MANAGING SELF AND PATIENTS FROM CORONA (during and after lockdown )
*MANAGING SELF AND PATIENTS FROM CORONA (during and after lockdown )*
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.
✓ ORIGIN :- WUHAN,Hubei Province, CHINA
✓Was declared a global pandemic by WHO on March 11th 2020.
✓Source of infection :- cases
✓Median incubation period :- 6 days (2-14 days)
✓ Mode of transmission :-
• PRIMARY : AEROSOLIZED DROPLETS
during coughing, Sneezing or breathing
• other :- CONTACT , FOMITES
• faecooral route :- rare
✓ Age affected :- all age group
Mostly 30+ age groups
✓ CFR :- CASE FATALITY RATE 3-4 %
CFR is highest if coexisting morbidities.
✓✓ imp fact :- if a person is tested positive after laboratory investigation irrespective of any clinical sign & symptom , that is a confirmed case of COVID-19.
World Situation :-
World's Coronavirus Cases:
5.01Millions + 57,747
∆ MANAGING SELF AND PATIENTS FROM CORONA is a huge matter of concern at the mean time.
✓ 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.
✓ Patient to be avoided .... (Is it feasible ? )
• All symptomatic individuals who have undertaken international travel in the last 14 days or
• All symptomatic contacts of laboratory confirmed cases 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 confirm case ]
✓ What should we do for them ?
DIRECTLY refer for TESTING
All those patients with any of these things positive should be referred to the nearby Covid centre for testing. (Government or Private diagnostic facility)
• Also we have to inform the authority about the case.
✓ Pregnant and Beast-feeding patient :-
• Testing to be prirotized if suspicion arises
• Currently there is no data suggestive of viral transmission via breast milk.
• However, due to close contact and risk of droplet transmission, breastfeeding should be avoided in COVID~19 confirmed mothers.
• In these cases EXPRESSED BREAST MILK
should be preferred .
✓ KEY CONCEPT
>> 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 COVlD-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.
✓ Telemedicine Healthcare teleconsultation service
Do’s and Don’t’s for Doctors during Telemedicine :-
~ Patient identification is mandatory during first consultation
~Patient identity confirmation is not mandatory during follow-up consultation, but may be carried out on need basis
~Caregiver identity and authorization should be checked
~Doctor should identify himself/herself to the patient before start of every teleconsultation
~Doctor should not continue with teleconsultation if it not appropriate
~maintain patient records of teleconsultation
~Patient’s personal data should not be disclosed or transferred without written consent of the patient
~Doctor should not deny emergency teleconsultation, but limit it for immediate assistance or first aid
Full article :-https://arogyalegal.com/2020/article/indias-new-telemedicine-practice-guidelines-analysis-and-dos-and-donts-for-doctors-offering-teleconsultation/
✓ TRIAGE AT CLINIC / HOSPITAL
(IF POSSIBLE)
• Triage stations with adequately trained staff should be allotted at the entrance of each health care facility.
• Physical barriers (glass/plastic barriers) 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.
Important steps
from DOCTOR APPOINTMENT to Clinic Exit
✓ 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.
✓✓ PATIENT WAITING AREA SET UP :
PICTURE OF BEFORE COVID-19
~ Multi seater sofas for Patients and accompanying persons
~ heavy seating arrangement
~ coffee table books
~ uncovered dustbins in un-noticeable corners.
PICTURE OF AFTER COVID-19
~ Single seater chairs for patient's accompanying persons to replace sofas
~ easily disinfectable single seater chairs in waiting area
~ Patient to come with prior appointment, no crowding permitted
~ All entrants to use disposable face covers, feet covers
~ Covered dustbins in easily noticeable area.
✓✓ CONSULTING ROOM SET UP
PICTURE OF BEFORE COVID-19
>>Multiple chairs for patient‘s accompanying persons
>> Patient too close to Doctor.
>> Drs table narrow and crowded with materials.
>> Dustbin not seen
PICTURE OF AFTER COVID-19
>> Only one chair for Patient's accompanying person
>> Patient atleast 3 ft from Doctor.
