04 June 2020
20:26AIM:Essentiality is; how to juggle with the patients who require ordinary urgent care along with treatment of those who are sick and carrying Covid -19 silently and asymptomatically.PURPOSE:

  • In the midst of the pandemic outbreak;
  • People will still have heart attacks and strokes.
  • Babies will still be born.
  • Appendixes will still burst.

Premises of current Understanding:The Theory is;

  • Virtually everyone is Covid possible
  • All patient are Covid-+ive unless and otherwise proven.

Issues:

  • “It’s very hard to cohort or gang up in a situation like this.”
  • Although patients attending hospital comes with a different complaint, they are now, compulsively treated as though may be infected.
  • Due to the silent spread of virus virtually everyone attending hospital is treated as “COVID-possible.”
  • Precisely “A woman came in with vaginal bleeding, but she was COVID-positive,” Her complaint wasn’t the disease; it was the bleeding.

HERE IS THE REASON WHY ALL HOSPITALS ARE AT THE MOMENT WHETHER A DETAILED COVID UNIT OR NOT ARE BEING TREATED AS A COVID WING.”Mandatories:

  • Strictly no visitors
  • Compulsory mask wearing (All staff /patient attendant )
  • Hand sanitizers (Alcohol based)
  • All attendant /patient scheduled for surgery will be tested regardless of symptoms.
  • Common areas like lobbies waiting room rest room to be clean often.
  • Social Distancing
  • Frequent hand wash
  • Gloves
  • PP E’s as per recommendation and first liners CHWs
  • Shield mask or transparent plastic shield for OPD all exposed staff /doctors
  • Disposable long sleeves gown
  • Shoe cover

WORKING STRATEGY:The Manchester Triage System is a clinical risk management tool used by clinicians worldwide to enable them to safely manage patient flow when clinical need far exceeds capacity.Triage:

  • The sorting out of patient or casualties to determine priority of need and proper place of treatment.
  • During infectious disease Pandemic outbreaks, triage is particularly important to separate patients likely to be infected with the non- infected for the pathogen of concern.

Protocol & Procedure:

  • Early case detection is a key to risk assessment
  • Early isolation and case identification is a pivotal way to stop transmission thus keeping reproduction rate less than.

Precautions before Reception Desk:

  • Implementing early triage and holding safety station shall keep threshold of transmissibility to lower level.
  • Every arrival shall pass through Safety station Triage preliminaries.
  • Only 1 person is allowed, less driver, with the patient to access hospital facility to avoid unwanted gathers.
  • Car or driver should not gain access beyond dropping point as such a single attendant shall be allowed with the patient.
  • Dropping points shall have wheel chairs and stretchers for prompt patient facilitation

Level (1) Safety station:

  • Arrival (Health Care Facility HCF)
  • Disinfectant spray (For cars)
  • Laser Gun screening for Fever (Fever >38°C)(For patient and attendant)
  • Initial inquiry /Complain (Fever /respiratory or others)

Level (2) safety station:

  • Dropping point
  • Surgical Mask / hand sanitizer alcohol-based hand rub
  • Surgical Gloves (Compulsory)
  • Soap and water counter only in rare cases if sanitizer unavailable

Level (3) Safety Station:

  • Walk through Disinfection Gates( Compulsory )
  • Triage Reception Desk is a respiratory virus carrier/ disease evaluation Desk

(Inquire, Identify & Sort signs and symptoms of respiratory infection)

  • History taking (At least 1 sign or symptom of respiratory disease) (e.g., cough or shortness of breath)
  • Compulsive Medical mask on patient and attendant/Driver
  • Compulsive PPE to be wear and worn by attending CHW at reception desk or N-95 with face shield and Gloves with shielding of counter/reception desk
  • Counter /desk shall have glass shield preferably so to avoid close direct contact with the patient
  • Necessary details regarding Covert disease shall be obtained as follows
  • Identify Travel and Direct Exposure History
  • Has the patient traveled or resided in another Country / City where COVID-19 is spreading during the 14 days prior to symptom onset?
  • Has the patient had contact with an individual with suspected or confirmed COVID-19 during the 14 days prior to symptom onset?
  • If yes, continue with triage and referral to:

Fever Clinic @ level 4 Safety Station ERE as suspected Covid -19Level 4 Safety Station:

