Guidelines for OPD practice for doctors in Covid Scenario

Issued in public interest by: Malad Medical Association

Introduction to the disease…

• The clinical disease termed COVID-19 is caused by a novel beta coronavirus, now named SARS-CoV-2.

• The SARS-CoV-2 is the seventh Corona virus known to infect humans.

• Was declared a global pandemic by WHO on March 11th 2020.

Route of transmission of COVID-19

• The primary route for the spread of COVID-19 is thought to be through aerosolized droplets

• Expelledduringcoughing,sneezing,or breathing,

• Butalsoconcernsaboutpossibleairborne transmission.

• Faeco-oraltransmissionhasalsobeen reported in a few cases, with viral isolation from the faeces of some patients

Confirmed Covid case

• Isapersonwithlaboratoryconfirmationof COVID-19 infection, irrespective of clinical signs and symptoms

Who should avoid practicing…

• Doctors and paramedical staff above age of 60 years.

• Those with underlying medical conditions (especially immunocompromised / predisposing to infections) like:
– DM, Chronic Liver, Heart & Kidney disease, Chronic lung conditions like Asthma, COPD, Bronchectasis, ILD, etc., Cancer, On Chemotherapy or Steroid treatment, Pregnant, Seropositive status.

Patients to be avoided…

• All symptomatic individuals who have undertaken international travel in the last 14 days or

• All symptomatic contacts of laboratory confirmed cases or

• All symptomatic healthcare personnel (HCP) or

• All hospitalized patients with severe acute respiratory illness (SARI) (fever AND cough and/or shortness of breath) or

• Asymptomatic direct and high risk contacts of a confirmed case (should be tested once between day 5 and day 14 after contact)

• (Symptomatic refers to fever/cough/shortness of breath.)

• (Direct and high-risk contacts include those who live in the same household with a confirmed case and HCP who examined a confirmed case.)

Directly refer for testing…

• All those with patients with any of these things positive should be referred to the nearby Covid centre for testing. (Government or Private diagnostic facility)

• Government testing facility near to Malad is at HBT Trauma Centre, Jogeshwari and Kasturba Hospital being the main centre.

Pregnant and Breastfeeding patients…

• Testing to be prioritized, if suspicion arises
• Currently there is no data suggestive of viral

transmission via breast milk.

• However,duetoclosecontactandriskof droplet transmission, breastfeeding should be avoided in COVID-19 confirmed mothers.

Key concepts in this Guidelines…

➢Limit how germs can enter the facility ➢Isolate symptomatic patient as soon as

possible
➢Protect healthcareworkers

Triage on phone

• The crucial 1st step in protecting doctors and other patients.

• All patients must be assessed for possible COVID-19 infection and suspects (as mentioned earlier), if they does not have any of them, call them to your clinic by appointment, keeping the reasonable time between each patient as per your discretion to avoid crowding at the clinic.

• If any patient seems to be Covid suspect, please refer him to the nearby Covid testing centre.

• Avoid routine follow ups, elective procedures

• You may guide the patient on phone for minor issues at your discretion

Triage at clinic/ Hospital, if possible…

• Triagestationswithadequatelytrainedstaff should be allotted at the entrance of each health care facility.

• Physicalbarriers(glass/plasticbarriers)should be installed at these stations to limit close contact between triage personnel and potentially infectious patients.

• Use of Personal Protective Equipments (PPE) is preferred.

Clinic management…

• Restrict the OPD time to limited hours

• Avoid walk-in patients

• All patients only, avoid relatives as much as possible

• Make the patients wait about 1 meter apart (can make squares)

• If possible, don’t make patient sit anywhere in your clinic

• If patient need to be examined on bed or table, clean it immediately following the examination.

Clinic management…

• Pleasedon’ttouchanydocumentsofthe patient, just see them from far. (may ask patients to click photos and send you in advance)

• Use new prescription for all patients ( may have an assistant for the same)

• Whiledispensingmedicines,prefernotouch techniques with the patient.

Clinic management…

• All patients with respiratory symptoms made to wear a paper mask in the waiting area and instructed on cough and sneeze hygiene.

• Doctors clinics should be well ventilated and patients should be seated and stay six feet apart except during physical examination.

• The doctor should wear a surgical mask and scrub hands with soap and water and use an alcohol- based disinfectant after each patient interaction.

Display in Clinics…

• Visual alerts should be posted at the entrance and strategic areas (waiting areas, elevators and cafeterias)

• To reinforce both patients and health care workers, the importance of hand hygiene, respiratory hygiene and cough etiquette

For all medical professionals (Basics…)

• Use only 1 pen, phone and water bottle (disposable better)

• Decontaminate phone

• Do not touch anything

• Everything is contaminated unless cleaned in your presence

• No watches no rings no bangles no dangling earrings

• Hairs tied and Cover your head with cap.