>> Drs table wide and not crowded with materials.
>> Dustbin seen (easily noticeable)
✓ CLINIC MANAGEMENT (continue...) :-
• Please don't touch any documents of the 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)
• While dispensing medicines, prefer no touch techniques with the patient.
• 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 alcoholbased disinfectant after each patient interaction.
✓✓ 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.
Q : 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
✓✓ 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.
✓✓ GUIDANCE TO PUTTING ON & TAKING OFF PPE
PPE :- Personal protective equipment
SEQUENCE FOR PUTTING ON PPE :-
~ mnemonic :- GMGG
Gown ---> Mask ---> Goggles ---> GLOVES
Picture:(source : WHO)
SEQUENCE FOR TAKING OFF PPE :-
Reverse of putting on but at last mask
Picture:(source :WHO)
Elaborated Video by AIIMS Delhi
ABOUT PPE
Link :- https://youtu.be/8PSBOZUelTc
✓✓ COMBINED PROTECTION:-
✓✓ TRANSPORT PROTOCOL :
Forshifting 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
✓✓ 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 ordinarybleach (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 containerbefore disposing of them with other household waste and wash hands with soap and water/alcohol-based hand rub as shown above in a picture.
✓✓ Duration of home quarantine period...
>> It 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 COVlD-19
• HCWs (Healthcare workers) conducting such procedures should be wearing full-body PPES including N95 particle-filtering mask
• Should be carried out in an adequately ventilated room or in airborne infection isolation rooms (AllR) which are negative pressure rooms .
✓✓ Emotional needs of HCWs
>> Must not be ignored
>> Health care workers at the front-line of COVlD-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 constantanxiety of passing infection on to their families.
>>> Suffer from extreme levels of stress, depressive orders, anxiety and insomnia.
✓✓ Access to PPE for health worker :-
~ ls 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% Sodium Hypochlorite can be used as a disinfectant for cleaning and disinfection
• The solution should be prepared fresh.
• Leaving the solution for a contact time of at least 10 minutes is recommended.
• 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.
• FUMIGATION
✓✓ Decontamination
PPE to wear while carrying out cleaning and disinfection works: .
>> 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)
>> Avoid touching the nose and mouth (goggles may help as they will prevent hands from touching eyes)
>> Disposable gloves should be removed and discarded ifthey become soiled or damaged, and a new pair worn
>> 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.
>> 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 offareas where the confirmed case has Visited, before carrying out cleaning and disinfection of the contaminated environmental surfaces. This is toprevent unsuspecting persons from being exposed to those surfaces. Inform the local authorities immediately.
✓✓✓ BASICS FOR ALL MEDICAL PROFESSIONALS ✓✓✓
~ DO'S and DON'T ~
1. Use only 1 pen, phone and waterbottle (disposablebetter)
2. Decontaminate phone
3. Donot touch anything
4. Everything is contaminated unlessCleaned in your presence
5. No watches, no rings, no bangles , no dangling earrings
6. Hairs tied and Cover your head with cap.
7. Shift to scrubs full sleeves, if available.
8. Empty bowel and bladder before you wear your PPE
9. Wear double glove
10. Keep your palms together when you see patients to remind you not to touch them.
11. Don't use stethoscope. These are not normal times
12. Wear goggles
13. Wear masks if patient contact or in busy area.
14. Wear foot wear which cover foot fully. plastic or rubber easy to disinfect.
15. Social distancing poorly practiced -in hospitals, so please pay attention .
16. Keep 1 m distance
17. Safe distance always
18. No elective job at hospital
19. Clean your desk, door knob, computer, workstation yourself or in your presence
20. Keep door opens
21. Minimal touching
22. Do not touch papers and files, prefer Electronic entries, if feasible
23. Wash hands after every patient examination and clean your instruments with sterilium, especially stethoscope to avoid cross infection
24. Avoid lifts, Closed space, Don't touch lift buttons. Get them cleaned often
25. Avoid Heavy load at clinic
26. Leave all your stethoscope,knee hammers and other medical stuff in hospital itself. Don't take home
27. Decontammate car handles
✓✓ WHILE GOING BACK TO HOME :-
1. Ring up home when you start from hospital.
2. 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.