  • Triage for suspected Covid -19
  • Fever evaluation
    Check for fever >38 Degree
  • Respiratory evaluation clinic

Cough shortness of breath (etc)

  • GIT, CNS or others Symptoms
  • Vomiting, Loose motions, cerebral issues
  1. If symptoms suggest provisional Covid -19 diagnosis as positive (suspect)
  • Hold patient at Isolation Bay at ERE for evaluation or further disposal to dedicated tertiary care Covid Facility

Protocol at Bay:

  • Separate from the rest of the patient
  • Detain /hold patient temp at Holding Bay
  • If test available at HC Facility Perform Covid testing/ Lab
  • If not refer to HC(Health Care ) facility for Covid -19 testing

Bay Environs Requirements:

  • Single room with negative pressure.

(Negative pressure prevents airborne diseases like TB and Flu from escaping from room and infecting others. This is performed by a Machine that pulls air in to the room and filters it before moving out.A positive air pressure is used when patient has a weakened immunity in which a clean filtered air is constantly pumped in to keep contagious disease out of room.)

  • Ensure healthcare personnel (HCP) caring for the patient adhere to Standard, Contact, and Droplet Precautions
  • Only essential HCP with designated roles should enter the room and wear appropriate personal protective equipment.
  1. If symptoms suggest provisional Covid -19 diagnosis as negative (asymptomatic)
  • Issue provisional clearance slip for OPD for further referral to OPD / ERE (non traumatic emergency cases only)

Protocol for CHW at Reception Desk:

  • Wear a face mask preferably N-95 or Medical grade surgical mask with or without PPE
  • Alcohol-based hand rub/sanitizer
  • Tissue papers
  • Social distancing one meter at least
  • Face shield
  • Clear signs at the entrance of the facility directing patients with Fever or respiratory symptoms for further report to the registration desk in the emergency department and thereof for next destination.
  • Installation of Physical Barriers (Glass or Plastic Screen to limit close and direct contact with potentially infectious
  • Trash Bin with Lid
  • Walk through disinfectant gates shall be installed well before entry corridors of OPD/ indoor building with one point of entry and exit.
  • Dedicated clinical staff (e.g. physicians or nurses) for physical evaluation of patients presenting with respiratory symptoms at level 4 safety triage point.
  • The staff should be trained on triage procedures, COVID-19 case definition.
  • Compulsory Complete appropriate personal protective equipment kit (PPE) be worn if available easily (i.e. Mask, eye protection, gown and gloves).
  • Standardized triage questionnaire for use and should include questions that will determine if the patient meets the COVID-19 case definite
  • Questionnaire should include history of;
  1. Travel within last 15 days
  2. Covid-19 positive contact history
  3. Fever
  4. Shortness of breath
  5. Any associated disease ranging from respiratory to medical like diabetes, hypertension or autoimmune
  6. Drug history
  • A notification system to hold patients to wait in personal vehicle so that social distance can be maintained and preliminary evaluation as to history or suspected Covid -19 evaluation can be made
  • Limiting the number of accompanying family members in the waiting area or hospital
  • No one under 18 years old unless a patient or a parent.
  • Anyone and everyone within hospital premises waiting area” should wear a facemask and Gloves.
  • Triage area, including waiting areas should be cleaned at least twice a day with a focus on frequently touched surfaces. (Disinfection can be done with 0.1% (1000ppm) chlorine or 70% alcohol for surfaces that do not tolerate chlorine. For large blood and body fluid spills, 0.5% (5000ppm) chlorine is recommended.)
  • All HCWs (Health Care Worker) should adhere to Standard Precautions, which includes hand hygiene, selection of PPE based risk assessment, respiratory hygiene, clean and disinfection and injection safety practices.
  • All HCWs should be trained on and adhere to precautions (e.g. contact and droplet precautions, appropriate hand hygiene, donning and doffing of PPE) related to COVID-19.
  • If wearing a PPE all must follow appropriate PPE donning and doffing steps.
  • Perform hand hygiene frequently with an alcohol-based hand rub
  • HCWs who are likely to come in contact with suspected or confirmed COVID-19 patients should wear appropriate PPE
  • HCWs in triage area who are conducting preliminary screening do not require PPE if they DO NOT have direct contact with the patient and MAINTAIN distance of at least one meter.
  • HCW does not need PPE as long as spatial distance can be safely maintained.
  • When physical distance is NOT feasible and yet NO direct contact with patients, use mask and eye protection (face shield or goggles).
  • HCWs conducing physical examination of patients with respiratory symptoms should wear gowns, gloves, medical mask and eye protection (goggles or face shield).
  • Cleaners in triage, waiting and examination areas should wear gown, heavy duty gloves, medical mask, eye protection (if risk of splash from organic material or chemical), boots or closed work shoes.
  • Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly
  • Expand hours of operation, if possible, to limit crowding at triage during peak hours and maintenance of social distancing must be observed.
  • All other departments shall observed similar safety precautionary measure while handling patients for any purpose as laboratory or investigations.
  • Admission discharge desk shall also follow recommended and defined SOP safeguarding desk and people in similar fashion.
  • All Patients tentatively cleared from Covid -19 shall pass through walk through disinfection gate with compulsory mask and gloves.
  • All clinician shall wear Gloves (disposable) for each patient with mask and face Shield so that safe distance and droplets affairs can be safely managed.

