID-19; counselling and consents should be completed during this time

o COVID-19 test if indicated and willing

o complete work-up and cross references as applicable

o Insurance pre-approval if applicable

• RT_PCR for COVID-19 by throat swab is recommended under the following situations:

• Patient from containment zone/ inter-district or inter-state or international travel whether

symptomatic or asymptomatic as described in Protocol 2.3 on page 29; in case of emergency and

throat swab results are awaited, the team members should in appropriate PPE.

• Symptomatic patient from within the district and not residing in containment zone

• Patients with co-morbidities as outlined in Part 1

• Patients preferring to have COVID-19 tested before surgery

• Highly aerosol generating procedures

• Pre-test counselling should be done and Isolation is mandatory until test results are available

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PROTOCOL 2.8: MANAGEMENT OF DEAD BODY AND GUIDELINES FOR AUTOPSY

2.8.1 Removal of the body from the isolation room or area

▪ The health worker attending to the dead body should perform hand hygiene, ensure proper use of PPE (water resistant apron, goggles, N95 mask, gloves).

▪ All the 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 sharp’s container.

▪ Plug Oral, nasal orifices of the dead body to prevent leakage of body fluids.

▪ There is no need to disinfect the body before transfer to the mortuary area

▪ 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 with 1% hypochlorite. The body bag can be wrapped with a mortuary sheet or sheet provided by the family members.

2.8.2 Instructions to be given to the family members before hand-over.

▪ In case of death, the body SHOULD NOT be handed over to patient party without CONFIRMED COVID-19 Swab report being negative. If result is awaited the patient party needs to be counselled that handing over the body would be done only after consultation and appropriate clearances from the district administration in case of positive COVID-19 report.

▪ Provide counseling to the family members and respect their sentiments. Give the family clear instructions not to touch/kiss/bathe the body. Adults >60 years and immunosuppressed persons should not directly interact with the body.

▪ 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.

▪ Those tasked with placing the body in the grave, on the funeral pyre, etc., should wear gloves and wash with soap and water after removal of the gloves once the burial is complete.

▪ 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.

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▪ (Clothing and other fabric belonging to the deceased should be machine washed with warm water at 60−90°C (140−194°F) and laundry detergent. If machine washing is not possible, linens can be soaked in hot water and soap in a large drum using a stick to stir and being careful to avoid splashing. The drum should then be emptied, and the linens soaked in 0.05% chlorine for approximately 30 minutes. Finally, the laundry should be rinsed with clean water and the linens allowed to dry fully in sunlight.)

2.8.3 Transportation

▪ The trolley, on which the body is to be shifted, must be disinfected before it is taken out from the ICU/ward/emergency.

▪ The body, secured in a body bag, exterior of which is decontaminated poses no additional risk to the staff transporting the dead body. Keep both the movement and handling of the body to a minimum.

▪ The personnel handling the body may follow standard precautions (surgical mask, gloves).

▪ The vehicle, after the transfer of the body to cremation/ burial staff, will be decontaminated with 1% Sodium Hypochlorite

▪ All COVID-suspect cases (report pending) are placed in the mortuary basement of the hospital and the non-COVID cases shall be placed within the college facility

2.8.4 Decontamination of the isolation area

▪ All used/ soiled linen should be handled with standard precautions, put in biohazard bag and the outer surface of the bag disinfected with hypochlorite solution.

▪ Used equipment should be autoclaved or decontaminated with disinfectant solutions in accordance with established infection prevention control practices.

▪ All medical waste must be handled and disposed of in accordance with Biomedical waste management rules.

▪ The health staff who handled the body will remove personal protective equipment and will perform hand hygiene.

▪ All surfaces of the isolation area (floors, bed, railings, side tables, IV stand, etc.) should be wiped with 1% Sodium Hypochlorite solution; allow a contact time of 30 minutes, and then allowed to air dry.

2.8.5 Storing of dead body in Mortuary when the test results are awaited.

▪ Mortuary staff handling COVID dead body should observe standard precautions. (Hand hygiene, ensure proper use of PPE)

▪ Dead bodies should be stored in cold chambers maintained at approximately 4°C. (Embalming is not recommended)

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▪ 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.

NOTE: Patient party to be sensitized that the body will be handed over only after clearance is obtained from district administration.

2.8.6 Autopsy on a COVID-19 dead-body.

Autopsies should be avoided. If autopsy is to be performed for special reasons, the following infection prevention control practices should be adopted:

1. Nasopharyngeal swab from the dead body need not be collected routinely. Only if indicated, under

special circumstances, the nasopharyngeal swab from the dead body can be collected upto six hours

after death. Following history to be noted by the Forensic expert before taking the appropriate sample for

COVID-I9 testing:

• History of previous illness in the past and treatment.

• History of international travel in last 14 days.

• History of contact with international traveller in last 14 days.

• History of Quarantine

• History of contact with COVID-I9 positive patients.

• History of severe acute respiratory illness, Influenza like illness with symptoms of fever and cough and/or shortness of breath.

2. BROUGHT DEAD / UNKNOWN/UNCLAIMED DEAD BODIES: Where there is no history of any

suspicion/foul-play/poisoning as mentioned by relatives or bystanders/ no external injuries on the body, in

such cases the Forensic expert can issue the cause of death as

"Death due to natural causes cannot be ruled out however the exact cause of natural death could not be

commented due to existing circumstances"(COVlD-19 pandemic).

Note: As per the present practice the Unknown/Unclaimed bodies are kept in the cold storage for 48

hours for identification purposes. This need not be followed. For identification purposes suitable

photographs/clothes/sample for DNA finger printing can be collected and preserved. If the police officer

requests sample for DNA finger printing in UNKNOWN/UNCLAIMED DEAD BODIES, tuft of scalp hair

(ensuring presence of hair-roots) should be plucked, collected, preserved & handed over to the

concerned police in sealed manner for submission to Forensic Science Laboratory.

3. Cause of death can be given without autopsy based on

• Available clinical history

• Available clinical documents

• Thorough external examination of the body

• The autopsy surgeon should take the proper photographs of the body.

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OR

Partial autopsy can be done wearing PPE. Target organ of suspected trauma / pathology should be

examined first.

4. In case of COVID-19 positive unnatural deaths (example: hanging, fall from height, RTA etc.,) the

autopsy surgeon can proceed in the following lines (DISCRETION OF THE AUTOPSY SURGEON).

Cause of death can be given without autopsy based on :

• Clinical case records and laboratory reports

• Thorough external examination findings and injuries. Documents confirming the COVID-19 positive status of the deceased should be collected and preserved

by the autopsy surgeon.

OR

Partial autopsy can be done wearing PPE and taking all precautionary measures. Target organ of

suspected Trauma/pathology should be examined first.

NOTE:

• The extent to which the dissection has to be performed/opening of the body cavities shall be at the discretion of the autopsy surgeon with the consultation with the Head of the department.

▪ The number of forensic experts and support staff in the autopsy room should be limited.

▪ The Team should use full complement of PPE (coveralls, head cover, shoe cover, N 95 mask, goggles / face shield)) along with plastic apron to prevent splashing of body fluids worn over the PPE.

▪ Round ended scissors should be used.

▪ PM40 or any other heavy-duty blades with blunted points to be used to reduce prick injuries.

▪ Only one body cavity at a time should be dissected

▪ Unfixed organs must be held firm on the table and sliced with a sponge – care should be taken to protect the hand

▪ Negative pressure to be maintained in mortuary. An oscillator saw with suction extraction of the bone aerosol into a removable chamber should be used for sawing skull; otherwise a hand saw with a chain-mail glove may be used.

▪ No viscera should be preserved

▪ Needles should not be re-sheathed after fluid sampling – needles and syringes should be placed in a sharps bucket.

▪ Reduce aerosol generation during autopsy using appropriate techniques especially while handling lung tissue.

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▪ After the procedure, body should be disinfected with 1% Sodium Hypochlorite and placed in a body bag, the exterior of which will again be decontaminated with 1% Sodium Hypochlorite solution.

▪ Autopsy table to be disinfected as per standard protocol.

▪ A log book will be maintained for receiving and preserving the body in mortuary, clearly recording the COVID-19 infection status.

The protocol is framed as per latest Guidelines on Dead Body Management issued by Ministry of Health &Family Welfare, Govt of India) &Infection Prevention and Control for the safe management of a dead body in the context of COVID-19 by WHO and is subject to revision.

https://www.mohfw.gov.in/pdf/1584423700568_COVID19GuidelinesonDeadbodymanagement.pdf#_blank

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PART 3: HOSPITAL SERVICES GUIDELINES


1. Protocol 3.1: Laboratory Guidelines for Handling Samples of COVID-19 Suspects / Positive Patients

2. Protocol 3.2: Guidelines for Radiology Investigations for COVID-19 Suspect/ Positive

3. Protocol 3.3: ICMR Guidelines for ICD Coding for COVID-19 discharges/ deaths Protocol

4. Protocol 3.4: Handling, Treatment and Disposal of Waste Generated During Diagnosis/ Treatment/ Quarantine of COVID-19 Suspects/ Positive Cases

5. Protocol 3.5: Workplace guidelines

6. Protocol 3.6: COVID-19 Quarantine Protocol

7. Protocol 3.7: COVID-19 Post-exposure prophylaxis

8. Protocol 3.8: Standard operating procedure for transporting a suspect / positive case of covid-19


1. Annexure 3.1 - Specimen collection, packaging and transport guidelines

2. Annexure 3.2: Self reporting form for all travelers arriving from areas reporting COVID-19

transmission

3. Annexure 3.3: List of individuals with travel / contact history reporting to hostels

4. Annexure 3.4: Medical form for release from quarantine

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PROTOCOL 3.1: LABORATORY GUIDELINES FOR HANDLING SAMPLES OF COVID-19

SUSPECTS AND CONFIRMED PATIENTS

3.1.1 Scope

This document gives guidelines for transport, handling, processing and discarding of COVID-19 suspected/confirmed samples for routine laboratory tests at Central laboratory services, JKSHCH. The guidelines have been designed to minimize the risk for Laboratory Staff. This document has been prepared keeping in view various National and WHO guidelines. All Good Lab practices such as proper hand washing etc. to be followed.

3.1.2 Ordering of Tests

All the tests required for COVID-19 suspect/confirmed cases should be ordered as per the management guidelines.

