09 Apr, 2020
Currently the world is facing ongoing Coronavirus disease 2019 (COVID 19) pandemic which has resulted in healthcare emergencies overwhelming the healthcare system. In this scenario it is important to prevent hospital transmission by following infection control protocols.
At hospital setting in emergency department, it is important to triage the patient with the flu like symptoms (like fever, cough, cold, dyspnea), with history of travel or contact with the COVID-19 positive patients. Rapid assessment on hemodynamic status, ventilation advise on intensive care or ward management or home isolation is important. Patients should be advised to wear face masks. Not COVID (flu) patients should be treated at separate area to prevent cross infection. It is better to avoid non-urgent OPD activity and postpone elective surgeries to reduce the risk in the health care setting. Measures should be taken to prevent crowding in the emergency department with adequate distance maintained between each patient.
For healthcare workers, standard contact and droplet precautions to be taken for any patients with an undiagnosed respiratory infection and in all the clinical settings which includes: wearing of medical facemasks, gloves, eye protection, hand hygiene. The use of respirators is indicated during aerosol generating procedures like tracheal intubation, non-invasive ventilation, mechanical ventilation prior to intubation, cardiopulmonary resuscitation, bronchoscopy, upper endoscopy. These steps help to reduce risk from unsuspected virus carriers.
For infection control it is emphasized by both WHO and CDC that strict hand hygiene is important in curtailing COVID 19 transmission. Healthcare personnel (HCP) and patients should either wash hands with soap and water for at least 40 seconds especially after examining the patients, after going to bathroom, before and after eating, after blowing the nose, coughing, sneezing, after touching garbage, after touching mask or soiled PPE. Alcohol based hand sanitizer (at least 60% of alcohol)for minimum 20 seconds can be also be used.
At hospital isolation ward while caring for patients suspected or confirmed cases, it is advised to follow standard, contact and droplet precautions. The patient should be cared in single occupancy room with closed door and dedicated bathroom. Patient should wear medical face masks to contain his respiratory secretions. CDC recommends an airborne infection room (single patient negative pressure room) should be reserved during aerosol generating procedures. If this is not possible, then a single room with attached toilet facilities should be used. Room doors should be kept closed. If there is no attached toilet, a dedicated commode (which should be cleaned as per local cleaning schedule) should be used with arrangements in place for the safe removal of the bedpan to an appropriate disposal point. The patient should wear a face mask if being transported out of the room (e.g., for studies that cannot be performed in the room). An airborne infection isolation room (i.e., a single-patient negative pressure room) should be reserved for patients undergoing aerosol-generating procedures.
HCP entering the room of a patient with suspected or confirmed COVID 19 should wear the appropriate personal protection equipment (PPE): gown, gloves, eye protection, respirator. Appropriate steps of PPE donning and doffing should be followed.
Environmental cleaning in hospital settings includes sealing of the area prior to carrying out cleaning and disinfection of potentially contaminated area by biological agents. Wipe all frequently touched areas (like lift buttons, hand rails, doorknobs, arm rests, tables, air/light controls, keyboards, switches) and toilet surfaces with chemical disinfectants every 3-4 hours per day and for low touch surfaces (walls and mirrors) mopping should be done at least once a day. 1% sodium hypochlorite with contact time of at least 10-15 minutes is recommended for cleaning and disinfection. Alcohol (e.g.: isopropyl 70% or ethyl alcohol 70%) can be used to wipe the surfaces where bleach is not suitable (e.g.: metals). PPE should be worn while carrying out disinfection works. Staff should wash their hands with soap and water immediately after removing PPE and after completion of cleaning and disinfection work. Double-bagged biohazard bags should be used to discard all the used PPE, cleaning item made of cloths and absorbent materials which should be securely sealed and labelled. Staff should be aware of symptoms and should report if they develop symptoms.
Management of deceased COVID 19 patient. Death due to COVID 19 is a non-medico legal case. Deceased must be placed in a zipped body bag immediately after death with identification tag marked 'COVID 19', which should be fully sealed and impermeable before removing from isolation room and before transferring to the mortuary to avoid leakage of the body fluid. Autopsy must be avoided if there is no substantial reason. If autopsy is considered, body to be kept in refrigeration in the mortuary and once the safe environment is available autopsy to be conducted. When properly packed in the body bag the body can be safely removed from the mortuary and sent to the crematorium or placed in a coffin for burial. The vehicle used for transporting the body should be properly disinfected and decontaminated with 1% sodium hypochlorite. Mortuary staff and burial team should follow standard precautions. Once the body of the deceased is handed to the family, precautions have to be taken to prevent the spread of the infection by using a fluid proof coffin. For the purpose of the last rites, cremation should be preferred in either electric or gas crematorium in situ in zipped bag. If burial requested, then it should be buried in a thick airtight coffin and placed at normal depth of burial (4-6 feet) and the area above and adjacent to the grave should be cemented immediately as an additional precautionary measures. Avoid large gathering and maintain healthy distancing during last rites. Remove PPE after handling the dead body and perform hand hygiene immediately.
Reference:
1. COVID-19 Preparedness Document AIIMS, New Delhi Version 1.0. Dated 27/03/2020
2. Mcintosh K. Coronavirus disease 2019- COVID 2019. Dated 31/3/2020. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19?source=history_widget
3. Giwa AL, Desai A, Duca A. Novel 2019 coronavirus SARS-CoV-2 (COVID-19): An updated overview for emergency clinicians. Emerg Med Pract. 2020 May 1;22(5):1-28. Epub 2020 Mar 24 (https://www.ebmedicine.net/topics/infectious-disease/COVID-19)
|