Guidelines for Isolation Ward and Infection Control in secondary healthcare facilities: COVID-19

  

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Scope and Objectives

The scope of these guidelines is limited to a Secondary Healthcare setting that includes DHs, SDHs and CHCs.
These simple and practical guidelines intents to serves the following purpose:-

To establish isolation facility at the level of Secondary health care facility DHs, SDHs and CHCs.

To Guide health care workers to improve infection prevention and control practices to tackle the COVID-19.

Introduction

Isolation refers to separation of individuals who are ill and suspected or confirmed of COVID-19. All suspect cases detected in the containment/buffer zones (till a diagnosis is made), will be hospitalized and kept in isolation in a designated facility till such time they are tested negative. Persons testing positive for COVID-19 will remain to be hospitalized till such time 2 of their samples are tested negative as per MoHFW discharge policy. (Annexure-A)

General Consideration

A patient with confirmed diagnosis of COVID-19 should not be housed in the same ward as a patient with an undiagnosed respiratory infection. Only patients with the same respiratory pathogen may be housed in the same ward.
All positive COVID-19 cases can be cohorted in a ward with good ventilation. Similarly, all suspect cases should also be cohorted in a separate ward. However under no circumstances these cases should be mixed up. A minimum distance of 1 meter needs to be maintained between adjacent beds. All such patients need to wear a triple layer surgical mask at all times.

Ideally, patients can be isolated in individual isolation rooms or negative pressure rooms with 12 or more air-changes per hour.
Air from these rooms should be exhausted directly to the outside or be filtered through a high-efficiency particulate air (HEPA) filter directly before recirculation.

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Monitored negative pressure relative to hallways and Isolation ward pressure should be lower than the adjoining rooms or corridor. Pressure differentials should not be less than 15 Pa between isolation rooms and the adjacent ambient air. Facilities should monitor and document the proper negative-pressure function of these rooms. A smoke test can help determine whether a room is under negative pressure. (see box)

Room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized.

SMOKE TEST: – Smoke is held near the bottom of the negative pressure room door, about 2 inches in front of the door. The smoke tube is held parallel to the door, and a small amount of smoke is then generated by gently squeezing the bulb. Care is taken to release the smoke from the tube slowly to ensure the velocity of the smoke from the tube does not overpower the air velocity. If the room is at negative pressure, the smoke will travel under the door and into

[A tube containing smo
the room. If the room is not at negative pressure, the smoke will be blown

outward or will stay stationary]

General Requirement for an Isolation Ward:-

Ensure that appropriate handwashing facilities and hand-hygiene supplies are available.
Stock the sink area with suitable supplies for handwashing, and with alcohol-based hand rub, near the point of care and the room door.

To create a 10 bed facility, a minimum space of 2000 sq. feet area clearly segregated from other patientcare areas is required.
Ensure adequate room ventilation. If room is air-conditioned, ensure 12 air changes/ hour and filtering of exhaust air. A negative pressure in isolation rooms is desirable for patients requiring aerosolization procedures (intubation, suction nebulisation). These rooms may have standalone air-conditioning. These areas should not be a part of the central air-conditioning.

If air-conditioning is not available negative pressure could also be created through putting up 3-4 exhaust fans driving air out of the room.
Preferably the isolation ward should have a separate entry/exit and should not be co-located with post-surgical wards/dialysis unit/SNCU/labour room etc.

There should be double door entry with changing room and nursing station.