3.1.2.1 Requisition forms

No requisition forms will be generated. The technicians must process the samples for required test based on the bills received in the laboratory. In case of any doubt, the Central Lab technician will inform the supervisor and contact the treating area. The technician should be aware that additional tests may be asked other than that listed in the panel.

3.1.2.2 Transport of Samples – Standard Operating Procedure

▪ The transport boxes labelled COVID-19 Transport Box should be collected by the interns from designated Pickup and drop point next to the clinical biochemistry lab.

▪ The intern will be provided with a pair of gloves along with the transport box and should be wearing a surgical mask and follow the due procedure.

▪ All samples have to be labelled with appropriate patient identification details and treating area. An additional label as ‘COVID’ has to be pasted on the sample container without fail.

▪ The intern at the lab informs the biochemistry/ microbiology technician when the transport box is dropped.

3.1.3 Sample Processing

3.1.3.1. Handling

▪ All laboratory technicians should change to scrubs before the shift starts in the department and the scrubs have to be dropped into hypochlorite tub before leaving the laboratory.

▪ The technician will carry the samples from the drop point to respective workstations in a separate closed box.

▪ The technicians handling the sample should wear appropriate personal protective equipment (PPE). The recommended PPE includes gloves, triple layer surgical mask, goggles and aprons.

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▪ PPE must be removed on leaving the laboratory and hygiene practices including hand washing must be rigorously maintained.

3.1.3.2 Processing

▪ Laboratory staff handling COVID-19 area samples must wear PPE when conducting work in the laboratory. The recommended PPE includes gloves, triple layer surgical mask and goggles.

▪ Follow all biosafety precautions while handling the specimen.

▪ During manipulation of potentially infectious materials including those that may cause splash, droplets or aerosols of infectious material the laboratory technician has to wear N95 mask along with other PPE. These include:

i. Loading and unloading of centrifuge cup

ii. Blending or vigorous shaking

iii. Vortexing or mixing

iv. Respiratory specimen handling and processing like Sputum/ BAL etc

▪ One centrifuge placed in the sample drop room, is exclusively dedicated for centrifuging all COVID-19 area samples. Centrifugation of the sample is to be done using the standard operating protocols. After centrifuging wait for 15 minutes for opening the lid of the centrifuge. Inner surface of the centrifuge and the lid to be wiped with 0.5% hypochlorite.

▪ Routine laboratory tests must be carried out using standard operating procedures.

▪ Disinfect the instruments and pipette tips using 0.5% sodium hypochlorite solution

▪ Work surfaces must be decontaminated using Lysoformin 3000 – 20 mL in 1 litre of water.

▪ Any spills should be disinfected using 1% hypochlorite solution as per hospital spill management policy.

3.1.3.3 Specific precautions in microbiology.

▪ All respiratory specimens (Sputum, ET secretion, BAL fluid, throat swabs etc.,) have to be processed in the Biosafety Cabinet III.

▪ Receiving and packaging of nasopharyngeal and oropharyngeal swabs have to be done according to specimen transport protocol and sample collection and transportation guidelines by ICMR/ NIV Pune respectively)

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3.1.4 Biomedical Waste Management

▪ Dedicated yellow bins labelled as COVID-19 is to be used. Double layered yellow bags (using 2 bags) should be used for collection of all COVID-19 related infectious waste including PPE to ensure adequate strength and no leaks.

▪ Remaining discards generated while processing the sample should be put in separate colourcoded bins as per BMW 2016 and 2018, 2019 amendment.

3.1.5 Sample Retention

• All samples should be discarded immediately after reports are released.

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PROTOCOL 3.2: GUIDELINES FOR RADIOLOGY INVESTIGATIONS FOR COVID-19

SUSPECTS/ POSITIVE

3.2.1 Radiographs in Fever clinic and SARI ward

▪ All Xrays of patients in SARI and Fever clinic to be taken with the portable machine as

provided in these areas wearing PPE as recommended.

▪ The cassettes need to be handled according to the department protocol which is in place

3.2.2 Radiographs in the Department

▪ Only one technician and one ward boy will be handling the patients throughout the day

▪ All technicians have to wear N95 masks and gloves throughout

▪ Only one room to be used for all X rays

▪ All the surfaces including the cassettes to be cleaned with glutaraldehyde after every

X-ray

3.2.3 Ultrasound Protocols for SARI and Fever clinic cases

▪ All fever clinic and SARI cases are to be scanned in the respective designated areas only

after donning PPE as provided by the hospital. These scans will include only emergency

cases as provided in the list and also antenatal emergencies (Term, Bleeding PV and

decreased fetal movements)

▪ USG machines allotted in these areas are to be used by Radiologists only. After every scan

the machine, including the probes, knobs, handles, monitor and body, to be disinfected

twice, after every use, thoroughly using glutaraldehyde solution. USG machines in these

areas are advised to be covered with plastic covers, which when used can be cleaned with

sodium hypochlorite solution after every scan and can be reused after 20-30 minutes

▪ All scans in these areas to be informed to both staff and PG, beforehand

▪ USG will be pooled at SARI ward as much as possible

▪ If staff scan is required, the same may be intimated to staff

▪ After 4pm, if required Duty PG will attend the emergency scans in these areas

▪ As advised, all PPE must be disposed off in the designated areas after the scan is done

3.2.4 Ultrasound and colour Doppler in the department

▪ No scans to be sent to Department of USG from fever clinic or SARI or isolation wards

▪ All scans being sent from respective departments and their OPDs to be informed to staff and

PG attending

▪ All PGs, staff, nurses and technicians in the department are required to wear N95 masks

and gloves at all times. N95 to be recycled as per hospital policy of reuse of N95

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▪ Two machines are to be used for routine scans, and other rooms may be opened depending

on the patient inflow

▪ All machines are to be cleaned after every scan including the probes, knobs, handles,

monitor and body with glutaraldehyde solution

▪ All patients must wear 3ply surgical mask without which scans will not be don

▪ Ultrasound beds to be covered by plastic sheets and to be disinfected after every scan.

▪ Resident/ Consultant performing the scans are required to wear modified PPE (N95 Mask,

Goggles, Face shield, Plastic gown, and gloves).

Ultrasound probe to be covered with gloves and glove covered probe to be cleaned with sterilium after

every scan.

3.2.5 CT and MRI protocols

▪ MRI for COVID suspect patient to be strictly restricted

▪ Every case being sent to CT/MRI to be informed as much as possible to the department

technician 20mins in advance, so as to make the necessary arrangements

▪ All patients requiring CTs and MRIs from SARI and fever clinic areas to be informed to PG

prior to the scan and scans are preferable to be done after 3pm, unless an emergency

▪ One technician and one ward boy to handle these patients wearing PPE throughout the

scan time. For MRI the patient, technician and ward boy to be wearing a mask WITHOUT

METALLIC CLIP. Patients shifted to CT room to be shifted with disposable body sheets

▪ The technician handling the suspect patients in the CT and MRI area are not allowed to

operate the monitor

▪ During the night time two technicians will be available. Only one technician and one ward

boy accompanying the patient are allowed to handle the patient throughout and they are

restricted only to the MRI and CT machine areas

▪ The console to be operated by another technician and it is imperative that no one else be

at the console or machine area (even doctors) when the scan is being done except for the

two technicians and one ward boy

▪ The technician inside the console has to wear a N95 mask during the entire scan and

leave the console area only when the other technician has cleaned the machine area and

has locked it from the outside. Only the outside door to be used for shifting the patient in

and out. The CT-console communicating door must be closed at all times

▪ The machines are to be cleaned with glutaraldehyde solution by the radiographer while

still in PPE. The room to be cleaned by the attending ward boy with the PPE on before

they exit using sodium hypochlorite solution

▪ The machine should not be operated again for a minimum of 1 hour after each such scan

▪ PPEs are to be disposed off in the designated areas only

3.2.6 Other General points

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▪ All non-emergent imaging and procedures to be postponed to preserve resources and

limit patient population exposure and the same should be referred to the attending

physician

▪ Clinicians to consider whether the imaging will impact the management after consulting

with the radiology staff

▪ All patients to be asked to wear masks

▪ All patients from hot spots to be considered COVID suspect as per the institutional

protocol

▪ Screening mammography, conventional procedures and routine body scans are not to be

done or should be postponed as much as possible

▪ All staff / Ultrasound PG must be provided with N95 mask

▪ No more than one attendant per patient will be allowed and patients should follow social

distancing outside in the hallways and waiting areas

▪ No more than one patient should be waiting outside in the waiting area in USG

department

SARI Ward / Isolation

ward

PPE Available in OT

Fever Clinic Plastic hazmat, N95,

face shield, leg cover,

nitrile gloves

Available in Radiology

department

Radiology department

for COVID suspect

PPE For radiology technician

only

Radiology department

for Non- COVID

Improvised PPE

NOTE:

N 95 will have to be dropped in a pouch (your name and phone number written) at CSSD

(-2 basement) every day when you leave the hospital for recycle as per hospital policy.

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PROTOCOL 3.3: ICMR GUIDELINES TO RECORD ICD-10 CODES DISCHARGES/ DEATHS

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PROTOCOL 3.4: HANDLING, TREATMENT AND DISPOSAL OF WASTE GENERATED

DURING DIAGNOSIS / TREATMENT / QUARANTINE OF COVID-19 SUSPECT / POSITIVE

[Adapted from recommendations from Central Pollution Control Board, (Ministry of Environment, Forest &

Climate Change), New Delhi]

3.4.1. Waste in COVID-19 Designated Areas:

▪ Keep separate color-coded bins/bags/containers in wards and maintain proper segregation of waste

▪ As precaution double layered bags (using 2 bags) will be used for collection of waste from COVID-19 isolation wards so as to ensure adequate strength and no-leaks.

▪ Biomedical waste will be collected and stored separately prior to handing over the same to the medical waste disposal agency. A dedicated collection bin labelled as “COVID-19” will be used to store COVID-19 waste and kept separately in temporary storage room prior to handing over to authorized staff of the agency.

▪ In addition to mandatory labelling, bags/containers used for collecting biomedical waste from COVID-19 wards, should be labelled as “COVID-19 Waste”. This marking would enable the agency to identify the waste easily for priority treatment and disposal immediately upon the receipt.

▪ General waste should be disposed separately as solid waste.

▪ Maintain separate record of waste generated from COVID-19 isolation wards

▪ Use dedicated trolleys and collection bins in COVID-19 isolation wards. A label “COVID-19 Waste” to be pasted on these items also.