3. 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.
4. Meanwhile use tissue and sanitizer and wipe the items you have placed in the box and the box.
5. Wash your hands with soap water again
6. Now enter the house without touching anything.
7. 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
8. Then take a head bath with a shampoo and body bath with soap
9. Wash your clothes/ put in washing machine with high temperature settings and dry clothes in direct sunlight.
✓✓ICMR recommendation for COVlD-19 ✓✓
~ Use of hydroxy-chloroquine for prophylaxis for selected individuals as follows;
# Eligible individuals:
>> Asymptomatic healthcare workers involved in the care of suspected or confirmed cases of COVlD-19:
400 mg twice a day on Day 1, followed by 400 mg once weekly for next 7 weeks; to be taken with meals
>> Asymptomatic household contacts of laboratory confirmed cases:
400 mg twice a day on Day 1, followed by 400 mg once weekly for next 3 weeks; to be taken with meals
✓✓ Revised Guidelines on Clinical Management of COVID 19 ✓✓
[Government of India Ministry of Health & Family Welfare Directorate General of Health Services (EMR Division) ]
>> Based on the available information the following drugs may be considered as an off label indication in patients with severe disease and requiring ICU management:
• Hydroxychloroquine (Dose 400mg BD for 1 day followed by 200mg ED for 4 days) in combination with
• Azithromycin (500 mg OD for 5 days)
~ These drugs should be administered under close medical supervision, with monitoring for side effects including QTC interval.
~ The above medication is presently not recommended for Children less than 12 years, pregnant and lactating women .
✓✓ PERSONAL MANAGEMENT ✓✓
>> Read :- story books , novels, life biography
>> Learn music , musical instruments.
>> Learn new language
>> Learn new courses
>> Exercises (achieve fitness goals by home workout )
>> Most crucial : spend time with Family
>> Increase your skill.
Source :- DR. N.Himansu Choudhury (MD, ENT)
- WHO
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.
✓ ORIGIN :- WUHAN,Hubei Province, CHINA
✓Was declared a global pandemic by WHO on March 11th 2020.
✓Source of infection :- cases
✓Median incubation period :- 6 days (2-14 days)
✓ Mode of transmission :-
• PRIMARY : AEROSOLIZED DROPLETS
during coughing, Sneezing or breathing
• other :- CONTACT , FOMITES
• faecooral route :- rare
✓ Age affected :- all age group
Mostly 30+ age groups
✓ CFR :- CASE FATALITY RATE 3-4 %
CFR is highest if coexisting morbidities.
✓✓ imp fact :- if a person is tested positive after laboratory investigation irrespective of any clinical sign & symptom , that is a confirmed case of COVID-19.
World Situation :-
World's Coronavirus Cases:
5.01Millions + 57,747
( 21/05/2020)
Recovered :- 1.91 millions
∆ MANAGING SELF AND PATIENTS FROM CORONA is a huge matter of concern at the mean time.
✓ 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.
✓ Patient to be avoided .... (Is it feasible ? )
• All symptomatic individuals who have undertaken international travel in the last 14 days or
• All symptomatic contacts of laboratory confirmed cases 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 confirm case ]
✓ What should we do for them ?
DIRECTLY refer for TESTING
All those patients with any of these things positive should be referred to the nearby Covid centre for testing. (Government or Private diagnostic facility)
• Also we have to inform the authority about the case.
✓ Pregnant and Beast-feeding patient :-
• Testing to be prirotized if suspicion arises
• Currently there is no data suggestive of viral transmission via breast milk.
• However, due to close contact and risk of droplet transmission, breastfeeding should be avoided in COVID~19 confirmed mothers.
• In these cases EXPRESSED BREAST MILK
should be preferred .
✓ KEY CONCEPT
>> 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 COVlD-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.