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Post signs on the door indicating that the space is an isolation area.
Keep a roster of all staff working in the isolation areas, for possible outbreak investigation and contact tracing.
Remove all non-essential furniture and ensure that the remaining furniture is easy to clean, and does not conceal or retain dirt or moisture within or around it.
Stock the PPE supply and linen outside the isolation room or area (e.g. in the change room). Set up a trolley outside the door to hold PPE. A checklist may be useful to ensure that all equipment is available. (Annexure-B)
Place appropriate waste bags in a bin. If possible, use a touch-free bin. Ensure that used (i.e. dirty) bins remain inside the isolation rooms.
Place a puncture-proof container for sharps disposal inside the isolation room or area.
Keep the patient s personal belongings to a minimum. Keep water pitchers and cups, tissue wipes, and all items necessary for attending to personal hygiene, within the patient s reach
Dedicate non-critical patient-care equipment (e.g. stethoscope, thermometer, blood pressure cuff and sphygmomanometer) to the patient, if possible. Thoroughly clean and disinfect patient-care equipment that is required for use by other patients before use.
Place an appropriate container with a lid outside the door for equipment that requires disinfection or sterilization.
Keep adequate equipment required for cleaning or disinfection inside the isolation room or area, and ensure scrupulous daily cleaning of the isolation room or area.
Set up a telephone or other method of communication in the isolation room or area to enable patients, family members or visitors to communicate with health-care workers. This may reduce the number of times the workers need to don PPE to enter the room or area.
The isolation ward should have a separate toilet with proper cleaning and supplies.

           

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Before entering the Isolation ward

 Collect all equipment needed for patient care.

 Perform hand hygiene with soap and water or Alcohol-based hand rub (If physically
not soiled)

 Gather Personal protective equipment (PPEs) based on hazard and risk involved.

 Put on PPE in a sequence. E.g. If all PPEs are needed than Don Gown first followed
by Mask or respirator, eye protection and gloves.

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Figure 1-Sequence of donning

After leaving the Isolation ward

 Either remove PPE in the anteroom or, if there is no anteroom, make sure that the PPE will not contaminate either the environment outside the isolation room or area, or other people.

 Remove the most contaminated PPE items

 Remove PPE in a sequence. E.g. If all PPEs were don, than remove gloves (If gown is
disposable, gloves can be peeled off together with gown upon removal), hand
hygiene, gown, eye protection, mask or respirator, and hand hygiene.

 Perform hand hygiene immediately after removing gloves.

 Discard disposable items in a closed bin.

 Put reusable items in a dry closed container.
Figure 2-Sequence of removing
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Infection Prevention and control strategies

Apply Standard precautions for all the patients
Ensure triage, early recognitions and source control
Implement empiric additional precautions for suspected cases of COVID-19 infection
Implement administrative control
Use environment & engineering control

Standard Precautions for HCWs

Health-care workers caring for PUI (Patient under investigation) should follow Standard precautions:-

Hand Hygiene
Rational use of appropriate personal protective equipment (PPE) Respiratory hygiene and Cough etiquette
Injection safety practices
Safe handling of patient care equipment
Environment cleaning
Safe handling and cleaning of soiled linen
Waste management

Hand Hygiene:

HCWs should wash hands frequently with soap and water for 40-60 Seconds.
An alcohol based hand rub with 60-95% alcohol may be used for 20-30 Seconds.
If hands are visibly soiled, do not use alcohol based hand rub, but wash hands with soap and water.
Ensure WHO s M Moment for Hand H giene-

i. Before touching a patient

ii. Before any clean or aseptic procedure

iii. After exposure to body fluid

iv. After touching a patient

v. After touching a patient s surroundings

Figure 3-WHO My 5 Moments for Hand Hygiene

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Figure 4- Hand Wash technique

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Figure 5-Hand Rub technique

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Personal Protective Equipment

PPE should be used based on the risk of exposure and the extent of contact anticipated with blood, body fluids, respiratory droplets, and or open skin
Select PPE items to wear based on the assessment. (Suggestive Poster-Annexure-A) Perform hand h giene according to the WHO Moments

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Particular

Hand Hygiene

Gloves

Gown

Medical Mask

Eye Wear

         

Always before and after patient contact and after contaminated environment

                       

If direct contact with blood & body fluids secretions, excretions, mucous membrane, non-intact skin

                 

If there is risk of splashes onto the HCWs body

              

If there is a risk of splashes onto the body and face

   

Figure 6-Rational Use of PPEs

When entering a room with a suspected or confirmed COVID-19 patient, put on: 1. Disposable gloves
2. A clean, long-sleeve gown
3. Medical mask that covers your mouth and nose

4. Eye protection such as goggles

If performing an aerosol generating procedure, such as intubation, use a Particulate respirator such as an N95 – do a seal check!