▪ The (inner and outer) surface of containers/bins/trolleys used for storage of COVID-19 waste should be disinfected with 1% sodium hypochlorite solution daily.

3.4.2. Sample Collection Centers and Laboratories for COVID-19 suspected patients

Guidelines given at section (a) for isolation wards should be applied suitably in in case of test centers and laboratories also.

3.4.3. Responsibilities of persons operating Quarantine Camps/Homes or Home-Care facilities*

Less quantity of biomedical waste is expected from quarantine Camps / Quarantine Home/ Home-care facilities. However, the persons responsible for operating quarantine camps/centers/home-care for suspected COVID-19 persons need to follow the below mentioned steps to ensure safe handling and disposal of waste;

▪ General solid waste (household waste) generated from quarantine centers or camps should be handed over to waste collector as per the prevailing local method of disposing general solid waste.

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▪ Biomedical waste if any generated from quarantine centers/camps should be collected separately in yellow colored bags (suitable for biomedical waste collection). These bags can be placed in separate and dedicated dust-bins of appropriate size.

▪ Hand over the yellow bags containing biomedical waste to authorized medical waste collector as outlines in section (a).

3.4.4. Biomedical Waste Treatment Facility

▪ The institution shall ensure regular sensitisation of workers involved in handling and collection of biomedical waste.

▪ Workers shall be provided with adequate PPEs including three layer masks, splash proof aprons/gowns, nitrile gloves, gum boots and safety goggles.

▪ In case of generation of large volume of yellow color coded (incinerable) COVID-19 waste, permit in-house incinerate to do the same by ensuring separate arrangement for handling and waste feeding.

▪ Use dedicated carts / trolleys / vehicles for transport of biomedical waste from COVID-19 service areas. Trolleys, etc., should be sanitized with sodium hypochlorite or any appropriate chemical disinfectant after every trip.

▪ Create a separate team of workers who shall be engaged in this.

▪ Any worker showing symptoms of illness to work at the facility should report at the Fever Clinic.

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PROTOCOL 3.5 WORKPLACE GUIDELINES

3.5.1 General instructions for employees

• The following work place ethics are advocated:

o Screening: Identity card, Hand sanitization, Thermal check

o Face mask

o Social distance

o Hand hygiene at regular intervals

o Respiratory hygiene

o Self-reporting if there is fever and respiratory illness

3.5.2 Workplace sanitisation

Requisite for cleaning personnel: Mask, heavy duty gloves, plastic apron

3.5.2.1 Work spaces

• Mopping of entire office area twice a day – before opening and after closure

• Visibly dirty areas should be first cleaned with soap and water

• All indoor areas such as entrance lobbies, corridors and staircases, elevators, security guard

booths, office rooms, meeting rooms, cafeteria should be mopped with a disinfectant with 1%

sodium hypochlorite or phenolic disinfectants.

• High contact surfaces such as elevator buttons, handrails / handles and call buttons, intercom

systems, equipment like telephone, printers/scanners, and other office machines should be

cleaned twice daily by mopping with a linen/absorbable cloth soaked in 1% sodium hypochlorite.

For metallic surfaces like door handles, security locks, keys etc. Use 70% alcohol to wipe down

surfaces where the bleach is not suitable. Frequently touched areas like table tops, chair handles,

pens, diary files, keyboards, mouse, mouse pad, tea/coffee dispensing machines etc. should

specially be cleaned.

• Hand sanitizing stations should be installed in office premises (especially at the entry) and near

high contact surfaces.

• In a meeting/conference/office room, if someone is coughing, without following respiratory

etiquettes or mask, the areas around his/her seat should be vacated and cleaned with 1% sodium

hypochlorite.

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3.5.2.2 Washrooms

• Shared washrooms should be disinfected at least thrice daily and personal toilets at least twice a

day

Areas Agents / Toilet cleaner Procedure

Toilet pot/ commode

1% Sodium hypochlorite / detergent soap powder & long handle angular brush

• Inside of toilet pot/commode: • Scrub with the recommended agents and the long handle angular brush. • Outside: clean with recommended agents; use a scrubber.

Lid/ commode

1% Sodium hypochlorite Soap powder / detergent Nylon scrubber

• Wet and scrub with soap powder and the nylon scrubber inside and outside. • Wipe with 1% Sodium Hypochlorite

Toilet floor 1% Sodium hypochlorite Soap powder / detergent Nylon broom

• Scrub floor with soap powder and the scrubbing brush • Wash with water • Use 1% sodium hypochlorite dilution

Sink 1% Sodium hypochlorite Soap powder / detergent Nylon scrubber

• Scrub with the nylon scrubber. • Wipe with 1% sodium hypochlorite

Showers area / Taps and fittings

Warm water Detergent powder Nylon Scrubber 1% Sodium hypochlorite/ 70% alcohol

• Thoroughly scrub the floors/tiles with warm water and detergent • Wipe over taps and fittings with a damp cloth and detergent. • Care should be taken to clean the underside of taps and fittings. • Wipe with 1% sodium hypochlorite/ 70% alcohol

Soap dispensers Detergent and water • Should be cleaned daily with detergent and water and dried.

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Guidelines for Preparation of 1% sodium hypochlorite solution:

Note: 1% sodium hypochlorite should always be freshly prepared. Substitute 70% alcohol, Chloroxylenol

(4.5-5.5%) or *Benzalkonium Chloride where 1% sodium hypochlorite cannot be used as it is corrosive on

long term use.

Product Available

chlorine

1percent

*Sodium hypochlorite – liquid

bleach

3.5% 1part bleach to 2.5 parts water

*Sodium hypochlorite – liquid 5% 1part bleach to 4 parts water

NaDCC (sodium dichloro-

isocyanurate) powder

60% 17 grams to 1 litre water

NaDCC (1.5 g/ tablet) – tablets 60% 11 tablets to 1 litre water

Chloramine – powder 25% 80 g to 1 litre water

Bleaching powder 70% 7g g to 1 litre water

* diluted hypoclorite and benzalkalonium solutions can be indented from hospital stores

3.5.3 Sanitisation of dining and catering areas

The current body of evidence does not support the transmission and causation of COVID-19 through food/ water or packed foods. However, the SARS-CoV2 virus is known to sustain and successfully transmit to individuals through fomites on surfaces and can remain viable on plastic and stainless steel up to 72 hours. Therefore, it is stressed to reinforce of hygiene measures and principles to reduce risk of transmission from surfaces and food packaging materials. Personal protective equipment like masks and gloves help in reduction of spread of SARS-CoV2 virus if properly used in tandem with social distancing measures, sanitation, and frequent handwashing measures. 3.5.3.1 General Guidelines:

1. Health education: to managers, cleaners, maintenance contractors, delivery workers. Good staff hygienic practices among the individuals involved in food and beverages includes:

i. Proper hand hygiene – washing with soap and water for at least 40 seconds in between provision of food to the customers.

ii. Frequent use of alcohol-based hand sanitizers (for a period of 20 seconds) by the staff handling food packing and serving the food.

iii. Good respiratory hygiene (cover mouth and nose when coughing or sneezing; dispose of tissues and wash hands) of the staff providing food related services.

iv. Frequent cleaning/disinfection of work surfaces and touch points such as door handles with Benzalkonium chloride 5% solution or alcohol-based sprays (Aerodesin like sprays) which has to be purchased by the individuals providing services in such service areas.

v. Avoiding close contact with anyone showing symptoms of respiratory illness such as coughing and sneezing.

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2. Self-reporting of COVID -19 like symptoms among individuals serving non-COVID and COVID areas is encouraged. Staff in the dining areas should refrain from coming to work if they have symptoms suggestive of COVID-19 and shall report illness to the competent authorities and will have to undergo testing and further management with COVID-19. The employee serving in COVID/non-COVID areas who is unwell should follow national guidelines for reporting cases/suspect cases of COVID-19.

3. An In and Out register of all the staff employees working in non-COVID/COVID areas shall be maintained to contact trace and decide the quarantine/ isolation of employees. The staff who have had close contact with the infected employee should be asked to stay at home for 14 days from the last time they had contact with the confirmed case and practice physical distancing.

3.5.3.2 Food and beverage services in the areas designated as COVID-19 areas in the hospital

Service Areas: Isolation ward- male and female (5th and 6th Floor general wards), Special wards at 5th floor, COVID ICUs Service provision: For all the patients and patient attenders in the above areas food is delivered as a trolley system at the end supplying all the other wards (non- COVID areas) to avoid contamination. Personal Protective Equipment (PPE) recommended: Three ply face masks, hair nets, disposable gloves, plastic apron and maintain distance between consumers and themselves of at least 1 meter/3 feet. Food handlers will use pair of disposable gloves for serving food to the patients and patient attenders and must be changed when visible tears/breach in the integrity of the gloves is noticed. While wearing disposable gloves, it should be taken care that the staff do not touch the mask or their nose/face. The wearing of disposable gloves shall not be a substitute for washing of hands with water and soap/ alcohol-based sanitizers. While changing the pair of gloves, hand washing with soap and water for 40 seconds or with alcohol-based sanitizers for 20 seconds must be observed. The used gloves have to be discarded in separate red bins daily. Social Distancing measures: Maintaining physical distancing -1 meter/3 feet distance from the patient and patient attenders is critical for reducing the risk of transmission of the disease. After the food is delivered to the COVID-areas the trolleys need to be cleaned with cetrimide 1% solution.

3.5.3.3. Food and beverage services in the areas designated as non- covid-19 areas in the hospital

Service areas: Restaurant within campus, Hospital canteen, Cafeteria (Kitchen Bells), Coffee shops Personal Protective Equipment (PPE) recommended: PPE such as face masks, hair nets, disposable gloves shall be provided for the staff providing service to Non-COVID areas. Food handlers will use pair of disposable gloves for serving food to the customers and must be changed when visible tears/breach in the integrity of the gloves is noticed. While wearing disposable gloves, it should be taken care that the staff do not touch the mask or their nose/face. The wearing of disposable gloves shall not be a substitute for washing of hands with water and soap/ alcohol-based sanitizers. While changing the pair of gloves, hand washing with soap and water for 40 seconds or with alcohol-based sanitizers for 20 seconds must be observed. The used gloves have to be discarded in separate red bins daily.