Lab Protocol:

  • Sampling and collection of sample shall be under strict defined SOP’s with preferred PPE or mask /shield and gloved protocol.
  • All patients regardless should be treated as Covid-(+ive) hence shall be under compliance of SOP’.
  • There will be one patient with attendant in a lab while and during sampling and registration with proper distancing protocol.
  • Disposal of used kits /syringes etc shall be under guided criterion with proper color codes as infectious.
  • Attendant at Reception counter must wear recommended available overalls.

Radiology Protocol:

  • All patients regardless should be treated as Covid-(+ive) hence shall be under compliance of SOP’.
  • Radiographer shall wear PPE or Disposable apron with mask/gloves /facial shield.
  • No patient with recommended SOPS shall be treated without.
  • Proper distant shall be maintained preferably and hand sanitizers be used in between patients along with disposable gloves.

Pharmacy Protocol:

  • Dispenser shall wear disposable gown, mask gloves and face shield maintaining recommended distance.
  • No patient or attendant shall gain access in pharmacy or dispensing Room.

Protocols at Reception Desk & counter

  • All Admission- Discharge counter /OPD counter and similar labs dispensing and radiology counter and reception desk shall be shielded with transparent glass or through and through plastic shields to avoid direct contact and exposure to the staff.
  • CHW/ Attendants at all reception shall be in complete compliance of SOP’s.

Protocols at OPD:

  • Specialist shall have selective days and hours of their OPD.
  • All walk –in patient shall abide hospital SOPS & protocols
  • Clinician shall take necessary precautions at their own in examination and handling of patient for their own safety.
  • Under no means clinician will be allowed to examine patient without mask, face shield and gloves.
  • Hospital shall make available requisite necessities at charges for patients attending hospital and clinicians.
  • There will be restricted number of patient in OPD hence as such a preferred mode of appointment shall be an E- appointment by Telephone.
  • However walk in customer will be to the maximum facilitated.
  • Different specialty will have different days as such specialties shall have different days.

Protocol for OT:

  • All patient undergoing elective surgery regardless of specialty and procedure shall be tested for Covid -19
  • Emergency surgery shall have defined Protocol of Covid-19 taking care as if operated upon Covid (+) positive case.
  • All procedures from anesthesia to recovery shall be governed and watched in full SOPs and disposal shall have structured criterion.
  • Gynecological procedures, caesarian sections and deliveries all shall have covid -19 testing prior to Hospital Visit.

Protocol of admission /Wards:

  • All Admission regardless of specialty and diagnosis shall be treated as suspect unless testing is done.
  • All Cases pertaining to fever or Respiratory symptoms should be dealt cautiously and consciously.
  • Wards must have less number of beds keeping distance between.
  • Rest of the SOPs as recommendation should be followed both by the patient, attendant and CHW.
  • Attendants will be treated in the same way as is protocols are being followed for a Covid (+) suspect.
  • Rest room and toiletries should be washed at frequent intervals.
  • Waiting areas and public place shall be cleaned at least twice.
  • Workers involved in cleanliness and disposal shall ideally be in PPE.
  • All donning and doffing procedure need to be followed in true letter and spirit as per WHO recommended Procedure (Dr Raza)