• Shift to scrubs full sleeves, if available.

• Empty bowel and bladder before you wear your PPE

• Wear double glove

• Keep your palms together when you see patients to remind you not to touch them.

• Don’t use stethoscope. These are not normal times

• Wear goggles

• Wear masks if patient contact or in busy area (Mask details later)

• Wear footwear which covers foot fully. Plastic or rubber easy to disinfect

For all medical professionals (Basics…)

• Social distancing poorly practiced in hospitals, so please pay attention

• Keep 1 m distance

• Safe distance always

• No elective job at hospital

• Clean your desk, door knob, computer, workstation yourself or in your presence

• Keep door opens

• Minimal touching

• Do not touch papers and files, prefer Electronic entries, if feasible

• Wash hands after every patient examination and clean your instruments with sterilium, especially stethoscope to avoid cross infection

• Avoid lifts, Closed space, Don’t touch lift buttons. Get them cleaned often

• Avoid Heavy load at clinic

• Leave all your stethoscope, knee hammers and other medical stuff in hospital itself. Don’t take home

• Decontaminate car handles

While going back home…

• Ring up home when you start from hospital.

• Someone at home should keep the front door open( so that you don’t have to touch the calling bell or door handle) and a bucket of water with washing soap powder or bleaching powder added to it in the front door.

• Keep things(car keys, pen, sanitiser bottle, phone) in box outside the door.

• Wash your hands in the bucket and stand in the water for a few minutes. Meanwhile use tissue and sanitizer and wipe the items you have placed in the box and the box.

• Wash your hands with soap water again

• Now enter the house without touching anything.

• The bathroom door is kept open by someone and a bucket of detergent soap water is ready. You take off all your clothes including innerwear and soak inside the bucket

• Then take a head bath with a shampoo and body bath with soap

• Wash your clothes/ put in washing machine with high temperature settings and dry clothes in direct sunlight

Hand hygiene…

• All health care workers should perform hand hygiene using alcohol-based hand rub (minimum 20 seconds) or by washing with soap and water (minimum 40 seconds). If hands are visibly soiled, use soap and water for hand wash.

• Performed before and after using bathroom, before, during and after preparing food, before and after eating /drinking, after coughing, blowing or sneezing, after touching garbage, after touching mask or soiled PPE.

• Foot operated sanitizers should be put outside elevators, OPDs, screening areas, ICUs and wards.

  

Need of the protective gears for all?

• Hand hygiene is for all healthcare workers

• Based upon your role in patient management and duration of exposure with patient (more than or less than 15 minutes), you have to donn the protective gears.

• Thus, need of protective gears depends upon the place where you are practicing

• It is classified in following slides…

Minimal Protective gears…OPD with

 

Advanced Protective gears…OPD with

  

Mask etiquette…

If masks are worn, appropriate use and disposal is essential to ensure they are effective and to avoid any increase in risk of transmission associated with the incorrect use and disposal of masks.

i. Place mask carefully to cover mouth and nose and tie securely to minimize any gaps between the face and the mask

ii. While in use, avoid touching the mask

iii. Remove the mask by using appropriate technique (i.e. do not touch the front but remove the lace from behind)

iv. After removal or whenever you inadvertently touch a used mask, clean hands by using an alcohol-based hand rub for 20 seconds or soap and water if visibly soiled for 40 seconds

v. Replace masks with a new one as soon as they become damp/humid

vi. Do not re-use single-use masks

vii. Discard single-use masks after each use and dispose-off them immediately upon removal

viii. For N95 respirators adequate fit check must be performed after wearing.

Steps of donning PPE …

1.Donning of the PPE must be performed in designated area.

2. Remove home clothes, jewelry, watches, electronic etc. and wear clean hospital scrubs

3. Wash hands with soap and water

4. Wear shoe covers – tie lace in front of the shin

5. Wear first set of gloves – should be smaller than second pair, comfortable size, can be sterile or unsterile

6. Gown – wear a clean disposable non-permeable gown, arm sleeves of gown should cover the gloves at the wrists, tie the lace behind snuggly without wrapping all around the waist. Decontaminate the gown if it becomes soiled. Remove gown only in designated doffing area and discard the gown (yellow bin) before leaving patient care area

Steps of donning PPE …

7. Wear the N-95 respirator – cup the mask in hand, place the lower strap behind the neck passing below ears , then place the upper strap over back of head passing above ear. Check for snug fit of mask. There should be no more than minimal air leak from sides

8. Wear eye piece – adjust the strap according to required size, open the ports at upper end to prevent fogging while wearing, upper end N-95 mask should be covered by eye piece

9. Wear the hood – hood should lay over the gown without leaving any open space.

10. Wear 2nd pair of the gloves – should be of larger size than 1st pair, should cover free end of arms of gown. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene

11. Gown fitness check: Take help of companion for fitness check.

  

Steps of doffing PPE…

• Doffing to be performed only in the designated area, check for any leak or soiling in PPE before doffing. If any, disinfect the area before doffing. Doffing room should have two chairs, one labelled “dirty” and the other “clean”. All the PPE must be discarded in the yellow bin. Hand hygiene MUST be performed after every step.