Cleaners and Bio Medical waste handlers should use following PPEs:- Three layer Medical/Surgical Mask
Gown/Apron (splash proof)
Nitrite gloves

Safety goggles
Gum boots or closed work shoes

 

Remember:-

Personal protective equipment should be changed between use and for each different patient.
If utilizing single-use personal protective equipment (e.g. single-use masks, gloves, and face shields) dispose in a waste bin with a lid and wash your hands thoroughly. Anything single-usAescapnenroAtvbaeilraebulseeidnoforrsmteartiliioznedti!ll-27/3/2020

Don t touch our e es nose or mouth ith gloves or bare hands until proper hand hygiene has been performed

   

  

Respiratory Hygiene and Cough Etiquette

Ensure that all patients, visitors and staff cover their nose and mouth with a tissue or elbow when coughing or sneezing
Offer a medical mask to patients/visitors with suspected infection
Patient with fever, cough/sneezing should be kept 1 Meter away from other patients

Post visual aids like posters to remind patients and visitors with respiratory symptoms to cover than cough
Consider having masks & tissues available for patients in all areas of the hospital.
Perform hand hygiene after contact with respiratory secretion

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Injection Safety Practices

Seven steps of safe injection practices in health facilities are:-

1. Clean workspace

2. Hand hygiene

3. Sterile safely-engineered syringes

4. Sterile vial of medication and diluent

5. Skin cleaning & antisepsis

6. Appropriate collection of sharps

7. Appropriate waste management

Remember:-

 Use a new injection device for each procedure

 Inspect the packaging of the injection device to ensure that the protective barrier ha
been breached

 Whenever possible, use a single-dose vial for each patient

 Open only one vial of a particular medication at a time

 Before use, examine the vial turbidity, particulate matter or discolouration, and disca
any are present

Safe handling of Patient Care equipment

Equipment should be either single-use/ disposable or dedicated equipment (e.g. stethoscope, blood pressure cuffs and thermometer).
If equipment needs to be shared among patients, clean and disinfect it between uses for each individual patient by using ethyl alcohol 70%.

Principle of Asepsis and Environmental Infection Control

Ensure the environment cleaning and disinfection procedures are followed consistently and correctly.

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Through cleaning of environment surface with water and detergent and apply commonly used hospital level disinfectant (such as sodium hypochlorite) at least thrice a day.
The Solution should be freshly prepared.
High touch surfaces like door handles, railing, and tabletops should be disinfected every 3-4 hours.

Low touch surfaces like walls, mirrors should be cleaned at least once daily.

Safe Handling of Patients linen

 All individuals dealing with soiled bedding, towels and clothes from patients with COVID-19 infection should wear appropriate PPE before touching it, including heavy duty gloves, a mask, eye protection (goggles or a face shield), a long-sleeved gown, an apron if the gown is not fluid resistant, and boots or closed shoes.

 They should perform hand hygiene after exposure to blood or body fluids and after removing PPE.

 Soiled linen should be placed in clearly labelled, leak-proof bags or containers, after carefully removing any solid excrement and putting it in a covered bucket to be disposed of in a toilet or latrine.
Machine ashing ith arm ater at C ith laundr detergent is recommended. The laundry can then be dried according to routine procedures.

 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 drying fully in sunlight.

 Curtains should be washed using the hot water cycle. For hot-water laundry cycles, wash with detergent or disinfect in water at 70% for at least 25 minutes.
Waste Management

 Keep separate colour coded bins/bags/containers in wards and maintain proper segregation of waste as per Bio Medical Waste Management (BMWM) Rules, 2016 as mended and Central Pollution Control Board (CPCB) guidelines for implementation of BMWM Rules.

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

 Collect and store Bio Medical Waste (BMW) separately prior to handing over the same CBMWTF. Use a dedicated collection bin labelled as COVID- to store COVID-19 waste and keep separately in temporary storage room prior to handing
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over to authorised staff of CBMWTF. BMW collected in such isolation wards can also

be lifted directly from ward into CBMWTF collection area.