Social distancing measures: The food and beverages areas and serving counters should be placed at 1-meter/3 feet distance from the customers. Regulating the numbers of customers who enter the hospital canteens to avoid overcrowding. As far as possible the dine-in option should be

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limited due to want of space in view of social distancing in the dining areas. The prepacked food parcels (both vegetarian and non-vegetarian) given the rush/peak hours between 12-3pm need to be kept packed well in advance and possibly arrange a separate counter for the distribution of the same to avoid overcrowding. The suggested measures include billing for the food being done at the doctor’s counter maintaining social distance and then proceed to pick up the ordered food. Other measures to ensure social distancing include

i. Placing signs at entry points to request customers not to enter the dining areas if they are unwell or have symptoms suggestive of COVID-19 redirecting them to the fever clinic/ triage area.

ii. Managing queue control consistent with physical distancing advice both inside and outside food service areas and parcel counters.

iii. Insisting on wearing a face mask with adequate covering of the nose and mouth area and providing hand sanitizers, at food service area entry points before entering food service areas is mandated.

iv. Using floor markings inside the food service area to facilitate compliance with the physical distancing, particularly in the most crowded areas, such as serving counters.

v. Encouraging the use of contactless payments on e-payment modalities

vi. Minimise the risk of transmitting COVID-19 by identifying high touch points in the retail premises and ensuring these are cleaned and disinfected regularly. Examples of high touch points are given here below with the suggested disinfection needed for the individual areas/ objects and ensure that the cleaning staffs in the area are provided with necessary means and materials to do the needful.

HIGH TOUCH SURFACES MODERATE TOUCH SURFACES

Twice daily cleaning- benzalkonium chloride solution

Door handles, thresholds, and hand railings

Handwash/sink handles

Dining tables and chairs Computers/ billing machine Billing area Calculators

Self-service Fridge door and handles Office cabinets TV and other Display screens Telephone

Serving trays Service area counter tops

Stainless steel service area

Trays

▪ Ensure natural ventilated rooms for food service provision within the dine-in areas. ▪ Wherever possible, disposable plates and cups need to be used to provide food and

beverages to the customers. ▪ The following cleaning protocol must be followed for non-disposable. The cleaning staff

involved in washing of utensils need to be provided with industry grade gumboots, gloves, goggles,3 ply mask and a plastic apron. The disinfection process includes cleaning with soap and water and then soaking them in hot water(>60֯C) for 15-30 minutes and drying them before use.

3.5.4 Laundry

It is currently unclear how long the COVID-19 virus can survive on fabric, but many items of clothing have plastic and metal elements on which it might live for a few hours to several days. Therefore, it is imperative to separate the laundry from COVID and non-COVID areas in hospital premises.

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3.5.4.1 COVID Areas: ▪ Laundry produced (bedlinen and bedcovers and bedsheets) used by the patients and patient

attenders admitted in Isolation ward- male and female (5th and 6th Floor general wards), Special wards at 5th floor, COVID ICUs and the changing rooms for hospital scrubs for the doctors and other supporting staff.

▪ The individuals collecting the laundry must be provided with 3 ply mask, hair net, goggles, industry grade rubber gloves and gumboots and, plastic apron to prevent fomite-based transmission of SARS-CoV2.

▪ The individuals collecting laundry shall observe hand washing with soap and water for at least 40 seconds before and after laundry collection and sanitize their hands when collecting laundry from one bed to another bed. They shall observe strict social distancing measures when collecting bed linen from each of the COVID-19 suspects in the wards. They shall not touch any surface within the ward and their mouth and nose while collecting the laundry. The individuals shall be educated on warning signs and symptoms suggestive of COVID-19. If the individual develops any symptom of fever, cough and breathlessness shall be referred to the Fever clinic/ Triage area for further assessment and management of the symptoms.

▪ The laundry baskets/bins that collect the laundry must be in a trolley system from COVID areas of the hospital need to be disinfected with benzalkonium chloride after the laundry is collected from each of the COVID are and is sent for further management as described below.

▪ The laundry produced in these areas need to be kept in separate tubs and soaked in 1% sodium hypochlorite solution for 30 minutes and then soaked in water ≥ 60 ֯ C following which it needs to be washed separately with detergent soap and water. To reduce the risk of fomite transmission of SARS-CoV2 bed linen needs to be dusted daily using 1% cetrimide solution (concurrent disinfection) and terminal disinfection when the patient is shifted out of the COVID area or dies within these wards. T

3.5.4.1 Non-COVID Areas:

The risk of contracting COVID-19 in these areas given the triaging is relatively lesser. However, given that SARS-CoV2 is shown to survive on inanimate objects like bed linen and sheets. The individuals who collect laundry from these areas need to be provided with 3 ply mask, industry grade rubber gloves and gumboots. It is suggested that the bed linen be dusted daily using 1% Cetrimide solution for concurrent and terminal disinfection of the beds within the wards and areas listed as Non-COVID. The laundry produced here should not be mixed with COVID area linen and laundry and can be washed with regular detergent soap and water.

Additional resources 1. COVID-19 Care at Workplace

2. Workplace Precautions – Poster

3. Handwashing technique – Video (https://youtu.be/IisgnbMfKvI)

Scan or click to watch video hand washing.

http://nitte.edu.in/naac/2019/COVID19/COVID-19_Workplace_guidelines.pdf

http://nitte.edu.in/naac/2019/COVID19/WorkEthics_poster.pdf



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PROTOCOL 3.6: COVID-19 QUARANTINE PROTOCOL

3.6.1 Definitions used

Suspect Case:

▪ A patient with acute respiratory illness (fever and at least one sign/ symptom of respiratory disease (e.g., cough, shortness of breath) AND a history of international travel or residence in an area or territory reporting local transmission of COVID-19 disease during the 14 days prior to symptom onset; OR

▪ A patient / Health care worker with any acute respiratory illness AND having been in contact with a confirmed COVID-19 case in the last 14 days prior to onset of symptoms; OR

▪ A patient with severe acute respiratory infection (fever and at least one sign/symptom of respiratory disease (e.g., cough, shortness breath) AND requiring hospitalization AND with no other etiologic that fully explains the clinical presentation; OR a case for whom testing for COVID-19 is inconclusive.

Contact:

▪ A contact is defined as a healthy person that has been in such association with an infected person or a contaminated environment as to have exposed and is therefore at a higher risk of developing disease.

▪ A person living in the same household/ hostel room as a COVID-19 case;

▪ A person having had direct physical contact with a COVID-19 case or his/her infectious secretions without recommended personal protective equipment (PPE) or with a possible breach/no PPE.

▪ A person who was in a closed environment or had face to face contact with a COVID-19 case at a distance of within 1 meter including air travel

High Risk Contact:

▪ Touched body fluids of the patients- Respiratory tract secretions, blood, vomit, saliva

▪ Had direct physical contact with body of the patient including Physical examination WITHOUT PPE.

▪ Touched/ cleaned linens clothes, dishes of the patient

▪ Lives in the same household as the patient

▪ Anyone in close proximity (< 3 feet) of the confirmed case without precautions

▪ Passenger in close proximity (<3 feet) of a conveyance with a symptomatic person who later tested positive for COVID-19 for more than 6 hours.

Low Risk Contact

▪ Shared the same space (same class for school/worked in same room/similar and not having a high-risk exposure to confirmed or suspect case of COVID-19)

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▪ Travelled in same environment (bus/train/flight/ any mode of transit) but not having a high-risk exposure

3.6.2 Protocol for hostel quarantine admission and release

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3.6.3 Instructions for contacts being hostel quarantined

▪ The hostel quarantined person should:

▪ Stay in a well-ventilated single-room preferably with an attached/separate toilet. If another person needs to stay in the same room, it’s advisable to maintain a distance of at least 1 meter between the two.

▪ Needs to stay away from elderly people, pregnant women, children and persons with co-morbidities within the household.

▪ Restrict his/her movement within the room in hostel.

▪ Under no circumstances attend any social/religious gathering e.g. wedding, condolences, etc.

▪ He/she should also follow the under mentioned public health measures at all times:

▪ Wash hand as often thoroughly with soap and water or with alcohol-based hand sanitizer

▪ Avoid sharing household items e.g. dishes, drinking glasses, cups, eating utensils, towels, bedding, or other items with other people at home

▪ Wear a surgical mask at all the time. The mask should be changed every 6-8 hours and disposed off

▪ Disposable masks are never to be reused.

▪ Masks used by patients / care givers/ close contacts during home care should be disinfected using ordinary bleach solution (5%) or sodium hypochlorite solution (1%) and then disposed of either by burning or deep burial.

▪ Used mask should be considered as potentially infected.

▪ If symptoms appear (cough/fever/difficulty in breathing), he/she should immediately inform the nearest health centre or call hostel warden

3.6.4 Instructions for the hostel caretakers and wardens where there is hostel quarantined

▪ Only an assigned caretaker should be tasked with taking care of the such person

▪ Avoid shaking the soiled linen or direct contact with skin

▪ Use disposable gloves when cleaning the surfaces or handling soiled linen

▪ Wash hands after removing gloves

▪ Visitors should not be allowed

▪ In case the person being quarantined becomes symptomatic, all his close contacts will be hostel quarantined (for 14 days) and followed up for an additional 14days or till the report of such case turns out negative on lab testing

3.6.5Environmental sanitation

▪ Clean and disinfect frequently touched surfaces in the quarantined person’s room (e.g. bed frames, tables etc.) daily with 1%Sodium Hypochlorite Solution.

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▪ Clean and disinfect toilet surfaces daily with regular household bleach solution/phenolic disinfectants c) Clean the clothes and other linen used by the person separately using common household detergent and dry.

3.6.6 Duration of home quarantine

The home quarantine period is for 14 days from contact with a confirmed case or earlier if a suspect case (of whom the index person is a contact) turns out negative on laboratory testing

3.6.7 Procedure for employees to report back to the institutes under NITTE(DU) who have travelled outside the district limits of Dakshina Kannada during the COVID-19 lockdown

The following procedure is described for all the faculty to report back to the institutes under NITTE(DU)

who were not able to return back to the institute and discharge their duties in view of the lockdown and

who have travelled outside the district limits of Dakshina Kannada during the COVID-19 lockdown. The

following procedure needs to be followed.

The individual should complete the government mandated quarantine procedure (institutional and/or

home quarantine) relevant according to the latest guidelines

The self-reporting form shall be made available at the fever clinic and the returning faculty shall carry the

original documents and a photocopy in support of their completion of quarantine and other government

mandated procedures.