✓ Telemedicine Healthcare teleconsultation service
Do’s and Don’t’s for Doctors during Telemedicine :-
~ Patient identification is mandatory during first consultation
~Patient identity confirmation is not mandatory during follow-up consultation, but may be carried out on need basis
~Caregiver identity and authorization should be checked
~Doctor should identify himself/herself to the patient before start of every teleconsultation
~Doctor should not continue with teleconsultation if it not appropriate
~maintain patient records of teleconsultation
~Patient’s personal data should not be disclosed or transferred without written consent of the patient
~Doctor should not deny emergency teleconsultation, but limit it for immediate assistance or first aid
Full article :-https://arogyalegal.com/2020/article/indias-new-telemedicine-practice-guidelines-analysis-and-dos-and-donts-for-doctors-offering-teleconsultation/
✓ TRIAGE AT CLINIC / HOSPITAL
(IF POSSIBLE)
• Triage stations with adequately trained staff should be allotted at the entrance of each health care facility.
• Physical barriers (glass/plastic barriers) 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.
Important steps
from DOCTOR APPOINTMENT to Clinic Exit
✓ 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.
✓✓ PATIENT WAITING AREA SET UP :
PICTURE OF BEFORE COVID-19
~ Multi seater sofas for Patients and accompanying persons
~ heavy seating arrangement
~ coffee table books
~ uncovered dustbins in un-noticeable corners.
PICTURE OF AFTER COVID-19
~ Single seater chairs for patient's accompanying persons to replace sofas
~ easily disinfectable single seater chairs in waiting area
~ Patient to come with prior appointment, no crowding permitted
~ All entrants to use disposable face covers, feet covers
~ Covered dustbins in easily noticeable area.
✓✓ CONSULTING ROOM SET UP
PICTURE OF BEFORE COVID-19
>>Multiple chairs for patient‘s accompanying persons
>> Patient too close to Doctor.
>> Drs table narrow and crowded with materials.
>> Dustbin not seen
PICTURE OF AFTER COVID-19
>> Only one chair for Patient's accompanying person
>> Patient atleast 3 ft from Doctor.
>> Drs table wide and not crowded with materials.
>> Dustbin seen (easily noticeable)
✓ CLINIC MANAGEMENT (continue...) :-
• Please don't touch any documents of the 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)
• While dispensing medicines, prefer no touch techniques with the patient.
• 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 alcoholbased disinfectant after each patient interaction.
✓✓ 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.
Q : 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
✓✓ 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 SURGICAL MASK WEAR AND REMOVE
Steps to wearing N-95 mask
Steps to wearing N-95 mask
✓✓ GUIDANCE TO PUTTING ON & TAKING OFF PPE
PPE :- Personal protective equipment
SEQUENCE FOR PUTTING ON PPE :-
~ mnemonic :- GMGG
Gown ---> Mask ---> Goggles ---> GLOVES
SEQUENCE FOR TAKING OFF PPE :-
Reverse of putting on but at last mask
Elaborated Video by AIIMS Delhi
ABOUT PPE
Link :- https://youtu.be/8PSBOZUelTc
✓✓ COMBINED PROTECTION:-
✓✓ TRANSPORT PROTOCOL :
Forshifting 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
✓✓ 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 ordinarybleach (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 containerbefore disposing of them with other household waste and wash hands with soap and water/alcohol-based hand rub as shown above in a picture.
✓✓ Duration of home quarantine period...
>> It 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 COVlD-19
• HCWs (Healthcare workers) conducting such procedures should be wearing full-body PPES including N95 particle-filtering mask
• Should be carried out in an adequately ventilated room or in airborne infection isolation rooms (AllR) which are negative pressure rooms .
✓✓ Emotional needs of HCWs
>> Must not be ignored
>> Health care workers at the front-line of COVlD-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 constantanxiety of passing infection on to their families.
>>> Suffer from extreme levels of stress, depressive orders, anxiety and insomnia.
✓✓ Access to PPE for health worker :-
~ ls 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% Sodium Hypochlorite can be used as a disinfectant for cleaning and disinfection
• The solution should be prepared fresh.
• Leaving the solution for a contact time of at least 10 minutes is recommended.
• 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.