 In addition to mandatory labelling bags/containers used for collecting BMW from
the COVID- ards should be labelled as COVID- Waste

 General waste not having contamination should be disposed as solid waste as per
Solid Waste Management Rules, 2016.

 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- aste to be placed 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.

 Depute dedicated sanitation workers separately for BMW and general solid waste so
that waste can be collected and transferred timely to temporary waste storage area.
Management of Excreta of COVID-19 Patients

 For smaller health care facilities, if space and local conditions allow, pit latrines may be the preferred option. Standard precautions should be taken to prevent contamination of the environment by excreta. These precautions include ensuring that at least 1.5 m exist between the bottom of the pit and the groundwater table (more space should be allowed in coarse sands, gravels and fissured formations) and that the latrines are located at least 30 m horizontally from any groundwater source (including both shallow wells and boreholes).

 If there is a high groundwater table or a lack of space to dig pits, excreta should be retained in impermeable storage containers and left for as long as feasibly possible to allow for a reduction in virus levels before moving it off-site for additional treatment or safe disposal, or both. A two-tank system with parallel tanks would help to facilitate inactivation by maximizing retention times, as one tank could be used until full, then allowed to sit while the next tank is being filled. Particular care should be taken to avoid splashing and the release of droplets while cleaning or emptying tanks.

 If the patient is unable to use a latrine, excreta should be collected in either a diaper or a clean bedpan and immediately and carefully disposed of into a separate toilet or latrine used only by suspected or confirmed cases of COVID-19. In all health care settings, including those with suspected or confirmed.

 COVID-19 cases, faeces must be treated as a biohazard and handled as little as possible. Anyone handling faeces should follow WHO contact and droplet precautions and use PPE to prevent exposure, including long-sleeved gowns, gloves,
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boots, masks, and goggles or a face shield. If diapers are used, they should be

disposed of as infectious waste as they would be in all situations.
If a bedpan is used, after disposing of excreta from it, the bedpan should be cleaned with a neutral detergent and water, disinfected with a 0.5% chlorine solution, and then rinsed with clean water; the rinse water should be disposed of in a drain or a

toilet or latrine.

Precaution after completing the clean-up and disinfection

 Staff should wash their hands with soap and water immediately after removing the PPEs and when cleaning and disinfection work is completed.

 Discard all used PPE in a double bagged biohazard bas, which should be securely sealed and labelled.
Transport of the Patient

In general, transport and movement of the patient outside of their isolation ward

should be limited to medically essential purposes. Like HCFs may consider

providing portable x-ray equipment in patient isolation areas to reduce the need

for patient transport.

If being transported outside of the room, such as to radiology, HCWs in the

receiving area should be notified in advance of transporting the patient.

Patients should wear a facemask to contain secretions during transport. If

patients cannot tolerate a facemask or one is not available, they should use

tissues to cover their mouth & nose, and be covered with a clean sheet.

If transport personnel must prepare the patient for transport (e.g., transfer them to the wheelchair or gurney), transport personnel should wear all recommended PPE (gloves, a gown, respirator and eye protection [i.e., goggles or disposable face shield that covers the front and sides of the face]).

Once the patient has been transferred to the wheelchair or gurney (and prior to exiting the room), transporters should remove their gown, gloves, and eye protection and perform hand hygiene

Handling of Dead Bodies

Please refer Government of India, Ministry of Health & Family Welfare, and Directorate General of Health Services (EMR Division)-COVID-19: Guidelines on dead body Management. Available at: – https://www.mohfw.gov.in/1584423700568_COVID19GuidelinesonDeadbodym anagement.pdf

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Administrative Measures

Ensure that all necessary preventive and protective measures are taken to minimize occupational safety and health risks.

Provide HCWs job- or task-specific education and training on preventing transmission of infectious agents, including refresher training.

 Ensure that HCWs are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment.

 Ensure uninterrupted supply of PPEs and its rational use.

 Ensure an adequate patient-to-staff ratio.

 Establish a surveillance process for acute respiratory infections potentially cause
by COVID-19 among HCWs.