1. College/Institutional Identity card

2. E-pass for travellers from other states coming in private vehicles

3. Air/train/ bus tickets in support of the travel

4. Photocopy of the COVID-19 test result(if done 2 days prior to the arrival to Mangalore from the place of

journey)

5. Aadhar card for proof of residence

6. Any other supporting documents for institutional quarantine as mandated by government guidelines

Annexures related to Quarantine:

▪ Annexure 3.2 on page 116- Self reporting form

▪ Annexure 3.3 on page 119- List of Individuals With Travel / Contact History Reporting To Hostels

▪ Annexure 3.4 on page 120- Medical Form for Release from Quarantine

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PROTOCOL 3.7: COVID-19 POST-EXPOSURE PROPHYLAXIS

3.7.1 Indication

For healthcare workers who are exposed unprotected (without PPE) while involved in the care of suspected cases (in SARI ward/PICU) OR confirmed cases of COVID-19.

3.7.2 Queries

Contact: Dr. Giridhar B.H. (9035140489)

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PROTOCOL 3.8: STANDARD OPERATING PROCEDURE (SOP) FOR TRANSPORTING A

SUSPECT/POSITIVE CASE OF COVID-19

Adapted from Ministry of Health and Family Welfare, Directorate General of Health Services

This SOP is applicable to current phase of COVID-19 pandemic, wherein as per plan of action, all suspect cases are admitted to Government identified COVID-19 facilities (Government Wenlock Hospital, Mangalore) in the absence/ delay of 108. These procedures are meant to guide and be used for training ambulance drivers and technicians in transporting COVID-19 patients.

3.8.1 General guidelines

1. Identify the ambulance and keep it in readiness for transporting a sick patient. These ambulances should have basic equipment like that of BLS. The fleet in - charge will be designated by the Medical Superintendent/ Task Force, who will supervise its adherence.

2. Ambulance staff (technicians as well as drivers) should be trained and oriented about common signs and symptoms of COVID-19 (fever, cough and difficulty in breathing). They should also be aware about common infection, prevention and control practices including use of Personal Protective Equipment (PPE). Both the EMT and driver of ambulance will wear PPE while handling, managing and transporting the COVID identified/ suspect patients. Similar use of PPE is to be ensured by the health personnel at receiving end.

3. Before transporting, the medical officer has to ensure that bed is available in referral hospital with supporting equipment and needs to convey the same while making the call. The contact person is Dr. Sharath Babu (7760564064).

3.8.2. Transportation of patients

A. Before transport

1. The Emergency Medical Technician (EMT) will wear the appropriate PPE.

2. The EMT shall assess the condition of the patient: If the patient is ambulatory and stable, he/she may be asked to board the ambulance otherwise the EMT (while using the prescribed PPE) may assist loading of patient. Only one caregiver should be allowed to accompany the patient and provided with triple layered medical mask.

B. Management on board

1. Measure vitals of patient and ensure patient is stable.

2. If required, give supplementary O2 therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥90%.

3. If patient is being transported on ventilator to a higher center, follow ventilator management protocols, provided the EMT is either trained or assisted by a doctor well versed in ventilator management.

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C. Handing over the patient

1. On reaching the receiving hospital, the EMT will hand over the patient and details of medical interventions if any during transport.

2. After handing over the patient, the PPEs will be taken off as per protocol followed by hand washing. Use Alcohol based rub /soap water for hand hygiene.

3. The biomedical waste generated (including PPE) to be disposed off in a bio-hazard bag (yellow bag). Inside would be sprayed with Sodium Hypochlorite (1%) and after tying the exterior will also be sprayed with the same. It would be disposed off at their destination hospital. This shall again be followed by hand washing.

3.8.3. Disinfection of ambulance

1. 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.

2. Clean and disinfect reusable patient-care equipment before use on another patient with alcohol-based rub.

3. Cleaning of all surfaces and equipment should be done morning, evening and after every use with soap/detergent and water.

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ANNEXURES

1. Annexures for Part 1

1.1. Guidelines on Rational Use of Personal Protective Equipment

1.2. Outpatient Triage Checklist

1.3. Case Information Form for COVID-19 Positive (Fever Clinic Checklist)

1.4. Throat swab for covid-19 and icmr rt-pcr application

1.5. Pediatric Fever Clinic Checklist for Vitals & Triage

1.6. Pediatric Drug Dosage Information


2.1. Check List for COVID -19 Isolation Ward

2.2. Pediatric Monitoring Checklist for COVID -19 in Isolation Ward

2.3. Pediatric Investigation Chart in COVID -19 Isolation Ward

2.4. Patient Education Material


3.1 Specimen Collection, Packaging and Transport Guidelines

3.2 Self Reporting Form for all Travelers Arriving from Areas Reporting Covid-19 Transmission

3.3 List of Individuals Who Have Travelled to An Area of Covid-19 And / or Contact History with a Suspect / Positive Case of Covid-19 Reporting to Hostels

3.4 Medical Form for Release from Quarantine

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ANNEXURE 1.1 - GUIDELINES ON RATIONAL USE OF PERSONAL PROTECTIVE

EQUIPMENT

About this guideline

This guideline is for health care workers and others working in points of entries (POEs), quarantine centre’s, hospital, laboratory and primary health care / community settings. The guideline uses setting approach to guide on the type of personal protective equipment to be used in different settings.

1. Personal Protective Equipment (PPE)

Personal Protective Equipment’s (PPEs) are protective gears designed to safeguard the health of workers by minimizing the exposure to a biological agent.

1.1 Components of PPE

Components of PPE are goggles, face-shield, mask, gloves, coverall/gowns (with or without aprons), head cover and shoe cover. Each component and rationale for its use is given in the following paragraphs:

1.1.1 Face shield and goggles

Contamination of mucous membranes of the eyes, nose and mouth is likely in a scenario of droplets generated by cough, sneeze of an infected person or during aerosol generating procedures carried out in a clinical setting. Inadvertently touching the eyes/nose/mouth with a contaminated hand is another likely scenario. Hence protection of the mucous membranes of the eyes/nose/mouth by using face shields/ goggles is an integral part of standard and contact precautions.

1.1.2 Masks

Respiratory viruses that includes Corona viruses target mainly the upper and lower respiratory tracts. Hence protecting the airway from the particulate matter generated by droplets / aerosols prevents human infection. Hence the droplet precautions/airborne precautions using masks are crucial while dealing with a suspect or confirmed case of COVID-19/performing aerosol generating procedures.

Masks are of different types.

1. Triple layer medical mask

2. N-95 Respirator mask

1.1.2.1 Triple layer medical mask

A triple layer medical mask is a disposable mask, fluid-resistant, provide protection to the wearer from droplets of infectious material emitted during coughing/sneezing/talking.

1.1.2.2. N-95 Respirator mask

An N-95 respirator mask is a respiratory protective device with high filtration efficiency to airborne particles. To provide the requisite air seal to the wearer, such masks are designed to achieve a very close facial fit. If correctly worn, the filtration capacity of these masks exceeds those of triple layer

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medical masks. Since these provide a much tighter air seal than triple layer medical masks, they are designed to protect the wearer from inhaling airborne particles.

1.1.3 Gloves

When a person touches an object/surface contaminated by COVID-19 infected person, and then touches his own eyes, nose, or mouth, he may get exposed to the virus. Although this is not thought to be a predominant mode of transmission, care should be exercised while handling objects/surface potentially contaminated by suspect/confirmed cases of COVID-19. Nitrile gloves are preferred over latex gloves because they resist chemicals, including certain disinfectants such as chlorine. There is a high rate of allergies to latex and contact allergic dermatitis among health workers. However, if nitrile gloves are not available, latex gloves can be used.

1.1.4 Coverall/Gowns

Coverall/gowns are designed to protect torso of healthcare providers from exposure to virus. Although coveralls typically provide 360-degree protection because they are designed to cover the whole body, including back and lower legs and sometimes head and feet as well, the design of medical/isolation gowns do not provide continuous whole-body protection (e.g., possible openings in the back, coverage to the mid-calf only).

An apron can also be worn over the gown for the entire time the health worker is in the treatment area. Coveralls/gowns have stringent standards that extend from preventing exposure to biologically contaminated solid particles to protecting from chemical hazards.

1.1.5 Shoe covers

Shoe covers should be made up of impermeable fabric to be used over shoes to facilitate personal protection and decontamination.

1.1.6. Head covers

Coveralls usually cover the head. Those using gowns, should use a head cover that covers the head and neck while providing clinical care for patients. Hair and hair extensions should fit inside the head cover.

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2. Rational use of PPE

The PPEs are to be used based on the risk profile of the health care worker. The document describes the PPEs to be used in different settings.

2.1 COVID-19 Service Areas

2.1.1 Fever clinic

Sl. No Setting Activity Risk Recommended

PPE for HCW

Remarks

1 Triage/ Temperature Recording station

Triaging patients Provide triple layer mask to Patient with cough /fever and attender .

Moderate risk

Improvised PPE Patients with cough get masked. Minimum distance of one-meter needs to be maintained No aerosol generating procedures should be allowed

2 Registration counter

Admission Billing Swab approval protocol activation

Low risk

N-95 Mask Gloves

3 Sanitary staff and patient transport team

Cleaning frequently touched surfaces/ Floor/ cleaning linen

Moderate risk

Improvised PPE

4 Visitors accompanying young children and elderlies

Support in navigating various service areas

Low risk Surgical mask No other visitors should be allowed to accompany patients in OPD settings. The visitors thus allowed should practice hand hygiene

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2.1.2. In-patient Services

Sl. No. Setting Activity Risk Recommended PPE

Remarks

1 General ward Sixth floor Covid-19 Isolation Area

Clinical management

Moderate risk

Improvised PPE Patient masked. Patients stable. No aerosol generating activity.

2 Covid-19 ICU care

Critical care management

High risk Complete PPE Aerosol generating activities performed

3 Covid-19 ICU Dead body packing

High risk Complete PPE

4 Covid-19 ICU Dead body transport to mortuary

Low Risk Triple Layer medical mask Gloves / Plastic apron

5 SARI ward Clinical and critical management


6 Covid-19 ICU / SARI Sanitation

Cleaning frequently touched surfaces/ floor/ changing linen

Moderate risk

Improvised PPE

7 PICU Clinical & critical management


8 Burns ICU Clinical management


9 Sample transporters

Carrying samples in closed labelled transport boxes

Low risk Triple layer medical mask Gloves

10 Sample handlers

Lab personnel handling


11 Caretaker accompanying the admitted

patient

Taking care of the admitted patient

Low risk Triple layer medical mask

The caretaker thus allowed should practice hand hygiene, maintain a distance of 1 meter

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2.1.3. Pre-hospital (Ambulance) Services (For COVID-19 Positive transport to designated District COVID Hospital)

Sl. No.