1. Disinfect the hands wearing gloves by following hand hygiene procedure.

2. Remove shoe covers only by touching the outer surface, and perform hand hygiene.

3. Remove outer gloves and perform hand hygiene.

4. Remove hood and perform hand hygiene.

5. Remove gown slowly by holding the gown at the waist and pullling. Without touching the outer surface, remove with a rolling inside out technique. Perform hand hygiene again.

Steps of doffing PPE…

6. Remove eye piece by holding the straps, and perform hand hygiene. 7. Remove inner gloves and perform hand hygiene.
8. Wear another pair of sterile /unsterile gloves.

9. Remove mask – Do not touch exposed surface of mask. First remove lower strap of mask, remove mask holding upper strap in a slow and steady pace (as to not generate aerosols)

10. Perform hand hygiene
11. Sit over clean chair and clean your shoes with alcohol swabs 12. Remove last pair of gloves and perform hand hygiene

If any leak is found in PPE while caring for infected patients, caring HCPs should self-quarantine

  

Combined protection…

Combining all measures — Hand-washing
Masks
Gloves and

Protective gown (wherever needed)

Increases the intervention effectiveness

TRANSPORT PROTOCOL

For shifting any suspected or confirmed COVID-19 patients, the following steps must be followed by the accompanying healthcare provider:

A. Decontaminate hands (alcohol-based sanitiser/soap)

B. Don PPE

C. Inform Trauma Centre control room regarding the admission/transfer of a potentially infectious patient.

D. In ambulance

• Use single use or single patient use medical equipment where possible

• Use disposable linen if available

• Monitor and document vitals and medical management done in ambulance

TRANSPORT PROTOCOL E. Arrival at Trauma centre

• Before the patient leaves the ambulance ensure arrangements are in place for receipt of the patient

• Transfer patient to the care of hospital staff at Trauma Centre • After transfer of patient remove PPE
• Perform hand hygiene

F. Before ambulance is used again

• Cleaning and disinfecting (PPE as outlined above should be worn while cleaning)

• Surfaces (stretcher, chair, door handles etc.) should be cleaned with a freshly prepared 0.5-1% hypochlorite solution or equivalent

• Medical equipment should be cleaned as per hospital infection control protocol

HOME QUARANTINE/ISOLATION GUIDELINES

FOR SUSPECTED OR CONFIRMED COVID-19 CASES Instructions for home quarantine of COVID-19 contacts:

• Stay in a well-ventilated room separated from other people and pets

• Should preferably have attached/separate toilet

• Restrict his/her movement within the house.

• In shared spaces, maintain a distance of at least 1-2 meters and wear a medical mask when in proximity with other people

• Take special care to stay away from elderly people, pregnant women, children and persons with co-morbidities

Do NOT attend any social/religious/public gathering e.g. wedding, condolences, etc.

• Wash hand often thoroughly with soap and water (at least 40 seconds) or with alcohol- based hand sanitizer (at least 20 seconds) especially after coughing and sneezing, and before and after eating, drinking and using the washroom

• Follow all steps of handwashing as described in chapter 4

• Avoid sharing household items with other people at home (e.g. dishes, drinking glasses, cups, eating utensils, towels, bedding etc.)

• Used three layered medical mask should be considered as potentially infected

• If symptoms appear (cough/fever/difficulty in breathing), he/she should immediately inform the nearest health center or call 011-23978046. or 1976

Instructions for the family members of person being home quarantined/isolated

• Household members should stay in a different room and be separated from the person as much as possible

• Only an assigned family member should be tasked with taking care of the person and should help with groceries, prescriptions and other personal needs

• Avoid shaking the soiled linen or direct contact with skin

• Pets should be cared for by household members and should be kept separate from the person

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

Stay at least 1 m away from those who are coughing

• Wash hands after removing gloves and before and after eating, drinking and using the washroom with soap and water (at least 20 seconds) or with alcohol-based hand sanitizer (at least 30 seconds)

• All non-essential visitors should be prohibited

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

Environmental sanitation:

• Immediately remove and wash clothes and bedding that have blood, stool or other body fluids on them

• Clean and disinfect frequently touched surfaces in the quarantined person’s room (e.g. bed frames, tables etc.) daily with Sodium Hypochlorite solution (1%) or ordinary bleach (5%)

• Clean and disinfect toilet surfaces daily with regular household bleach solution/phenolic disinfectants

• Wash laundry used by the person separately using common household detergent and dry thoroughly using the warmest temperatures recommended on the clothing label

• Place all used disposable gloves, masks and other contaminated waste in a lined container before disposing of them with other household waste and wash hands with soap and water/alcohol-based hand rub as shown in the picture below

Duration of home quarantine period…

Is for 14 days from contact with a confirmed case or earlier if a suspected case (of whom the index person is a contact) turns out negative on laboratory testing.