 Monitor compliance with standard precautions and provide mechanisms for
improvement as needed.
Visitors Policy
Visitor should not be allowed inside the Isolation ward.
Encourage use of alternative mechanisms for patient and visitor interactions such as
video-call applications on cell phones or tablets.
Restrict HCWs from entering the isolation ward, if they are not involved in direct
patient care (e.g. food delivery).
Maintain a record of all persons entering the isolation ward.
Do s and Don ts for COVID-19 Isolation Wards

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Do s

Don ts

Use Standard precautions for all patients

Move and transport patients out of their isolation ward unless medically necessary

Appl WHO s M Moments and Six steps for Hand Hygiene

Touch eyes, nose or mouth with potentially contaminated gloved or bare hands

Notify the area receiving the patient of suspected cases in advance before arrival

Allow HCWs showing symptoms of illness to work

Routinely clean and disinfect surfaces which the patient is in contact

Put untrained staff to take care of COVID-19 patients

Put on, use, take off and dispose of PPEs properly

Allow healthcare workers not directly involved in patient care

Self-monitor for sign of illness and self- isolate or report illness to immediate supervisor

Allow visitors in the ward

Inform supervisor if you are experiencing

Use Respirator (e.g. N-95, FFP2 or

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sign of undue stress or mental health challenges

equivalent standard) for routine patient care

Practicing respiratory hygiene by coughing or sneezing into a bent elbow or tissue and then immediately disposing of the mask

Allow the needle to touch any contaminated surface

Maintain social distance ( a minimum of 1 m) from individual with respiratory symptoms

Use the same needle and syringe for several multi-dose vials.

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Discharge Policy of COVID-19

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Annexure-A

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Checklists for Isolation ward:-

1. Eye protection (visor or goggles)

2. Face shield (provides eye, nose and mouth protection)

3. Gloves

4. Reusable vinyl or rubber gloves for environmental cleaning

5. Latex single-use gloves for clinical care

6. Hair covers

7. Particulate respirators (N95, FFP2, or equivalent)

8. Medical (surgical or procedure) masks

9. Gowns and aprons

10. Single-use long-sleeved fluid-resistant or reusable non-fluid-resistant gowns

11. Plastic aprons (for use over non-fluid-resistant gowns if splashing is anticipated and if fluid-resistant gowns are not available)

12. Alcohol-based hand rubs

13. Plain soap (liquid if possible, for washing hands in clean water)

14. Clean single-use towels (e.g. paper towels)

15. Sharps containers

16. Appropriate detergent for environmental cleaning and disinfectant for disinfection of surfaces, instruments or equipment

17. Large plastic bags

18. Appropriate clinical waste bags

19. Linen bags

20. Collection container for used equipment

21. Standard IEC

22. Standard protocols for hand hygiene, sample collection and BMW displayed clearly

23. Standard Clinical management protocols

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Annexure-B

  

References:-

1. Guidelines for Handling, Treatment, and disposal of waste Generated during treatment/Diagnosis/Quarantine of COVID-19 patients, March 2020, Central Pollution Control Board.

2. CDC Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings

3. Guidelines for Setting up Isolation Facility/Ward- NCDC

4. Discharge Policy, NCDC

5. Interim Guidance from WHO- Rational use of personal protective equipment for
Coronavirus disease (COVID-19)

6. Interim Guidance from WHO- Consideration for Quarantine of individuals in the
context of containment for Coronavirus disease (COVID-19)

7. WHO Guidelines- Coronavirus Disease (COVID-19) Outbreak: Rights and
Responsibilities of Health workers, including key consideration for Occupational safety
and Health.

8. Guidelines for implementation of Kayakalp initiatives, MoHFW, GOI.

9. Guidelines for management of healthcare waste as per BMW Management Rules, 2016,
MoHFW, CPCB

10. National Guidelines for Infection Prevention and Control in Healthcare facilities,
MoHFW, GOI

11. AIIMS Guidelines- Infection Prevention & Control Guidelines for 2019-nCoV (COVID-19)

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