Setting Activity Risk Recommended PPE

Remarks

1

Ambulance Transfer to designated

hospital

Transporting patients not on any assisted ventilation

Moderate risk

Improvised PPE

When aerosol Generating procedure are not anticipated

Management of SARI patient / COVID-19 positive patient while transporting

High risk Complete PPE When aerosol generating procedures are anticipated

Driving the ambulance


Driver helps inshifting patients to the emergency

2.1.4. Other Supportive/ Ancillary Services when handling COVID-19 Suspect/ Positive

Sl. No. Setting Activity Risk Recommended PPE

Remarks

1 Mortuary Dead body handling

Moderate Risk

N 95 mask, plastic apron Gloves

No aerosol generating procedures should be allowed. No embalming.

While performing autopsy

High Risk Complete PPE No post-mortem unless until specified.

2 CSSD/Laundry Handling linen of COVID patients

Moderate risk

N-95 mask, plastic apron Gloves

3 Other supportive services

Administrative Financial Engineering Security, etc.

No risk No PPE No possibility of exposure to COVID patients. They should not venture into COVID-19 treatment areas.

Aerosol generating procedures: Nebulization, Bag and mask ventilation, Cardiopulmonary resuscitation, Endotracheal intubation, broncho-alveolar lavage, Non-invasive ventilation

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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.

2.2 Rational use of Personal Protective Equipment for Health functionaries working in non-COVID areas (Adapted from MoHFW & DGHS Guidelines)

2.2.1 Out Patient Department

Sl.No. Setting Activity Risk Recommended PPE

Remarks

1 Help desk/ Registration counter

Provide information to patients

Mild risk • Triple layer medical mask

• Nitrile gloves

Physical distancing to be followed at all times

2 Doctors chamber

Clinical management


• Nitrile gloves

No aerosol generating procedures should be allowed.

3 Chamber of Dental/ENT doctors/ Ophthalmology doctors

Clinical management

Moderate risk

• N-95mask

• Goggles

• Nitrile gloves

+ face shield

Aerosol generating procedures anticipated.

Face shield, when a splash of body fluid is expected

4 Pre- anesthetic check-up clinic

Pre-anesthetic check-up

Moderate risk

• N-95mask

• Goggles*

• Nitrile gloves

* Only recommended when close examination of oral cavity/dentures is to be done

5 Pharmacy counter

Distribution of drugs


Frequent use of hand sanitizer is

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• Nitrile gloves advised over gloves.

6 Sanitary staff Cleaning frequently touched surfaces/ Floor


• Nitrile gloves

7. OPD triage Verbal checklist & ID proof

Moderate Risk

• N-95mask

• Goggles*

• Nitrile gloves

• Plastic apron

Frequent use of hand sanitizer is advised over gloves.

#All hospitals should identify a separate triage and holding area for patients with Influenza like illness so that suspect COVID cases are triaged and managed away from the main out-patient department.

2.2.2 In-patient Department (Non-COVID Hospital & Non-COVID treatment areas of a hospital which has a COVID block)


Remarks

1 Ward/individual rooms

Clinical management


• Nitrile examination gloves

Patients stable. No aerosol generating activity.

2 ICU/ Critical care

Critical care management

Moderate risk

• N-95mask

• Goggles


Aerosol generating activities performed.

+Face shield Face shield, when a splash of body fluid is expected

3 Ward/ICU /critical care

Dead body packing

Low Risk • Triple Layer medical mask

• Nitrile gloves

4 Ward/ICU/ Critical care (Non-COVID)

Dead body transport to mortuary



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5 Labor room Intra-partum care

Moderate Risk

• Triple Layer medical mask

• Face shield

• Nitrile gloves

Patient to be masked in the Labor room

6 Operation Theater

Performing surgery, administering general anaesthesia

Moderate Risk

• Triple Layer medical mask

• Face shield (- wherever feasible)

• Sterile Nitrile gloves

Already OT staff shall be wearing

+ Goggles N-95 mask*

For personnel involved in aerosol generating procedures *If the person being operated upon is a resident of containment zone

7 Sanitation Cleaning frequently touched surfaces/ floor/ changing linen



2.2.3 Emergency Department(Non-COVID)

S.No. Setting Activity Risk Recommended PPE

Remarks

1 Emergency Attending emergency cases

Mild risk • Triple Layer medical mask


No aerosol generating procedures are allowed

2

Attending to severely ill patients while performing aerosol generating procedure

High risk Full complement of PPE (N-95 mask, coverall, goggle, Nitrile examination gloves, shoe cover)

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2.2.4 Other Supportive/ Ancillary Services (Non-COVID)

S.No. Setting Activity Risk Recommended

PPE Remarks

1. Routine Laboratory

Sample collection and transportation and testing of routine (non- respiratory) samples



Respiratory samples

Moderate risk

• N-95mask


2 Radio- diagnosis, Blood bank, etc.

Imaging services, blood bank services etc.



3

CSSD/Laundry Handling linen Mild risk • Triple layer medical mask

• Latex examination gloves

4 Other Administrative Low risk • Face cover ** Engineering and

supportive Financial dietary service services incl. Engineering** and personnel visiting Kitchen dietary** treatment areas will services, etc. wear personal protective gears appropriate to that area

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2.2.5 Pre-hospital (Ambulance) Services (Non-COVID)


Remarks

1 Ambulance Transfer to designated hospital

Transporting patients not on any assisted ventilation

Low risk • Triple layer medical mask


Management of SARI patient

High risk • Full complement of PPE (N-95 mask, coverall, goggle, latex examination gloves, shoe cover)

While performing aerosol generating procedure

Driving the ambulance

Low risk • Triple layer medical mask • Nitrile examination gloves

Driver helps in shifting patients to the emergency

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ANNEXURE 1.2 – OUTPATIENT TRIAGE CHECKLIST

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ANNEXURE 1.3 – CASE INFORMATION FORM FOR COVID-19 SUSPECT/ POSITIVE

Form A

NATIONAL CENTRE FOR DISEASE CONTROL

(To be filled COVID-19 Acute Respiratory Disease)

A PATIENT INFORMATION

1. Name of patient: Age/Gender Date of interview

2. Name of Health Facility where isolated: District (Isolation facility): State (Isolation facility):

3. Name of interviewer Address of interviewer: Contact Number of interviewer: 4. Case Classification: Confirmed Suspect

5. Current Status of case: Stable □ Admitted in ICU □ Deceased □

B SOCIODEMOGRAPHC PROFILE Nationality: Indian Non-Indian (Name of the country) ………………………………….. Postal Address District Phone

number email id

C CLINICAL INFORMATION

1 Patient clinical course

1.1 Date of Onset of symptoms

1.2 Details of contact with heath facility (name ofhealthfacility: ) (date of contact withhealthfacility: ) (name ofhealthfacility: ) (date of contact withhealthfacility: ) (name ofhealthfacility: ) (date of contact withhealthfacility: ) (name ofhealthfacility: ) (date of contact withhealthfacility: )

1.3 Dateofadmission to isolation facility:

1.4 Outcome (circle): Under treatment/ Discharged/ LAMA/ Died 1.5Date of outcome(if applicable)

1.5 Cause of death (As mentioned on death certificate):

2 Patient Symptoms at admission (tick all reported)

a) Fever/chills b) Sore throat c) Nausea/Vomiting

d) General weakness e) Breathlessness f) Headache

g) Cough h) Diarrhea i) Irritability/confusion

j) Runny nose k) Pain(circle)muscular, chest, abdominal, joint

l) Any other(specify)

3 Patient signs at admission: Details of following Signs to be taken from the case sheet if the patient is admitted

a) Temperature b) Abnormal Lung X-Ray findings (yes/no)

c) Coma(yes/no)

d) Stridor (yes/ no) e) Tachypnoea(yes/no) f) Seizure(yes/no)

g) Redness of eyes (yes/no) h) Abnormal lung auscultation(yes/no)

i) Any other(specify)

4 Underlying medical conditions (tick all that apply)

CENTRAL CASE

NUMBER

To be filled at NCDC

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a) COPD b) Hypertension c) Chronic neurological or neuromuscular disease

d) Chronic Renal Disease e) Asthma f) Heart disease

g) Bronchitis h) Pregnancy i) (trimester)

j) Immunocompromised condition including HIV, TB

k) Malignancy l) Post-partum(< 6 weeks)

m) Any other(mention)

n) Diabetes o) Liver Disease p) None

D EXPOSURE HISTORY

5 Occupation (circle): Student/ Businessman/ Health care worker/Health care lab worker/ animal handler/ any other (specify)………………………

6 H/O contact with COVID-19 case (Circle): Yes/ No

6.1 If yes, then was it any of the following (tick appropriate option)

a) laboratory confirmed case of COVID-19 b) person who is under investigation for COVID-19 while that person was ill

6.2 If yes to Q. 6, then mention contact setting (tick all that apply)

a) While taking samples/ other investigations

b) Visit to a place where COVID-19 cases are treated or sampled(specify detail)

c) Clinical care of case (among HCW) d) Immigration Staff at Point of Entry (details of place)

e) Housekeeping (Hospital) f) Others, Specify

g) Caregiver of the case (specify details of case)

h) Not known

7 Is patient a member of a cluster of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) or COVID 19? (Yes/No)

8 Patient attended festival or mass gathering ?(Yes/No/Unknown) if yes, specify:

E TRAVEL HISTORY

10. Have you travelled outside India in the past one month? Yes/ No. If yes then fill details from Q. 10.1 onwards else skip to Q.11

10.1

Name of the country (City) Date of arrival Date of departure

10.2 Did you visit Wuhan (yes/no) During your stay, did you visit any animal market? Yes/No

10.3 Date of arrival in India (Including transit flights in India): Flight No: Seat No:

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11

Have you travelled within India in the past one month? Yes/ No. If no, skip to Section F

If yes, details of visit to other places: Names of places

a) Place & Duration of stay:

Date of arrival: Date of departure:

Mode of travel: Details:

b) Place & Duration of stay:



c) Place & Duration of stay:



F LABORATORY INFORMATION (to be obtained from treating physician)

12 Details of sample collected for confirmation of COVID-19 case:

a)

Type of sample collected

Name of sample collection center

Date of sample collection

Sent to which Lab

Test Performed

Result

b) Name of lab that confirmed result:

G PATIENT SYMPTOMS(Complication)

13a) Hospitalization(Yes/No) Date of hospitalization:

b) ICU Admission(Yes/No) Date of ICU admission : Date of discharge from ICU:

Mechanical Ventilation(Yes/No) Date of mechanical ventilation Start: Date of mechanical ventilation Stop:

ARDS (Yes/No) Cardiac failure (Yes/No)

Pneumonia by Chest X ray(Yes/No) Acute Renal Failure (Yes/No)

Consumptive coagulopathy( Yes/No) Other complication (Yes/No), if yes please specify

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ANNEXURE 1.4: THROAT SWAB FOR COVID-19 AND ICMR RT-PCR APPLICATION

What is the test recommended presently by the GOI for confirmation of COVID-19?