Duration of home isolation for confirmed cases with mild disease is:

• Afebrile for 72 hours AND at least 7 days after symptom onset OR

• 2 negative samples 24 hours apart

Special precautions to be followed for aerosol generating procedures

• Include tracheal intubation, non-invasive ventilation, tracheostomy, cardiopulmonary resuscitation, and bronchoscopy.

• Are all associated with increased risk of transmission of COVID-19

• HCWs conducting such procedures should be wearing full-body PPEs including N95 particle-filtering masks

• Should be carried out in an adequately ventilated room or in airborne infection isolation rooms (AIIR) which are negative pressure rooms

Emotional needs of HCWs

• Must not be ignored

• Health care workers at the front-line of COVID-19 are under
extreme physical and mental stress.

• They are physically overworked beyond conceivable limits, they are forced to make tormenting triage decisions,

• Racked by guilt and pain from losing patients and colleagues.

• Additionally, worrying about their own health and the constant anxiety of passing infection on to their families.

• Suffer from extreme levels of stress, depressive orders, anxiety and insomnia.

Access to personal protective equipment (PPE) for health workers

• Is another key concern.

• Even developed countries like the UK and USA report extreme shortages, and these concerns are multiplied in parts of the developing world which may be most hit by the epidemic.

• PPE shortages have been described in almost all affected facilities.

• Many physicians are forced to put themselves at risk and are already managing these patients using equipment (out of the box ideas) which does not measure up to standard recommendations.

Decontamination and waste management in clinics

• Any surface or material known to be, or potentially be, contaminated by biological agents must be correctly disinfected to control infectious risks.

• Proper processes for the identification and segregation of contaminated materials must be adopted before decontamination and/or disposal.

• Where decontamination cannot be performed in the laboratory area or onsite, the contaminated waste must be packaged in an approved (that is, leak proof) manner, for transfer to another facility with decontamination capacity.

• Practices for environmental cleaning in healthcare facilities:

• Environmental cleaning is part of standard precautions, which should be applied to all patients in all healthcare facilities. Ensure that cleaning and disinfection procedures are followed consistently and correctly.

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

Decontamination
PPE to wear while carrying out cleaning and disinfection works:

1. Wear heavy duty/disposable gloves, disposable long-sleeved gowns, eye goggles or a face shield, and a medical mask (please see the PPE document for details)

2. Avoid touching the nose and mouth (goggles may help as they will prevent hands from touching eyes)

3. Disposable gloves should be removed and discarded if they become soiled or damaged, and a new pair worn

4. All other disposable PPE should be removed and discarded after cleaning activities are completed. Eye goggles, if used, should be disinfected after each use, according to the manufacturer’s instructions.

5. Hands should be washed with soap and water/alcohol-based hand rub immediately after each piece of PPE is removed, following completion of cleaning.

• Where possible, seal off areas where the confirmed case has visited, before carrying out cleaning and disinfection of the contaminated environmental surfaces. This is to prevent unsuspecting persons from being exposed to those surfaces. Inform the local authorities immediately.

Decontamination Frequency of cleaning of surfaces:

• 1. High touch surfaces: Disinfection of high touch surfaces like (doorknobs, telephone, call bells, bedrails, stair rails, light switches, wall areas around the toilet) should be done every 3-4 hours.

• 2.Low-touchsurfaces:ForLow-touchsurfaces (walls, mirrors, etc.) mopping should be done at least once daily.

Prophylactic drug for HCWs…

The use of prophylactic chloroquine is controversial. A major RCT on 40,000 HCWs randomisedtoreceive chloroquine/ hydroxychloroquine or placebo with a loading dose of 10mg base/kg followed by 250 mg chloroquine phosphate salt or 200 mg hydroxychloroquine taken over 3 months has begun recruiting and the initial results are eagerly awaited

Management of Covid patient at a glance…

  

Contacts…

Emergencycontactnumbers: – 011-23978046
– 1075
– 020-26127394

WhatsApp No.: 9013151515 • Email:ncov2019@gmail.com • Website:mohfw.gov.in

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