• FUMIGATION
✓✓ Decontamination
PPE to wear while carrying out cleaning and disinfection works: .
>> 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)
>> Avoid touching the nose and mouth (goggles may help as they will prevent hands from touching eyes)
>> Disposable gloves should be removed and discarded ifthey become soiled or damaged, and a new pair worn
>> 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.
>> 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 offareas where the confirmed case has Visited, before carrying out cleaning and disinfection of the contaminated environmental surfaces. This is toprevent unsuspecting persons from being exposed to those surfaces. Inform the local authorities immediately.
✓✓✓ BASICS FOR ALL MEDICAL PROFESSIONALS ✓✓✓
~ DO'S and DON'T ~
1. Use only 1 pen, phone and waterbottle (disposablebetter)
2. Decontaminate phone
3. Donot touch anything
4. Everything is contaminated unlessCleaned in your presence
5. No watches, no rings, no bangles , no dangling earrings
6. Hairs tied and Cover your head with cap.
7. Shift to scrubs full sleeves, if available.
8. Empty bowel and bladder before you wear your PPE
9. Wear double glove
10. Keep your palms together when you see patients to remind you not to touch them.
11. Don't use stethoscope. These are not normal times
12. Wear goggles
13. Wear masks if patient contact or in busy area.
14. Wear foot wear which cover foot fully. plastic or rubber easy to disinfect.
15. Social distancing poorly practiced -in hospitals, so please pay attention .
16. Keep 1 m distance
17. Safe distance always
18. No elective job at hospital
19. Clean your desk, door knob, computer, workstation yourself or in your presence
20. Keep door opens
21. Minimal touching
22. Do not touch papers and files, prefer Electronic entries, if feasible
23. Wash hands after every patient examination and clean your instruments with sterilium, especially stethoscope to avoid cross infection
24. Avoid lifts, Closed space, Don't touch lift buttons. Get them cleaned often
25. Avoid Heavy load at clinic
26. Leave all your stethoscope,knee hammers and other medical stuff in hospital itself. Don't take home
27. Decontammate car handles
✓✓ WHILE GOING BACK TO HOME :-
1. Ring up home when you start from hospital.
2. 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.
3. 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.
4. Meanwhile use tissue and sanitizer and wipe the items you have placed in the box and the box.
5. Wash your hands with soap water again
6. Now enter the house without touching anything.
7. 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
8. Then take a head bath with a shampoo and body bath with soap
9. Wash your clothes/ put in washing machine with high temperature settings and dry clothes in direct sunlight.
✓✓ICMR recommendation for COVlD-19 ✓✓
~ Use of hydroxy-chloroquine for prophylaxis for selected individuals as follows;
# Eligible individuals:
>> Asymptomatic healthcare workers involved in the care of suspected or confirmed cases of COVlD-19:
400 mg twice a day on Day 1, followed by 400 mg once weekly for next 7 weeks; to be taken with meals
>> Asymptomatic household contacts of laboratory confirmed cases:
400 mg twice a day on Day 1, followed by 400 mg once weekly for next 3 weeks; to be taken with meals
✓✓ Revised Guidelines on Clinical Management of COVID 19 ✓✓
[Government of India Ministry of Health & Family Welfare Directorate General of Health Services (EMR Division) ]
>> Based on the available information the following drugs may be considered as an off label indication in patients with severe disease and requiring ICU management:
• Hydroxychloroquine (Dose 400mg BD for 1 day followed by 200mg ED for 4 days) in combination with
• Azithromycin (500 mg OD for 5 days)
~ These drugs should be administered under close medical supervision, with monitoring for side effects including QTC interval.
~ The above medication is presently not recommended for Children less than 12 years, pregnant and lactating women .
✓✓ PERSONAL MANAGEMENT ✓✓
>> Read :- story books , novels, life biography
>> Learn music , musical instruments.
>> Learn new language
>> Learn new courses
>> Exercises (achieve fitness goals by home workout )
>> Most crucial : spend time with Family
>> Increase your skill.
Source :- DR. N.Himansu Choudhury (MD, ENT)
- WHO
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