RT-PCR for Covid-19 (SARS-CoV-2 nucleic acid)

Which specimen to use?

Throat swab (Nasopharyngeal & oropharyngeal), Tracheal aspirate, Bronchoalveolar lavage

Whom to test and where to test? Does it cost?

Can I request for testing without any of the above indication?

• Free of cost

• 9.00 am – 4.00 pm

• SARI – emergency sample

• ICMR/ GOK does not mandate testing for Covid-19 other than above

• If desired for any compulsive reason, it has to be done in a private lab, recognized by ICMR at a cost. Once swabbed, until results are available, patient has to be in strict Isolation

What should I know when requesting for a throat swab for indications other than the above?

• All requisitions for throat swab are now APP based which is connected online to District Surveillance Office & ICMR

• The App details are to be filled only after collecting the specimen. All throat swab samples will be collected only in the Isolation areas [General ward 6th floor/ Special ward 5th floor] and the patient will continue in Isolation until report is available

• The authorized phone with RT-PCR APP for our hospital is made available at the Fever Clinic & SARI ward. It cannot be done on personal phones

• The onus is on the consultant to ensure correctness of the data filled in the APP; duplication and incomplete/ incorrect data is answerable to DHO

• Any patient with fever & breathlessness in the last 14 days (Severe Acute Respiratory Illness) – D1, D5, D12

• Fever & upper respiratory illness in the last 10 days (Influenza Like Illness) AND

• International Travel/ Domestic travel from other states/ Living or travel to Containment zones/ Contact history with Covid Positive

• Pregnant women within 14 days of EDD with H/O International travel/ travel from other states/ Living or travel to Containment zones/ Contact history with Covid Positive

Government

Wenlock

Hospital

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• Resident of the concerned department under the supervision of the consultant has to fill the APP following the instructions outlined below

• Please note commercial labs process samples received until 9.00 am only. Transport to the commercial lab is to be arranged through patient party

• A bystander with a functioning phone and Aadhar card should be available when filling the data. Additionally, a photocopy of the Aadhar card of the patient needs to be attached along with the sample while sending to the microbiology lab.

• If the patient is a BPL (Below Poverty Line) card holder and is claiming admission under Ayushman Bharath – copies of BPL card needs to be attached. If any healthcare personnel are exposed and the sample needs to be sent for COVID testing to Wenlock Hospital, Photocopy of the Healthcare Institution Identity card compulsorily attached along with the specimen referral form2 photocopies of the specimen collection form needs to be sent along with the Throat/Nasal swab.

COVID-19 RT-PCR SAMPLE FORM – APPLICATION DETAILS

*NAME OF THE PATIENT:

Ensure full name is written as in hospital file/ ID proof

MOBILE NUMBER (*Self/ Family):

*For paediatric patients, the mobile number will be of the family

*OTP to be generated in patient party mobile

*SRF ID self-generated by the app

PATIENT IN QUARANTINE FACILITY: *Yes / No *Always Yes

VILLAGE/ TOWN: DISTRICT:

STATE:

*ADDRESS: *Present address

PIN CODE:

AGE: years/ *months *For infants

GENDER: MALE / FEMALE

NATIONALITY:

(In case the patient is International traveler/ NRI, passport number needed)

AADHAAR NUMBER: (needs to be filled compulsorily, attach a photocopy/Xerox of the same)

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Specimen information from referring agency

*TS/ NPS/ NS *Check only this

BAL/ ETA

*Sample date: same date as processing *Sample ID: *Hospital number

Patient category: TO BE SELECTED FROM THE DROPDOWN MENU

Cat 1 Symptomatic international travelers in last 14 days

Cat 2 Symptomatic contact of lab confirmed case

Cat 3 Symptomatic health care worker

Cat 4 Severe acute respiratory illness (SARI)

Cat 5 (a) Asymptomatic direct and high-risk contact of confirmed case family member

Cat 5 (b) Asymptomatic health care worker in contact with confirmed case without adequate protection

Cat 6 Symptomatic influenza like illness (ILI) patient in hospital/ MoHFW identified clusters

Cat 7 Pregnant woman in/ near labour

Others

Clinical symptoms and signs

Symptoms present:

YES

NO

Select symptoms:

Cough Chest pain Breathlessness Abdominal pain

Sore throat Vomiting

Sputum Hemoptysis

Diarrhoea Nasal discharge

Nausea Fever at evaluation

Body ache

*Date of onset of first symptom: FROM DROPDOWN MENU*To be written from longest duration of

symptoms

Which of the above was the first symptom?

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Pre-existing medical condition:

Chronic lung disease

Chronic renal disease

Malignancy

Diabetes Heart disease

Hypertension

Chronic liver disease

Immunocompromised condition: YES / NO

Other underlying conditions:

Hospitalization details:

Has the patient been hospitalized: *YES / NO* COMPULSORILY TO BE FILLED AS YES

Hospitalization date: FROM DROPDOWN MENU

Hospital district: Dakshina Kannada Hospital name: Justice K.S. Hegde Charitable Hospital

Referring doctor details:

Name of doctor: *Resident/ Consultant name

Doctor’s mobile number: Doctor’s email id: [email protected]

Select lab where RT-PCR test will be conducted: Select from drop down menu

WENLOCK HOSPITAL (only for swabs meeting above criteria)

YENEPOYA MEDICAL COLLEGE

K.S. HEGDE MEDICAL ACADEMY (when available)

The Pdf generated needs to be sent to [email protected] with CC to [email protected]

LABELLING OF THE VACCUTAINER

Name of the patient as in Hospital file

Age

Gender

Hospital number

Date collected Ensure the dates written on the vacutainer and the APP are the same

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*IN CASE OF REPEAT TEST: *SARI patients only D5 specimens

*SRF ID:

REGISTERED MOBILE NUMBER:

Data needs to be filled again:

• Specimen information

• Clinical symptoms and pre-existing medical conditions

• Hospitalization details

• Referring doctor details and lab test name

No changes are allowed to be made in the personal details and category of the patient

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ANNEXURE 1.5 – PAEDIATRIC FEVER CLINIC CHECKLIST

Date: Resident on call:

Patient identification criteria for COVID-19 suspect:

Sl.no Chief Complaints Yes/No

1. History of travel: Domestic/International

2. History of contact withCOVID-19 positive.

3. Whether resident of Kasaragod/Others

4. Fever: duration

5. Cough: duration

6. Running nose

7. Sore throat/throat ache

8. Difficulty in breathing/Fast breathing

If any of the answer is YES and requires investigations or Xray/ Admission

• If stable shift to isolation (6th floor)

• If unstable (criteria given below) contact pediatric PG and shift to PICU

Criteria for unstable children

Age Respiratory rate

Heart rate SPO2 Temp

0-2mo >60 >150

2mo-1 year >50 >140 <93% >100 F

1-5 year >40 >120 >5 years >30 >100

Remarks:

Affix Hospital ID Sticker Here

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ANNEXURE 1.6 - PAEDIATRIC DRUG DOSAGE INFORMATION

Drug Age Dose

Paracetamol drops(100mg/ml) 0-6 months 0.5 ml tid

6months -1 year 0.75 ml tid

Syp Paracetamol (125mg/ml) 0-6 months 2.5ml tid

6months -1 year 3ml tid

1-3 years 5ml tid

Syp Paracetamol (250 mg/5ml)

0-6 months

6months -1 year

1-3 years

3-6years 5ml tid 6-10 years 7.5ml tid

10-15 years 10ml tid

T paracetamol 500mg 15-18years 1tab tid

SypCPM (2mg/5ml) 0-6 months 1.5ml tid


1-3 years 3ml tid

3-6years 5ml tid

6-10 years 5ml tid

10-15 years 7.5ml tid

15-18 years 7.5 ml tid

SypSalbutamol (2mg/5ml)

0-6 months 1.5ml tid

6months -1 year 2ml tid 1-3 years 3ml tid

3-6years 5ml tid

6-10 years 5ml tid

10-15 years 7.5ml tid


SypAmoxiclav (228mg/5ml)

0-6 months 2ml tid


1-3 years 5ml tid

Syp Amoxiclav (457mg/5ml)

3-6years 3ml tid

6-10 years 4ml tid

10-15 years 5ml tid


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ANNEXURE 2.1 - CHECK LIST FOR COVID -19 ISOLATION WARD

Patient Name: IP. No: DOA:

Age/sex: DOD:

Admission Chest X ray: Done/ Not Done Impression:

Admission ECG: Done/ Not Done Impression:

Admission COVID-19 Panel 1: Done/ Not Done

Symptoms:

Date Fever Cough Shortness of breath

Chest Pain

Headache Diarrhea Any other

Specify

Signs:

Date PR/min) SPO2 % RR/min BP (mm/Hg)

Temp0C GCS RS signs

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Enter Investigations as and when done:

Date Specify

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ANNEXURE 2.2 - PEDIATRIC MONITORING CHECKLIST FOR COVID -19 IN ISOLATION

WARD

Date: Patient Name: IP. No: DOA: Age/sex: DOD: Admission Chest X ray: Done/ Not Done Impression: Admission Covid panel: Done/ Not Done Time: Time:

Symptoms

Signs Symptoms

Signs

Fever Temp Fever Temp

Hypothermia HR Hypothermia HR

Cough RR Cough RR

Difficulty in breathing

SPO2 Difficulty in breathing

SPO2

Hurried breathing GCS Hurried breathing GCS

chest indrawing RS signs chest indrawing RS signs

Not Feeding crepitations Not Feeding crepitations

Cyanosis wheeze Cyanosis wheeze

Drowsiness Stridor Drowsiness Stridor Convulsion Conducted

sounds Convulsion Conducted

sounds

Inform paediatric PG and shift to COVID-19 PICU if the child is unstable

Criteria for unstable children Age Respiratory rate

(per min) Heart rate (per min)

SpO2 Temperature

0-2 months >60 >150

2 months - 1 year >50 >140 <93% >100 F

1 - 5 years >40 >120

>5 years >30 >100

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ANNEXURE 2.3 - PAEDIATRIC INVESTIGATION CHART IN COVID -19 ISOLATION WARD

Date: Patient Name: IP. No: DOA: Age/sex: DOD: Admission Chest X ray: Done/ Not Done Impression: Admission Covid Panel: Done/ Not Done Enter Investigations as and when done:

Date Specify

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ANNEXURE 2.4 – PATIENT EDUCATION MATERIAL

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ANNEXURE 3.1 SPECIMEN COLLECTION, PACKAGING AND TRANSPORT GUIDELINES

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Specimen Packaging and Transport:

Requirements:

• Viral transport medium vial

• Adsorbent material (cotton, tissue paper) Paraffin, scissor, cello tape

• A leak-proof container (Ziplock pouch, 50ml centrifuge tube/plastic container)

• Hard frozen gel packs

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• Suitable outer container (Thermocol box/Ice box)

Packaging Procedure

• Use PPE while handling specimen

• After putting both swabs in single VTM vial tightly screw the cap and seal the neck of the

sample vials using parafilm

• Cover the sample vials using absorbent material

• Arrange primary container(vial) in ziplock pouch

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• Place the zip-lock pouch inside a sturdy plastic container and seal the neck of the

container

• Place the secondary container within a thermocol box as an outer container and surround

it by hard- frozen gel packs.

• Close the thermocol box and transport the box along with the form to the laboratory

Precautions:

• Always use personal protective equipment appropriately.

• Perform hand hygiene before and after contact with the sample.

• Follow all biosafety measures

• Follow biomedical waste disposal guidelines

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ANNEXURE 3.2: SELF REPORTING FORM FOR ALL TRAVELLERS ARRIVING FROM

AREAS REPORTING COVID-19 TRANSMISSION

PART-A

Personal Information

1 Name of the passenger

2 Flight/train Number

3 Seat Number

4 Passport Number

5 Date and time of arrival/travel

6 Port of origin of journey

7 Port of final destination

Permanent Contact Address in India for all travelers

1 House number

2 Street / village

3 Tehsil / city

4 District

5 State

6 Pin

7 Residence number

8 Mobile number

9 E-mail ID

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PART-B

1. During your visit to the destination, you travelled to, which are all the places you have come in contact with the date of visit?

Date Place of visit Date Place of visit Date Place of Visit

2. Have you visited/come in close contact with any individual who has travelled from an area/country reporting COVID-19 infection? Yes/No

If yes, Mention the date of contact and number of days of contact-

3. Are you currently suffering from any of the following symptoms?

Symptoms Present since Yes* No

Fever

Cough

Cold

Shortness of Breath

Others(specify)

Signature of the passenger

Received from Mr./ Ms………………………………………………….on / / 2020 by in-charge

Mr./Ms./Dr. ……………………………………………………….of …………………………………………………….hostel.

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Individuals who are residing in the hostels affiliated to

Nitte (deemed to be University) constituent institutions

Report to the concerned hostel wardens and to fill the

SELF-DECLARATION FORM (ANNEXURE -1) which is made available

to all the hostels through the hostel wardens

Based on the self-declaration form filled by the individual classify the

individuals

Suspect case Contact- high/low risk None of the above

To be sent to FEVER CLINIC

for further management of the

suspect/ contact

Refer DEFINITIONS 1.2

To self-report if

symptoms

suggestive of

COVID-19 arise Test for COVID-19 approved by the

government Asymptomatic/ test not approved

by the government Managed in the hospital based on

GUIDELINES FOR IDENTIFICATION AND

MANAGEMENT OF COVID-19 PATIENTS

Hostel quarantine for 14 days Tests positive

for COVID-19

Tests negative for COVID-19,

discharge if medically stable

Further management of patients as per

GUIDELINES FOR IDENTIFICATION

AND MANAGEMENT OF COVID-19

PATIENTS

Details to be entered in hostel

quarantine form (ANNEXURE-2)

update Dr. Ankeeta via email

Monitor patients daily in hostel and

maintain register for symptoms in hostel

refer to fever clinic if any symptoms

Physicians intimated for release from quarantine by hostel warden

Examination and release from quarantine form to be filled by physicians available at hostel

(ANNEXURE -3)and to be filed in the hostel.

Signature of the Hostel Warden

* To intimate the fever clinic if any symptoms and to monitor the individuals in hostel quarantine for 14 days, advise self-reporting of above symptoms after this for another 14 days.

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ANNEXURE 3.3: LIST OF INDIVIDUALS WITH TRAVEL / CONTACT HISTORY REPORTING

TO HOSTELS

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ANNEXURE 3.4: MEDICAL FORM FOR RELEASE FROM QUARANTINE

Date: / / 2020

PART-A

PARTICULARS DETAILS (Tick wherever appropriate)

NAME OF THE INDIVIDUAL QUARANTINED

AGE

SEX

LOCATION OF QUARANTINE

REASON FOR QUARANTINE International travel/ Contact with suspect

DATE OF ARRIVAL/ CONTACT / / 2020

PERIOD OF QUARANTINE / / 2020 to / / 2020

Development of symptoms On arrival/contact During quarantine

Fever

Cough

Cold

Shortness of breath

Current physical symptoms if any

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PART-B(MEDICAL EXAMINATION)

Name of the doctor conducting medical examination: Dr.

Date and time of examination:

GENERAL PHYSICAL EXAMINATION FINDINGS

Vitals: Temperature: Blood pressure: Pulse rate:

Respiratory System examination:

Upper respiratory tract examination: Nose:

Throat:

Mouth:

Respiratory system examination

Other findings (if any)

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PART-C (DECLARATION BY THE EXAMINING DOCTOR)

I, Dr. _______________________________________ have examined the above-mentioned individual and deem him/her fit/ unfit to be released from quarantine. He/she is currently showing/ not showing any signs and symptoms of fever, cough, cold and chest congestion and is clinically stable/unstable. He/she may be discharged from quarantine as he/she has completed the period of observation for the above-mentioned symptoms in the quarantine period. I have counselled him/her regarding self-reporting of symptoms of fever, cough, cold or shortness of breath to the fever clinic in our hospital for any further management of the same.

NAME OF THE EXAMINING DOCTOR:

DATE & SIGNATURE OF THE EXAMINING DOCTOR:

PART-D (SELF-DECLARATION FROM THE INDIVIDUAL)

I, Mr./Ms.______________________________ have been counselled by Dr.______________________,regarding the possibility of symptoms of fever, cough, cold, shortness of breath suggestive of COVID-19 in the next 14 days, given my history of travel from a country/ area reporting transmission of COVID-19/ contact with an individual fitting case definition of COVID-19/ suspected case of COVID-19.

I hereby declare that I shall self-report to the fever clinic of our hospital, in case I develop any of the above symptoms in the next 14 days for the management of the same.

NAME:

DATE AND SIGNATURE:

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ANNEXURE 3.5: SELF REPORTING FORM FOR ALL EMPLOYEES REPORT BACK TO THE

INSTITUTES UNDER NITTE(DU) WHO HAVE TRAVELLED OUTSIDE THE DISTRICT LIMITS

OF DAKSHINA KANNADA DURING THE COVID-19 LOCKDOWN

PART-A

NAME: AGE: SEX:

FACULTY: DESIGNATION/BATCH/YEAR/ROLLNO:

DATE OF REPORTING: TIME: OP NO:

Personal Information

1 Type of travel- international/interstate/Inter-district

2 Origin of journey: Place: Date: Time:

3 Arrival at destination Place: Date: Time:

4 Mode of transport (air/train/bus/personal vehicle, etc.)

5 E Pass number (attach photocopy with this form)

6 COVID – 19 stamping – quarantine period mentioned

7 Do you have any health problems /illnesses to declare?

Permanent Contact Address in India for all travellers

1 Area Urban / Rural

2 House number, Street/village

3 Tehsil/city

4 District

5 State

6 Pin

7 Landline Number

8 Mobile number

9 E-mail ID

PART-B SELF REPORTING FORM (Kindly circle the response)

1. To the best of your knowledge, have you visited/come in close contact with anyone reported to have COVID-19

infection during your stay? Yes/No

If yes, were you placed under quarantine? Yes/no (duration / /2020 to / / 2020)

Last day of contact with the person reportedly having the symptoms / / 2020

2. Are you travelling from an active containment zone/area/ high prevalence state? Yes/no

3. Have you undergone nasopharyngeal/throat swab for COVID-19 in the past 2 days prior to commencement of you

journey? Yes / No

If yes furnish the report details and photocopy of the report

4. Have you downloaded the following Apps? (Tick the appropriate response)

App Tick Aarogya Setu App YES / NO

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Apthamitra App YES / NO

Quarantine Watch App YES / NO

History: Yes No If yes, please give details

Fever

Cough

Expectoration

Shortness of breath

Rhinorrhoea

Sore throat

Sneezing

International travel after March 1, 2020

H/o medications

H/o fever in the households

Declaration by the individual

The above information furnished is true to the best of my knowledge. I shall hold myself responsible for any legal

implications that may occur consequent to any false information provided above.

Signature of the individual

PART- C (to be filled by the health care personnel at fever clinic)

Clinical examination - Signs

Temperature: 0 C SPO2: % PR: beats / min

BP: mm/hg RR: / min

Examination findings:

Certified that Mr / Mrs / Dr / Prof ________________________________________________ whose details are

mentioned above has been screened for COVID 19 symptoms. He / She has no symptom of COVID 19 and does

not have any history of contact with confirmed COVID 19 case detected up to

______________________________________________________. This certificate is based on the history given by

the individual and the examination findings in order to facilitate him / her for

_____________________________________________________________________________________________

_______________ and the hospital or the doctor is not responsible if he/she develops any symptoms.

The individual is counselled to maintain social distancing; wash hands regularly with soap and water for at least 40

seconds practice good cough etiquette and wear a clean face mask as appropriate.

Any other remarks:

Date: Name & Signature of the examining doctor

Seal of the Doctor:

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